Echocardiographic pattern of right atrial tumour motion.

Propagation of Wilm's tumour to the right atrium was diagnosed by echocardiography. The tumour prolapsed into the right ventricle during each atrial systole. The presence of the tumour and its motion were confirmed by cardiac catheterization, cineangiography, and surgical exploration. Successful resection of the tumour was accomplished. Echocardiography was helpful in detecting the presence of the right atrial tumour and accurately reflected the pattern of its atrioventricular motion.     

Tumoral vascularization in a case of asymptomatic myxoma

A 67 year old woman was admitted for assessment of asymptomatic aortic stenosis. A large left atrial myxoma was demonstrated by 2D and M mode echocardiography. Coronary angiography was performed as part of the investigation of the aortic stenosis and showed that the tumour depended on the right coronary artery for its blood supply. Careful frame-by-frame study showed the presence of a true right coronary-left coronary fistula through the tumour. The authors discuss the different clinical presentations of left atrial myxomas and their vascularisation in the rare cases in which it has been described.     

Angiographic demonstration of blood supply of right atrial myxoma.

A 53-year-old woman underwent cardiac catheterization for assessment of coronary arterial disease. An unexpected finding of a gradient between right atrium and right ventricle led to the discovery of an unsuspected right atrial myxoma. The diagnosis was established by the presence of a filling defect in the right atrial angiocardiogram and by the demonstration of "tumour vessels" by selective right coronary angiography. Selective coronary angiography can visualize the blood supply to an intracardiac tumour and thus confirm the diagnosis preoperatively.     

Abnormal diastolic movement of the interventricular septum caused by a prolapsing right atrial myxoma.

A 40 year old woman with cough and exertional dyspnoea was found to have a large right atrial myxoma by M mode and cross sectional echocardiography. Prolapse of the tumour into the right ventricle occurred during diastole with sufficient force to cause mechanical distortion of the interventricular septum. Septal motion became normal after surgical resection of the myxoma.     

Abnormal diastolic movement of the interventricular septum caused by a prolapsing right atrial myxoma

A 40 year old woman with cough and exertional dyspnoea was found to have a large right atrial myxoma by M mode and cross sectional echocardiography. Prolapse of the tumour into the right ventricle occurred during diastole with sufficient force to cause mechanical distortion of the interventricular septum. Septal motion became normal after surgical resection of the myxoma.     

Contrast echocardiography of right atrial mass due to hepatocellular carcinoma

We describe one patient suffering from hepatocellular carcinoma who presented with a right atrial metastatic tumour as a result of invasion of the inferior vena cava and extension into the right atrium. Two-dimensional echocardiography disclosed the right atrium tumour and SonoVue contrast agent echocardiography was employed to assess the local extension of the mass and to exclude an important obstruction due to a mass in the right ventricular inflow. Surgical management in the presence of metastatic right atrial tumour thrombus is described in the literature with poor results and this type of treatment should be reserved only for selected cases in which acute and severe cardiovascular distress due to obstruction of right ventricular inflow is present.     

Right atrial tumour and right ventricular failure - diagnostic role of echocardiography and cardiovascular magnetic resonance

A case of a 66 year-old female with advanced right ventricular failure is described. Echocardiography and MRI revealed the presence of right atrial tumour. The patient underwent successful surgery and histological examination revealed lymphoma.     

Right atrial spleen.

A large cardiac tumour occupying most of the right atrium and the right ventricle and causing inflow obstruction to the right heart was confirmed by cross sectional echocardiography in a 41 year old man. After surgical resection histological examination showed that the atrial tumour had the characteristics of splenic tissue. Possible mechanisms for the development of such a tumour include an origin analogous to that of an accessory spleen or the implantation and subsequent growth of lymphoid tissue in a pre-existing superior vena caval or high right atrial angioma.     

Echocardiographic assessment of atrial tumour size and endogeneously generated contrast imagesAn experimental study

Experimental models, in vitro and in vivo, were designed tosimulate the motion of an atrioventricular valve leaflet andan atrial tumour. Cross-sectional echocardiography was usedto investigate any changes in apparent tumour size related toits motion. Both parts of the study suggest that endogenouscontrast, due to surfaces of different acoustic densities generatedaround the rapidly moving tumour, contributes to the echo-graphicpattern of the tumour. Thus, during diastole, the echo-masscloud is greater than the real size of the tumour. The echocardiographicand actual size of the tumour may be identical only in ventricularsystole when the blood flow around the atrial tumour is greatlydecreased.     

