956 Image Focus IMAGE FOCUS doi:10.1093/ehjci/jey063 Online publish-ahead-of-print 10 April 2018 .................................................................................................................................................... A slowly growing mass in the left chest wall: additive value of real time myocardial contrast echocardiography Ramasamy Manivarmane*, Rajdeep S. Khattar, Saeed Mirsadraee, Neil Moat, and Roxy Senior Department of Echocardiography, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK * Corresponding author. E-mail: email@example.com An 81-year-old man with mitral valve repair in 2005, developed worsening mitral regurgitation and underwent trans-apical mitral valve replacement with a 26 mm Sapien tissue valve 12 years later. Two months following the procedure, he was admitted with a left pleural effu- sion, which was drained. A further 8 weeks later, he noted a gradually enlarging, painful soft tissue swelling over the left lateral chest. A contrast-enhanced computed tomography (CT) scan of the thorax demonstrated a soft tissue lesion consistent with a haematoma over- lying the left ventricular (LV) apex and extending into the chest wall but no active contrast extravasation was demonstrated (Panel A). Subsequent cardiac magnetic resonance (MR) imaging showed the collection around the LV apex mostly contained around the pericardium but some amount extending into the intercostal space and chest wall (Panel B). Transthoracic echocardiography also demonstrated a sus- pected mass around the LV apex. None of the imaging modalities were able to confirm the precise source of the probable haematoma. A myocardial contrast echocardiogram (Panel C and D) was then performed, which clearly demonstrated isolated microbubbles escaping from the LV apex into the surrounding mass in the chest wall (see Supplementary data online, Video S1). The patient was managed conserva- tively and follow-up echocardiograms showed a reduction in bubble extravasation and resolving haematoma. This case highlights the novel use of real time myocardial contrast echocardiography in delineating the bleeding point and visualizing the continued extravasation of blood into a slowly growing haematoma from the LV cavity through the apex and into the surrounding thorax. Multimodality imaging of the LV apex and surrounding tissues. (Panel A) Contrast enhanced CT scan of the chest showing a haematoma overlying the LV apex (long arrow) and extending in to the chest wall (arrows). (Panel B) Cardiac MR image of the two-chamber view with gadolinium contrast showing a contrast filled mass around the LV apex and intercostal space (arrows). (Panel C) Low mechanical index myo- cardial contrast echocardiogram in a zoomed apical four-chamber view showing a soft tissue space overlying the LV apex (arrow) and (Panel D) which slowly fills with microbubbles (arrow). Supplementary data are available at European Heart Journal - Cardiovascular Imaging online. Acknowledgements We would like to thank Cathy West for her assistance with acquisition of the echocardiographic images. Published on behalf of the European Society of Cardiology. All rights reserved. V The Author(s) 2018. For permissions, please email: firstname.lastname@example.org. Downloaded from https://academic.oup.com/ehjcimaging/article-abstract/19/8/956/4965900 by Ed 'DeepDyve' Gillespie user on 24 July 2018
European Heart Journal – Cardiovascular Imaging – Oxford University Press
Published: Apr 10, 2018
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