echo 3 exam 3

cardiac tumors classified as

primary or secondary

primary=tumors that originate in the heart, they can be benign or secondary

primary cardiac tumors benign

myxoma

lipomatous hypertrophy of the IAS

papilloma

fibroma

rhabdomymoma

mesothelioma of the AV node

angioma

teratoma (dermoid)

myxoma

most common primary benign tumor found in adults. over 90% are found in the atria, 75% found in left atrium, 18% found in the right atrium or biatrial. they are always intracardiac

myxomas most commonly found

in females most often between ages of 30-60

myxoma size

quite large, up to 8 cm in length, if they reach this size they can almost fill the atrium. they're soft, gelatinous in texture and can change shape during systole and diastole

atrial myxomas

usually attached to the interatrial septum in the area of fossa ovalis. they may be pedunculated (attached by a narrow stalk) or sessile (attached by a broad base)

myxoma in diastole

will typically partially obstruct blood flow across the mitral or tricuspid valve. the tumor narrows the effective valve orifice, will produce the same symptoms as stenosis of the valve. often associated with valvular regurgitation

right atrial myxomas

obstruct blood flow to right ventricle. will result in congestion of blood and cause dilated of the IVC and jugular veins

left atrial myxomas

partially obstruct flow across the mitral valve resulting in pulmonary venous congestion, pulmonary hypertension and possible right heart enlargement

myxomas are solid but friable meaning

small pieces can break off causing embolization

tumors in right heart will embolize to

the lungs as pulmonary emboli, possibly resulting in pulmonary infarction

tumors in the left heart will embolize to

the systemic circulation, possibly resulting in cerebrovascular accident (stroke)

other symptoms of myxoma

fever

cachexia (poor health)

malaise

rash

chest pain

syncope

congestive heart failure

myxoma treatment

surgical excision, removing part of the IAS .

myxoma 2D findings

hypoechoic mass most likely seen in LA

contain small calcifications

accurate size of the tumor may be made in three dimensions

myxoma characteristic

speckled, ovoid, well defined, possibily containign calcification

arises from IAS in the region of fossa ovalis

mobile, may be seen prolapsing through valve

thrombus

irregular, laminated (layer)

most commonly found in the left atrial appendage

associated with low flow states with possibility of spontaneous contrast

papilloma (papillary fibroelastoma PFE)

benign tumors that grow on the endocardial surface of the valves or less commonly on the endocardial surgaface of the ventricle.

papilloma (papillary fibroelastoma PFE) location

on the downstream side of the valve, (the ventricular side of the mitral valve and aortic side of the aortic valve).

papilloma (papillary fibroelastoma PFE) size

less than 1 cm, they are not surgically removed unless they significantly interfere with the valve function

lipomatous hypertrophy of the interatrial septum

benign fatty tumor, occurs when there is infiltration of the IAS by fetal fat cells, causing it to become thick and hypertrophied

dumbell shape mass, does not occur in the region of the fossa ovalis

lipomatous hypertrophy of the interatrial septum 2D findings

the lipomatous tissue will appear hyperechoic and may bulge into the right atrium

lipomatous hypertrophy of the interatrial septum 2D views

views that show the IAS (PSSA @AOV level and subcostal four chamber view) will best demonstrate this condition

fibroma

benign tumors that may be found within the myocardium, most commonly in the left ventricular anterior wall and the interventricular septum. composed of fibroblasts and fibrous tissues.

asymptomatic unless their location will obstruct blood flow

fibroma size

can be quite large, measure up to 7 cm in maximum dimension

fibroma on 2D

hyperechoic when compared to normal myocardium, doppler examination will demonstrate any velocity increase caused by obstruction

rhabdomyoma

benign tumors are the most common tumor found in children. they are often multiple and are found within the ventricular myocardium. strong association with a condition known as tuberous sclerosis.

