Atlas of Transesophageal Echocardiography, 2nd Edition (2007)

Chapter 10. Miscellaneous Lesions

Pericardial Disease

A small amount of pericardial fluid is normally present between the visceral and parietal pericardium (approximately 20 to 30 mL). Larger collections present as an echo-free space. While three-dimensional echocardiography, or computerized tomography (CT) or magnetic resonance imaging (MRI) permit precise quantification of the amount of pericardial fluid, such numbers are seldom, if ever, used. Hence, a semiquantitative approach is used. A pericardial effusion is regarded as small when the maximum width is <10 mm, moderate when the maximum width is between 10 mm and 15 or 20 mm and large beyond that. In addition to the size, the rate at which the effusion accumulates determines its physiologic significance. Slower accumulation allows a gradual increase in the compliance of the pericardium, sometimes allowing massive effusions to form without tamponade. Diastolic collapse of the right atrium and/or right ventricle suggests cardiac tamponade; the latter is more specific than the former.

When both a pleural and a pericardial effusion are present, the width of the pericardium can often be measured, a point in the differential diagnosis of constrictive pericarditis (constrictive pericarditis generally causes thickening of the pericardium to >5 mm).

Most often, pericardial effusions can be adequately worked up with transthoracic echocardiography but the same information is available through transesophageal echocardiography.

Pericardial cysts are benign collections of fluid that abut and distort the border of the heart. Color flow Doppler can be used to rule out fluid flow within the structure. MRI and CT can confirm the diagnosis and provide an insight regarding the anatomic topography of the cyst.

Other Miscellaneous Lesions

Examples of a variety of other lesions including pleural effusion, right heart catheters with associated thrombus, pacemaker wires, pacemaker vegetations, artifacts, contrast effects during cardiac surgery, left ventricular assist devices, and intraaortic balloon pumps are shown in this chapter.

FIGURE 10.1. Pericardial effusion. A–C. Transgastric views demonstrate pericardial effusion (PE) behind the right ventricle (RV). The pericardium (P) is mildly thickened. AL, anterior papillary muscle; PM, posterior papillary muscle. D. PE around the left atrial appendage (LAA). AV, aortic valve; LA, left atrium; LV, left ventricle; RVO, right ventricular outflow tract.

FIGURE 10.2. Pericardial cyst. A–C. A large pericardial cyst (PC) located anteriorly with compression of the right ventricle (RV) (C). D. Intraoperative examination in another patient shows a large pericardial cyst (C) located lateral to the left atrium (LA) and right atrium (RA). This frame was taken after cardioplegic arrest of the heart, when the cardiac chambers were empty and collapsed. E–I. An 18-year-old man had a pericardial hydatid cyst (C) compressing the left ventricle (LV) lateral wall (arrowheads in G). The linear echoes in the cyst represent the laminated hydatid membrane. Prominent intramyocardial coronary arteries (arrowheads in H) with high velocity flow were imaged within the compressed LV lateral wall, consistent with coronary flow obstruction. This was confirmed by coronary angiogram, which showed systolic emptying of the first marginal branch of the circumflex coronary artery. The cyst was surgically resected. I. Microscopic examination of the hydatid cyst fluid shows typical scolices, one of which contains hooklets. AO, aorta; MV, mitral valve; PA, pulmonary artery; RVO, right ventricular outflow tract.

FIGURE 10.3. Pleural effusion. A. A large left pleural effusion (PLE) with a villus (VI) is present behind the descending thoracic aorta (DA). B,C. Large left pleural effusions (PLE) in two other patients are imaged behind the aorta (AO) in the short-axis (B) and long-axis (C) views. D. A right pleural effusion (RPE) in another patient.

FIGURE 10.4. Right heart catheter. C in A and arrowheads in B and C indicate a long segment of a Swan-Ganz catheter in the right heart. AO, aorta; LA, left atrium; LVO, left ventricular outflow tract; MPA, main pulmonary artery; PA, pulmonary artery; RA, right atrium; RAA, right atrial appendage; RPA, right pulmonary artery; RV, right ventricle;RVO, right ventricular outflow tract; SVC, superior vena cava.

