Lipomatous hypertrophy of the interatrial septum in a patient with carcinoma: a case report of the importance of multi-modality imaging

Introduction: Lipomatous hypertrophy of the interatrial cardiac septum is a benign disorder. In rare cases, the disorder can cause obstruction of atrial inflow, causing symptoms of heart failure, or cardiac arrhythmias resulting from the involvement of the atrial wall and atrioventricular conduction pathways. Case presentation: We present a case of a Caucasian 66‐year‐old man with urothelial carcinoma where transthoracic echocardiolography showed a mass in the basal part of the interatrial septum. After injection of echo contrast, it was suggested that the structure was vascularized, thus implying tumour. Transoesophageal echocardiography and cardiac magnetic resonance imaging gave the correct diagnosis of lipomatous hypertrophy. It was then discovered that the patient had been referred to a computed tomography (CT) earlier, but no mention of the mass was found in the report from the examination. Re‐evaluation of the images showed a clearly visible mass indicative of fatty tissue. Conclusion: This case report highlights the importance of multi‐modality imaging when the findings are not concordant. Moreover, this case report also highlights the importance of careful examination of the heart on routine CT scans, something that is often overlooked by the radiologists. In this case, the CT scan clearly indicated the diagnosis of lipomatous hypertrophy of the interatrial septum and thus could have prevented the subsequent imaging cascade.     

CT findings of an intracardiac bronchogenic cyst

Bronchogenic cysts are classified as congenital bronchopulmonary foregut malformations. It is very rare for bronchogenic cysts to occur within the heart. A 59-year-old woman had a cardiac mass which was detected incidentally during a CT examination. The lesion was a hypoechoic mass with internal echoes on transthoracic echocardiography, and a well-defined hyperdense mass within an interatrial septum with poor enhancement on electrocardiography (ECG)-gated cardiac CT. The lesion was diagnosed as a bronchogenic cyst in the interatrial septum after surgical excision.     

An acquired interatrial fistula secondary to para-aortic abscess documented by transesophageal echocardiography

Para-aortic ring abscess and resulting fistulous communication between adjacent structures frequently occur in prosthetic aortic valve endocarditis but are rarely diagnosed preoperatively. We report a patient who had an abscess involving the aortic-mitral intervalvular fibrosa that eroded into the interatrial septum, causing an interatrial communication with a left-to-right shunt. The abscess was detected by transthoracic echocardiography, but the fistula was only seen by the subsequent transesophageal echocardiogram. To our knowledge, this is the first report of an interatrial fistula secondary to a para-aortic valve abscess and its diagnosis preoperatively. Transesophageal echocardiography should be performed in any patient suspected to have complicated aortic endocarditis.     

Fenestrated atrial septal aneurysm: diagnosis by transesophageal echocardiography

The diagnosis of atrial septal defect by transthoracic echocardiography remains difficult in a small subset of patients because of either suboptimal acoustic windows or unusual anatomy, for example, fenestrated defects. We report the case of a 55-year-old woman with a fenestrated atrial septal aneurysm that was incompletely visualized by transthoracic echocardiography. Subsequent transesophageal echocardiography demonstrated three defects within the atrial septal aneurysm with left-to-right shunting across each defect. Normal pulmonary venous connections were also defined. All echocardiographic findings were confirmed at surgery. This case demonstrates the additional diagnostic accuracy of transesophageal echocardiography for detecting disease of the atrial septum.     

Intrapericardial carcinoid metastasis.

Carcinoid tumors are malignancies of neuroendocrine tissue. Metastasis, most commonly to the liver, is associated with the carcinoid syndrome characterized by secretory symptoms and right-sided valvular heart disease. We report a case of previously unidentified pericardial metastasis, in the absence of any valvular disease, thus, reflecting an unusual cardiac complication of this tumor. A 50-year-old patient with histologically confirmed carcinoid syndrome underwent screening transthoracic echocardiography that demonstrated a large mass posterior to the interatrial septum. The location of this mass was confirmed by transesophageal echocardiography and magnetic resonance imaging to be entirely within the pericardial space without evidence of myocardial involvement. The mass was removed at thoracotomy and histology confirmed metastatic carcinoid disease. Although patients with carcinoid syndrome are at risk of cardiac valvular complications, and should be screened, this case demonstrates an unusual and previously unidentified site of metastatic disease.     

