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 Table of Contents  
ORIGINAL RESEARCH
Year : 2019  |  Volume : 3  |  Issue : 3  |  Page : 150-155

Echocardiographic Study of Left Ventricular False Tendons


1 Department of Cardiology, Pushpagiri Medical College, Thiruvalla, Kerala, India
2 Department of Cardiology, Government Medical College, Thiruvananthapuram, Kerala, India

Date of Submission12-Aug-2019
Date of Decision18-Nov-2019
Date of Acceptance03-Nov-2019
Date of Web Publication18-Dec-2019

Correspondence Address:
Cherian Koshy
Department of Cardiology, Pushpagiri Medical College, Thiruvalla, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiae.jiae_40_19

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  Abstract 

Introduction: Left ventricular false tendons (LVFTs) are discrete, fibromuscular structures of varying length and thickness that traverse the left ventricular (LV) cavity. The aim of the present study was to describe the echocardiographic characteristics and associations of 100 consecutive cases of LVFTs that presented to the echocardiography laboratory at a tertiary care teaching hospital in India. Subjects and Methods: One hundred consecutive patients with LVFTs were studied. They were classified based on the number (single and multiple), morphology (simple and complex), and location (apical, mid, and basal). The individuals were divided into three groups (Group 1: with LV dilatation and/or LV hypertrophy [LVH], Group 2: abnormal echocardiogram other than Group 1, and Group 3: normal echocardiogram). Analysis was done using SPSS 15 software. Results: A total of 121 LVFTs were identified in the 100 individuals. The LVFTs were more commonly single (81%), simple (92.56%), and apically located (52.90%). Complex LVFTs and apical location were more common among males, while multiple LVFTs and mid location were more common among females. LVFTs were most commonly visualized in the apical four-chamber view. There was a preponderance of males (67%), patients with structural heart disease (79%), and patients with LVH and/or dilatation (44%) in the study group. Conclusions: LVFTs are readily identifiable on echocardiography and can be characterized based on their number, location, and morphology. Their relationship to structurally abnormal hearts, male gender, LVH, and dilatation requires further study.

Keywords: Anatomy. echocardiography, left ventricular false tendon


How to cite this article:
Ahmad ZS, Koshy C, Koshy GA. Echocardiographic Study of Left Ventricular False Tendons. J Indian Acad Echocardiogr Cardiovasc Imaging 2019;3:150-5

How to cite this URL:
Ahmad ZS, Koshy C, Koshy GA. Echocardiographic Study of Left Ventricular False Tendons. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2019 [cited 2020 May 29];3:150-5. Available from: http://www.jiaecho.org/text.asp?2019/3/3/150/273297


  Introduction Top


Left ventricular false tendons (LVFTs) are discrete, fibromuscular structures of varying length and thickness that traverse left ventricular (LV) cavity.[1] LVFTs, also referred to as pseudotendons or bands, were first described by Turner nearly a century ago.[2] They are readily recognized by two-dimensional (2D) echocardiography.[3] An autopsy prevalence of up to 55% and 2D echocardiographic prevalence ranging from 0.4% to 61% have been reported.[4]

Although LVFTs have generally been considered as benign anatomic variants, numerous disease associations have been reported in literature. These include an increased prevalence of precordial murmurs, repolarization abnormalities on the resting electrocardiogram (ECG), preexcitation, ventricular arrhythmias, mitral regurgitation, and a dilated left ventricle.[5],[6],[7] A slightly higher incidence in pathologic than in normal hearts, a higher frequency in male patients than in female patients, and associations with LV hypertrophy (LVH), and systolic dysfunction have been described.[8] Patients with false tendons and cardiomyopathy presumably have less severe functional mitral regurgitation due to less mitral valve deformation.[9] LVFTs have been suggested as a useful anatomical landmark of LV for the differentiation of morphological LV and right ventricle in segmental analysis of congenital heart disease (CHD).[10] Data from India is lacking regarding this echocardiographic entity.

The aim of the present was to study the echocardiographic characteristics and associations of 100 consecutive cases of LVFTs that presented to the echocardiography laboratory at a tertiary care teaching hospital in India.