FIGURE 10.5. Right heart catheter thrombus. A–C. A large mass (M) is noted in the right atrium (RA). D. Further examination demonstrated a catheter (arrow) embedded in the mass, leading to the diagnosis of catheter-induced thrombus. AO, aorta; LA, left atrium; RV, right ventricle; SVC, superior vena cava; TV, tricuspid valve.

FIGURE 10.6. Denver peritoneovenous shunt thrombus. A 41-year-old man with Laennec cirrhosis and a Denver peritoneovenous shunt presented with recurrent episodes of syncope whenever he sat up or stood. The Denver shunt and the massive thrombus were successfully removed surgically. A. Longitudinal plane examination demonstrates a large right atrial mass (maximum size, 5.5 × 4.5 cm) attached to the anterior wall of the superior vena cava (SVC) near its entrance into the right atrium (RA). The arrow points to a portion of the Denver shunt that is seen embedded in the mass. The inferior vena cava was not involved. B. Transverse plane examination also visualized the mass well and demonstrated a portion of it protruding into the right ventricle (RV) through the tricuspid orifice. The relationship of the mass to the superior vena cava could not be visualized in this plane, however. There were prominent echo-free spaces in the tumor mass. LA, left atrium; LV, left ventricle. (Reproduced with permission from 

Holman WL, Coghlan CH, Dodson MR, et al. Removal of massive right atrial thrombus guided by transesophageal echocardiography. Ann Thorac Surg 1991;52:313–315.

)

FIGURE 10.7. Right heart catheter thrombus. The bright echoes in the right atrium (RA) in A and B are caused by the infusion catheter (C). This is the typical appearance of a catheter, which appears thicker in A than its real size because of the presence of reverberations. Catheter-induced thrombus in the RA is well seen (M in A–C and arrow in D). The arrowhead in C shows an attachment of the thrombus to the RA wall near the eustachian valve (EV). E. Gross specimen shows a catheter-induced thrombus in the RA. IVC, inferior vena cava; LA, left atrium; RAA, right atrial appendage; SVC, superior vena cava.

FIGURE 10.8. Pacer lead in the right ventricle. The pacer lead (P) is seen in the right atrium (RA) and right ventricle (RV) in the four-chamber view (A,B), but the location of its tip in the RV apex (arrowhead in D) is identified only using the transgastric approach (D,E). The metal in the electrode tip produces prominent reverberations (black arrowheads in E) that assist in locating it. Other portions of the pacer may also produce reverberations (white arrowheads in C). L, liver; LA, left atrium; LV, left ventricle.

FIGURE 10.9. Right heart pacer: endocarditis. A. A large, mobile vegetation (arrow) on the right atrial portion of the pacing wire (C). B. Another patient with a vegetation (VEG) attached to a pacing wire in the right atrium (RA). AO, aorta; LA, left atrium; LV, left ventricle; RV, right ventricle. (A reproduced with permission from 

Nanda NC, Pinheiro L, Sanyal RS, et al. Transesophageal biplane echocardiographic imaging: technique, planes, and clinical usefulness. Echocardiography 1990;7:771–783.

)

FIGURE 10.10. Artifacts. A. A large artifact (arrowheads) partially obscuring the left ventricle (LV). B,C. Multiple curved artifacts produced by electrocautery. RV, right ventricle.

FIGURE 10.11. A–E. Mirror image from a left atrial line mimicking a catheter in the left ventricle. 1, true image of the left atrial line recorded in the left atrium (LA). The arrowhead points to a reverberatory tail. 2, artifactual image of the left atrial line visualized (B,C) in the left ventricle (LV). The arrowhead (C) points to a reverberatory tail. Note that this image is not recorded on the scan lines that include the true atrial line, but is placed more medially (B–D), making it difficult to recognize it as an artifact. 3, a second artifactual image of the left atrial line recorded in the aorta (AO). (E). Unlike image 2, this image is recorded on the scan lines that include the true atrial line and therefore is easily recognized as a mirror-image artifact. RVOT, right ventricular outflow tract. (Reproduced with permission from 

Pothula AR, Nanda NC, Agarwal G, et al. Mirror image from a left atrial line mimicking a catheter in the left ventricle during transesophageal echocardiography. Echocardiography 1997;14:165–167.

