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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 7  |  Issue : 5  |  Page : 288-292

Point-of-care ultrasound in pediatric cardiac masses: A case series


Department of Pediatric Critical Care, Bai Jerbai Wadia Hospital for Children, Mumbai, Maharashtra, India

Date of Submission10-Jun-2020
Date of Decision05-Aug-2020
Date of Acceptance18-Aug-2020
Date of Web Publication14-Sep-2020

Correspondence Address:
Dr. S Sachin Jangam
Shivkrupa Niwas, Plot No - 19, Ashtha Bypass, Madhavnagar Road, Kalanagar, Sangli - 416 416, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JPCC.JPCC_61_20

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  Abstract 


The utility of point-of-care ultrasound (POCUS) is well supported by evidence In the Indian scenario, there are no standard guidelines or special training for POCUS in the pediatric intensive care unit. We present here a case series of nine patients with intracardiac masses in whom POCUS performed by pediatric intensivist helped in the management of critically ill patients. The final diagnosis of these patients included left atrial myxoma, two cases of thrombus, four cases of infective endocarditis (IE) with unusual organisms, and two cases with diagnostic confusion about IE/thrombus/cardiac tumor. In all these patients POCUS helped in deciding the line of management such as choice of antimicrobial therapy, site of the central venous catheter, and timely involvement of cardiologist and cardiothoracic surgeon. One of the children presented with obstructive shock and bedside ultrasound helped in the diagnosis of a left atrial mass and early surgery with a good outcome.

Keywords: Cardiac masses in pediatric patients, infective endocarditis, point of care ultrasound


How to cite this article:
Jangam S S, Lakshmi S, Jayashree M, Rekha S, Nakul P. Point-of-care ultrasound in pediatric cardiac masses: A case series. J Pediatr Crit Care 2020;7:288-92

How to cite this URL:
Jangam S S, Lakshmi S, Jayashree M, Rekha S, Nakul P. Point-of-care ultrasound in pediatric cardiac masses: A case series. J Pediatr Crit Care [serial online] 2020 [cited 2020 Sep 23];7:288-92. Available from: http://www.jpcc.org.in/text.asp?2020/7/5/288/295022




  Introduction Top


Point-of-care ultrasound (POCUS) is emerging as a reliable and valid tool for clinicians for bedside diagnosis, clinical decision-making as well as timely intervention for optimum patient management. Recently, the American Academy of Pediatrics, in its policy statement, recommended the establishment of training and credentialing programs for POCUS to improve the care of pediatric patients.[1] The technological advances in the field of ultrasound have made it easier to provide POCUS by first responders. The smaller size and easy portability of ultrasound machines coupled with a better understanding of ultrasound techniques and improvements in imaging quality have made it possible to use ultrasound as a great tool of examination. In the context of neonatology, it has been already widely adopted tool for neurosonogram and neonatal two-dimensional echocardiogram.[2] The areas where the point of care sonography routinely used in pediatric intensive care units (PICUs) are for fluid responsiveness, preload estimation, lung ultrasound, intracranial pressure monitoring, functional 2 d echo for cardiac contractility, cardiac output, and detection of pleural and pericardial effusion. Furthermore, ultrasound-guided central line placement, pericardiocentesis, or thoracocentesis is now standard of care.[3] The advantages of POCUS include rapid detection of problems and timely intervention which can be done at the bedside in patients who cannot be moved to the cardiology or radiology department because of their critical condition.[4]

The concept of POCUS in pediatric intensive care with intracardiac masses is more compelling than its use in adults because pediatric cardiology itself is in budding shape in India and children are more likely to succumb to the disease process if the diagnosis and timely involvement of respective specialist is not done in time.

We present a case series including nine patients with intracardiac masses from Bai Jerbai Wadia Hospital for Children, Mumbai diagnosed over 2½ years (January 2017–May 2019) in whom POCUS played a major role in diagnosis and management. The patients were diagnosed to have atrial myxoma, cardiac thrombus, bacterial, and fungal infective endocarditis (IE). In all these case POCUS helped us in the diagnosis and management of patients before a cardiology reference could be made.