  Subjects and Methods Top


An observational study of 100 consecutive patients with LVFTs attending the echocardiography laboratory at the Department of Cardiology in a major teaching hospital in Kerala, India was planned. The patients were recruited between November 1, 2012, and November 15, 2012 and between February 1, 2013, and March 31, 2013. Patients aged >13 years and of either sex were included. Echocardiography was performed for outpatients and inpatients for varied clinical indications, as decided by the treating cardiologist. All echocardiographic studies were performed by a single trained echocardiographer using Vivid 7 GE and HD11XE Philips echocardiography machines. Standard echocardiographic views and parameters were taken, in addition to additional modified views to better characterize the LVFTs.

Diagnosis of left ventricular false tendons

This was based on the finding of a distinctive linear echogenic strand, traversing the LV cavity, connecting the LV free wall or papillary muscle and the ventricular septum, not related to the mitral valve apparatus.[10] Exclusion of “LVFT mimics” was done by special attention to differentiate LVFTs from other entities such as thickened ventricular trabeculations. When there was ambiguity regarding the findings, confirmation was done after review of echo by additional senior echocardiographers.

Left ventricular false tendon characteristics

Based on the number of LVFTs, patients were classified into those with single LVFT or multiple LVFTs (2 or more in number). Based on the location of the LVFTs, depending on the site of attachment to the interventricular septum (IVS) and based on locations along the long axis of the left ventricle (apical-, mid-, or basal-third segments), we classified each LVFT into apical/mid/basal, and transverse (localized to one zone), diagonal (extending across two adjacent zones) or longitudinal (extending across all 3 zones) types.[11],[12] Based on the morphologic appearance, we classified LVFTs that appeared as a single chord traversing the LV with 2 points of insertion as simple, and LVFTs that appeared as branching with 3 or more points of insertion as complex/branching.[10]

Echocardiographic measurements

Echo assessment included study of LV dimensions, LV mass (LVM), LV function and structural heart disease (SHD). LV internal dimensions (LVID), thickness of the interventricular septum (IVST) and LV posterior wall thickness (PWT) at end diastole (d) were obtained by averaging M-mode measurements using a leading edge technique as recommended by the American Society of Echocardiography.[13] LV dimensions (LVIDd, IVSd, PWd at end-diastole) were obtained by averaging M-mode measurements using a leading edge technique as recommended by the American Society of Echocardiography. LV wall thickness was calculated as the sum of end-diastolic IVSTd and PWTd. LVM was calculated using the equation 0.8 (1.04 [IVSTd + LVIDd + PWTd]3 – [LVIDd] 3) +0.6. LV systolic function was assessed by estimation of LV ejection fraction (LVEF) by M mode, and an LVEF of <50% was considered to indicate LV systolic dysfunction. LV systolic dysfunction was graded as “Mild” (EF 40%–49%), “Moderate” (EF 26%–39%), and “Severe” (EF <25%). LV diastolic dysfunction was graded as Grades 1 to 4 based on standard parameters (Mitral E/A, DT, E/E'). Assessment of SHD was described under the following categories: LVH, LV dilatation, regional wall motion abnormality and territory, hypertrophic cardiomyopathy (HCM), dilated cardiomyopathy (DCM), CHD, valvular heart disease (VHD), rheumatic heart disease, sclerotic aortic valve, and mitral annular calcification.

The individuals were divided into 3 groups for comparison: Group 1 (LVH and/or dilatation), Group 2 (abnormal echo other than Group 1), and Group 3 (normal echo study).

Analysis of data

Data were entered into Microsoft Excel datasheet. Mean, range, and standard deviations were calculated. Subgroup analysis was done. The t-test – was used for continuous variables and the Chi-square test for categorical variables. Logistic regression analysis was done. The analysis was done using SPSS 15 software (SPSS Inc., Chicago, Illinois, USA).


  Results Top


One hundred consecutive patients with LVFTs were studied. Seventy nine percent had an abnormal echocardiogram, and 21% had structurally normal hearts. The mean age of the study population was 49.89 years (38 ± 13.07 years in the subjects with a structurally normal heart and 52.37 ± 13.39 years in the group with an abnormal echocardiogram, t-test P < 0.001). The youngest patient was 14 years of age, and the oldest patient was 76 years of age. A male preponderance (67%) was noted.

