welcome to mastering and guide learning ultrasound and echo
hi everyone uh in this group of the lectures about the artifact normal variant and pathology,
I try to finish all the topics about this important issue that we dealing every day in echo
this group cover all artifacts, normal variant in transthoracic, trans- esophageal and 3D
The first one- this one- will be public but the other clips will be only for member group.
so, if you like it, please join us! let's do it The definition of artifacts uh are structures
in images that they are not real or they are in the wrong places in image.
based on the principle of the ultrasound they are the machine showed in the wrong place or the
echogenicity is not the same should be; or the shape or size of the image
and that structure has changed; or some part of the image has been missing
that is general uh different variant types of the artifacts.
but before we go to see the artifact each of them what are? let's go first
see normal variant that we have uh in some cases and it can confuse us with artifact or pathology
First of them is crista terminalis. crista terminalis is a muscular ridge
that extends from anterior of the superior vena cava to the anterior of the uh inferior vena cava
and all pectinate muscle insert from there to the atrioventricular groove and to the auricle.
this structure has smooth border (and surface) and very
hyper echo (echogenicity) as you can see here. in apical four (chamber) we see it at level of
anterior to in this apical is anterior to the IVC, is a smooth and hyperecho.
Here in short axis we can see that hyperecho. sometimes, this is another artifact
that later we talked about it, at this level we can see
or here you can see this part is uh close to the interatrial septum at this level
and close to the aorta and here right in the transesophageal we can see
anterior to the SVC that's hyperecho structure, smooth border and related to the
entrance of the SVC to the right atrium here in this one you can see Eustachian valve
on this case here you have in right side you can see the orientation exactly come from
anterior of the superior vena cava to the anterior of the inferior vena cava all the way here.
Another normal variant is eustachian valve that we called it sometimes IVC valve and Chiari network.
eustachian valve in less than five percent of the population we can see.
it is remaining of the fetus life that valve. the size of this valve will be different and
extended from the anterior of the IVC extent to the anterior fossa ovalis.
so the mechanism of having this uh valve in the fetus life is that guides
the blood flow that come from the placenta -that is oxygenated- goes more to the foramen ovalis
and go to the left side of the heart that is the point of uh developing this well.
but after birth uh most of the time this valve regressed and you don't see it.
but in less than five percent of people maybe you can see.
the size will be different the characteristic echocardiography of this valve
is that attached to the interior of the IVC is thin and floating and doesn't have any other
structure or any vegetation pattern or process outside
in some cases is long. very long; in some cases no.
in less than two to four, five percent sometimes ten percent of the people.
they think that the Chiari network is the same as the uh Eustachian valve that has been fenestrated
so it becomes like the fishing network and pattern and extended sometime from the
anterior to the interatrial septum close to the fossa ovalis, in some patient no.
and the feature echocardiography of that is flying a membranous shape that
sometimes it gives impression of the thrombosis, vegetation,
mass and all those stuff in those and in those cases that
fossa ovalis is opened we call it foramen ovalis it can cause paradoxical thromboembolism.
as you can see here the flail valve and connected to the interior of the IVC
here is mirror image of that part here we have x plane of the the same structure you can call
and here you can see the other side of the this valve that is here we can call it Chiari
most probably if you go different angle four chamber and connected to the interatrial septum.
here we have different pattern shape you can see sometimes they looks like the mass
but uh moving around and going the blood inside and outside and flaying and connected to the ivc
is the specific pattern and characteristic feature of the curing network here sometimes you can see
especially in applicable for or of access for chamber it extended from the close to the
IVC if you open it you can see it's attached to the IVC anterior and to the interatrial septum
and it impressed like the cor- triatrium uh but you can differentiate it- if you go
perpendicular you can see is fenestrated and blood goes through that in cor-triatrium
you will see only one hole that there is a turbulence from that hole
and i am going to talk about that in the pediatric echo
here we have different shape you can see flail moving like the membrane free uh flying inside
of the right atrium here is in transesophageal you can see just one flap as valve as anterior
of the eye we see or here at short axis of the PSAX you can see a small membrane shape come
from anterior of the IVC moderator band i talked on the anatomy of RV you can check on that clip
uh Lambl's excrescences uh this uh type of the we maybe we can call it normal variant but it's not
normal is a process of aging uh due to physical trauma tearing and all those blood turbulence
that cause an effect on the cooptation of the those valve especially left side because the
velocity is high and physical trauma is higher this type of the anomaly
form at an elder age and it looks like they've lint-like
process and mobile in echo uh that start originated at the coaptation area surface
it can be at the ventricle site or aortic site and the mitral valve usually at the atrial side
and they are uh usually one, sometimes two or sometimes many then stick together
and they can create a giant lambl's excrescence the feature of echocardiography is more clear on
TEE than we have to do on those cases especially there is any suspicions about endocarditis rule
out endocarditis we have to do TEE the another feature of this
process or strands are the lengths usually less than one centimeter and the thickness
is less than two millimeter they are very tiny and filament shape and if you magnify and zoom on the
TEE you can appreciate those lint-like process come small tiny fine process come out of that
uh there has been still some kind of discussion is if it can cause
thromboembolism or embolism systemic embolism and they recommend that in those patients with
the recurrent stroke or TIA if they have this type of their process maybe treatment indicate.
popular fibroelastoma or cardiac papilloma like the Lambl's excrescence is a vascular
mass or two more that arise from the endocardium in echocardiography it's characterized by
around small mobile hyper echo mass that attached to the endocardium with a small stock
here we have uh it can be happen in any part of the heart but usually an aorta is more common
than mitral valve and then tricuspid but it can happen any of those valves
on the CT-scan we will see a low density structure around at the level of the valve and in
gross anatomy it can be completely different but the shape specific is very
classic and typic sometimes they are very close like the giant lambl's excrescence
so the pathology helps uh which one is that .... this type of the mass can move and close
the ostimum (orifice) coronary artery. there are some report that this mass move
and close the orifice of coronary artery and cause heart attack
the differentiation of those two uh anomaly or normal variant -we can call
or better we call the valvular mass -with the vegetation is very challenging this
feature can help us to differentiate all those three from each other
but the clinical judgment is the most important- means beside of the echocardiography feature
the clinical pattern and blood culture is very critical to make a diagnosis
LV bands or left ventricle bands and
/or false tendon is a common finding and can been seen in half of the
normal heart in autopsy
based on the embryogenic embryogenic in this origin of the
lv bands they can be tendon or muscular tendon usually are transverse from the free wall to the
septum but it can be oblique or longitudinal or between the popular muscle or popularity muscle to
the wall the feature of the tendon or fast tendon is that during diastole it expand and stretch
and become tough rigid and during systole lose those cases that has a muscular band
can be confused uh for the pathology like the thrombosis or mass sometimes we have accessory
popularity muscle that is from the unusual origin and have a chordae tendinea that attached to their
mitral valve the contraction of that area that connected to the accessory popularity muscle or
muscular band can help differentiate it from the thrombosis because if there is thrombosis
it happen after myocardial infarction and that area should not contract and thickening but in
both cases -doesn't matter like here- you can see some hypoecho structure above the
apex we can see or here thickening. for making sure we have to do contrast
study and if still we are suspicious about it, performing CT-scan or MRI will be a wise choice
until the next time have a wonderful time