  Case Report Top


Case 1

A 45-day-old male infant was admitted with severe respiratory distress with oxygen saturation of 90% on oxygen with hood. He had a low pitched rumbling mid-diastolic murmur and required ventilator support for respiratory failure. Chest X-ray showed bilateral pulmonary plethora and bedside POCUS showed large left atrial mass measuring 15 mm × 15 mm causing almost complete obstruction to blood flow across the mitral valve [Figure 1] which was confirmed by a pediatric cardiologist. Because of pulmonary edema refractory to medical line of management the cardiothoracic surgeon was involved and the patient underwent removal of mass under cardiopulmonary bypass. POCUS helped in the detection of obstructive cardiac mass leading to timely surgical intervention. Histopathological examination revealed atrial myxoma. Postsurgery patient was stable and was discharged 2 weeks later.
Figure 1: A 45-day-old infant with refractory pulmonary edema

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Case 2

A 18-month-old boy, known case of nephrotic syndrome with documented episode of bacterial peritonitis and shock 2 months earlier was admitted with respiratory failure and shock. He required ventilator support along with fluid resuscitation and inotropic support. POCUS showed a mobile right atrial mass [Figure 2]. It was decided to place a central venous catheter in the femoral vein rather than the internal jugular vein (IJV) so that mass could not be disturbed or dislodged. With the differential diagnosis of IE and thrombus, the patient was treated with appropriate antibiotic therapy (meropenem and vancomycin) and low molecular weight heparin (LMWH). Detection of cardiac mass in this helped us to decide the site of the central line, collection of the appropriate number of blood culture for IE, and also to start LMWH and proper antibiotics. Complete disappearance of mass on follow-up 2 D Echo and the presence of predisposing factor (IJV catheter during first admission and nephrotic syndrome) pointed toward the possibility of it being intracardiac thrombus.
Figure 2: A 18-month-old child with nephrotic syndrome with right atrial mass

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Case 3

A 12-year-old boy who was a known case of end-stage renal disease awaiting renal transplant was admitted to PICU with respiratory failure. At the time of admission, he had left IJV dialysis catheter. POCUS showed right atrial mass measuring 13 mm × 14 mm at the tip of the catheter suggestive of thrombus or vegetation. He was started on Piperacillin-Tazobactum, vancomycin, fluconazole, and LMWH empirically. The patient improved to the above treatment and was eventually extubated on the 6th day of admission. Cardiothoracic and vascular surgeon was involved after stabilization and advised removal of mass by open heart surgery but his parents opted for medical management. He was listed for renal transplant but the child succumbed to his illness after 6 months.

Case 4

A 12-year-old boy diagnosed to be have acute myeloid leukemia (M2-Stage) on chemotherapy developed febrile neutropenia. He was started on Piperacillin-Tazobactum, vancomycin, amikacin, and fluconazole. On the day 4, he developed shock and was shifted to PICU. POCUS showed hypoechoic mass measuring 4 cm in the right ventricle [Figure 3]. As this child had an immunocompromised state differential of the fungal ball was considered and was started on a parenteral antifungal (voriconazole and amphoterecin B). The mass was removed by open heart surgery and biopsy confirmed as mucormycosis [Figure 4]. Hence in this case, POCUS helped us in considering antifungal drugs and the involvement of cardiologist and cardiothoracic surgeon in time. Despite all medical and surgical management child succumbed on the 10th day of admission.
Figure 3: A 12-year-old child with acute myeloid leukemia and prolonged fever. Subcostal view: right ventricular mass

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Figure 4: Histopathology of mass in the right ventricle from a 12-year-old boy with acute myeloid leukemia: mucormycosis

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Case 5

A 3½-year-old male child was admitted with a history of fever, breathing difficulty, and convulsions. The central nervous system examination revealed left hemiparesis with left side upper motor neuron type of facial palsy. He had a history of unsuccessfully attempted ventricular septal defect (VSD) device closure 9 months earlier. POCUS echo showed the presence of VSD along with vegetations over anterior leaflet of the mitral valve. Appropriate blood cultures were collected and the patient was empirically started on LMWH for suspected thrombus as well as antibiotics for IE. Blood culture grew rapidly growing nontuberculous Mycobacteria. Magnetic resonance images (MRI) of the brain showed nonhemorrhagic infarct. The patient was started on clarithromycin, linezolid, rifampicin ethambutol, and ofloxacin after infectious disease expert consultation. He was stabilized and was transferred to ward with neuro deficit after 2 weeks; he had a complicated hospital course and died of septic shock 2 months later.