Left ventricular false tendon characteristics

A total of 121 LVFTs were identified from the 100 individuals. Eighty-one percent of individuals had a single LVFT [Figure 1], while 19% had multiple (2 or more) LVFTs [Figure 2]. There were 112 simple LVFTs (92.56%) and 9 complex (7.44%) LVFTs [Figure 3]. The most common location in relation to the IVS was apical (52.90%) [Figure 4], followed by mid (38.84%) [Figure 5] and basal (8.26%) [Figure 6] attachments. LVFTs were most commonly visualized in the apical four-chamber view. The other useful views were parasternal long axis, parasternal short axis, and apical 2 chamber views. With the help of multiple views and transducer angulations, multiple false tendons and complex patterns including branching or “net” patterns were identified.
Figure 1: Single, simple LV false tendon. LV: Left ventricle

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Figure 2: Multiple LV false tendons. LV: Left ventricle

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Figure 3: Complex/Branching type of LV false tendon, ‘net’ pattern.
LV: Left ventricle


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Figure 4: Apical location of LVFT. LVFT: Left ventricular false tendon

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Figure 5: Mid location of LVFT. LVFT: Left ventricular false tendon

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Figure 6: Basal location of LVFT. LVFT: Left ventricular false tendon

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Disease profile

The patients with pathologic hearts were categorized into different disease groups.

Valvular heart disease

Patients with VHD were classified into stenotic and regurgitant lesions, and the severity was graded into mild, moderate, and severe groups. Mitral regurgitation was the most common lesion (35%), and it was most commonly mild in severity. Aortic regurgitation was the next in frequency (20%).

Left ventricular dysfunction

LV dysfunction was categorized into systolic and diastolic dysfunction, and the severity was graded. Twenty-one percent of patients had LV systolic dysfunction and 46% of patients had evidence of LV diastolic dysfunction.

Rhythm

Ninety-four percent of patients were in sinus rhythm. None of the patients had a history of documented ventricular tachycardia (VT)/resuscitated cardiac arrest.

Disease associations

The individuals were divided into 3 groups: Group 1 (LVH and/or dilatation) predominated (44%), followed by Group 2 (abnormal echo other than Group 1) comprising 35% and Group 3 (normal echo study) comprising 21%. Among the 44 patients in Group 1, 26 had LVH and 21 had LV dilatation.

Forty-three percent had systemic hypertension, 19% had type 2 diabetes mellitus, and 35% had evidence of coronary artery disease (CAD). Twenty-one percent of patients had LV systolic dysfunction and 46% had LV diastolic dysfunction. Thirty-seven patients had mitral regurgitation (mild in 23, moderate in 8, and severe in 6). Nine patients had DCM and five patients had HCM.

Subgroup analysis

Subgroup analysis was done with respect to the following parameters:

  • Single versus multiple
  • Simple versus complex
  • Echo subgroups
  • Males versus females.


Logistic regression (univariate/multivariate analysis)

  • In the single versus multiple groups, end systolic volume was found to be more in the patients with a single false tendon compared to those with multiple false tendons (odds ratio [OR] 1.04, P < 0.04)
  • In the complex versus simple groups, the end systolic volume was found to be more in those with complex rather than simple false tendons.


Males versus females

A higher percentage of female patients had multiple LVFTs (21.21% vs. 17.91%), while a higher percentage of male patients had complex LVFTs compared to females (11.94% vs. 3.03%).

Among males, the most common location was apical (62.69%), whereas among females, the most common location was mid (54.55%).


  Discussion Top


Although LVFTs have generally been considered as benign anatomic variants, numerous disease associations have been reported in literature. We studied the echocardiographic profile of 100 consecutive cases of LVFTs that presented to the Echocardiography Laboratory at Government Medical College, Thiruvananthapuram.

In a study by Kenchaiah et al. in 2009 that compared 101 Framingham study participants with LVFTs (mean age 56 years, 45% women) on routine 2D echocardiograms with 151 referents without LVFTs (mean age 57 years, 44% women), a total of 107 LVFTs (94 simple with two points of attachment, and 13 complex/branching type with three or more points of attachment) were identified in 101 participants.[11] LVFTs were most commonly visualized in the apical four chamber view (81%) and were predominantly localized to apical-third of the LV cavity (78%). LVFTs were associated with the presence of innocent precordial murmurs (multivariable adjusted OR 5.55, 95% confidence interval [CI] 1.40–21.94), and electrocardiographic LVH (OR 4.43, 95% CI 1.08–18.25).

