IMAGING IN CARDIOLOGY
Intracardiac catheter mimicking right atrial mass
M.M. Ragland, Yanping Ye, T. Tak
A 38-year-old female with a three-year history of shortness of breath presented to the emergency department with increasing shortness of breath, palpitations, and symptoms compatible with a cerebrovascular accident. The patient's past medical history was significant for a mediastinal mass, with a pathological diagnosis of lymphangioma, which was surgically resected. During this admission, the patient was found to be in atrial fibrillation with rapid ventricular response. On physical examination, she had normal blood pressure, an irregular heart rate, decreased breath sounds over the right lung, and a 2/6 systolic murmur over the apex. An electrocardiogram showed atrial fibrillation with a rapid ventricular rate of 102 to 176 beats/min. The chest x-ray demonstrated right-sided pleural effusion. A transoesophageal echocardiography was performed to rule out an intracardiac source of embolism. This revealed a linear structure extending from the superior vena cava into the right atrium (figure IA). Based on the fact that the patient had a right intrajugular catheter placed seven days prior to the transoesophageal procedure, it was concluded that the mass was most likely an artifact caused by the catheter. Therefore, the catheter was removed and a follow-up transthoracic echocardiogram confirmed the absence of any spaceoccupying lesions in the right atrium (figure 1B). A cardiac source of embolism was not found during this admission. The patient's subsequent hospital course was uncomplicated and she was discharged a few days after the admission date in stable condition.
The identification of cardiac masses is one ofthe most important uses of echocardiography.' However, not all masses seen on echocardiography are pathologic. There are several normal variants of the heart as well
M.M. Ragland Yanping Ye T. Tak Department of Medicine, University of North Texas Health Science Center, Fort Worth, Texas, USA
Correspondence to: T. Tak Department of Medicine, Division of Cardiology, University of North Texas Health Science Center, 855 Montgomery Road, 4th Floor, Fort Worth, Texas 76107, USA E-mail: [email protected]
370
Figure 1. A: Transoesophageal echocardiography (longitudinal view) at the level of the atria demonstrating the presence of a mass extending from the superior vena cava into the right atrium (arrow). B: Transthoracic echocardiography demonstrating the absence of the mass after removal of the catheter. LA=left atrium, RA=right atrium, SVC=superior vena cava.
Netherlands Heart Journal, Volume 13, Number 10, October 2005
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IMAGING IN CARDIOLOGY
as iatrogenic structures (such as catheters) that can be misinterpreted as cardiac masses.2 The presence of right-atrial catheters or electrodes on echocardiography is well known in the echocardiographic literature.34 Clinically, these iatrogenic structures may cause misinterpretations. With the increasing use of interventional procedures, one needs to be aware of such possible misinterpretations in order to avoid erroneous diagnosis and patient mismanagement.' Transoesophageal echocardiography is extremely sensitive in determining the presence and position of indwelling catheters in the heart.5 6 * References 1
2 3 4
Sajeev C, Krishnan M, Venugopal K An Unusual "Right Atrial Mass" on Echocardiography. Heart 2003;89:268. Feigenbaum H, Armstrong W, Ryan T. Feigenbaum's Echocardiography. Philadelphia, Lippincott Williams & Wilkins, 2005, p701. Fry S, Picard M, Tseng J, Briggs S, Isselbacher E. The Echocardiographic Diagnosis, Characterization, and Extraction Guidance ofCardiac Foreign Bodies. JAm Soc Echocardiogr2000;13:232-9. Yeo T, Miller F, Oh J, Freeman W. Retained Left Atrial Catheter: an Unusual Cardiac Source of Embolism Identified by Transesophageal Echocardiography. JAm Soc Echocardiogr 1998;11:6670.
Ncthcrands Heart Journal, Volume 13, Number 10, October 2005
5 6
Kingdon E, Holt S, Davar J, Pennell D, Baillod R, Bums A, et al. Atrial Thrombus and Central Venous Dialysis Catheters. Am J KidneyDis 2001;38:631-9. Gilon D, Schechter D, Rein A, Gimmon Z, Or R, Rozenman Y, et al. Right Atrial Thrombi are Related to Indwelling Central Venous Catheter Position: Insight Into Time Course and Possible Mechanism of Formation. Am HeartJ1998;135:457-62.
In this section a remarkable 'image' is presented and a short comment is given. We invite you to send in images (in triplicate) with a short comment (one to two pages at the most) to Bohn Stafleu van Loghum, P0 Box 246, 3990 GA Houten, e-mail: [email protected]. 'Moving images' are also welcomed and (after acceptance) will be published as aWeb Site Feature and shown on our website: www.cardiologie.nl
This section is edited byM.J.M. Cramer andjj. Bax.
