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Endocarditis | Masses | PE 

Two of the suggested targets of the focused cardiac ultrasound (FoCUS) involve the detection of large intracardiac masses which makes reference to large valve vegetations or visible intracardiac or inferior vena cava thrombi. The second portion is the detection of valvular abnormalities recognizable with FoCUS (without the use of Doppler-based techniques) which entail leaflet or cusp massive disruption or marked thickening, flail, or anatomic gaps. Here we focus on the detection of visible vegetations or masses and the use of FoCUS in the management of patients with pulmonary embolism. 


Endocarditis and Masses

Infective endocarditis can be recognized as masses arising from upstream valvular structures. This means that they would appear on the atrial side of the atrioventricular valve. While a large vegetation may be easy to spot on 2D ultrasound, another smaller mass and it associated functionality deficit (valve failure or surrounded support) may be difficult to see on FoCUS. The general recommendation is that if there is clinical suspicion and on examination there is a nondiagnostic screening study, proceeding with a comprehensive examination would be prudent.  Our primary goal is to screen for catastrophic or severe failure of the valve on 2D imaging. These can be seen as large oscillating masses on a valve or its supporting structure or on a foreign device 

Endocarditis could be mistaken in patients who have Lambl's excrescences (idiopathic linear mobile structures on the downstream side of AV), previously treated infective endocarditis and nonbacterial thrombotic endocarditis (secondary to antiphospholipid syndrome, SLE and others). It may not be straightforward to distinguish infective endocarditis from one of these. If there is clinical suspicion for endocarditis, further examination may include Transesophageal Echocardiography (TEE) which improves the image resolution when interrogating the valve

Normal Parasternal Long Axis View

On this view we can appreciate a large mass that appears attached to the posterior mitral valve and on the atrial side of the valve. On this clip it is difficult to differentiate morphologically between the valve and the mass. This mass is also attached to the base of the valve.

On the following clips we can appreciate normal findings with that of a patient who has a pacemaker wire. On the wire there is a mass or thrombus that move in and out of right atrium and ventricle. This is more apparent on the apical 4 chamber view below.





Masses. Clips 1 and 3 act as reference. Clips 2 and 4 with a mobile mass on the RV. 

On the IVC view below (Clip 2), we can observe a mass or thrombus on the right atrium with a dilated and barely collapsible IVC. This mass also appears mobile.  Compare that to an IVC view without a mass in Clip 1 below: