Introduction: The large-scale availability of transtho-racic echocardiography in examining an increasing number of patients also unmasked the high incidence of newly discovered intra-cardiac masses. However, due to technical reasons or patients particularities, the de-scription of these intra-cavitary formations cannot be properly performed by transthoracic echocardiography alone. For this reason, in these patients with uncertain diagnosis, transesophageal echocardiography becomes the exploration that can determine the correct diagno-sis and the subsequent therapeutic approach
Methods: We present the cases of three patients admitted to the Cardiology Clinic, where the final diagnosis based on transesophageal echocardiography was completely different from the initial diagnosis, from admission, determined by classical, transthoracic echocardiography. The first case was that of a patient who suffered a subarachnoid haemorrhage with consecutive hydrocephalus for which a ventriculo-atrial shunt was placed, also with a history of bacterial endocarditis of tricuspid valve. The patient experienced progressive dyspnea atrest, chest pain and intermittent fever. Initial transthoracic echocardiography revealed an extremely mobile mass in the right atrium, without being able to specifyits exact origin or place of insertion. In addition, severe pulmonary hypertension and major tricuspid regurgitation have been reported. Computed tomography also revealed bilateral pulmonary thromboembolism.Clinical characteristics and echocardiographic aspects suggested a possible infectious endocarditis of the tricuspid valve, therefore a transesophageal echocardiography was required, revealing the presence of a ~ 40mm longish mass, inserted in the inter-atrial septum, near the opening of superior vena cava in the right atrium, without any link to the tricuspid valve. Basically, the mass described was a thrombus formed as an endoluminal mold of the catheter used for the drainage of cerebro-spinal fluid. The second case was that of a patient with multiple cardiovascular risk factors who presented for a routine control. Initial transthoracic echocardiography revealed the presence of an immobile mass in the right atrium, possibly a thrombus or a tumor. To clarify the diagnosis, a transesophageal ultrasound was required, revealing a hypertrophic crista terminalis. Th is formation is a fi bro-muscular bridge formed by the junction of the venous sinus with the primitive atrium, in the adult virtually delimiting the atrial wall from the right atrial appendage. Th e third case was that of a patient with a history of atrial fi brillation, without anticoagulant treatment at home, who presented for symptoms of heart failure. Transthoracic echocardiography revealed a 25/35 mm, seemingly mobile, well-defined mass at the left atrium level, the suspicion being that of an atrial mixoma.
When transesophageal echocardiography was performed, it was revealed that the mass initially described had thrombus characteristics, located on the septal wall of left atrium and associating left appendage thrombosis. Taking into account that the formations had the same homogeneous appearance in multiple atrial sites, with no other signs advocating for the mixoma, the final diagnosis was the left intra-atrial thrombus.
Conclusions: In conclusion, transesophageal ultra-sound has once again proved its central role in the approach of any patient presenting an intra-cardiac mass, providing accurate anatomical data. Correct di-agnosis of intra-cavity masses has major therapeutic implications, whether we are talking about optimizing anticoagulant treatment in a patient with extensive left-atrial thrombosis or initiating it in a patient with ven-triculo-atrial shunt thrombosis. Also, transesophageal ultrasound has been able to avoid further expensive explorations or the initiation of an unnecessary anti-coagulant treatment in the patient with hypertrophy of crista terminalis.