rhabdomyoma size

range in size from 2-20cm, usually asymptomatic unless their location obstructs blood flow

tuberous sclerosis

a neuroectodermal disorder characterized as by the classic triad of mental retardation (71%) siezures (78%) adenoma sebaceum (27%)

primary cardiac tumors malignant

angiosarcoma

rhabdomyosarcoma

angiosarcoma

second most common primary cardiac tumor and the most common maligment tumor. occurs in right atrium. it grows rapidly. patient may experience right heart failure

secondary cardiac tumors

tumors found in the heart that metastasized (spread) from malignant primary tumors elsewhere in the body. they're about twenty times more common than primary tumors

secondary cardiac tumors metastic spread from

bronchogenic carcinoma

breast carcinoma

hodgkins disease

reticular cell sarcoma

carcinoid tumors of appendix

renal cell carcinoma

lung carcinoma

secondary cardiac tumors localized invasion from

melanoma

leukemia

lymphoma

the malignancy that is most likely to metastasize to the heart is

melanoma

secondary cardiac tumors echogenic appearance

they vary and tumors may be found anywhere in the myocardium, endocardium, or pericardium

structures that may be mistaken for cardiac tumors or masses

eustachian valves

chiari network

moderator band

pacemaker wire

swan ganz catheter

false tendon or cord

smoke or spontaneous contrast

mass

thrombus

vegetations

pulmonary emboli

ischemic heart disease

occurs when there is a decreased perfusion and oxygenation of the myocardium. most commonly caused from stenosis of the coronary arteries which supply the myocadrium. the myocardium which is inadequatly perfused will respond to the decrease in oxygen supply by a decrease in the strength of contraction, aka hypokinesis

Ischemic heart disease clinical suspicion

the patient experiences angina with exertion and the resting echo is normal, a stress echo may be ordered

treatment of cardiac ischemia

usually by coronary artery bypass or angioplasty. these techniques restore coronary artery flow allowing normal perfusion of the myocardium and restoring normal myocardial wall motion

infarction

occurs when the myocardium recieves no oxygen for a period of time and the myocardium is effectivly dead. restoring blood supply to the area will have no effect. infarcted myocardium will not contract and is seen on echo as akinetic.

normal wall motion for myocardium

contracting, systolic thickening, normal systolic thickening is greater than or equal to 40%.

hypokinesis wall motion for myocardium

decreased contraction is present, systolic thickening will be less than 30%. this may be seen with myocardial ischemia and dilated cardiomyopathy. ejection fraction will be decreased

akinesis wall motion for myocardium

myocardium is not contracting and there is no systolic thickening, less than 10%. the ventricle will move up and down as the ventricle fills and empties, however it is not contracting. this is known as tethering. is seen with myocardial infarction

Dyskinesis wall motion for myocardium

wall motion is paradoxical (in the opposite direction) than what is expected. may be seen in LV aneurysms where there is expansion of the aneurysmal segment during systole

hyperkinetic

contraction is increased and so is the ejection fraction. is seen in cases of ventricular volume overload such as is seen with aortic insufficiency. ventricular contraction is increased as the ventricle works to eject extra volume

clinical signs and symptoms of coronary artery disease (CAD)

chest pain syndrome, angina pectoris and prinzmetals angina

angina pectoris

characterized by chest pain as a result of decreased perfusion (oxygenation) of the myocardium with exertion. occurs in patients with CAD and may be described as stable or unstable

stable angina pectoris

patient is not in immediate danger and is given nitroglycerin

unstable angina pectoris

the patient is in danger and should be hospitalized

prinzmetal's angina

aka varient angina, coronary artery spasm that decreases flow to the myocardium. when the muscle spasm relaxes, flow returns to normal. patients often have CAD but it is the vasospasm that causes this type of angina, usually develops at rest

use of mmode in CAD

assesment of wall motion/thinning

-interventricular septum may be akinetic or hypokinetic in the presence of occlusion or stenosis of the left anterior descending coronary artery or main coronary artery

-left ventricular posterior wall may be akinetic or hypokinetic in the presence of occlusion or stenosis of the circumflex or right coronary artery

-mitral valve e point septal seperation may be increased although FS is normal

-LV aneurysm may be detected

findings associated with ischemic heart disease

thrombus formation, myocardial scarring, LV aneurysm, pseudoaneurysm, papillary muscle dysfunction, pericardial effusion, ventricular septal rupture, subacute cardiac rupture, cardiac rupture, congenital CAD

thrombus formation

mural thrombus is most commonly associated with anteroseptal infarcts involving the apex, although thrombus can be found in other locations. generally, it can be detected within the first 24-48 hours following infarct. they may vary in size and shape and may flatten to the contour of the wall over time

