ECHOGENIC MASS ATTACHED TO TRICUSPID VALVE

SUMMARY A 5-day old female child with complaints of tachypnea, had TTE which revealed an echogenic mass on septal leaflet of Tricuspid valve. Based on echocardiographic features, it was diagnosed as Papillary fibroelastoma. CASE DESCRIPTION A 5-day old female child was referred for transthoracic echocardiographic study due to respiratory difficulty. The child was afebrile and had a respiratory rate of 60/min, heart rate 130 bpm, and blood pressure 80/50 mmHg. No murmur or added sound heard on CVS examination. TTE revealed a dense mass (Figure 1) attached to right atrial side of septal leaflet of Tricuspid valve by a small pedicle. The mass was mobile, prolapsing into right ventricle during diastole (Clips) without causing obstruction with size of 0.8 X 0.74 cm. Intracardiac masses attached to valves are usually Papillary fibroelastomas. Other possible differential diagnoses could be myxoma, vegetation, Lambl’s excrescence or secondary tumors etc. Based on the location and echo features of the mass (mobility, attachment to downstream side of valve, and frond like speckled appearance) the diagnosis of Papillary fibroelastoma was made. LEARNING POINTS Cardiac tumors are rare and mostly benign. The three most common primary tumors of heart, in order of frequency, are myxomas, lipomas and papillary fibroelastomas respectively. PFE constitute 7% - 9% of all.1 PFE usually arise from valves of the heart and are mostly left-sided.2 They are mobile, range from 0.5 – 2 cm in size and have a frond-like appearance. On echo, they are dense with a speckled interior and shimmering surface.3 Being prone to embolization and thrombosis, their clinical course may not be benign, especially left sided. Clips Subcostal Clip: https://youtu.be/_xTZmx--WcA PS SAX View: https://youtu.be/lLh6D9Vn4Fw A4C View: https://youtu.be/_xZZvTIh0S8 A4C RV Directed View: https://youtu.be/vJRyHrevftA QUESTIONS WITH ANSWERS Question 1: What is the most common complication of papillary fibroelastoma? Question 2: The behavior of right and left sided papillary fibroelastomas could be markedly different, Y/N? Question 3: What is the most important feature of papillary fibroelastoma for embolization? Question 4: PFE preferentially affects females, Y/N? Answers Question 1: Cerebral embolism Question 2: Yes Question 3: Mobility Question 4: No References Bouhzam N, Kurtz B, Doguet F, Eltchaninoff H, Bauer F. Incidental papillary fibroelastoma multimodal: imaging and surgical decisions in 2 patients. Tex Heart Inst J. 2012;39(5):731-5. Eidem BW, Cetta F, O’ Leary PW. Echocardiography in pediatric and adult congenital heart disease. Lippincott, Williams and Wilkins, Wolters Kluwer. 2010 p 355-361. Klarich KW, Enriquez-Sarano M, Gura GM, Edwards WD, Tajik AJ, Seward JB. Papillary fibroelastoma: echocardiographic characteristics for diagnosis and pathologic correlation. J Am Coll Cardiol. 1997;30(3):784-90.

Echocardiographic evaluation of paravalvular aortic regurgitation of a patient with recurrent aortic valve replacements

Paravalvular regurgitation (PVR) is a serious complication after surgical valve replacement. Echocardiography is the gold standard technique to assess the severity of PVR with an integrated approach.A 48-year-old male underwent aortic valve replacement due to infective endocarditis (IE). During in-hospital cardiac rehabilitation after a redo surgery for a new IE three years later, an echo-free anterior space around the valve with several PVRs through transthoracic echocardiography (TTE) was identified. On transesophageal echocardiography (TOE) a double PVR (anterior and posterior) with abscessual cavity was detected. The patient’s conditions worsened within six months with hemodynamic instability: a massive PVR due to a large abscess cavity next to the right cusp was confirmed by TTE and TOE and a third surgery was carried out. On the third admission at our Rehabilitation Unit the echo features were normal. Patient did not report any cardiovascular symptoms at 1 year follow-up.

