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A Phantom in the Aortic Valve: Tumor, Thrombus, or Artifact?
A Phantom in the Aortic Valve: Tumor, Thrombus, or Artifact? Satyajeet Misra, MD, DNB, PDCC, Koniparambil Pappu Unnikrishnan, MD, Thomas Koshy, MD, PDCC, Prasanta Kumar Dash, MD, and Sushanta Panda, MD
A
37-year-old man presented to the authors’ institute with complaints of angina on exertion for the last 2 months. His past history was relevant for acute coronary syndrome in 2002, which was treated with a stent to the left anterior descending artery. A recent coronary angiogram revealed 80% stent steno-
Fig 2. A midesophageal short-axis view of the aortic valve at 45° showing the mass (arrow) in the noncoronary cusp. The warfarin ridge (dashed arrow) can be seen similarly in this view also. LA, left atrium; RA, right atrium.
Fig 1. A modified midesophageal short-axis view of the aortic valve at 0° showing the mass (arrow) in the left coronary cusp. The bulbous end of the warfarin ridge (dashed arrow) can be seen in this view. LA, left atrium.
From the Department of Anesthesiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India. Address reprint requests to Satyajeet Misra, MD, DNB, PDCC, Department of Anesthesiology, Flat B-6, NFH, SCTIMST Quarters, Poonthi Road, Kumarapuram, Trivandrum, Kerala 695011, India. E-mail: [email protected] © 2011 Elsevier Inc. All rights reserved. 1053-0770/2502-0033$36.00/0 doi:10.1053/j.jvca.2010.01.010 Key words: warfarin ridge, aortic valve, side-lobe artifact, transesophageal echocardiography
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sis of the left anterior descending artery with total occlusion of the circumflex artery (after the first obtuse marginal branch) as well as the right coronary artery (after origin). Preoperative transthoracic echocardiography showed normal left ventricular function and no valve abnormalities. Clinical examination was unremarkable, and routine biochemical investigations were within normal limits. After the induction of anesthesia, a echocardiography probe was inserted, and images were acquired and archived on a Philips iE 33 machine (Philips, Bothell, WA). Apart from confirming the preoperative findings, an echogenic circular mass was seen in the left coronary cusp in the modified midesophageal short-axis view of the aortic valve at 0° (Fig 1 and Video 1 [supplementary videos are available online]). The mass was again visualized in the short-axis view of the aortic valve at 45°; however in this view, the mass was seen lying in the noncoronary cusp (Fig 2 and Video 2). What is the diagnosis?
Journal of Cardiothoracic and Vascular Anesthesia, Vol 25, No 2 (April), 2011: pp 380-381
A PHANTOM IN THE AORTIC VALVE
381
Fig 3. Long-axis views of the aortic valve showing absence of the mass in the non/left coronary cusp. (A) Midesophageal long-axis view and (B) Deep transgastric long-axis view. LA, left atrium; LV, left ventricle; AO, aortic root.