Right-left shunt caused by sarcoma of the right atrium

A 70 year old woman was admitted for right ventricular failure and cyanosis of recent onset. Echocardiography showed a very large, homogenous, immobile, smooth-contoured mass filling the right atrium. Right atrial pressures were raised but the other intracardiac pressures were normal at catheterisation. Right heart angiography confirmed the voluminous right atrial mass and dilatation of the hepatic veins and showed early opacification of the left heart chambers. A right-to-left shunt was confirmed by oximetry which showed significant desaturation of the blood in the left atrium and ventricle (saturation 78% in the left ventricle). The tumour was also documented by a thoracic CT scan. At surgery, a very large, malignant right atrial tumour was resected which histological examination showed to be an angiosarcoma. The interatrial septum seemed to be intact: there was no true atrial septal defect but a persistent foramen ovale was found. After resection of the tumour the right atrium was reconstructed. The initial postoperative period was uncomplicated but the patient died nine months later of metastatic disease particularly affecting the liver and brain. The clinical presentation of malignant cardiac tumour is very variable but a right-to-left interatrial shunt through a patent foramen ovale has only been reported previously in 2 cases of primary malignant tumours (a rhabdomyosarcoma and an angiosarcoma) and in 1 case of a secondary cardiac metastasis.     

Right atrial spleen

A large cardiac tumour occupying most of the right atrium and the right ventricle and causing inflow obstruction to the right heart was confirmed by cross sectional echocardiography in a 41 year old man. After surgical resection histological examination showed that the atrial tumour had the characteristics of splenic tissue. Possible mechanisms for the development of such a tumour include an origin analogous to that of an accessory spleen or the implantation and subsequent growth of lymphoid tissue in a pre-existing superior vena caval or high right atrial angioma.     

Diastolic forward blood flow in the pulmonary artery detected by Doppler echocardiography

The etiology of diastolic motion of the pulmonary valve seen on the M-mode echocardiogram has been the subject of much debate. To further investigate diastolic events in the pulmonary artery, the patterns of diastolic pulmonary artery blood flow velocity were studied using pulsed Doppler echocardiography in patients with a normal heart. Two diastolic waveforms were found, one in early diastole related to passive filling of the right ventricle and one in late diastole related to atrial contraction. These waveforms were also related to the two recognized phases of diastolic pulmonary valve motion detected by M-mode echocardiography. The presence of biphasic diastolic blood flow in the pulmonary artery was confirmed by electromagnetic flow velocimetry in four additional patients with various cardiac diseases and normal right heart pressures. It is concluded that both atrial contraction and passive right ventricular filling produce blood flow in the pulmonary artery.     

Demonstration of the inner structure of a right atrial myxoma by transoesophageal echocardiography

We report a case of a large right atrial myxoma. With the useof transoesophagal echocardiography, several cysts were idntifieldwithin the tumour and necrotic tissue was differentiated frommyxomatous tissue according to its echo-level. Transoesophagealechocardiography was very useful for the precise diagnosis ofcardiac tumour and demonstration of the inner structure.     

Analysis of Arrhythmias Based on Atrial Wall Motion

ABSTRACT. The usefulness and feasibility of recording atrial wall motion by M-mode echocardiography guided by two-dimensional examination was evaluated in three groups of consecutive patients'. 7 with undefined tachyarrhythmias, 25 in sinus rhythm, and 20 with atrial flutter or fibrillation. Atrial systole was recorded in the left and right atrium in 58 and 98% of the patients, respectively (p < 0.05). Six of the patients with undefined tachyarrhythmias exhibited electrocardiographic atrioventricular dissociation revealed by preceding echocardiography in all. The precise timing of left and right atrial systole could be recorded in patients in sinus rhythm; right atrial contraction preceded left atrial systole by 42±31 msec (mean ± SD). Among patients with atrial flutter or fibrillation, one case of dissimilar atrial rhythms was revealed by echocardiography. Thus, recording of atrial wall motion is feasible in the majority of patients and provides information which is otherwise available only by esophagus ECG or by invasive means.     

Subcostal M-mode echocardiography of the right atrial wall in the diagnosis of cardiac arrhythmias

The M-mode echocardiogram of the right atrial (RA) wall can be easily recorded in each person from the subcostal location. In a normal RA wall motion pattern, atrial contraction is represented by a markedly prominent posterior motion. The presence or absence of atrial contractions in the subcostal RA wall echocardiogram, their amplitude, and their timing may help in the diagnosis of cardiac arrhythmias with the simultaneously recorded non-diagnostic electrocardiogram. Flat and hidden P waves can be accurately identified throughout the cardiac cycle. It is possible to distinguish between atrial, ventricular, and nodal premature beats and to recognize atrial fibrillation, atrial flutter, paroxysmal atrial tachycardia, paroxysmal atrial tachycardia with block, atrioventricular (AV) nodal tachycardia, and supraventricular tachycardias with aberrant ventricular conduction. The diagnosis of wandering pacemaker, AV dissociation, sinoatrial block, and AV block is facilitated. On the basis of study of 60 patients with various rhythm disturbances, it was concluded that analysis of the subcostal RA wall echocardiogram is a new, helpful noninvasive approach in the diagnosis of cardiac arrhythmias.     

