1. Dr. Fuad Farooq
INFECTIVE ENDOCARDITIS AND
HEART MASSES

2. Infective Endocarditis

3. Introduction
 Infective endocarditis occurs primarily on cardiac
valves but can involve other endocardial surfaces or
intracardiac devices
 Potentially fatal with 6 month mortality rate of 25 to
30%
 The incidence of IE is higher in patients who have
valvular heart disease (rheumatic valve, bicuspid
aortic valve, mitral valve prolapse, or prosthetic valve)
or congenital heart disease and among intravenous
drug users
 Most commonly mitral and aortic valves are involved
but involvement of right side of heart is not
uncommon, especially in intravenous drug users

4.  Hydraulic features of the blood stream are
important in the pathogenesis of endocarditis
 Associated with a high-pressure source
(i.e., aorta, left ventricle) that drives blood at a
high velocity through a narrow orifice
(coarctation, PDA, VSD, AR or MR or obstructive
hypertrophic cardiomyopathy) into a low-pressure
chamber
Introduction
Rodbard S. Blood velocity and endocarditis. Circulation, 1963;27:18-28

5.  Since the 1st M-Mode echo observation of valvular
vegetation in 1973, the role of echo in diagnosing IE
has grown in conjunction with improvement in
resolution and technology including Doppler
echocardiography, color flow imaging, and
transesophageal echocardiography (TEE)
 Indeed the echo detection of vegetation is one of the
two major diagnostic criteria for IE
Introduction
American Heart Journal, 1973;86:698-704

6.  Vegetation is an oscillating intracardiac mass on
a valve or supporting structure or in the path of
regurgitation get or an iatrogenic device
 Can be linear, round, irregular or shaggy and
frequently show high frequency flutter or
oscillation
Echocardiographic Appearance

7. Echocardiographic Appearance

8.  Other associated findings
 Abcesses
 New partial dehiscence of prosthetic valve
 New valvular regurgitation
 Initial attachment to MV and TV is usually on
atrial side
 An aortic vegetation usually start from ventricular
surface
Echocardiographic Appearance

9.  The sensitivity of 2D echo for the detection of
vegetation depends on the size and location of
the vegetation and echocardiographic window
used
 The sensitivity for detection of vegetation with
TTE is 65 to 80% when size of vegetation <1cm
and with TEE is 95%
 For prosthetic endocarditis the diagnostic yield of
TTE is especially poor, but the sensitivity of TEE
is 90%
Echocardiographic Appearance
Journal of the American College of Cardiology, 1989;14:631-38
Journal of the American College of Cardiology, 1991;18:391-97

10.  The vegetation on the right side of the heart are
larger (mean diameter 17mm) than those on the
left side
 Vegetations frequently persist after successful
medical treatment, however persistent vegetation
are not independently associated with the late
complication
Echocardiographic Appearance

13.  Complications arise from primarily from
 Vegetation embolization
 Destruction of valve or intracardiac structures
 Abcesses and subsequent haemodynamic
deterioration
 In the left sided valve endocarditis, the frequency of
clinical complications increased with the greater
mobility and size of vegetation
 When vegetations were larger than 11 mm, 50% or
more of patients developed at least one complication
of infective endocarditis
 In patients with tricuspid valve endocarditis, PE is the
most common complication 69%
Complications

14.  Structural
 Cusp or leaflet rupture/flail
 Perforation
 Abscess
 Aneurysm
 Fistula
 Dehiscence of prosthetic
valve
 Pericardial effusion (more
frequent with abscess)
 Embolization
 Systemic
 Cerebral
 Pulmonary
 Hemodynamic
compromise
 Valvular regurgitation
 Acute mitral regurgitation
 Acute aortic regurgitation
 Premature mitral valve
closure
 Restrictive mitral inflow
pattern
 Valvular stenosis
 Shunt
 Congestive heart failure
Complications

17.  When the endocardial surface is traumatized, a
series of events may lead to platelet
deposition, creating a nonsterile platelet fibrin
thrombus
 Libmann sacks endocarditis: (Associated with
APLA)
 This condition usually involve mitral valve and is
found most commonly on the basal portion of MV
but it can extend to the cordal structure or papillary
muscles
 The lesions are difficult to see with TTE
Non-bacterial Thrombotic Endocarditis

23.  Young male
 Intravenous drug abuser
 Presented with fever, pedal edema and shortness
of breath
Case

28. Vegetation on Prosthesis

30. Vegetation on Shunts

35. A metastatic tumor also can involve cardiac
valves and produce lesions similar to those in
Libman-Sacks endocarditis. This is called
marantic endocarditis and occurs most commonly
with Hodgkin disease and adenocarcinoma of the
lung, pancreas, stomach, and colon
Marantic Endocarditis

36.  Several limitations and pitfalls
 Other lesions of the valves, such as marked
myxomatous degeneration of the mitral valve,
nonbacterial thrombotic endocarditis or tumor,
thrombus attached to the valve (i.e., papilloma),
may simulate or mask vegetations
 When a valve is sclerotic, calcified or prosthetic, it
is more difficult to visualize a vegetation - TEE
may be useful
 Clinical presentation and lab data need to be
incorporated into the interpretation of the
echocardiographic findings
Clinical Caveats