DIAGNOSIS: SIDE-LOBE ARTIFACT OF THE WARFARIN RIDGE
The “mass” was diagnosed as a side-lobe artifact of the warfarin (“coumadin”) ridge because midesophageal and deep transgastric long-axis views of the aortic valve failed to reveal the mass in either the left coronary cusp or the noncoronary cusp (Fig 3). Furthermore, there was absence of turbulence on color-flow Doppler (Videos 3 and 4), which is usually seen with intracardiac masses due to abnormal frequency shifts secondary to dispersion of flow around the tumor or valvular dysfunction. The warfarin ridge is a muscular structure that is present normally between the left atrial appendage and the left upper pulmonary vein and is usually seen best in the midesophageal 2-chamber view.1 The ridge has a long stalk and a bulbous body and has been misdiagnosed previously as a thrombus.1 Side lobes are multiple ultrasound beams of low amplitude that project radially from the main beam axis and are generated principally by the radial expansion of piezoelectric crystals.2 When these low-energy waves encounter strong reflectors in their path, the display assumes that the resulting echoes have originated from the axis of the main beam.2 Hence, the off-axis echoes are duplicated and placed in the path of the main beam.2 In this case, the side-lobe
artifact was generated because the warfarin ridge was large, highly echogenic, and present in the near field. The differential diagnosis includes primary valvular tumors, thrombus, or clots. The most common primary benign valvular tumors of the heart are papillary fibroelastomas, which occur with an incidence of 8%.3 The aortic valve is most commonly involved followed by the mitral valve.4 The tumor may be pedunculated or sessile and present either on the ventricular or the aortic side.4 It is typically described on echocardiography as a small (ⱕ20 mm), round, oval, or irregular homogenous mass with well-demarcated borders.4 The presence of atrial fibrillation, stasis, low-flow states, and valvular dysfunction are features more suggestive of thrombus or vegetations than tumors.3 In this case, a tumor or thrombus was excluded in the differential diagnosis based on absence of the “mass” in other imaging planes (eg, midesophageal and deep transgastric long-axis views of the aortic valve). Unnecessary re-exploration of the aortic root caused by an artifact mimicking aortic valve tumor has been reported.5 A phasic nature, lack of attachment to any known structure, and the absence of turbulence on color-flow Doppler are points in favor of artifacts. Obtaining multiple views, adjusting gain, and a thorough knowledge of echocardiography imaging constraints can help prevent unwarranted treatment.
REFERENCES 1. Miller JP, Perrino AC Jr, Hillel Z: Common artifacts and pitfalls of clinical echocardiography, in Perrino AC Jr, Reeves ST (eds): A Practical Approach to Transesophageal Echocardiography (ed 2). Philadelphia, PA: Wolters Kluwer Lippincott, Williams and Wilkins, 2008, pp 417-432 2. Feldman MK, Katyal S, Blackwood MS: US artifacts. Radiographics 29:1179-1189, 2009 3. Ragland MM, Tak T: The role of echocardiography in diag-
nosing space-occupying lesions of the heart. Clin Med Res 4:22-32, 2006 4. Sun JP, Asher CR, Yang XS, et al: Clinical and echocardiographic characteristics of papillary fibroelastomas: A retrospective and prospective study in 162 patients. Circulation 103:2687-2693, 2001 5. Neustein SM, Narang J: Transesophageal echocardiographic artifact mimicking an aortic valve tumor. J Cardiothorac Vasc Anesth 6:724-727, 1992
A
37-year-old man presented to the authors’ institute with complaints of angina on exertion for the last 2 months. His past history was relevant for acute coronary syndrome in 2002, which was treated with a stent to the left anterior descending artery. A recent coronary angiogram revealed 80% stent steno-
Fig 2. A midesophageal short-axis view of the aortic valve at 45° showing the mass (arrow) in the noncoronary cusp. The warfarin ridge (dashed arrow) can be seen similarly in this view also. LA, left atrium; RA, right atrium.
Fig 1. A modified midesophageal short-axis view of the aortic valve at 0° showing the mass (arrow) in the left coronary cusp. The bulbous end of the warfarin ridge (dashed arrow) can be seen in this view. LA, left atrium.
From the Department of Anesthesiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India. Address reprint requests to Satyajeet Misra, MD, DNB, PDCC, Department of Anesthesiology, Flat B-6, NFH, SCTIMST Quarters, Poonthi Road, Kumarapuram, Trivandrum, Kerala 695011, India. E-mail: [email protected] © 2011 Elsevier Inc. All rights reserved. 1053-0770/2502-0033$36.00/0 doi:10.1053/j.jvca.2010.01.010 Key words: warfarin ridge, aortic valve, side-lobe artifact, transesophageal echocardiography
380
sis of the left anterior descending artery with total occlusion of the circumflex artery (after the first obtuse marginal branch) as well as the right coronary artery (after origin). Preoperative transthoracic echocardiography showed normal left ventricular function and no valve abnormalities. Clinical examination was unremarkable, and routine biochemical investigations were within normal limits. After the induction of anesthesia, a echocardiography probe was inserted, and images were acquired and archived on a Philips iE 33 machine (Philips, Bothell, WA). Apart from confirming the preoperative findings, an echogenic circular mass was seen in the left coronary cusp in the modified midesophageal short-axis view of the aortic valve at 0° (Fig 1 and Video 1 [supplementary videos are available online]). The mass was again visualized in the short-axis view of the aortic valve at 45°; however in this view, the mass was seen lying in the noncoronary cusp (Fig 2 and Video 2). What is the diagnosis?