Case 6

A 10-year-old boy was admitted with pneumonia and septic shock. He had a history of multiple admissions since 1 year of age and was diagnosed case of hyper immunoglobulin M syndrome with failure to thrive. He had chronic diarrhea, chronic eczema, chronic suppurative otitis media, hepatomegaly, and iron deficiency anemia. POCUS showed 1.2 cm × 1.2 cm hyperechoic mobile mass attached to interventricular septum near the apex of the left ventricle. His blood cultures were sterile. Dilemma remained whether it was culture-negative IE, thrombus, or cardiac tumor. On the 3rd hospital day, he developed sudden respiratory distress which rapidly progressed to cardiopulmonary failure and he died within 3 h.

Case 7

A 15-month-old girl was admitted to the intensive care unit with severe respiratory distress due to pneumonia with empyema and congestive cardiac failure. She was a diagnosed case of large patent ductus arteriosus. There had been a failed attempt at device closure 3 months earlier. POCUS showed 11 mm × 10 mm vegetation over the tricuspid valve with severe tricuspid regurgitation and severe hyperkinetic pulmonary artery hypertension. She was started on LMWH considering thrombus and antibiotics for IE. Her blood culture was sterile but pleural fluid grew pseudomonas aeroginosa. The patient expired 22 days after admission.

Case 8

A 2-year-old male child was admitted with refractory shock. POCUS found mitral valve vegetations along with pyopericardium and small VSD. Here, the presence of pyopericardium with vegetations pointed toward the possibility of IE more than thrombus, so he was treated with ceftriaxone and vancomycin. However, had a fulminant course and died within 5 days of admission. His blood culture and pericardial fluid grew vancomycin-resistant Staphylococcus aureus (VRSA).

Case 9

A 9-year-old boy known case of dialysis-dependent chronic kidney disease was admitted with cardiogenic shock with multiorgan failure. POCUS showed a right ventricular mass of 1.4 mm × 1.2 cm mass attached to the right ventricle wall towardthe apex with an ejection fraction of 15%–20%. He was stabilized and discharged. His blood culture was negative and his cardiac mass responded to LMWH. He is listed for renal transplant.


  Discussion Top


In our case series we had one child with atrial myxoma, two with intracardiac thrombus, five with IE (of which four were culture positive) and dilemma remained in one patient whether it was thrombus or IE or cardiac tumor. POCUS helped in their timely detection of cardiac mass and had a significant impact on clinical decision-making such as choice of drug (LMWH or drugs for IE), site of the central line, and a further line of management like earlier involvement of cardiac surgeons. A recent retrospective study showed a similar utility of bedside echocardiography.[5] In this study out of 424 patients admitted in PICU 101 had a clinical indication for transthoracic echocardiograms and out of these 82 (81.8%) patients had new findings that significantly impacted the clinical decision of patient management, namely, alteration in drug therapy and procedure, whereas no difference in the management was yielded in the remaining 19 (17.8%) patients.

POCUS by definition is the use of ultrasound to diagnose problems at the place of treatment and it is usually done by the physician providing emergency care.[6] The concept of POCUS in children with suspected intracardiac pathologies is relatively new. While performing POCUS pediatric emergency care providers must distinguish abnormal masses (myxomas, vegetations, and thrombi) from normal cardiac structures ( Eustachian valve More Details, Chiari network, and moderator band) that may mimic a mass.[7] A sound knowledge of ultrasound artifacts and ways to overcome it (multiple acoustic windows) is essential for pediatricians doing POCUS.[5] Common ultrasound artifacts which may appear as pathological lesions include mirror artifacts, reverberation artifacts, and near field clutter. In addition to ultrasound artifacts and normal variants consideration must also be given to extracardiac pathologies (mediastinal tumors and hiatal hernias) which may cause compression over the heart and mimic intracardiac pathologies. The common pathologies which may be encountered by a pediatric intensivist during POCUS may include atrial myxomas, lipomas, papillary fibroelastosis, rhabdomyoma, fibromas, thrombus, vegetations, and congenital heart diseases.[8]