-it is important to describe location, size, shape and echogenicity of the thrombus

types of thrombus

potruding, mobile, non-protruding

myocardial scarring

-wall segment with decreased or absent motion post infarction

-usually thinner than adjacent wall

-increased echogenicity

-frequent association with thrombus

LV aneurysm

is the most serious complication of ischemic heart disease. it usually occurs 2-4 weeks after MI. 80% of LV aneurysms occur in the antero-apical region. the inferior and lateral walls are rarely affected

LV aneurysm echocardiographic features

systolic expansion of the effected LV wall is a characteristic finding (dyskinesis)

true aneurysms have a wide neck

pseudoaneurysm

most common site is inferior and lateral walls.

echocardiographic features

-a sharp discontinuity of the endocardium occurs

-may have a saccular or globular contour

-there is a narrow orifice neck

-there is occasional displacement of the other cardiac structures

papillary muscle dysfunction

-occurs later after MI

-the PML may be retracted with reduced motion

-a double diamond sign may be seen on the mmode tracing of MV

pericardial effusion

-hemorrhage from infarcted epicardium

-pericarditis is not unusual

-pericarditis and effusion following a myocardial infarction is known as dresslers syndrome

ventricular septal rupture

-occurs in less than 1% of patients

-there is a high prevalence with first infarcts

-usually occurs with anterior of inferior infarcts

-the rupture usualoly occurs at the center of a septal aneurysm

-clinically and hemodynamically similar to a VSD

-RV volume overload due to left to right shunt

subacute cardiac rupture

-slow leakage of blood into pericardium

-slow evolution of cardiac tamponade

-associated with regional wall motion abnormality

cardiac rupture

-tamponade

-acute, catastrophic situation

-demands immediate drainage and or surgery

congenital coronary artery disease

anomalous origin LCA from pulmonary artery

-dilated hypokinetic LV, dilated RCA, direct visualization of LCA from pulmonary artery

-mucocutaneous lymph node syndrome (Kawasaki's disease)

-coronary artery aneurysm, decreased LV function

fibrous pericardium

the outer sac

serous pericardium

a double layered inner sac, a closed sac within the fibrous pericardium

consists of two layers

-visceral

parietal

2 pericardial sinuses

transverse and oblique

transverse sinus

a tunnel-like structure located anterior to the SVC and posterior to the ascending aorta and pulmonary trunk above the left atrium

oblique sinus

is a "J" shape cul-de-sac located superior and posterior to the left atrium (where the SVC, IVC and pulmonary enter the heart)

function of the pericardium

-stabilizes the hearts position within the thoracic cavity

-protects the heart from infection

-acts as a lubricant to prevent friction

-facilittes the interaction and coupling of the ventricles

pericardial effusion types classified as

transudative effusion, exudative effusion, hemorrhagic effusion, malignant effusion

transudative effusion

results from an increase in capillary hydrostatic pressure or decrease in osmotic pressure

exudative effusion

occurs due to increased capillary permeability or decreased lymphatic resorption resulting in an oozing or extravascular fluid into the pericardial cavity

hemorrhagic effusion

occur when blood leaks into the pericardial cavity

malignant effusion

occur due to obstruction of the lymphatic drainage of the heart, a fluid secreting malignancy or fluid accumulation caused by metastic spread

pericardial effusion characteristics

-often related to inflammation of the pericardium due to disease or injury

-very small amount of fluid within the pericardium is normal

-heart failure or death can occur

Pericardial effusion etiology

infection

after myocardium infarction

after cardiac surgury

trauma

chemotherapy

metastatic cancer

Pericardial effusion symptoms

dyspnea

painful breathing

chest pain

cough

fainting or dizziness

fever

rapid heart rate

fatigue or weakness

Pericardial effusion pathophysiology

-rapid accumulation (80 ml) causes an increase in intrapericardial pressure

-slow accumulation (2 L) can be achieved without symptoms

pericardial effusion hemodynamics

-fluid accumulation leads to intrapericardial pressure increases

-changes in ventricular filling pattern develops

-reduction in filling volume results

-cardiac output drops

pericardial versus effusion

-potentially important diagnosis

-both are posterior to the left ventricle

-pericardial will terminate before the descending thoracic aorta

-pleural extends posterior to the descending aorta

pericardial effusion "tamponade"

emergency condition caused by an accumulation of pericardial fluid in the parietal space

significant elevation of intrapericardial pressure that exceeds intracavitary pressure

-results in low stroke volume

-end result is shock or death

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