Lipomatous Hypertrophy of the Interatrial Septum

Lipomatous hypertrophy of the interatrial septum is a benign disorder that is characterized by the fat deposition in the interatrial septum. It typically occurs in elderly, obese patients and may cause arrhythmia. We report a case in which lipomatous hypertrophy of the interatrial septum was found incidentally.     

Large cystic mass in the right atrium: multimodality imaging and pathologic features of a giant interatrial septal aneurysm

The case demonstrates the use of echocardiography, cardiac computed tomography (CCT) and cardiac magnetic resonance imaging (CMRI) to determine the size, location, anatomic connection, perfusion and hemodynamic significance of a large tumor in the right atrium. The mass was surgically excised and pathology confirmed an ultimate diagnosis of an interatrial septal aneurysm (ISA). Transesophageal echocardiography enhances the sensitivity of detecting ISA and is the initial test of choice when an ISA is suspected on transthoracic echocardiography. In addition, the use of CCT and CMRI helps further define the anatomy, perfusion and tissue characteristics of the mass. Our case demonstrates the utility of multimodality non-invasive imaging to characterize an unusual tumor leading to a successful surgical treatment and a corresponding pathologic diagnosis of a large, cystic aneurysm of the interatrial septum.     

Tricuspid insufficiency and interatrial septum rupture: a cause of persistent systemic hypoxemia after blunt chest trauma.

The case of a 45-year-old man with severe tricuspid insufficiency and interatrial septum rupture caused by a car accident is described. The patient had a rupture of the anterior papillary muscle of the tricuspid valve and right-to-left shunt through an interatrial defect with severe hypoxemia that was difficult to distinguish from that caused by pulmonary damage. Transesophageal echocardiography was extremely useful for early diagnosis.     

Interatrial septum in B-mode and conventional echocardiograms - a clue for the diagnosis of congenital heart diseases

The interatrial septum was studied with B-mode echocardiography to determine whether there were specific ultrasonic features characteristic of such congenital heart diseases as atrial septal defect and endocardial cushion defect. In transverse tomograms in the third and fourth intercostal space the interatrial septum is detected almost parallel to the anterior chest wall. The septum continues leftward to the echo of the anterior mitral leaflet. When the interatrial septum extends beyond the left sternal border, it can also be recorded near the left sternal border in the sagittal tomogram. The interatrial septum can also be recorded conventional echocardiography. The pattern is wavy and synchronous with the heart beat with an amplitude of about 10 mm. It is seen near the chest wall in patients with left atrial enlargement and far from the chest wall in patients with right atrial enlargement. The defect in the interatrial septum was visualized B-mode and conventional echocardiogram in patients with ostium secundum atrial septal defect. The defects were no longer observed after surgery.     

Impact of Patent Foramen Ovale Anatomic Features on Right-to-Left Shunt in Patients with Cryptogenic Stroke

The purpose of this study was to investigate the impact of the morphologic characteristics of patent foramen ovale (PFO) on right-to-left shunt (RLS) in patients with PFO and cryptogenic stroke using transesophageal echocardiography and saline contrast transthoracic echocardiography (c-TTE). Of the 165 patients with PFO stroke, both the height and the length of PFO in the provoked RLS group were smaller than those in the constant RLS group. PFO height, interatrial septum mobility and proportion of atrial septal aneurysms were greater in the severe RLS group than in the mild and moderate RLS groups. Multivariate analysis revealed that PFO height and interatrial septum mobility were independent predictors of severe RLS. Multiple territorial ischemic lesions were more common in the severe RLS or constant RLS group. Our findings indicated that the severity of RLS was related to the anatomic features in PFO, inducing different cerebral ischemia lesion patterns in cryptogenic stroke patients with PFO.     

