1、DIFFERENTIAL DIAGNOSIS OF A CARDIAC MASS,Masses in or around the heart are most often incidental findings on echocardiography. Less frequently, a tumor involving the heart causes direct symptoms that lead the clinician to suspect a cardiac abnormality. True intracardiac or extracardiac masses need t
2、o be distinguished from the entities in the following section.,Eustachian valveChiari network Bulging of the interatrial septum Annular calcification Fat deposition Pectinate muscles False tendons Aberrant muscle bands Subaortic membranes Moderator band Epicardial fat Pericardial fat,1. Normal Struc
3、tures/Variants Simulating Tumors,2.Thrombus,4.Artifact,3.Vegetation,In the right atrium, the Eustachian valve (also known as the valve of the inferior vena cava IVC) is a ridge of tissue that extends from the entry of the IVC to the interatrial septum. In fetal life, this valve directs blood to the
4、fossa ovalis. It can remain prominent in adults, where it appears as a transverse linear echo running approximately parallel to the tricuspid annulus across the posterior right atrium in right ventricular inflow views, or in subcostal views.http:/ Subcostal images showing Eustachian valve (left, arr
5、ow) with directed flow on color Doppler examination (right).,Fig.2.When present, the Eustachian valve (arrow) can be well visualized in the right ventricular inflow view.This patients tricuspid valves were thickened and immobile owing to the carcinoid syndrome.,The Chiari network is similarly an emb
6、ryonic remnant of the sinus venosus, which extends from and is continuous with the Eustachian valve. It persists in 23% of normal adults (confirmed by autopsy), and appears on ultrasound as a lacy weblike or fenestrated membranous echogenic mass with a characteristic chaotic, undulating motion indep
7、endent from that of the tricuspid valve and right heart.,Fig.3.Chiaris network usually appears as a highly mobile undulating echogenic mass arising in the right atrioinferior vena caval junction.,On parasternal long- or short-axis views, bulging of the interatrial septum into the right atrium, owing
8、 to an interatrial septal aneurysm or left atrial volume overload, can be mistaken for a “tumor” when the scanning plane cuts tangentially across the septum. Careful inspection of both atria from all windows should clarify this misdiagnosis.,Annular calcification, particularly of the mitral apparatu
9、s, and fat deposition, often seen around the tricuspid annulus and interatrial septum ,can also simulate intracardiac masses. Calcific deposits tend to be very echobright and irregular, whereas fat usually appears as a less echodense, homogenous mass with smoother edges.,Fig.4.Lipomatous hypertrophy
10、 (arrow) of the interatrial septum.,Within the left ventricle, prominent left ventricle trabeculations, false tendons , aberrant muscle bands or bridges, and subaortic mbranes should be distinguished from tumors. Delineation of the origins and insertions of these structures, a cylindrical or linear
11、morphology, and the presence of thickening during systole can aid in the differential diagnosis.,Fig.5.A false tendon (straight arrow) appears as a mobile string (a few millimeters in width) that bowstrings the ventricular cavity. Note the attachments to the interventricular septum (ivs) and the bas
12、e of the papillary muscle (pm). Note the appearance of the true endonchorda tendinae (curved arrow),Thrombi can form in the left atrial body and appendage, particularly in patients with atrial fibrillation, mitral stenosis, or hypercoagulable states. The thrombi vary tremendously in size, shape, and
13、 appearance. The differentiation of a thrombus from a tumor may be difficult if predisposing factors for thrombus are not present .,Fig.6.These images are from a 63-yr-old man with coronary artery disease and lung cancer. Multiple echodensities (intracardiac thrombi) were observed in right and left
14、heart chambers. Smaller thrombi had embolized to his coronary arteries resulting in multiple infarcts.,Discrete mobile masses that are attached to valves are more likely to be vegetations, especially if clinical and laboratory signs of endocarditis are present, and symptoms of valvular regurgitation
15、 are of recent onset. Myxomatous mitral valves should also be distinguished from vegetation and tumors.,Artifacts resembling an echogenic mass can be caused by reflections from the pericardium, valves, and foreign objects (e.g., catheters, pacemaker wires). A useful way to distinguish an artifact is
16、 to examine the blood flow around the putative mass with color Doppler, which should respect the borders of a true mass but will appear to pass through an artifact.,Fig7.Color Doppler interrogation of the right atrial mass (arrow, A,B) in confirmed its intracardiac location. Compare this to color Doppler interrogation of the left atrium that shows extracardiac compression by the descending thoracic aorta (DTA; C,D).,THANK YOU!,
