CASE REPORT |
https://doi.org/10.5005/jp-journals-10034-1135 |
Intraoperative Transesophageal Echocardiography Diagnosis of a Left Ventricular False Tendon Mimicking a Left Ventricular Mass: A Case Report
1Department of Anesthesia and Intensive Care, Army Hospital (Research and Referral), Delhi, India
2Department of Anaesthesiology and Critical Care, Army Hospital (Research and Referral), Delhi, India
3Department of Anaesthesiology & Critical Care, Armed Forces Medical College, Pune, Maharashtra, India
4Department of Anaesthesia, Armed Forces Medical College, Pune, Maharashtra, India
Corresponding Author: Alok Kumar, Department of Anesthesia and Intensive Care, Army Hospital (Research and Referral), Delhi, India, Phone: +91 8146044104, e-mail: mipayal07@gmail.com
Received: 29 September 2023; Accepted: 13 December 2023; Published on: 20 February 2024
ABSTRACT
Background: Left ventricle false tendons (LVFTs) are discrete and relatively rare, fibromuscular structures of varying length and thickness that traverse the left ventricle (LV) cavity. Routine transthoracic echocardiography (TTE) is the commonly used diagnostic technique to diagnose and evaluate LVFT.
Case description: Thickened LVFT not oriented in either longitudinal or transverse fashion was misdiagnosed as a case of LV mass on two-dimensional (2D) echo and cardiac magnetic resonance index (MRI) in a young patient. He was listed for excisional surgery. Preoperative transesophageal echocardiography (TEE) revealed it to be LVFT and the surgery could be averted.
Conclusion: Though TTE and cardiac MRI are the commonly used diagnostic techniques to diagnose and evaluate cardiac masses, TEE provides superior image resolution and better visualization of cardiac masses.
How to cite this article: Kumar A, Joshi A, Devarakonda BV, et al. Intraoperative Transesophageal Echocardiography Diagnosis of a Left Ventricular False Tendon Mimicking a Left Ventricular Mass: A Case Report. J Perioper Echocardiogr 2021;9(2):45–47.
Source of support: Nil
Conflict of interest: None
Patient consent statement: The author(s) have obtained written informed consent from the patient for publication of the case report details and related images.
Keywords: Cardiac mass, Case report, Left ventricular false tendon, Transesophageal echocardiography, Transthoracic echocardiography
INTRODUCTION
Left ventricular (LV) masses are a rare echocardiographic finding in the asymptomatic general population without any known cardiac illness. With careful attention to its morphology, location, and relevant application of clinical information, echocardiography can distinguish between the various LV mass lesions. We present the case of a young healthy male with an LV mass detected during echocardiographic evaluation for an episode of syncope presenting for surgical excision.
CASE DESCRIPTION
A 34-year-old healthy male, without any known comorbidities, presented to the emergency department in a peripheral hospital after experiencing a brief episode of syncope. The patient was walking during the episode. He denies sudden exertion, chest pain, shortness of breath, palpitations, or neurologic deficits before the event. He denied recent dieting, use of over-the-counter or illicit drugs, and any significant past illness. On examination, vital parameters were normal. Biochemical and hematologic parameters were found normal. The 12-lead resting electrocardiogram (ECG) showed sinus rhythm with no signs of early repolarization or conduction abnormalities. Two-dimensional (2D) transthoracic echocardiography (TTE) at the tertiary care center was suggestive of LV apical mass without any evidence of valvular abnormality, outflow tract obstruction/turbulence, or LV regional wall abnormalities. There was no evidence of any mass in any other cardiac chamber. There were no neurological deficits, features of systemic embolization, or biochemical features of metastatic spread from the unknown primary tumors (carcinoembryonic antigen was negative). Further evaluation by cardiac magnetic resonance index (MRI) was suggestive of papillary fibroelastoma of the interventricular septum with a differential diagnosis of cardiac myxoma (Fig. 1) and the patient was posted for surgical excision at our cardiac center.