Pharmacologic exposure of an occult atrial septal defect

OBJECTIVE: To describe the diagnostic technique used to identify the presence of a symptomatic interatrial shunt obscured by normal intracardiac pressures and to discuss the unusual findings in this case and their relevance to the investigation of patients with unexplained hypoxemia. DESIGN: Case report. SETTING: Intensive care unit of a university teaching hospital. PATIENT: A patient with a variant of the platypnea-orthodeoxia syndrome. INTERVENTIONS: Intravenous administration of metaraminol. MEASUREMENTS AND MAIN RESULTS: Clinical examination and routine investigations ruled out pneumonia or myocardial infarction as a cause of respiratory failure, and pulmonary angiography was normal other than for the demonstration of an interatrial communication. Repeated transthoracic echocardiograms failed to indicate the presence of a significant interatrial shunt that was eventually detected following temporary shunt reversal with intravenous metaraminol and confirmation by bubble-contrast transesophageal echocardiography and right heart catheter studies. CONCLUSIONS: Symptomatic right-to-left intracardiac shunt may occur in patients with normal intracardiac and pulmonary artery pressures. The presence of a significant shunt cannot be ruled out by transthoracic echocardiography without the use of bubble contrast.     

18F-FDG PET/CT helps rule out malignancy in lipomatous hypertrophy of the interatrial septum with atypical MRI manifestations,to avoid unnecessary surgical treatment

The International Journal of Cardiovascular Imaging - Lipomatous hypertrophy of the interatrial septum (LHIS) is a rare benign heart disease characterized by excessive deposition of adipose tissue...     

Interatrial mechanical dyssynchrony shown by tissue doppler imaging during atrial flutter

Although regular supraventricular tachycardia is traditionally classified on the basis of P-wave morphology, diagnostic accuracy is limited to information obtained from surface electrocardiography. Intracardiac electrophysiology is a conclusive although invasive diagnostic method. We report a case of regular supraventricular tachycardia with a heart rate of 162 bpm. M-mode echocardiography of the interatrial septum clarified both the atrial rate and the ventricular response ratio. Tissue Doppler M-mode imaging demonstrated the delay between the posterior wall motion of the left and right atrium. Although it deserves further study, transthoracic echocardiography may provide useful information in addition to electrocardiography.     

Can cardiac magnetic resonance imaging reliably differentiate between benign and neoplastic fat?

Magnetic resonance imaging is currently frequently used to differentiate lipomatous hypertrophy of the interatrial septum from other cardiac lesions involving abnormal fatty tissue including lipomatous neoplasms. This report discusses potential problems with this approach by emphasizing the variable appearance of lipomatous hypertrophy of the interatrial septum on magnetic resonance imaging.     

A case of lipomatous hypertrophy of the interatrial septum detected via transthoracic 2-dimensional echocardiography

A 71-year-old woman underwent echocardiography for the evaluation of hypertensive heart disease. A 2-dimensional echocardiogram revealed an abnormal mass that protruded into the left atrium from the atrial septal side of the left atrial wall. Microscopic examination of the surgical specimen disclosed a mixture of normal-appearing fat, vesicular fat, and hypertrophied myocytes, and degenerated cardiac tissue with foci of necrotic fat tissue, consistent with lipomatous hypertrophy. Although lipomatous hypertrophy of the interatrial septum is rare, this little-known entity should be included in the differential consideration of the left atrial mass detected via echocardiographic examination, particularly in both obese and elderly patients.     

Intracardiac Echocardiography

Intracardiac echocardiography (ICE) uses a catheter‐based steerable ultrasound probe that is passed into the right heart chambers to image intracardiac structures. The transducer can be variably positioned for optimal imaging: in the inferior vena cava to visualize the abdominal aorta; in the right atrium for the interatrial septum, aortic, mitral, and tricuspid valves, and pulmonary veins; or in the right ventricle for the left ventricular function, outflow tract, or pulmonary artery. Intracardiac echocardiography is primarily used for imaging during an invasive cardiac procedure using conscious sedation, when transthoracic image quality would likely be inadequate, and transesophageal imaging would require general anesthesia. Intracardiac echocardiography is generally well tolerated and provides adequate images and sufficient information for the procedure performed. In the cardiac catheterization laboratory, ICE is routinely used for patent foramen ovale, atrial septal defect, and ventricular septal defect closures, allowing adequate percutaneous placement of septal occluders. It is now being considered in the current era of transcatheter aortic valve implantation necessitating improved imaging approaches for accurate placement. It is also routinely used for trans‐septal punctures during mitral valvuloplasty and, more recently, with the advent of left atrial appendage closure devices. This article provides a comprehensive review of the current technology for ICE and its growing applications in the realm of interventional cardiology.     