In a study by Tamborini et al. in 2004, among 1580 patients the presence of false tendons, trabeculations, or thrombi (termed “anomalous images [AI]”) was evaluated with transthoracic echocardiography and correlated to clinical characteristics and echocardiographic parameters.[8] Incidence of AI was 46.7% (75% false tendons, 23% trabeculations, 2% thrombi), slightly higher in pathologic (48.9%) than in normal hearts (40.8%). AI were more frequent in male patients (52%) than in female patients (39.7%) and associated with LV dilatation, hypertrophy, and systolic dysfunction. False tendons and trabeculations were not related to age. Male sex was the most significant independent predictor of AI. This study showed a high prevalence of AI for patients with and without pathologic hearts suggesting the need of updating LV echocardiographic anatomy.

In 2011, Philip et al. from Kerala prospectively studied the prevalence of LVFTs by 2D echocardiography in 476 infants and children referred for cardiac evaluation.[10] They also studied the morphology and histopathology of LVFTs in 68 CHD specimens and in 20 piglet hearts. LVFTs of varying size and different location were detected in 371 (77.9%) of 476 infants and children studied, and in 42 (61.8%) of 68 CHD specimens.

Demographics

In our study, 100 consecutive patients with LVFTs were studied. The mean age of the study population was 49.89 years (38 years in the subjects with a structurally normal heart and 52.37 years in the group with an abnormal echocardiogram). The youngest patient was 14 years of age, and the oldest patient was 76 years of age. A male preponderance was noted (67%).

Left ventricular false tendon characteristics

A total of 121 LVFTs were identified from the 100 subjects. There were 112 simple LVFTs (92.56%) and 9 complex LVFTs (7.44%). The most common location in relation to the IVS was apical (52.90%), followed by mid (38.84%) and basal (8.26%) attachments. LVFTs were most commonly visualized in the apical four-chamber view.

Disease associations

Echocardiograms demonstrating severe cardiomyopathy (ejection fraction ≤30%) were retrospectively examined for LVFTs by Bhatt et al. in 2009.[9] A cohort of patients (n = 82) with severe LV systolic dysfunction (mean ejection fraction, 21%) and false tendons were compared with a control group with similar LV dysfunction and no false tendons (n = 121). The patients with false tendons had similar LV diastolic internal dimensions compared with the control group (5.99 and 6.18 cm, respectively; P = 0.086). Yet, patients with false tendons had a very low incidence of severe functional mitral regurgitation compared with the control group (4.9% vs. 27%, P < 0.001). Patients with false tendons had significantly smaller mitral annular diameters (3.57 vs. 4.03 cm, P < 0.001). The reduction of mitral regurgitation was more significant for patient with transverse midcavity false tendons. Patients with false tendons and cardiomyopathy had less severe mitral regurgitation. The mechanism for the reduction in functional mitral regurgitation might be less mitral valve deformation, specifically lower coaptation depth and coaptation area when a false tendon is present.

In our study, 79% had an abnormal echocardiogram and 21% had structurally normal hearts. The individuals were divided into 3 groups: Group 1 (LVH and/or dilatation) predominated (44%), followed by Group 2 (abnormal echo other than Group 1) comprising 35%, and Group 3 (normal echo study) comprising 21%. Forty-three percent had systemic hypertension, 19% had type 2 diabetes mellitus, and 35% had evidence of CAD.

In our study, 21% of patients had LV systolic dysfunction and 46% had LV diastolic dysfunction. Thirty-seven patients had mitral regurgitation (mild in 23, moderate in 8 and severe in 6). Nine patients had DCM and five patients had HCM.