)

FIGURE 10.12. Cardioplegia solution. A. Contrast echoes are caused by the cardioplegia solution introduced during heart surgery. B. The cardioplegia solution (arrowheads) is seen crossing the aortic valve into the left ventricular outflow tract (LVOT) because of valve incompetence produced by cardiac standstill. C. The cardioplegia needle/catheter (arrowheads) imaged in the ascending aorta (A) in another patient. AO, aorta; LA, left atrium; LV, left ventricle; MV, mitral valve; RA, right atrium; RPA, right pulmonary artery; RVO, right ventricular outflow tract.

FIGURE 10.13. A. Spontaneous contrast echoes in the left atrium. Stasis of blood in the left atrium (LA) post-bypass causes spontaneous contrast echoes (SC). B. Left ventricle venting. Balloon-tipped catheter (arrowheads) in the left ventricle (LV) used for de-airing in the immediate post-bypass period. This patient underwent prosthetic replacement (P) of a degenerated heterograft. MV, mitral valve; RA, right atrium; RV, right ventricle.

FIGURE 10.14. A,B. Left heart air bubbles. A. Contrast echoes (arrowheads) fill the left heart as a result of the presence of air, which enters when the left ventricle (LV) is opened during surgery. Intraoperative study is useful in helping the surgeon de-air the left heart to prevent air embolization. B. Another patient with air in the left heart imaged as the patient was coming off bypass following prosthetic (MP) replacement of the mitral valve. C. De-airing of the left ventricle. F is an image of the finger of a surgeon who is holding and “shaking” the heart to de-air it. LA, left atrium; RA, right atrium; RV, right ventricle.

FIGURE 10.15. Intra-aortic balloon pump. An intra-aortic balloon pump (arrows) in the descending aorta imaged in the short-axis (top) and long-axis (bottom) views.

FIGURE 10.16. Transesophageal echocardiographic diagnosis of valve leakage of the left ventricular assist device. A. The arrow points to the left ventricular assist device (LVAD) positioned in the left ventricular (LV) apex. It is viewed in short axis. B. Normal inflow (I) signals into the LVAD (arrow). C. Extensive flow signals entering the LV from the LVAD (arrow) and filling most of the chamber, consistent with severe regurgitation (R). D. Pulse Doppler examination showing the regurgitation (R, arrowheads) from LVAD (arrow) into the LV. E. Pulse Doppler examination demonstrating only mild regurgitation (Doppler signals below the baseline) at the aortic end of the conduit (filled arrowhead). Doppler signals above the baseline represent flow into the aorta (AO) from the LVAD. F. Diagrammatic representation (not to scale) of the HeartMate LVAD. RV, right ventricle. (Reproduced with permission from 

Moursi M, Nanda NC, Holman W, et al. Usefulness of transesophageal echocardiography in diagnosing valve leakage of left ventricular assist device. Echocardiography 1998;15:703–707.

)

 

Suggested Readings

Agmon Y, Khandheria BK, Gentile F, et al. Echocardiographic assessment of the left atrial appendage. J Am Coll Cardiol 1999;34:1867–1877.

Asher CR, Klein AL. Transesophageal echocardiography in patients with atrial fibrillation. Pacing Clin Electrophysiol 2003;26:1597–1603.

Asinger RW, Herzog CA, Dick CD, et al. Echocardiography in the evaluation of cardiac sources of emboli: the role of transthoracic echocardiography. Echocardiography 1993;10:373–396.

Cohen GI, Klein AL, Chan KL, et al. Transesophageal echocardiographic diagnosis of right-sided cardiac masses in patients with central lines. Am J Cardiol 1992;70:925–929.

Dellsperger KC. Transthoracic echocardiography for evaluation of hypertensive heart disease. Echocardiography 1993;10:295–302.

Ducart A, Broka S, Collard E, et al. Regional increment in myocardial reflectivity after aortic valve replacement—early detection of air and assessment of treatment by transesophageal echocardiography. J Cardiothorac Vasc Anesth 1996;10:926–927.

Falcone RA, Morady F, Armstrong WF. Transesophageal echocardiographic evaluation of left atrial appendage function and spontaneous contrast formation after chemical and electrical cardioversion of atrial fibrillation. Am J Cardiol 1996;78:435–439.

