Subcostal view

Fig. 5. Lipomatous hypertrophy (arrow) of the interatrial septum. (Please see companion DVD for corresponding video.)

Echocardiography Trauma

Fig. 6. 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 base of the papillary muscle (pm). Note the appearance of the true tendon—chorda tendinae (curved arrow).

Fig. 6. 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 base of the papillary muscle (pm). Note the appearance of the true tendon—chorda tendinae (curved arrow).

The thrombi vary tremendously in size, shape, and appearance. The differentiation of a thrombus from a tumor may be difficult if predisposing factors for thrombus are not present (Figs. 9 and 10; please see companion

DVD for corresponding video for Fig. 9). In cases of trauma or mediastinal surgery, coagulated blood and fibrin may appear in the pericardial and pleural space as gelatinous or coalescing echogenic masses.

Large Fibrinous Left Pleural Effusion

Fig. 7. Apical four-chamber (A4C) views from an 86-yr-old woman with generalized sepsis and endocarditis show a large left-sided pleural effusion with atelectatic lung segments (arrowheads). A pleural effusion should be distinguished from a pericardial effusion (arrow) by viewing from multiple views, and noting their relationships to regional anatomic structures, such as the aorta and the coronary sinus.

Fig. 7. Apical four-chamber (A4C) views from an 86-yr-old woman with generalized sepsis and endocarditis show a large left-sided pleural effusion with atelectatic lung segments (arrowheads). A pleural effusion should be distinguished from a pericardial effusion (arrow) by viewing from multiple views, and noting their relationships to regional anatomic structures, such as the aorta and the coronary sinus.

Apical Four Chamber Pleural Effusion

Fig. 8. Midesophageal image of the left atrial appendage (ominplane 59°) showing a left atrial thrombus (arrow) and spontaneous echocontrast within the left atrium (LA). Thrombi need to be distinguished from artifacts and the pectinate muscles that line the walls of the left atrial appendage. Spontaneous echocontrast frequently coexists with thrombus, as in the LA of this patient with mitral stenosis and atrial fibrillation.

Fig. 8. Midesophageal image of the left atrial appendage (ominplane 59°) showing a left atrial thrombus (arrow) and spontaneous echocontrast within the left atrium (LA). Thrombi need to be distinguished from artifacts and the pectinate muscles that line the walls of the left atrial appendage. Spontaneous echocontrast frequently coexists with thrombus, as in the LA of this patient with mitral stenosis and atrial fibrillation.

of recent onset. Myxomatous mitral valves should caused by reflections from the pericardium, valves, and

Vegetation also be distinguished from vegetation and tumors (Fig. 11).

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 are

Artifact

Artifacts resembling an echogenic mass can be

Artifact Echocardiography

Fig. 9. 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 heart chambers. Smaller thrombi had embolized to his coronary arteries resulting in multiple infarcts. (Please see companion DVD for corresponding video.)

Apical 4-Chamber

Fig. 9. 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 heart chambers. Smaller thrombi had embolized to his coronary arteries resulting in multiple infarcts. (Please see companion DVD for corresponding video.)

Peritoneum Infection
Fig. 10. These images are from a 51-yr-old male with end-stage liver disease, hepatitis C infection, ascites, and peritoneum-to-inferior vena cava (Denver) shunts. A thrombus was seen in his right atrium in addition to a patent foramen ovale.

foreign objects (e.g., catheters, pacemaker wires). Because of the way echo images are processed, artifacts often appear either halfway or whole multiples of distance from the reflecting object to the transducer, and do not move independently of heart motion. A useful way to distinguish an artifact is 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 (Fig. 12). On transesophageal echocardiography, the normal tissue infolding between the left atrial appendage and left upper pulmonary vein can cause an acoustic artifact which has occasionally been mistaken for a thrombus, hence the nickname "warfarin ridge" (Fig. 13).

In difficult cases, transesophageal echocardiography or even transcatheter biopsy may be called on to clarify the origins and nature of intracardiac masses.

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