Cardiac thrombus in the pediatric age group is a rare occurrence. It may be seen in children with dilated cardiomyopathy, nephrotic syndrome, or postcardiac surgery (Fontan operation). John et al. in their study of 31 pediatric patients with intracardiac thrombi found that embolic events were uncommon and were seen in 4 out of 31 patients.[9] Most of the patients were either treated by heparin infusion, warfarin, or aspirin. In 19 out of 31 (63%) patients intracardiac thrombi resolved by medical management only. They further found that prognosis was poor for patients with left ventricular thrombus and the presence of coexistent ventricular dysfunction. Both our cases with thrombosis responded well to LMWH.

Most of our IE patients had predisposing factors with unusual organisms, namely, Citrobacter freundii, VRSA, Rapidly growing nontariff barrier, and mucormycosis with high mortality. The reason for unusual microorganisms can be contributed to antibiotic misuse along with increased invasive interventions such as device closure for congenital heart disease and central vascular catheters. Differentiating thrombus from vegetation may be challenging. Diagnosis is often perormed by a combination of clinical, laboratory, and echocardiographic findings. Vegetations usually have irregular margins; valvular vegetations are usually on the upstream side and have disordered motility. Occasionally, further imaging such as transesophageal ECHO, computed tomography or MRI scans may be needed to aid diagnosis. Where possible biopsy and culture of the mass should be performed.

POCUS has helped us in this case series early diagnosis of cardiac masses, to start appropriate therapy and surgical intervention whenever needed. Death is almost two-third of the patients in this series can be attributed to marked hemodynamic instability at admission and underlying complex disease process in these patients. It is not possible to comment whether POCUS has changed the outcome of these patients from this case series, but it can help the intensivist in deciding initial treatment before a formal cardiology consultation is done. Application of POCUS in the detection and treatment of pediatric cardiac masses has tremendous potential. Further studies and standardization of educational curriculum are needed for its proper application in pediatric emergency care.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Marin JR, Lewiss RE, American Academy of Pediatrics, Committee on Pediatric Emergency Medicine, Society for Academic Emergency Medicine, Academy of Emergency Ultrasound, American College of Emergency Physicians, Pediatric Emergency Medicine Committee, World Interactive Network Focused on Critical Ultrasound. Point-of-care ultrasonography by pediatric emergency medicine physicians. Pediatrics 2015;135:e1113-22.  Back to cited text no. 1
    
2.
Evans N, Gournay V, Cabanas F, Kluckow M, Leone T, Groves A, et al. Point-of-care ultrasound in the neonatal intensive care unit: International perspectives. Semin Fetal Neonatal Med 2011;16:61-8.  Back to cited text no. 2
    
3.
McLario DJ, Sivitz AB. Point-of-care ultrasound in pediatric clinical care. JAMA Pediatr 2015;169:594-600.  Back to cited text no. 3
    
4.
Kugler J. Point-of-care ultrasound in internal medicine: Challenges and opportunities for expanding use. South Med J 2016;109:750-3.  Back to cited text no. 4
    
5.
Rabah F, Al-Senaidi K, Beshlawi I, Alnair A, Abdelmogheth AA. Echocardiography in PICU: When the heart sees what is invisible to the eye. J Pediatr (Rio J) 2016;92:96-100.   Back to cited text no. 5
    
6.
Feigenbaum H, Armstrong WF, Ryan T. Masses, Tumors, and Source of Embolus. Feigenbaum's Echocardiography. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005. p. 701-33.   Back to cited text no. 6
    
7.
Ragland MM, Tak T. The role of echocardiography in diagnosing space-occupying lesions of the heart. Clin Med Res 2006;4:22-32.   Back to cited text no. 7
    
8.
Gaspar HA, Morhy SS, The role of focused echocardiography in pediatric intensive care: A critical appraisal. Biomed Res Int 2015:1-7.  Back to cited text no. 8
    
9.
John JB, Cron SG, Kung GC, Mott AR. Intracardiac thrombi in pediatric patients: Presentation profiles and clinical outcomes. Pediatr Cardiol 2007;28:213-20.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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