Feinberg MS, Davila-Roman VG, Hopkins WE, et al. Successful withdrawal of biventricular assist devices after assessment of left ventricular function by transesophageal echocardiography and automatic border detection. Echocardiography 1994;11:575–578.

Fishel RS, Merlino JD, Felner JM. Diagnosis of main-stem pulmonary thromboemboli by transesophageal echocardiography. Echocardiography 1994;11:189–195.

Gomez CR, Tulyapronchote R. Neurologists perspective in the evaluation of ischemic stroke. Echocardiography 1994;10:367–372.

Gutterman DD, Ayres RW. Use of echocardiography in detecting cardiac sources of embolus. Echocardiography 1993;10:311–320.

Holman WL, Bourge RC, Fan P. Influence of left ventricular assist on valvular regurgitation. Circulation 1993;88:309–318.

Holman WL, Coghlan CH, Dodson MR, et al. Removal of massive right atrial thrombus guided by transesophageal echocardiography. Ann Thorac Surg 1991;52:313–315.

Hutchison SJ, Smalling RG, Albornoz M, et al. Comparison of transthoracic and transesophageal echocardiography in clinically overt or suspected pericardial heart disease. Am J Cardiol 1994;74:962–965.

Kamp O, De Cock C, Visser CA. High quality stress echocardiography using simultaneous transesophageal echocardiographic imaging and atrial pacing. Echocardiography 1995;12:43–48.

Karia DH, Xing YQ, Kuvin JT, et al. Recent role of imaging in the diagnosis of pericardial disease. Curr Cardiol Rep 2002;4:33–40.

Katz WE, Jafar MZ, Mankad S, et al. Transesophageal echocardiographic identification of a malpositioned extracorporeal membrane oxygenation cannula. J Heart Lung Transplant 1995;14:790–792.

Kay GN, Holman WL, Nanda NC. Combined use of TEE and endocardial mapping to localize the site of origin of ectopic atrial tachycardia. Am J Cardiol 1990;65:1284–1286.

Klein AL, Cohen GI, Pietrolungo JF, et al. Differentiation of constrictive pericarditis from restrictive cardiomyopathy by Doppler transesophageal echocardiographic measurements of respiratory variations in pulmonary venous flow. J Am Coll Cardiol 1993;22:1935–1943.

Klein AL, Stewart WC, Cosgrove DM III, et al. Visualization of acute pulmonary emboli by transesophageal echocardiography. J Am Soc Echocardiogr 1990;3:412–415.

Kochar GS, Jacobs LE, Kotler MN. Right atrial compression in postoperative cardiac patients: detection by transesophageal echocardiography. J Am Coll Cardiol 1990;16:511–516.

Kronzon I, Tunick PA, Freedberg RS, et al. Transesophageal echocardiography in pericardial disease and tamponade. Echocardiography 1994;11:493–505.

Labovitz AJ. The increasing role of transesophageal echocardiography in unexplained cerebral ischemia. Echocardiography 1993;10:363–365.

Maxted W, Finch A, Nanda NC, et al. Multiplane transesophageal echocardiographic detection of sinus venosus atrial septal defect. Echocardiography 1995;12:139–143.

Moursi M, Nanda NC, Holman W, et al. Usefulness of transesophageal echocardiography in diagnosing valve leakage of left ventricular assist device. Echocardiography 1998;15:703–707.

Nanda NC, Pinheiro L, Sanyal RS, et al. Transesophageal biplane echocardiographic imaging: technique, planes, and clinical usefulness. Echocardiography 1990;7:771–783.

Nellessen U, Daniel WG, Matheis G, et al. Impending paradoxical embolism from atrial thrombus: correct diagnosis by transesophageal echocardiography and prevention by surgery. J Am Coll Cardiol 1985;5:1002–1004.

Neskovic AN, Popovic AD, Babic R, et al. Color Doppler transesophageal echocardiography in detection of massive pulmonary embolism. Echocardiography 1996;13:631–633.

Nixdorff U, Erbel R, Drexler M, et al. Detection of thromboembolus of the right pulmonary artery by transesophageal two-dimensional echocardiography. Am J Cardiol 1988;61:488–489.