In this observational study, the echocardiographic features of 100 consecutive patients with LVFTs were studied at the echocardiography laboratory of a tertiary care center. Compared to previously reported series, there was a higher proportion of males, multiple false tendons, and mid location of false tendons [Table 1].
Table 1: Comparison of findings from current study with previous studies

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Study limitations

This is an observational study, and age and sex matched controls were not taken. Being a hospital based study, the data may not be representative of the characteristics of LVFTs in the community. ECG could not be analyzed in all patients. Even though ECG correlation (ventricular premature complexes, nonsustained/sustained VT, and LVH) was not an objective of this study, it would have added to the information gained. However, none of the individuals had a history of documented VT/ventricular fibrillation/resuscitated cardiac arrest. Similarly, the relationship of LVFTs to murmurs on clinical examination was not specifically studied.


  Conclusion Top


In this observational study, the echocardiographic features of 100 consecutive patients with LVFTs were studied at the echocardiography laboratory of a tertiary care center. A total of 121 LVFTs were identified in the 100 individuals and characterized. There was a preponderance of males (67%), patients with SHD (79%), and patients with LVH and/or dilatation (44%) in the study group. The LVFTs were more commonly single (81%), simple (92.56%), and apically located (52.90%). Complex LVFTs and apical location were more common among males, while multiple LVFTs and mid location were more common among females. LVFTs were most commonly visualized in the apical four-chamber view. The relationship of LVFTs to structurally abnormal hearts, male gender, LVH, dilatation, and function requires further study.



Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Nishimura T, Kondo M, Umadome H, Shimono Y. Echocardiographic features of the false tendons in the left ventricle. Am J Cardiol 1981;48:177-83.  Back to cited text no. 1
    
2.
Turner W. Another heart with moderator band in left ventricle. J Anat Physiol 1896;30:568-9.  Back to cited text no. 2
    
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Keren A, Billingham ME, Popp RL. Echocardiographic recognition and implications of ventricular hypertrophic trabeculations and aberrant bands. Circulation 1984;70:836-42.  Back to cited text no. 3
    
4.
Luetmer PH, Edwards WD, Seward JB, Tajik AJ. Incidence and distribution of left ventricular false tendons: An autopsy study of 483 normal human hearts. J Am Coll Cardiol 1986;8:179-83.  Back to cited text no. 4
    
5.
Malouf J, Gharzuddine W, Kutayli F. A reappraisal of the prevalence and clinical importance of left ventricular false tendons in children and adults. Br Heart J 1986;55:587-91.  Back to cited text no. 5
    
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Keren A, Billingham ME, Popp RL. Ventricular aberrant bands and hypertrophic trabeculations. A clinical pathological correlation. Am J Cardiovasc Pathol 1988;1:369-78.  Back to cited text no. 6
    
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Madhavan M, Asirvatham SJ. The fourth dimension: Endocavitary ventricular tachycardia. Circ Arrhythm Electrophysiol 2010;3:302-4.  Back to cited text no. 7
    
8.
Tamborini G, Pepi M, Celeste F, Muratori M, Susini F, Maltagliati A, et al. Incidence and characteristics of left ventricular false tendons and trabeculations in the normal and pathologic heart by second harmonic echocardiography. J Am Soc Echocardiogr 2004;17:367-74.  Back to cited text no. 8
    
9.
Bhatt MR, Alfonso CE, Bhatt AM, Lee S, Ferreira AC, Salerno TA, et al. Effects and mechanisms of left ventricular false tendons on functional mitral regurgitation in patients with severe cardiomyopathy. J Thorac Cardiovasc Surg 2009;138:1123-8.  Back to cited text no. 9
    
10.
Philip S, Cherian KM, Wu MH, Lue HC. Left ventricular false tendons: Echocardiographic, morphologic, and histopathologic studies and review of the literature. Pediatr Neonatol 2011;52:279-86.  Back to cited text no. 10
    
11.
Kenchaiah S, Benjamin EJ, Evans JC, Aragam J, Vasan RS. Epidemiology of left ventricular false tendons: Clinical correlates in the Framingham heart study. J Am Soc Echocardiogr 2009;22:739-45.  Back to cited text no. 11
    
12.
Henry WL. Report of the American Society of Echocardiography Committee on Nomenclature and Standards: Identification of Myocardial wall Segments. Raleigh, N.C: American Society of Echocardiography; 1982.  Back to cited text no. 12
    
13.
Sahn DJ, DeMaria A, Kisslo J, Weyman A. Recommendations regarding quantitation in M-mode echocardiography: Results of a survey of echocardiographic measurements. Circulation 1978;58:1072-83.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
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