Cross-sectional Echocardiographic Characterization of Atelectatic Lung Segments
The diagnosis of extracardiac tumors is an important clinical application of the cross-sectional echocardiographic technique. In the present report we describe a unique series of patients who, during routine echocardiographic examination, were each noted to have a large echo-dense extracardiac mass adherent to the lateral aspect of the left ventricle. Although an extracardiac tumor was considered initially in the differential diagnosis of two of these patients, the echo- dense mass was shown subsequently to be an atelectatic segment of the left lower lobe of the lung. While the finding of atelectatic lung segments on routine echocardiographic examinations is not infrequent, such atelectatic lung segments are usually visualized as discrete, free-floating echo-dense masses, as opposed to masses that appear firmly adherent to the heart. Thus, the series of patients described herein represents, to the best of our knowledge, the first description of a pulmonary atelectatic lung mass simulating an extracardiac tumor. The salient diagnostic features of this new finding are discussed.
Case Reports
Case 1
A 72-year-old man with a history of a previous myocardial infarction and congestive heart failure presented with a three-week history of progressive dyspnea, orthopnea, and pedal edema. Physical examination disclosed a cachectic, chronically ill-appearing man in mild respiratory distress. Examination of the lungs disclosed decreased breath sounds at the bases with early inspiratory crackles. The chest roentgenogram at the time of hospital admission showed an enlarged cardiac silhouette, pulmonary vascular redistribution, and bilateral pleural effusions. His electrocardiogram revealed an old lateral myocardial infarction. levitra plus
FIGURE 1. Echo-dense extracardiac mass in a patient (patient 1) with a large left pleural effusion. Panel A shows a large echo-dense extracardiac mass (stippled area) adherent to the lateral aspect of the left ventricle. Although the echocardiographic “texture” of this mass was mostly solid, a small sonolucent area was observed in the upper right-hand aspect of the mass. A large left pleural effusion (PE) is also evident. Panel В illustrates a serial echocardiogram obtained in the same patient one day after the left pleural effusion was drained. This panel shows that the large echo-dense mass resolved coincident with the drainage of the left pleural effusion, confirming that the echo-dense extracardiac mass was an atelectatic segment of lung. Panel С depicts an echocardiogram obtained in the same patient several months after his initial discharge from the hospital. This panel shows that the echo-dense extracardiac mass and pleural effusion had reappeared. All echocardiographic studies were performed with an ATL M 6(XX) series machine, using a 3.0-mIIz medium-focus transducer. LA indicates left atrium; LV, left ventricle; RA, right atrium; and RV, right ventricle.
Hospital Course
An echocardiogram obtained on the first hospital day showed a dilated left ventricle and moderate left ventricular dysfunction with hypokinesis at the apex and midventricular anterolateral and posterolateral walls. Figure 1A shows that there was a large echo- dense mass adherent to the midventricle, which during examination in real-time, moved in synchrony with the motion of the heart. Angulated sweeps of the echocardiographic transducer did not demonstrate that the mass was contiguous with any mediastinal structures. As shown in Figure 1A, the mass was solid with a brightly reflective ground-glass appearance. Although no direct intramyocardial infiltration was apparent, the myocardial segments beneath the mass were in fact hypokinetic, raising the possibility that the mass had infiltrated into the myocardium. Further, there was no discernible cleai-cut pericardial stripe between the mass and the ventricular wall. A computed tomographic (CT) scan of the chest was obtained to more fully delineate the interface between the echo-dense mass and the heart. As shown by the CT scan in Figure 2, the mass was solid in appearance with compressed air bronchograms radiating out from its center; these findings were believed to be consistent with “passive” atelectasis of the lung. Subsequent to this the patient underwent a left thoracentesis and a repeated echocardiographic examination. Figure IB shows that the echo-dense mass disappeared following drainage of the pleural effusion and reexpansion of the lung.
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FIGURE 2. Computed tomographic (CT) scan of the thorax in a patient with a large echo-dense mass. The CT scan shown in this figure was performed in patient 1 shortly after the cross-sectional echocardiogram shown in Figure 1A was obtained. This CT scan suggested that the large extracardiac mass adherent to the lateral aspect of the left ventricle was most consistent with an atelectatic segment of lung. Thus, in this figure, the pleural surface of the atelectatic segment of lung abutted the pericardium. A large left pleural effusion is also evident. LA indicates left atrium; LV, left ventricle; M, extracardiac mass; PE, pleural effusion; RA, right atrium; and RV, right ventricle.
