1. ALSHARQIA ECHO CLUB Al Qusaibi Hotel Al Khobar May 23 rd 2013 Eric McWilliams MB, FRCPI, FRCP, FACC Consultant Cardiologist Dhahran Health Center Diplomate of the Certification Board of Cardiovascular Computed Tomography 2008 – 2018 Honorary Clinical Senior Lecturer, Brighton and Sussex Medical School August 2009 – August 2014

2. History  75 yr lady dyspnoea on exertion  Type 2 Diabetes  Hypertension  Hypothyroidism  Hyperlipidemia  Glaucoma  No murmurs  Chest clear

3. Echo

6. Mass 2.7 x 3.3 cmsPA pressure 43mmHg above RA

7. Transesophageal Echocardiography

8. 3D RTE Left Atrial Surgeons View Phillips IE 33

9. What Is It ?  Calcified Amorphous Tumour (CAT)  Mitral Valve Thrombus  Calcified Vegetation  Pericardial Teratoma  Caseous Calcification of Mitral Annulus  Left Atrial Sarcoma  Artefact

10. CXR

11. Cardiac CT

12. CTA

13. CMR

14. No Enhancement with Gad

15. CTCMR What is it ?

16. What Is It ?  Calcified Amorphous Tumour (CAT)  Mitral Valve Thrombus  Calcified Vegetation  Pericardial Teratoma  Caseous Calcification of Mitral Annulus  Left Atrial Sarcoma  Artefact

17. Mitral Annular CalcificationCaseous Calcification  Degenerative abnormality 10% of >50yr olds commoner in women  Deposition of calcium between the basal infero- lateral ventricular wall and posterior mitral leaflet  Typically posterior mitral annulus  Soft periannular calcification : calcium, fatty acids and cholesterol  Toothpaste like material Caseous calcification of the mitral annulus

18. Caseous Calcification of Mitral Annulus  Rare  0.6% of MAC patients in echo series  2.7% necropsy series  Usually incidental finding  Mitral stenosis can occur  Misdiagnosed as abscess, cardiac tumour etc  MAC and Caseous calcification similar baseline characteristics:  Elderly, hypertension,coronary artery disease, aortic disease etc

19. Caseous Calcification

20. CAT  Calcified amorphous tumor (CAT) was coined in 1997 by Reynolds et al,1 who described 11 cases with non neoplastic cardiac masses characterized by a pedicle and diffuse calcification

21. Evaluation of Intra- and Extra-Cardiac Structures Cardiac CTCMR  Evaluation of cardiac mass (suspected tumor or thrombus) A (8)  Patients with technically limited images from echocardiogram, MRI, or TEE  Evaluation of pericardial conditions  Evaluation of cardiac mass (suspected tumor or thrombus) A (9)  Use of contrast for perfusion and enhancement  Evaluation of pericardial conditions (pericardial mass, constrictive pericarditis) A (8) Appropriateness Criteria ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR

22. Ghada Al Dossary, BS, RDCS Senior Echo Technologist Eric McWilliams MB, FRCPI,FRCP,FACC Dhahran Health Center

23. Another Mitral Mass  63 year old lady with chronic renal failure  Multiple Access site failures  Infected Gortex  graft  MRSA  bacteremia  What is the appropriate first imaging test ?  TTE  TEE

24. TTE or TEE ? Appropriateness Criteria The American College of Cardiology Foundation (ACCF) and the American Society of Echocardiography (ASE)

25. Clinical Practice Guidelines by the Infectious Diseases Society of America for the Treatment of Methicillin-Resistant Staphylococcus AureusInfections in Adults and Children 2011  Echocardiography is recommended for all adult patients with bacteremia. Transesophageal echocardiography (TEE) is preferred over transthoracic echocardiography (TTE).

26. Another Mitral Mass  63 year old lady with chronic renal failure  Multiple Access site failures  Infected Gortex  graft  MRSA  bacteremia

27. TEE May 21 st,2013

30. What is It ?  Caseous Calcification of Mitral Annulus  Mitral Cusp Prolapse  Vegetation  Papillary Fibroelastoma of Mitral Valve  Mitral Thrombus

31. What is it ? Mitral MassProlapse P2

32. MCP With Vegetations

33. Mitral Mass Mitral Papillary Fibroelastoma

34. Staph Aureus Bacteremia  13% of hospital acquired Staphylococcus aureus infection develop endocarditis  31% Staph aureus bacteremia : endocarditis  Echocardiography  TEE

35. MRSA Endocarditis  The S. aureus organism carries particular adhesin molecules : can attack structurally Normal valves  The bacteria can either internalise and persist locally, protected from antibiotic therapy and host defences, or lyse the endothelial cells, causing local tissue destruction and distant emboli  S. aureus endocarditis can present either acutely or with a more indolent presentation

36. Acute pericarditis as presenting symptom of staphylococcal endocarditis: Mitral valve involvement with fistulous tract from LV to LA and subsequent pseudoaneurysm development. Eric McWilliams, Smriti Saraf, Katarzyna Dickinson World Journal of Cardiovascular Diseases, 2013, 3, 31-33 WJCD

37. Re-entry on Left Atrial Side

38. MRSA Endocarditis

40. TTE versus TEE  The sensitivity for detecting vegetation with 2D TTE is 65 to 80 percent and 95 percent with TEE but depends on vegetation size, location, and the echocardiographic window  The yield of TTE is poor in patients with prosthetic valve endocarditis, but the sensitivity for TEE is 90 percent

42. TEE Mitral Bioprothesis

43. Vegetation on MVR