Ivan A. D'cruz

Echocardiographic manifestations of mediastinal masses compressing or encroaching on the heart.

Because of its central position within the thorax, the heart can be encroached upon by masses originating in either anterior, posterior, or superior mediastinum. A distinction may be made between (A) Encroachment: distortion or partial displacement of one or more cardiac chambers by a contiguous mediastinal mass, without adverse hemodynamic effects, and (B) Compression: resulting in clinical manifestations similar to tamponade. Transthoracic and, recently, transesophageal echocardiography have been found useful in detecting mediastinal masses, the information obtained being complementary or preliminary to more complete imaging by CT or MRI. Anterior masses tend to compress the right heart chambers; posterior masses impinge on or compress the left atrium or ventricle, particularly the former. The wide variety of echographic appearances are briefly reviewed. Recently TEE has made it possible to diagnose masses obstructing the superior vena cava or pulmonary veins. A common, though little known, type of posterior mediastinal encroachment that echocardiographers need to be aware of is that of abnormal esophageal Igastric masses including hiatus hernia and esophageal carcinoma, which have typical two‐dimensional echo features and may sometimes simulate left atrial masses.

Echocardiographic characteristics of diaphragmatic hiatus hernia

lschemm of uncertain eaology J Am Coll Cardtol 1991,17 66-72 5. Schneider B, Hanrath P, Vogel P, Memertz T Improved rnorphologlc charactunzataon of atrial septal aneurysm by transesophageal echocardlography rclaaon to cerebrovascular events J Am Coil Cardtol 1990,16 1000-1009 6. Gallet B, Malergue MC, Adams C, Sandemont JP, Collot AM, Druon MC, Hdtgen M Atrial septal aneurysm--a potentaal cause of systemic embohsm Br Heart J 1985,53 292-297 7. Belkm RN, Hurwltz B J, Klsslo J Atrial septal aneurysm assocmtlon with cerebrovascular and peripheral embohc events Stroke 1987,18 856-862 8. Shenoy MM, VIjaykumar PP, Friedman SA, Grief E Atrial septal aneurysm assocmted with systenuc embohsm and mteratnal right-to-left shunt Arch Intern Med 1987,147 605-606 9. Pearson AC, Nagelhout D, Castello R, Gomez CR Atrial septal aneurysm and stroke a transesophageal echocarthographlc study J Am Coil Cardzol 1991,18 1223--1229 10 Hanley PC, Tajhk AJ, Hynes JK, Edward WD, Reeder GS, Hagler DJ, Seward JB Dmgnosls and classification of areal septal aneurysm by two-thmenslonal echocardiography report of 80 conseculave cases J Am Coil Car&ol 1985,6 1370-1382 11 Barbosa MM, Pena JL, Motta M, Fortes PR Aneurysms of the atrial septum diagnosed by echocarthography and their assocmted cardmc abnonnalmes lnt J Cardtol 1990,29 71-78 12. Grosgogeat Y, Lhermltte F, CarpenUer A, Facquet J, Alhomme P, Tran TX An6vrysme de la clolson mterauncularre r~v616 par une embohe c6r6brale Arch Mal Coeur 1973,66 169-177 13. Wdson JH Lever HM, Moothe DS Aneurysm of the lnteratnal septum Cleve Chn Q 1986,53 105-108 14. Wysham DG, McPherson DD, Kerber RE Asymptomatlc aneurysm of the rateratrial septum JAm Coil Cardzol 1984,4 1311-1314 15 Onegha C, Fagglano P, Sabatml T, Ghlzzom G, Ruscont C Atrial septal aneurysm and assoctated anomahes Personal expenence with 38 cases Minerva Car&ol 1993,41 95-100 •

Pericardial Complications of Cardiac Surgery: Emphasis on the Diagnostic Role of Echocardiography

Pericardial effusions are common following cardiac surgery; uncommonly they are large in size and may cause tamponade, either in the early or late postoperative period. Such effusions causing tamponade may be circumcardiac, but are frequently loculated, in which case one or more cardiac chambers is selectively compressed. Fortunately, echocardiography is capable of imaging not only the presence, location, and size of the pericardial effusion, but also indicating the presence of tamponade. Constrictive pericarditis resulting from cardiac surgery is being recognized with increasing frequency and has been associated with various echocar‐diographic abnormalities. This review also discusses certain other pericardial complications of cardiac surgery including supraventricular arrhythmias, chylopericardium, and posttransplant problems.

Echocardiography of Posterior Mediastinal Masses Encroaching on the Left Atrium

A huge volume of echocardiographic literature has accumulated on intra-atrial masses, of which left atrial myxomas are the best known, with thrombi and malignant neoplasms accounting for smaller numbers. In comparison, much less has been published on extrinsic mediastinal masses compressing the left atrium. We feel that it is worth reviewing such reports and calling attention to the echocardiographic appearances described, because: (A) Extrinsic atrial masses may be mistaken for intracavitary left atrial masses, an error that would be unfortunate since the management is quite different in the two situations; (B) Many echocardiographers are not fully aware of the diagnostic potential of echocardiography with regard to mediastinal or pleural pathology involving the heart; and (C) We believe that extrinsic left atrial masses are not excessively rare; the two representative instances we describe in this paper were encountered within the space of 4 months.

