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Chapter 15 | Cardiac Masses and Potential Cardiac Source of Embolus

THE ECHO EXAM

Echocardiographic Findings Associated With Systemic Embolism

Potential Embolic Clinical Setting Echocardiographic Caveats

Source Findings
PFO • Cryptogenic stroke • Saline contrast shows • PFO is present in 20%–30%
right-to-left shunt at the of people.
atrial level.
• Best visualized in TEE
LA thrombus • Atrial fibrillation—before • LA mass, most often • TEE required for diagnosis of
cardioversion, AF located in LA LA thrombus because of low
ablation, or mitral appendage, often sensitivity of TTE
commissurotomy mobile
Endocarditis • Bacteremia • Valve vegetations on • TEE often needed in addition
• Clinical criteria for downstream side of to TTE
endocarditis valve with valve
destruction
Prosthetic valve • Mechanical or • Mobile mass attached • A prosthetic valve is always a
thrombosis bioprosthetic valve to leaflets or sewing potential embolic source,
ring even when echo findings are
• Valve obstruction or absent.
regurgitation
LV thrombus • Apical akinesis after • Echodense mass in LV • Best seen on TTE apical
myocardial infarction apex views with high-frequency
• Global hypokinesis with transducer
dilated cardiomyopathy • TEE has low sensitivity.
Aortic atherosclerosis • Evaluation for stroke or • Typical atheroma • Aortic arch visualization
intraoperative evaluation suboptimal on TEE
of aorta for graft • Intraoperative direct
placement placement of a sterile probe
on the aorta is an option.
Nonbacterial • Systemic inflammatory • Valve masses with less • Blood cultures are needed to
thrombotic disease independent motion exclude infective endocarditis.
endocarditis than typical vegetations
Lipomatous • Benign incidental finding • Bright, smooth • Echo appearance is typical,
hypertrophy of the thickening of the but computed tomography
atrial septum interatrial septum with allows tissue characterization
sparing of the fossa if diagnosis is unclear.
ovalis
Papillary fibroelastoma • Cryptogenic stroke or • Highly mobile small • Blood cultures are needed to
incidental echo finding mass, usually attached exclude infective endocarditis.
to valve, often with a
stalk
Atrial myxoma • TIA or stroke • Well-circumscribed • Best seen on TEE, but initial
mass attached to atrial diagnosis often with TTE
septum, most often in imaging
LA
Secondary cardiac • Direct extension of lung • Pericardial effusion and • Further evaluation for a
tumors or breast cancer into tumor involvement are specific diagnosis is needed.
heart, or metastatic most common.
disease
Malignant primary • Rare in adults • Intracardiac mass with • Imaging with cardiac
cardiac tumors invasion of chamber magnetic resonance imaging
walls or computed tomography
provides better definition of
the site and extent of tumor
involvement.

AF, Atrial fibrillation; PFO, patent foramen ovale; TIA, transient ischemic attack.
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Cardiac Masses and Potential Cardiac Source of Embolus | Chapter 15

Distinguishing Characteristics of Intracardiac Masses

Characteristic Thrombus Tumor Vegetation

Location • LA (especially when
enlarged or associated
with MV disease)
• LV (in setting of
reduced systolic
function or segmental
wall abnormalities)
Appearance • Usually discrete and
somewhat spherical or
laminated against LV
apex or LA wall
Associated findings • Underlying cause
usually evident
• LV systolic dysfunction
or segmental wall
motion abnormalities
(exception: eosinophilic
heart disease)
• MV disease with LA
enlargement
• LA (myxoma) • Usually valvular
• Myocardium • Occasionally on
• Pericardium ventricular wall or Chiari
• Valves network
• Various: circumscribed • Irregular shape,
or irregular attached to the proximal
(upstream) side of the
valve with motion
independent from the
valve
• Intracardiac obstruction • Valvular regurgitation
depending on site of usually present
tumor
• Clinically: fevers,
systemic signs of
endocarditis, positive
blood culture results

MV, Mitral valve.

SUGGESTED READING
Cardiac Source of Embolus
1. Di Tullio M: Echocardiographic
evaluation of the patient with a
systemic embolic event. In Otto CM,
editor: The Practice of Clinical
Echocardiography, ed 5, Philadelphia,
2017, Elsevier, pp 802–821.
Review of the role of echocardiography in the
management of patients with systemic
embolic events. Topics include LA thrombus,
spontaneous echo contrast, atrial septal
aneurysm, patent foramen ovale, mitral valve
strands, Lambl excrescences, and aortic
atheroma. Includes systematic review of the
literature, examples of TTE and TEE
findings, and clinical implications.
2. Pepi M, Evangelista A,
Nihoyannopoulos P, et al: European
Association of Echocardiography:
recommendations for
echocardiography use in the diagnosis
and management of cardiac sources
of embolism, Eur J Echocardiogr
11(6):461–476, 2010.
Ischemic stroke is related to a cardiac
embolic source in 15% to 30% of cases.
This guideline document provides a concise
overview of potential cardiac sources of
embolism and provides recommendations for
the use of TTE and TEE in the evaluation
of patients with a stroke or transient
ischemic attack..
3. Saric M, Armour AC, Arnaout MS,
et al: Guidelines for the use of
echocardiography in the evaluation of
a cardiac source of embolism, Am Soc
Echocardiogr 29(1):1–42, 2016.
Comprehensive document details the
echocardiographic approach to evaluation of
cardiac source of embolus with
recommendations for clinical use of TTE
and TEE in specific clinical situations.
Includes 39 illustrations, 43 online videos,
and 229 references.
4. Leitman M, Tyomkin V, Peleg E,
et al: Clinical significance and
prevalence of valvular strands during
routine echo examinations, Eur Heart
J Cardiovasc Imaging 15(11):1226–1230,
2014.
Valvular strands were present on about 1%
of 21,000 echocardiographic studies and
were most often seen on the left ventricular
side of the aortic valve in men 61 to 70
years of age, often with associated leaflet
thickening or calcification.
Cardiac Masses and Tumors
5. Bruce CJ: Cardiac tumors. In Otto
CM, editor: The Practice of Clinical
Echocardiography, ed 5, Philadelphia,
2017, Elsevier, pp 837–860.
This comprehensive textbook chapter includes
sections on cardiac myxomas, papillary
fibroelastoma, other benign cardiac tumors,
malignant primary and secondary cardiac
tumors, and the differential diagnosis of a
cardiac mass. Clinical management also is
reviewed.
6. Auger D, Pressacco J, Marcotte F,
et al: Cardiac masses: an integrative
approach using echocardiography and
other imaging modalities, Heart
97:1101–1109, 2011.
This review presents six cases of cardiac
masses and demonstrates how multimodality
imaging, including echocardiography, is used
for diagnosis and clinical management. Key
questions imaging should address include
location, size, mobility, hemodynamic effects,
and extracardiac involvement. Compared with
echocardiography, CT and CMR provide
better assessment of extracardiac involvement
and tissue characterization.
7. Bruce CJ: Cardiac tumours: Diagnosis
and management, Heart 97:151–160,
2011.
Detailed review of the clinical presentation,
imaging features, and management of cardiac
tumors. Key points are: (1) most cardiac
masses are thrombi or vegetations (tumors
are rare), most cardiac tumors originate
outside the heart, and most primary cardiac
tumors are histologically benign; (2) the
diagnosis of a cardiac tumor depends on
clinical history, location, age, presentation,