Fig. 1: Cardiac MRI image showing a pedunculated mass arising from the interventricular septum
Intraoperative transesophageal echocardiography (TEE) using an S7-3t TEE probe with Philips iE33 ultrasound system (Philips Ultrasound, Bothell, Washington) soon after anesthetic induction demonstrated a band-like structure measuring about 4 × 1 cm, with the same echogenicity as the surrounding myocardium, extending from the LV free wall near apex to the mid-basal anteroseptal LV segment with an echo-free space on either side (Fig. 2 and Video 1). The origin and the insertion of this band-like structure were found to be continuous with the LV wall without any evidence of wall motion abnormality (Video 2). The entire length of this structure, seen traversing the entire ventricular cavity, could not be imaged completely in any single conventional TEE view (Video 3). However, there was no evidence of a freely floating edge in the ventricular cavity in any of the TEE views. There was no echocardiographic evidence of any relation to the mitral or aortic valvular structure, associated valvular dysfunction, LV outflow tract obstruction, or ventricular dysfunction. Systolic laxity of the structure could not be demonstrated conclusively as the mass disappeared from the echocardiographic view during some part of the cardiac cycle. A type-4 LV false tendon, extending from the LV free wall to the ventricular septum, was considered highly possible given the benign clinical presentation and suggestive echocardiographic features. Given the intraoperative TEE features suggestive of this benign structure without any obstructive features, the planned surgical intervention was abandoned. The patient had an uneventful recovery from anesthesia to tracheal extubation with an uneventful course till hospital discharge. He has been on regular follow-ups and has been asymptomatic without any functional limitation for >1 year now.
Figs 2A and B: (A) TEE image showing part of the band-like structure arising from the interventricular septum to LV free wall in mid-esophageal LV two-chamber view; (B) TEE image showing the full length of the band-like structure arising from the interventricular septum to LV free wall in transgastric LV long axis view
Informed consent has been taken from the patient for the publication of this case report.
DISCUSSION
Intraoperative TEE has been shown to alter the surgical management in the operating room.1 LV masses are rarely detected in asymptomatic individuals. However, all symptomatic patients with LV mass should be evaluated for a thrombus, vegetation, tumor, or hypertrophied papillary muscle.2,3 LV false tendons (LVFT) are considered benign anatomic variants that can be mistaken for LV mass.4 However, patients with LVFT have been reported to suffer a higher incidence of heart failure, reduced systolic function, diastolic dysfunction, and mitral regurgitation.5
Left ventricle false tendons (LVFTs) are thin, discrete, cord-like fibromuscular bands that connect either two walls or papillary muscle to the interventricular septum without connecting to the mitral leaflets.4 They are remnants of the inner trabecular myocardial layer but differ from the trabeculations by traversing the ventricular cavity found in more than half of the hearts examined during autopsy. Described first as a heart with a moderator band in the LV by Turner,6 they have been detected during the evaluation of patients for murmurs and arrhythmias. LVFTs can be single or multiple and can be classified into transverse, diagonal, or longitudinal types depending on the relation to the long axis of the left ventricle. Luetmer et al. classified LV false tendons into five types based on attachments to the LV structures and orientation to the LV long-axis.7
Left ventricle false tendon (LVFT) 2D echocardiographic prevalence ranging from 0.4 to 61% has been reported.7 These anatomical variants should not be mistaken for subaortic membranes, papillary muscles, thrombus borders, trabeculations, or septal hypertrophy.4 The echocardiographic features of LVFT include a linear structure traversing the ventricular cavity, systolic laxity, and attachment to the LV wall without any demonstrable free-floating end and any attachment to the mitral valve.4 The turbulence of the LV flow and mitral regurgitation have been described to be associated with LVFT. The possibility of a papillary muscle was unlikely since both ends of the structure were attached to the ventricular wall. Systolic laxity could not be demonstrated in the present case as the structure disappeared from the echocardiography view during some part of the cardiac cycle.
Preoperative echocardiography has a sensitivity and specificity of 82 and 85% in detecting false tendons.4 Off-axis imaging instead of conventional imaging planes is better suited for the detection of LVFT.8 Despite TTE being an excellent diagnostic technique to evaluate and diagnose cardiac masses, TEE may provide better image resolution and superior visualization of such cardiac masses due to multiplane imaging of posterior structures in the near field at multiple levels and is unhindered by chest wall structures. The present case describes intraoperative TEE imaging which resulted in avoiding a surgical intervention for this condition.