Feature of Echo Envelope Fluctuation and Its Application in the Discrimination of Underwater Real Echo and Synthetic Echo

Discriminating a real underwater target echo from a synthetic echo is a key challenge to identifying an underwater target. The structure of an echo envelope contains information which closely relates to the physical parameters of the underwater target, and the characterization and extraction of echo features are problematic issues for active sonar target classification. In this study, firstly, the high-frequency envelope fluctuation of a complex underwater target echo was analyzed, the envelope fluctuation was characterized by the envelope fluctuation intensity, and a characterization model was established. The features of a benchmark model echo were extracted and analyzed by theoretical simulation and sea testing of a scaled model, and the result shows that the envelope fluctuation intensity varies with carrier frequency and azimuth of incident signal, but the echo envelope fluctuation of the synthetic target echo does not present these features. Then, based on the characteristics of echo envelope fluctuation, a novel method was developed for active sonar discrimination of a real underwater target echo from the synthetic echo. Through a sea experiment, the real target echo and synthetic echo were classified by their different echo envelope fluctuations, and the feasibility of the method was verified.

Prevalence and echo features of mediastinal lymph nodes in EUS for non-malignant indications: a prospective study in a Southern European Population

Background and study aims Significant heterogeneity in geographic distribution regarding the prevalence of mediastinal lymph nodes (MLN) has been documented in autopsy and computed tomography (CT) studies. Awareness of the local prevalence and characteristics of lymph nodes will be relevant when performing endoscopic ultrasonography (EUS) for staging of malignant neoplasias. The aims of this study were to document the prevalence and echo features of MLN in patients undergoing EUS for non-malignant extrathoracic disease and to identify predictive factors for the presence of MLN. Patients and methods A prospective single-center study was performed over 6 months. Mediastinal stations 9, 8, 7, 6, 5, 4 L and 2 were systematically evaluated using a linear echoendoscope in all patients undergoing EUS due to benign extrathoracic pathology and without history of oncologic disease. Demographic, clinical and EUS features of the lymph nodes were analysed. Results Seventy-five patients were included: male/female 32/43; mean age, 63 years. The majority of patients (72 %) had lymph nodes in at least one mediastinal station and 88 % of these were found in stations 7 or 4 L. Overall, 133 MLN were identified: 19 % were hypoechogenic, 6 % had a short-axis diameter > 10 mm, and 6 % were round. The prevalence of lymph nodes was higher in smokers (83 % vs 64 %, P = 0.024), with a higher average number of lymph nodes per patient in this group (2.1 vs 1.6; P = 0.017). By logistic regression analysis, none of the variables analyzed were independently associated with the presence of MLN. Conclusion This prospective Portuguese study documented a higher prevalence of MLN than previously reported in Northern Europe, in patients with no evidence of oncologic disease. This higher prevalence may negatively influence the specificity and positive predictive value for malignancy of MLN (N) staging by EUS.

On wh-movement in Spanish Echo Questions

This paper examines Spanish echo questions, an understudied phenomenon even in extensively described languages such as English. In particular, it focuses on a very particular type of echo questions, such as those made in response to a previous yes/no question (e.g. –Did you buy {mumble}?; –Did I buy what?) and makes a detailed description, on the one hand, of inherent echo features, common across most languages, and, on the other, those language-specific. In particular, I argue that wh-in-situ is not the only possible option in Spanish EQs in order to get a proper, echo interpretation. In addition, I offer some evidence from Spanish data in favour of a particular syntactic structure underlying this sort of questions (Sobin 2010).

Coexistence of Cardiomyopathy and Chronic Liver Disease in Non-Moderate Drinkers

Introduction: The dose-response relationship suggests a toxic effect of alcohol on heart and liver and the possibility of a correlation between alcohol-induced liver and heart disease. The present study was aimed to look into the relationship between chronic liver and heart muscle disease among the non-moderate drinkers in our context.Methods: An observational study on non-moderate chronic drinkers was carried out. Clinical evaluation along with detail sonographic study of heart and liver was conducted.Results: Fifty-eight percent had echocardiographic features consistent with heart muscle disease, either as a dilated cardiomyopathy, categorized by the presence of echo features of impaired LV systolic function and dilated left ventricle or as a possible cardiomyopathy categorized by the presence of any of these two echo features. Similarly, 56 of the total recruits showed ultrasonographic evidence of chronic liver disease as cirrhosis or early cirrhosis. Approximately, 86% of these 56 non-moderate drinkers with chronic liver disease also had echocardiographic features of heart muscle disease and 83% of the 58 non-moderate drinkers showing echo features of heart muscle disease had ultrasonographic features of chronic liver disease.Conclusions:Our study showed a strongly positive relationship on the coexistence of chronic liver disease and cardiomyopathy among the non-moderate drinkers. Non-moderate drinkers with chronic liver disease have a high likelihood of having a concurrent clinical or sub-clinical heart muscle disease and vice versa.Keywords: alcohol; chronic liver disease; heart muscle disease; non-moderate drinking.