Case Report: Pericardial Metastasis from Testicular Seminoma: Appearance and Disappearance by Echocardiography

At the time of initial diagnosis, testicular malignancy is usually limited to the testicle and infradiaphragmatic lymph nodes. Metastases initially follow the retroperitoneal lymph channels and subsequently extend to the supradiphragmatic lymph nodes in the mediastinum and supraclavicular fossa. Testicular metastases to the pericardium are rare and usually asymptomatic. These lesions are most commonly identified at autopsy; therefore, the actual incidence is unknown. The authors report a 32-year-old man with testicular carcinoma, who developed asymptomatic pericardial metastases without concomitant supradiaphragmatic nodal or pulmonary metastases. They review the efficacy of echocardiography in diagnosis and follow up or pericardial metastasis.

Left Ventricular Shape and Size in Dilated Cardiomyopathy: Quantitative Echocardiography Assessment

Left ventricular shape is an aspect of the left ventricular image (on the two‐dimensional echocardiogram) that has hitherto received little attention. Although it has long been known to cardiologists that patients with dilated cardiomyopathy tend to have more spherical hearts than normal individuals, this remained a qualitative “impression,” and a quantitative approach to left ventricular shape is not part of routine clinical echocardiography. The few published studies that did address overall left ventricular shape used a simple length/width ratio as the index of shape. Using left ventricular shape descriptors, which are ratios of various left ventricular dimensions (and area) to each other, we characterized left ventricular shape in normals and in patients with dilated cardiomyopathy in a quantitative manner, independent of left ventricular size. We confirmed the previous “impression” that left ventricular chamber shape is abnormal (more spherical) in patients with dilated cardiomyopathy. We showed that dilated but normally contracting, volume overloaded left ventricles do not show such spherical shape alteration. We have recently found that abnormal spherical shape change of a similar degree to that observed in classical dilated cardiomyopathy is also seen in patients with diffuse hypokinetic cardiomyopathy whose left ventricular chambers are not dilated, or only marginally dilated, beyond the normal range. It may be worthwhile, therefore, to perform the simple measurements and calculations necessary to obtain left ventricular shape descriptors in patients with suspected myocardial disease. (ECHOCARDIOGRAPHY, Volume 8, March 1991)

A Reappraisal of the Mitral B‐Bump (B‐Inflection): Its Relationship to Left Ventricular Dysfunction

A prolonged AC interval, decreased PR ‐ AC interval, and a B‐inflection (“bump” or “notch”) on the mitral AC slope, have been widely regarded as evidence of abnormally high LVEDP for the last 16 years. However, several groups have questioned the reliability of these signs as predictors of high LVEDP. In 50 patients subjected to LV catheterization, we found no correlation between LVEDP and the AC interval or PR ‐ AC interval. A better correlation was obtained between the presence of a B‐inflection and diminished LV ejection fraction on angiocardiography. In our series, the B‐inflection was noted in 1/19 patients with LVEDP < 15 mmHg as well as LV ejection fraction > 55%, but it was present in 7/10 patients with LVEDP over 15 mmHg, as well as LV ejection fraction < 55%. When properly recorded, the presence of a B‐inflection is a useful sign of significant LV dysfunction.

Mitral Valve Prolapse and Stroke: Echocardiographic Evidence for a Missing Causative Link

There is general acceptance of a causal connection between mitral valve prolapse and systemic embolic events. The precise mechanism, however, remains controversial, with current hypotheses favoring the embolization of thrombotic deposits from the abnormal mitral valve. It might be surmised that echocardiography could easily document the presence of such thrombi, but actually, this has never been reported previously. Described herein is a patient with a severe cerebrovascular accident in whom echocardiography clearly demonstrated a mass of high embolic potential attached directly to the prolapsing mitral valve leaflet.

Echocardiographic Features of Large Posterobasal Left Ventricular Aneurysms

We describe the echocardiographic characteristics of 12 patients with left ventricular aneurysms involving posterobasal segments of the ventricular septum and of the adjacent ventricular wall. In 5, the septal as well as ventricular wall components of the aneurysm were both conspicuous; in 3 the septal but not ventricular wall component was large; and in 4 the ventricular wall part of the aneurysm was predominant. In all, the mouth (rim) of the aneurysm was wider than its fundus, thus distinguishing the posterobasal ventricular aneurysm from a pseudoaneurysm. The echographic features are striking, but are easily overlooked in standard echo planes. Aneurysmal complications (acquired ventricular septal defect, mural thrombus) can also be detected. Together with echo appearances, other consistent findings of this entity include deep, wide inferior Q waves, posteromedial papillary muscle calcification, and total or subtotal occlusion of right coronary or circumflex coronary artery.

Pulsus Alternans With Alternation of Mitral Flow and Motion Patterns

A 41-year-old man with dilated cardiomyopathy had persistent pulsus alternans on physical examination and on cardiac catheterization. On M-mode echocardiography patterns of mitral valve diastolic motion showed alternation such that the E phase was longer and the A phase shorter after stronger ventricular contractions. At faster rates the A peak was apparently absent in alternate diastoles. Doppler recordings of mitral flow exhibited alternation such that the peak velocity and duration of early diastolic flow were larger after stronger ventricular contractions; diastolic mitral regurgitation was noted only in such (alternate) diastoles.