37. TUMORS AND MASSES

38.  Detection of a large intracardiac mass is an
impressive experience for clinical
echocardiographers
 Some cardiac masses are suspected from the
clinical presentation of the patient and other are
incidental findings
 Occasionally, a normal structure or a variant of a
normal structure may appear as an intracardiac
mass
 Accurate diagnosis is crucial because
misinterpretation may lead to an incorrect
management strategy, including an unnecessary
surgical procedure
Cardiac Masses

39.  Cardiac masses can be classified as
 Cardiac tumor
 Thrombus
 Vegetation
 Iatrogenic material
 Normal variant
 Extracardiac structure
 These masses usually can be differentiated by
their size, shape, location, mobility and
attachment site as well as by their clinical
presentation
Cardiac Masses

40. Echo Indications in Cardiac Masses

41.  Although primary cardiac tumors usually are
benign, they can cause systemic symptoms,
embolic events, malignant arrhythmias, chest
pain, and heart failure
 So, it is recommended that cardiac tumors be
removed whenever possible
 They can be
 Benign
 Malignant
 Primary
 Secondary
Cardiac Tumor

42. Tumor and Masses

43. Tumor and Masses

44.  Not all masses detected with echocardiography
are thrombus or intracardiac tumor
 The normal appearance of cardiac and
extracardiac structures can be misinterpreted
as an intracardiac mass
…Normal Anatomic Varients

45. …Normal Anatomic Varients

46. …Normal Anatomic Varients

47. Cordae

48. Lipomatous Interatrial Septum

49. Moderator Band

50. Moderator Band

51. Reverberation Artefact

52. Papillary Muscle

53. Pacemaker Lead

54. Chiari Network

55. Lamble’s

56.  Myxoma is the most common cardiac
tumor, accounting for 20 to 30% of intracardiac
tumors
 LA is the most common location with attachment
site at the atrial septum
 Typical M-mode and 2D echo appearance
 Other locations and attachment sites have been
observed including RA, RV, LV and atrioventricular
valve
 Atypically located myxoma is usually familial -
Carney Complex
 Familial atrial myxomas account for 7% of all atrial
myxomas
Myxoma

57.  Atrial myxoma appear gelatinous and friable with
occasional central necrosis
 Embolic events are more common with a small
myxoma
 These tumors can obstruct AV valve
 Yearly echo is indicated after resection of
myxoma at for 5 years
Myxoma

62.  Fibromas usually are located in the LV free
wall, ventricular septum or at the apex
 It is well demarcated from surrounding
myocardium by multiple calcifications
 May grow in LV cavity and interfere with LV filling
 Potential problems resulting from a fibroma are
congestive heart failure and malignant
arrhythmias
 When the tumor is located at the apex, the
condition may be misinterpreted by other imaging
modalities as apical hypertrophic cardiomyopathy
Cardiac Fibroma

65.  It is the most common cardiac tumor in
children, particularly those with tuberous sclerosis
 Rhabdomyomas are often multiple, found in
RV, RVOT and even in pulmonary artery
 May be diagnosed before birth with fetal echo
 Rhabdomyoma may regress spontaneously after
birth
Cardiac Rhabdomyoma

68.  It is a benign intracardiac tumor, found in the
endocardium
 These tumors are usually small (mean size 12
into 9 mm) and have characteristic stippled edge
with shimmer or vibration at the tumor blood
interface
 Most frequently papillary fibroelastomas are
located on the aortic valve (either aortic or
ventricular surface), TV, PV, Septum, LV free
wall, RVOT and LA
 90% of patient have single tumor and other 10%
have multiple tumors
Papillary Fibroelastoma

70.  Primary cardiac pheochromocytomas is very rare
but it has characteristic location, size and shape
 Found mostly in AV grove, well circumscribed
and ovoid, ranging from 1.5 to 5.1 cm
 Common in female (mean age 38 years)
 Coronary angio shows that the tumor has
coronary neovascular blood supply
Pheochromacytoma

72.  Malignant primary cardiac tumors include
 Angiosarcoma
 Rhabdomyosarcoma
 Myxosarcoma
 Osteosarcoma
 Fibrosarcoma
 Synovialsarcoma
 Angiosarcoma occur commonly in RA in
conjuction with paricardial effusion
 Rhabdomyosarcoma and fibrosarcoma can occur
any where in the heart
 Synovial sarcoma is rare and occurs in RA
Malignant Tumors

77.  Frequently secondary malignant tumors
metastasize from
lungs, breast, kidney, liver, melanoma, osteogenic
sarcoma
 Whenever RA mass is detected, the IVC should
be scanned carefully
Secondary tumor

78. Secondary tumor

79.  RA thrombus:
 Thrombi from lower extremity deep vein must go
through RA to pulmonary circulation
 They are mobile, have a characteristic popcorn or
snake like appearance
 Almost always are associated with pulmonary embolism
Thrombus

84.  RV thrombus
Thrombus

87.  LA Thrombus:
 Common in mitral stenosis or atrial fibrillation
 Infrequently occurs as a paradoxical embolus from an RA
thrombus passing through a patent foramen ovale
 TTE is limited in detecting thrombus in LAA
 In all patients, the LA appendage is visualized from a
transesophageal window
Thrombus

90.  LV thrombus
 Easily differentiated from a tumor because the
thrombus is almost associated with akinetic to
dyskinetic myocardium underlying the thrombus
 Contrast echo can be very helpful in identifying and
evaluating an apical mass/thrombus
Thrombus

96.  IVC CLOT
Thrombus

102. case
 Young female
 With chest pain

103. Another case

106. Take Home Message

107. Take Home Message

108. Take Home Message