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Vegas, MD, FRCP, FASE 2 1/16/2019 Question 1 Pitfalls What structure is shown in this clip? 1. Eustachian valve Annette Vegas, MD, FRCP, FASE 2. Thebesian valve Professor Anesthesiology 3. Chiari network 4. Cor triatriatum Question 2 Question 3 What structure is shown in What structure is shown this clip? by the double arrows in 1. Eustachian valve this clip? 2. Thebesian valve 1. Pericardial fat 3. Coumadin ridge 2. Epicardial fat 4. Crista terminalis 3. Hematoma 4. Myocardium Question 4 Question 5 What structure is shown in What finding is shown in this clip? this clip? 1. Moderator band 1. Aortic dissection 2. False chordae 2. Pericardial effusion 3. False tendon 3. Aberrant subclavian 4. Papillary muscle artery 4. Innominate vein 1 1/16/2019 Question 6 Outline • Normal structures that mimic pathology What finding is shown in this clip? • 3 categories 1. Normal left upper – Structures pulmonary vein – Echo-free spaces 2. Normal left atrial – Foreign material appendage • Identify to avoid unnecessary clinical 3. Cyst interventions 4. Persistent left SVC Structures RA Anatomy • RA • Aortic valve 1. pectinate muscles – Eustachian valve – Nodules of Arantius 2. crista terminalis – Lambl’s excrescences – Chiari network Right Atrium 3. SVC – Crista terminalis • Pericardium – Thebesian valve – Epicardial fat 4. right auricle – Pectinate muscles – Transverse sinus ① 5. tricuspid valve SVC • RV • Aorta 6. position of AV node – Moderator band – Innominate vein ② 7. coronary sinus – Trabeculations • Interatrial septum • LA – Lipomatous hypertrophy 8. coronary sinus valve – Coumadin ridge – IAS aneurysm CS 9. IVC valve (eustachian) – Pectinate muscles ⑨ ⑧ 10.IVC • IVC LV 11.fossa ovalis – False tendon – Papillary muscles 12.limbus of fossa ovalis – Apical trabeculations RA Eustachian Valve RA Chiari Network Bartolomeo Hans Chiari Eustachi • Important fetal structure • Embryologic remnant – Directs blood IVC to fossa ovalis – R sided sinus venosus valve • Embryonic valve of IVC – Variant of Eustachian valve – Fold RA at posterior margin • 2-3% at autopsy • Often involutes, adult (25%) • Fenestrated membrane • RA/IVC junction • Connect vena cavae + RA • Variable length • IVC attachment, mobile – Cortriatriatum dexter curvilinear structure • Independently mobile • Mimic free RA thrombus, TV • Mimic RA thrombus vegetation, tumors • May obstruct IVC flow 2 1/16/2019 RA Crista Terminalis Thebesian Valve • Fibromuscular ridge smooth Adam Thebesius sinus venarum + trabeculated RA • Valve of coronary sinus • IVC to SVC at lateral RA wall • Fold of RA endocardium • Bicaval view – 65-90% of patients • Anterior SVC + RA • Posterior RA • Echogenic mass • Between TV + IVC • Moves with heart • Rarely obstructs flow • ↑ atrial systole • Complicate cannulation • Mimic thrombus or • Mimic thrombus or vegetation vegetation Katti K and Patel NP. Clin Anat 2012; 25:379–385. Pectinate Muscles RV Moderator Band • Prominent RV trabeculation • Parallel muscle ridges in – Differentiate RV from LV the RA free wall + RAA • Base of anterior papillary • Echogenic masses muscle to IVS • Move with the RA – Contains RBB • Mimic thrombus or • ME 4C view vegetation • Thick echo-dense muscle band • Tumor, thrombus, vegetation RV Epicardial Fat LA Coumadin Ridge • Epicardial fat between outer myocardium and visceral • LA tissue between LUPV + pericardium LAA • Pericardial fat • Muscle ridge • Moves with heart – between visceral + parietal pericardium • Globular fatty appearance – Q-tip sign – anterior to epicardial fat • Mimic tumor, thrombus • Echogenic layer • Mimic pericardial effusion Iacobellis G et al. J Am Soc Echocardiogr 2009;22:1311-9 3 1/16/2019 LA Appendage LV False Tendon • Fibromuscular structures • Variable number 1(20%), that cross the LV 2(54%), 3(23%), 4(3%) – Fine filamentous – Muscle band • Pectinate muscles • 55% of normal hearts • ME views • ME views (2 views) • Echogenic masses • Solid structure, non- • Mimic thrombus contractile • Inversion • Not affect LV function • Associated – Mural thrombus – Arrhythmias AV Nodules of Arantius AV Lambl’s Excresences Julius Caesar Vilem Dusan Arantius Lambl • Fibrous strands from • Fibrous thickening at nodules midpoint of AV cusp edge at • < 1mm thick, <1 cm long point of coaptation • Fillatum or lamellar • Associated with excrescences • 90% of patients • Mimic vegetations • Can occur on MV • May be calcified • No independent motion • No functional abnormality • Mimic vegetation, tumor Lipomatous Hypertrophy of IAS IAS Aneurysm • Redundant IAS • Fatty infiltrate within IAS • Mobile > 10mm beyond – Not true tumor – Also ↑ pericardial fat plane of IAS • Bicaval view • Passive motion with heart • > 2cm thickness • Increased stroke risk • Dumbbell shape • Associated – Spares the fossa ovalis – PFO – • Rarely SVC obstruction ASD – MV prolapse • Mimic amyloid (LV wall – Marfan thickened), tumors 4 1/16/2019 Aorta Innominate Vein Echo Spaces • Persistent left SVC • Transverse sinus • Innominate vein anterior to • Oblique sinus aorta looks like an aortic dissection • Effusions • Differentiate color and spectral Doppler • Agitated saline in left arm shows contrast in vein Persistent LSVC Transverse Pericardial Sinus • 10% congenital patients • Echo free space between LAA + LUPV • Color flow • ME AV LAX and ME RVOT • Big coronary sinus (> 2 cm) views • Left arm injection into CS • No color flow • Mimic cyst or abscess • Fibrinous material • Associated • Floating LAA tip – Coarctation • Mimic cyst or abscess – ASD – VSD – Cor-triatriatum Foreign Material Pacer Wires • Catheters • Pacer wires • Sutures 5 1/16/2019 Readings • Kim MJ and Jung HO. Anatomic Variants Mimicking Pathology on Echocardiography: Differential Diagnosis. J Cardiovasc Ultrasound 2013;21(3):103-112. • Katti K and Patel NP. The Thebesian Valve: Gatekeeper to the Coronary Sinus. Clin Anat 2012; 25:379–385 • Iacobellis G et al. Echocardiographic Epicardial Fat: A Review of Research and Clinical Applications J Am Soc Echocardiogr 2009;22:1311-9 • Goyal SK, et al. Persistent left superior vena cava: a case report and review of literature. Cardiovasc Ultrasound 2008 10;6:50. doi: 10.1186/1476-7120-6-50. 6.
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