Journal of Cardiothoracic and Vascular Anesthesia, Vol 25, No 2 (April), 2011: pp 380-381
A PHANTOM IN THE AORTIC VALVE
381
Fig 3. Long-axis views of the aortic valve showing absence of the mass in the non/left coronary cusp. (A) Midesophageal long-axis view and (B) Deep transgastric long-axis view. LA, left atrium; LV, left ventricle; AO, aortic root.
DIAGNOSIS: SIDE-LOBE ARTIFACT OF THE WARFARIN RIDGE
The “mass” was diagnosed as a side-lobe artifact of the warfarin (“coumadin”) ridge because midesophageal and deep transgastric long-axis views of the aortic valve failed to reveal the mass in either the left coronary cusp or the noncoronary cusp (Fig 3). Furthermore, there was absence of turbulence on color-flow Doppler (Videos 3 and 4), which is usually seen with intracardiac masses due to abnormal frequency shifts secondary to dispersion of flow around the tumor or valvular dysfunction. The warfarin ridge is a muscular structure that is present normally between the left atrial appendage and the left upper pulmonary vein and is usually seen best in the midesophageal 2-chamber view.1 The ridge has a long stalk and a bulbous body and has been misdiagnosed previously as a thrombus.1 Side lobes are multiple ultrasound beams of low amplitude that project radially from the main beam axis and are generated principally by the radial expansion of piezoelectric crystals.2 When these low-energy waves encounter strong reflectors in their path, the display assumes that the resulting echoes have originated from the axis of the main beam.2 Hence, the off-axis echoes are duplicated and placed in the path of the main beam.2 In this case, the side-lobe
artifact was generated because the warfarin ridge was large, highly echogenic, and present in the near field. The differential diagnosis includes primary valvular tumors, thrombus, or clots. The most common primary benign valvular tumors of the heart are papillary fibroelastomas, which occur with an incidence of 8%.3 The aortic valve is most commonly involved followed by the mitral valve.4 The tumor may be pedunculated or sessile and present either on the ventricular or the aortic side.4 It is typically described on echocardiography as a small (ⱕ20 mm), round, oval, or irregular homogenous mass with well-demarcated borders.4 The presence of atrial fibrillation, stasis, low-flow states, and valvular dysfunction are features more suggestive of thrombus or vegetations than tumors.3 In this case, a tumor or thrombus was excluded in the differential diagnosis based on absence of the “mass” in other imaging planes (eg, midesophageal and deep transgastric long-axis views of the aortic valve). Unnecessary re-exploration of the aortic root caused by an artifact mimicking aortic valve tumor has been reported.5 A phasic nature, lack of attachment to any known structure, and the absence of turbulence on color-flow Doppler are points in favor of artifacts. Obtaining multiple views, adjusting gain, and a thorough knowledge of echocardiography imaging constraints can help prevent unwarranted treatment.
REFERENCES 1. Miller JP, Perrino AC Jr, Hillel Z: Common artifacts and pitfalls of clinical echocardiography, in Perrino AC Jr, Reeves ST (eds): A Practical Approach to Transesophageal Echocardiography (ed 2). Philadelphia, PA: Wolters Kluwer Lippincott, Williams and Wilkins, 2008, pp 417-432 2. Feldman MK, Katyal S, Blackwood MS: US artifacts. Radiographics 29:1179-1189, 2009 3. Ragland MM, Tak T: The role of echocardiography in diag-
nosing space-occupying lesions of the heart. Clin Med Res 4:22-32, 2006 4. Sun JP, Asher CR, Yang XS, et al: Clinical and echocardiographic characteristics of papillary fibroelastomas: A retrospective and prospective study in 162 patients. Circulation 103:2687-2693, 2001 5. Neustein SM, Narang J: Transesophageal echocardiographic artifact mimicking an aortic valve tumor. J Cardiothorac Vasc Anesth 6:724-727, 1992