解剖M型超声心动图评价原发性高血压病的左房功能

目的 探讨解剖M型超声心动图在评价原发性高血压病I期患者左房构型及功能中的应用价值.方法 选择原发性高血压病Ⅰ期患者40例,健康者40例为对照组,应用解剖M型超声心动图测量其左心房壁、房间隔收缩期和舒张期厚度,左心房收缩期和舒张期内径,计算左房壁增厚率、房间隔增厚率.结果 与对照组比较,原发性高血压病Ⅰ期患者左房壁、房...     

Giant interatrial septal aneurysm mimicking a right atrial tumor

We report the case of a patient with a giant interatrial septum aneurysm who was admitted to our hospital for analysis of palpitations. Transthoracic echocardiography was not contributive and cardiac magnetic resonance imaging demonstrated a small interatrial septal aneurysm. In our study, only transesophageal echocardiography provided the correct diagnosis, showing a giant interatrial septal aneurysm protruding far away into the right atrium and mimicking a right atrial cystic tumor.     

Intracardiac echocardiography (9 MHz) in humans: methods, imaging views and clinical utility

A new low-frequency (9 MHz, 9 Fr) catheter-based ultrasound (US) transducer has been designed that allows greater depth of cardiac imaging. To demonstrate the imaging capability and clinical utility, intracardiac echocardiography (ICE) using this lower frequency catheter was performed in 56 patients undergoing invasive electrophysiological procedures. Cardiac imaging and monitoring were performed with the catheter transducer placed in the superior vena cava (SVC), right atrium (RA) and/or right ventricle (RV). In all patients, ICE identified distinct endocardial structures with excellent resolution and detail, including the crista terminalis, RA appendage, caval and coronary sinus orifices, fossa ovalis, pulmonary vein orifices, ascending aorta and its root, pulmonary artery, RV and all cardiac valves. The left atrium and ventricle were imaged with the transducer at the limbus fossa ovalis of the interatrial septum and in the RV, respectively. ICE was important in identifying known or unanticipated aberrant anatomy in 11 patients (variant Eustachian valve, atrial septal aneurysm and defect, lipomatous hypertrophy, Ebstein's anomaly, ventricular septal defect, tetralogy of Fallot, transposition of the great arteries, disrupted chordae tendinae and pericardial effusion) or in detecting procedure-related abnormalities (narrowing of SVC-RA junction orifice or pulmonary venous lumen, atrial thrombus, interatrial communication). In patients with inappropriate sinus tachycardia, ICE was the primary ablation catheter-guidance technique for sinus node modification. With ICE monitoring, the evolution of lesion morphology with the three imaging features including swelling, dimpling and crater formation was observed. In all patients, ICE was contributory to the mapping and ablation process by guiding catheters to anatomically distinct sites and/or assessing stability of the electrode-endocardial contact. ICE was also used to successfully guide atrial septal puncture (n = 9) or RA basket catheter placement (n = 4). Thus, ICE with a new 9-MHz catheter-based transducer has better imaging capability with a greater depth. Normal and abnormal cardiac anatomy can be readily identified. ICE proved useful during electrophysiological mapping and ablation procedures for guiding interatrial septal puncture, assessing placement and contact of mapping and ablation catheters, monitoring ablation lesion morphological changes, and instantly diagnosing cardiac complications.     

正常肺静脉经胸超声心动图与64层螺旋CT对比定位观察

目的 探讨经胸超声心动图显示肺静脉及对4条肺静脉定位的有效方法.方法 选取同时行肺静脉CT血管造影检查及超声心动图检查的拟行心房颤动消融患者12例.进行CT三维图像后处理分析,观察4条肺静脉与相邻重要解剖结构的空间位置关系,同时对比分析CT三维图像后处理相关断层与超声心动图切面.结果 12例患者肺静脉螺旋CT血管造影成像均清晰显示,且无结构异常及解剖变异.右上肺静脉开口紧邻房间隔,近端与上腔静脉相邻.右下肺静脉相对于右上肺静脉稍远离房间隔,位于右侧.左上肺静脉紧邻左心耳.左下肺静脉相对于左上肺静脉远离左心耳,靠近胸降主动脉.超声心动图标准切面左心室长轴、大动脉短轴、心尖四腔观在调整探头的基础上可以显示4条肺静脉.结论 经胸超声心动图可以显示4条肺静脉,参照邻近重要的解剖结构可以对4条肺静脉进行空间位置定位.