Guinness Book of Echo I

It is part of human nature to be fascinated by extremes, by the unusual or the bizarre. Why should it be different in echocardiography? One of my passions is to collect such cases, as others would collect stamps or beer coasters. Today I want to share some of these images with you. You will be astonished, and will also learn to interpret these findings. Here is the first example:

STEMI disaster

The following echo was taken from a 32-year-old man who ignored his symptoms of anterior infarction. When we saw him at the hospital his echo was as follows:

Huge anterior aneurysm after anterior myocardial infarction.

This is certainly a huge aneurysm. Its length was 7 cm and its width 6 cm. This is what happens when you have a large LAD with a proximal occlusion and no collateral flow. If you want to read up on this case, click here.

Almost popping

Another 32-year-old man received a mechanical aortic valve in Romania 5 years ago. He must have had a bicuspid valve because the aorta is highly predisposed to aneurysm in this setting:

Aortic aneurysm in a patient with aortic valve replacement. The diameter is 8.5 cm.

We do not know how large the aneurysm was at surgery. Now it measures 8.5 cm! The patient was lucky it didn’t rupture. Fortunately we solved the problem and he received a tube graft of the aorta. Remember, aortic surgery should be performed when the aorta measures 5-6 cm, especially when the patient has an underlying connective tissue disease (i.e. Marfan or Ehlers Danlos syndrome).

Completely filled

The next case is that of an elderly lady who presented with recurrent syncope. What a surprising finding. No wonder she fainted. The entire left atrium was filled with a mass that also caused left ventricular inflow obstruction. In very rare cases you will find a mass of this size in the left atrium (7.2 x 4.3 cm).

Large left atrial myxoma that fills the entire left atrium.

If you want to see another example of a much smaller myxoma, check out our blog entry entitled "Surprise". The appearance of the mass, which was attached to the interatrial mass, is very typical of myxoma. As the patient has normal left ventricular function and is in sinus rhythm, a thrombus is very unlikely. The myxoma was confirmed at surgery.

Clogging the valve

Here is another patient with a myxoma - this time in the right atrium. Incredibly, this was an incidental finding. However, in retrospect the patient did have dyspnea:

Huge right atrial myxoma causing tricuspid valve stenosis.

Myxomas are usually found in the left atrium, but may appear at other sites in the heart as well - including valves and ventricles. This myxoma protrudes into the right ventricle and causes functional tricuspid stenosis. Note that the ventricles are “underfilled” because of flow obstruction.

Where is the ventricle?

Here is a rather sad case: a 25-year-old woman with a history of a synovial sarcoma of the arm. We found the tumor when investigating the patient. Note that the entire right ventricle is filled with the tumor:

Metastasis of a synovial malignancy occupying the entire right ventricle. Short-axis view.

This again is an example of how tumors can lead to obstruction and obliteration. The entire right ventricle is filled with tumor masses. Its echogenicity is inhomogeneous. There is a small pericardial effusion. This points to a malignant etiology. One of the key features of malignant tumors is invasive and expansive growth. Look for these aspects when the tumor is present in more than one chamber and is somehow “passing” through the wall. In such cases you can be quite certain of malignant disease.
In a heroic act, we sent her to surgery for excision of her primary as well as secondary malignancy. She underwent chemotherapy and radiation, but died of right ventricular failure shortly after the operation.

The Guinness collection

These are just a few cases which would fit into a Guinness Book of Echo. Be sure to check your mailbox for a sequel.
If you have any peculiar echoes, just send them to us with a short description of the case, a photograph of yourself, and a few lines about your work setting.

Best wishes,


PS: Probably any echo novice will be able to point out that there's something wrong in the echos I showed you today. However, if you want to be able to recognize even the most subtle abnormality using echo, then check out our Echo MasterClass. It's the fastest way of becoming an echo expert....someone that others rely on and look up to.