371
Intracardiac catheter mimicking right atrial mass
M.M. Ragland, Yanping Ye, T. Tak
A 38-year-old female with a three-year history of shortness of breath presented to the emergency department with increasing shortness of breath, palpitations, and symptoms compatible with a cerebrovascular accident. The patient's past medical history was significant for a mediastinal mass, with a pathological diagnosis of lymphangioma, which was surgically resected. During this admission, the patient was found to be in atrial fibrillation with rapid ventricular response. On physical examination, she had normal blood pressure, an irregular heart rate, decreased breath sounds over the right lung, and a 2/6 systolic murmur over the apex. An electrocardiogram showed atrial fibrillation with a rapid ventricular rate of 102 to 176 beats/min. The chest x-ray demonstrated right-sided pleural effusion. A transoesophageal echocardiography was performed to rule out an intracardiac source of embolism. This revealed a linear structure extending from the superior vena cava into the right atrium (figure IA). Based on the fact that the patient had a right intrajugular catheter placed seven days prior to the transoesophageal procedure, it was concluded that the mass was most likely an artifact caused by the catheter. Therefore, the catheter was removed and a follow-up transthoracic echocardiogram confirmed the absence of any spaceoccupying lesions in the right atrium (figure 1B). A cardiac source of embolism was not found during this admission. The patient's subsequent hospital course was uncomplicated and she was discharged a few days after the admission date in stable condition.
The identification of cardiac masses is one ofthe most important uses of echocardiography.' However, not all masses seen on echocardiography are pathologic. There are several normal variants of the heart as well
M.M. Ragland Yanping Ye T. Tak Department of Medicine, University of North Texas Health Science Center, Fort Worth, Texas, USA
Correspondence to: T. Tak Department of Medicine, Division of Cardiology, University of North Texas Health Science Center, 855 Montgomery Road, 4th Floor, Fort Worth, Texas 76107, USA E-mail: [email protected]
370
Figure 1. A: Transoesophageal echocardiography (longitudinal view) at the level of the atria demonstrating the presence of a mass extending from the superior vena cava into the right atrium (arrow). B: Transthoracic echocardiography demonstrating the absence of the mass after removal of the catheter. LA=left atrium, RA=right atrium, SVC=superior vena cava.
Netherlands Heart Journal, Volume 13, Number 10, October 2005
C6C
IMAGING IN CARDIOLOGY
as iatrogenic structures (such as catheters) that can be misinterpreted as cardiac masses.2 The presence of right-atrial catheters or electrodes on echocardiography is well known in the echocardiographic literature.34 Clinically, these iatrogenic structures may cause misinterpretations. With the increasing use of interventional procedures, one needs to be aware of such possible misinterpretations in order to avoid erroneous diagnosis and patient mismanagement.' Transoesophageal echocardiography is extremely sensitive in determining the presence and position of indwelling catheters in the heart.5 6 * References 1
2 3 4
Sajeev C, Krishnan M, Venugopal K An Unusual "Right Atrial Mass" on Echocardiography. Heart 2003;89:268. Feigenbaum H, Armstrong W, Ryan T. Feigenbaum's Echocardiography. Philadelphia, Lippincott Williams & Wilkins, 2005, p701. Fry S, Picard M, Tseng J, Briggs S, Isselbacher E. The Echocardiographic Diagnosis, Characterization, and Extraction Guidance ofCardiac Foreign Bodies. JAm Soc Echocardiogr2000;13:232-9. Yeo T, Miller F, Oh J, Freeman W. Retained Left Atrial Catheter: an Unusual Cardiac Source of Embolism Identified by Transesophageal Echocardiography. JAm Soc Echocardiogr 1998;11:6670.
Ncthcrands Heart Journal, Volume 13, Number 10, October 2005
5 6
Kingdon E, Holt S, Davar J, Pennell D, Baillod R, Bums A, et al. Atrial Thrombus and Central Venous Dialysis Catheters. Am J KidneyDis 2001;38:631-9. Gilon D, Schechter D, Rein A, Gimmon Z, Or R, Rozenman Y, et al. Right Atrial Thrombi are Related to Indwelling Central Venous Catheter Position: Insight Into Time Course and Possible Mechanism of Formation. Am HeartJ1998;135:457-62.
In this section a remarkable 'image' is presented and a short comment is given. We invite you to send in images (in triplicate) with a short comment (one to two pages at the most) to Bohn Stafleu van Loghum, P0 Box 246, 3990 GA Houten, e-mail: [email protected]. 'Moving images' are also welcomed and (after acceptance) will be published as aWeb Site Feature and shown on our website: www.cardiologie.nl
This section is edited byM.J.M. Cramer andjj. Bax.
371