Oh JK, Seward WC, Khandheria BK, et al. Transesophageal echocardiography in critically ill patients. Am J Cardiol 1990;66:1492–1495.

Oka Y, Inoue T, Hong Y, et al. Retained intracardiac air: transesophageal echocardiography for definition of incidence and monitoring removal by improved techniques. J Thorac Cardiovasc Surg 1986;91:329–337.

Omoto R, Kyo S, Matsumura M, et al. Variomatrix—a newly developed transesophageal echocardiography probe with a rotating matrix biplane transducer. Echocardiography 1993;10:79–84.

Pearson AC, Labovitz AJ, Tatineni S, et al. Superiority of transesophageal echocardiography in detecting cardiac source of embolism in patients with cerebral ischemia of uncertain etiology. J Am Coll Cardiol 1991;17:66–72.

Pop G, Sutherland GR, Koudstaal PJ, et al. Transesophageal echocardiography in the detection of intracardiac embolic sources in patients with transient ischemic attacks. Stroke 1990;21:560–565.

Pothula AR, Nanda NC, Agarwal G, et al. Mirror image from a left atrial line mimicking a catheter in the left ventricle during transesophageal echocardiography. Echocardiography 1997;14:165–167.

Pretre R, Faidutti B. Surgical management of aortic valve injury after nonpenetrating trauma. Ann Thorac Surg 1993;56:1426–1431.

Rosenzweig BP, Glassman L, Kronzon I. Images in cardiovascular medicine. Impending paradoxical embolus. Circulation 1996;93:387.

Rosenzweig BP, Guarneri E. Transesophageal echocardiography in the evaluation of aortic trauma. Echocardiography 1996;13:247–257.

Roudaut R, Durandet P, Leherissier A, et al. Spontaneous echo contrast in patients with sinus rhythm but poor atrial contraction. Echocardiography 1993;10:5–10.

Roudaut R, Lartigue MC, Dartigues JF, et al. Meta-analysis of positive blood cultures during transesophageal echocardiography. Echocardiography 1993;10:289–292.

Samuels LE, Kaufman MS, Rodriguez-Vega J, et al. Diagnosis and management of traumatic aorto-right ventricular fistulas. Ann Thorac Surg 1998;65:288–292.

Sarnoski J, Bajwa T, Deshpande S, et al. Transesophageal echocardiography during radio frequency ablation of left-sided free wall atrioventricular accessory pathways in Wolff-Parkinson-White Syndrome. Echocardiography 1994;11:461–467.

Simon P, Owen AN, Moritz A, et al. Transesophageal echocardiographic evaluation in mechanically assisted circulation. Eur J Cardiothorac Surg 1991;5:492–497.

Snoddy BD, Nanda NC, Holman WL, et al. Usefulness of transesophageal echocardiography in diagnosed and guiding correct placement of a right ventricular assist device malpositioned in the left atrium. Echocardiography 1996;13:159–163.

Tighe DA, Tejada LA, Kirchhoffer JB, et al. Pacemaker lead infection: detection by multiplane transesophageal echocardiography. Am Heart J 1996;131:616–618.

Topol EJ, Humphrey LS, Borkon AM, et al. Value of intraoperative left ventricular microbubbles detected by transesophageal two-dimensional echocardiography in predicting neurologic outcome after cardiac operations. Am J Cardiol 1985;56:773–775.

Vilacosta I, Sarria C, San Ramon JA, et al. Usefulness of transesophageal echocardiography for diagnosis of infected transvenous permanent pacemakers. Circulation 1994;89:2684–2687.

Voller H, Schroder K, Spielberg C, et al. Does cardiac function modify left heart opacification with transpulmonary echo contrast agents? Echocardiography 1993;10:41–47.

Wellford AL, Lawrie G, Zoghbi W. Transesophageal echocardiographic features and management of retained intracardiac air in two patients after surgery. J Am Soc Echocardiogr 1996;9:182–186.

Yao FS, Barbut D, Hager DN, et al. Detection of aortic emboli by transesophageal echocardiography during coronary artery bypass surgery. Cardiothorac Vasc Anesth 1996;10:314–317.