1. Lecture 18 Foreign bodies, Masses, Etc.
Holdorf

2. Foreign Bodies Etiology Pathophysiology Foreign bodies (missiles)
Iatrogenic (healthcare provider induced
Bullets
Knives
Nails
Ice picks, etc.
Pathophysiology
Penetrating missiles may cause:
Myocardial rupture
ASD and or VSD
Valvular disruption
Pericardial effusion (25-50% will not have a effusion
Coronary artery trauma

3. Physical signs ECHO Bleeding (entrance and possible exit wound)
Murmur possible
Tamponade physiology
ECHO
Missiles may occur anywhere in the heart – look for echogenic structures with strong reverberations
Pericardial effusion not always present
Disrupted valve leaflets/support apparatus
ASD/VSDs may be visualized if large enough
Look for wall motion abnormalities
Always perform a micro-cavitation study to rule out an atrial level shunt
NOTE:
Use x-rays for reference. Use off-axis views

4. DOPPLER
Intracardiac shunt may be present in the case of missile penetration.
Valvular regurgitation may be present
ASD/VSDs may demonstrate abnormal or turbulent flow
Trans-valvular respiratory flow variations when tamponade physiology is present
NOTE: What part of the heart is most likely to be affected by cardiac contusion?
Right ventricle

5. Bullet in the heart via CT scan

6. Bullet in the region of the tricuspid valve

7. MASSES Etiology Thrombus formation
Benign tumors (most common are myxomas)
Malignant tumors
Primary < 20%
Metastatic (more common)
What might be the 1st indication of metastatic cardiac disease?
Pericardial effusion
Which cardiac chamber is most likely involved with metastatic tumors?
Right atrium
The most common benign tumor on the aortic valve is
papillary fibroelastoma

8. Myxoma

9. Metastatic tumor

10. Papillary fibroelastoma

11. Masses: Pathophysiology
Thrombus may form in areas of Akinesis or dyskinesis
Left atrial thrombi usually associated with MS and left atrial enlargement
Most commonly found at ventricular apex (anterior MI’s)
Papillary fibroelastoma (10% of all primary cardiac tumors – 85% of valve tumors- mostly on AoV and MV).
Rhabdomyoma is most common benign tumor in children.
Approximately 20% of primary cardiac tumors are malignant
Metastatic (secondary) are more common than primary
Most metastatic tumors are sarcoma, melanoma or lymphoma from the breast or lung

12. Physical Signs:
Valvular stenosis and/or regurgitation may result in murmurs
Echo
Thrombus may be layered, pedunculated, multi-lobulated, or single.
Thrombus will appear as an echogenic mass in areas of Akinesis or dyskinesis
Search ventricular apex closely with a high frequency transducer (5 MHz- short focus)
To rule out artifacts, try to visualize the mass at different depths and from two or more views
Right sided masses can be delineated with micro-cavitation injections.
Angiosarcoma seen most often in the RA: is the most common primary tumor
Know how to identify a TEE image of a left atrial appendage clot.

13. Left atrial appendage

14. Doppler-Valvular stenosis and or regurgitation may occur with obstructive masses.

15. Myxomas Etiology Pathophysiology Physical signs
Benign tumors (comprise 30% of all primary benign cardiac tumors in adults)
Pathophysiology
Over 75% of myxomas are left atrial
Atrial myxomas may mimic mitral stenosis
Physical signs
Malaise/dyspnea
Chest pain (rare)
Dyspnea
Murmur of mitral stenosis with tumor plop is classic (50% of time)
Embolic phenomena(35% of the time)
Know that Myxoma symptoms mimic mitral stenosis

16. Echo Atrial myxomas usually attach to the interatrial septum
Intra-cavity tumors will usually move with blood flow
Intra-myocardial tumors usually have borders or texture which is different from myocardium
DOPPLER
Stenosis and regurgitation may be present with obstructiuve left atrial masses
Know that left atrial myxomas are usually attached to the interatrial septum

18. Left atrial myxoma M-mode