Relationship between interatrial pressure gradient and motion of the interatrial septum

To evaluate interatrial septal motion throughout the cardiac cycle, echocardiograms of the septum were obtained by esophageal echocardiography simultaneously with left and right atrial pressures using Millar's micromanometers in nine subjects with sinus rhythm. There were four patients with atypical chest pain but with normal coronary arteries, two with old myocardial infarction, one with angina pectoris, one with aortic regurgitation and one with sick sinus syndrome. The relationship between interatrial pressure gradient (IAPG: left atrial pressure minus right atrial pressure) and the motion of the septum was examined. In all nine patients, the curves of IAPG showed two peaks near the second heart sound and during the atrial contraction period, and the motion of the septum throughout the cardiac cycle showed a similar pattern except during the late diastolic period. During atrial contraction the septum moved posteriorly (decrease in left atrial dimension) against the IAPG. Therefore, except during the atrial contraction period, the motion of the atrial septum is considered to be dependent on this pressure gradient. During the atrial contraction period, the direction of the septal movement might be dependent on the force of active contraction of the left atrial muscles.     

Echocardiographic evaluation of the significance of shunt in secondary communications and in partial abnormal pulmonary venous returns]

Although echocardiography has been useful in diagnosing significant left-to-right shunts at the atrial level, few studies using this technique to quantitate shunt size have been performed. Echocardiograms and hemodynamic data from 28 patients, ages 15 to 58 (mean : 30 years) were reviewed. Twenty patients had isolated atrial septal defects (ASD), 6 patients has associated partial pulmonary venous returns (PPVR) and 2 patients had isolated PPVR. Echocardiograms in the supine position were performed within 24 hours preceding cardiac catheterization. The presence or absence of paradoxical septal motion was noted and right ventricular diameter index (RVDE : right ventricular diameter/body surface area) was calculated. Hemodynamic parameters studied included pulmonary to systemic flow ratio (Qp/Qs) determined by oxymetry, right ventricular pressure (RVP) and pulmonary resistance (PR). One patient with a Qp/Qs of 1.3 had normal septal motion. Type A paradoxical septal motion was noted in 22 cases, type B in 5 cases. For these 27 patients, the average RVDI was 2.42 (range 1.45 to 3.7), Qp/Qs ranged from 1.5 to 5 (mean : 2.45), RVP from 23 to 71 mmHg (mean : 39) and PR from 0.6 to 4 units (mean : 1.79). A very strons correlation between RVDI and Qp/Qs was observed from equation Qp/Qs : 1.19 RVDI-0.43 with a standard error of 0.4. This relationship was not altered by either RVP or PR values, which also had no apparent correlation with RVDI. This study indicates that echocardiographic measurement of RVDI is a reliable and non-invasive method of evaluating the size of left to right shunts at the atrial level.     

Two-dimensional echocardiography in the diagnosis of left atrial myxoma.

We performed M-mode echocardiograms on 11 patients who later had left atrial myxomas removed at operations. Seven of these 11 patients were also examined with two-dimensional echocardiography. M-mode echocardiography showed the characteristic pattern of a left atrial mass entering the mitral orifice during diastole in nine of the 11 patients. M-mode echocardiographic findings were equivocal in two patients because a short tumour stalk prevented significant motion of the tumour. Cross-sectional echocardiography clearly showed a left atrial mass attached by a stalk to the interatrial septum in all seven patients examined, including one patient in whom the tumour was immobile. Three-dimensional measurements of tumour size made from orthogonal cross-sectional echocardiographic planes were within 6 mm of similar measurements made on the excised tumours.     

Transesophageal echocardiographic demonstration of distinct mechanisms for right to left shunting across a patent foramen ovale in the absence of pulmonary hypertension

The optimal visualization of the atrial septum and fossa ovalis by transesophageal echocardiography was utilized to demonstrate saline contrast transit across the atrial septum and to relate it to the motion of the flap valve (septum primum) of the fossa ovalis. In three cases, three distinct mechanisms of right to left interatrial shunting in the absence of right ventricular systolic hypertension were identified: 1) transient spontaneous reversal of the left to right atrial pressure differential with each cardiac cycle; 2) sustained elevation of right atrial pressure above left atrial pressure induced by respiratory maneuvers; and 3) aberrant flow redirection across the foramen ovale due to a large right atrial mass. Any of these three mechanisms may be operative during paradoxic embolism in the absence of elevation of right ventricular pressures.