Although LVFTs have generally been considered benign anatomic variants, numerous disease associations have been reported in the literature. These include an increased prevalence of precordial murmurs, repolarization abnormalities on the resting ECG, preexcitation, ventricular arrhythmias,9 mitral regurgitation, and a dilated left ventricle.5 LVFT is associated with the development of membrane formation in discrete subaortic stenosis.4 A slightly higher incidence in pathologic than in normal hearts, a higher male preponderance, association with LV hypertrophy, and systolic dysfunction have been described.4 The reported patient, presently on regular follow-up, has been asymptomatic without any functional limitation in the last year.
CONCLUSION
The LVFT is an uncommon benign anatomic variant seen in most asymptomatic patients and is identified by distinct echocardiographic features that are useful to differentiate it from other causes for LV mass. Intraoperative TEE for evaluation of intracardiac mass should include assessment in multiple views, both during systole and diastole considering various possibilities of a tumor, thrombus, or an abnormal papillary muscle by assessment of echocardiographic features in conventional views and off-axis planes. Careful intraoperative TEE evaluation soon after anesthetic induction in a case of LV mass resulted in the echocardiographic diagnosis of LVFT avoiding the need for a major surgical intervention.
Supplementary Material
The supplementary videos 1 to 3 are available online on the website of www.jpecardio.com
Video 1: TEE view in transgastric LV long axis views showing a band-like structure arising from the myocardium
Video 2: TEE view in transgastric LV short axis view showing a band-like structure arising from the myocardium
Video 3: TEE view in mid-esophageal LV two-chamber view showing a band-like structure arising from the myocardium
ORCID
Alok Kumar https://orcid.org/0000-0002-2037-2173
Bhargava V Devarakonda https://orcid.org/0000-0002-5574-9188
Gurpinder S Ghotra https://orcid.org/0000-0002-7944-0214
REFERENCES
1. Badamali AK, Madhavan JS, Ghuman BPS, et al. Routine intraoperative transesophageal echocardiography: impact on intraoperative surgical decision making, a single center interim analysis. J Perioper Echocardiogr 2013;1(1):16–20. DOI: 10.5005/jp-journals-10034-1002
2. Peters PJ, Reinhardt S. The echocardiographic evaluation of intracardiac masses: a review. J Am Soc Echocardiogr 2006;19(2):230–240. DOI: 10.1016/j.echo.2005.10.015
3. Thingnum SS. Hypertrophied papillary muscle causing mid cavity left ventricular obstruction after cardiac surgery. J Perioper Echocardiogr 2015;3(1):32–34. DOI: 10.5005/jp-journals-10034-1033
4. Silbiger JJ. Left ventricular false tendons: anatomic, echocardiographic, and pathophysiologic insights. J Am Soc Echocardiogr 2013;26(6):582–588. DOI: 10.1016/j.echo.2013.03.005
5. Hall ME, Halinski JA, Skelton TN, et al. Left ventricular false tendons are associated with left ventricular dilation and impaired systolic and diastolic function. Am J Med Sci 2017;354(3):278–284. DOI: 10.1016/j.amjms.2017.05.015
6. Turner W. Another heart with moderator band in left ventricle. J Anat 1896;30:568–569. PMID: 17232219.
7. Luetmer PH, Edwards WD, Seward JB, et al. Incidence and distribution of left ventricular false tendons: an autopsy study of 483 normal human hearts. J Am Coll Cardiol 1986;8(1):179–183. DOI: 10.1016/s0735-1097(86)80110-3
8. Kervancioglu M, Ozbag D, Kervancioglu P, et al. Echocardiographic and morphologic examination of left ventricular false tendons in human and animal hearts. Clin Anat 2003;16(5):389–395. DOI: 10.1002/ca.10152
9. Madhavan M, Asirvatham SJ. The fourth dimension endocavitary ventricular tachycardia. Circ Arrhythmia Electrophysiol 2010;3(4):302–304. DOI: 10.1161/CIRCEP.110.958280
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