What is the clinical significance of a false tendon in the apex of the heart on an echocardiogram?

From the Guidelines

False tendons in the apex of the heart have minimal clinical significance on an echocardiogram and typically require no treatment or follow-up. These fibrous or fibromuscular structures are considered normal anatomical variants, present in approximately 50% of healthy individuals, and rarely cause symptoms or cardiac dysfunction 1. They connect the ventricular walls or papillary muscles but do not attach to valve leaflets like true chordae tendineae. While usually benign, they occasionally may be associated with innocent heart murmurs due to blood flow vibrations across these structures. In rare cases, they might serve as a substrate for ventricular arrhythmias, particularly if they contain conducting tissue. They can sometimes be mistaken for thrombi, vegetations, or tumors on imaging, so proper identification is important to avoid unnecessary interventions 1. During echocardiographic evaluation, these structures should be documented but generally do not warrant additional cardiac testing unless associated with symptoms or abnormal cardiac findings. Some key points to consider when evaluating false tendons on an echocardiogram include:

• They are common in healthy individuals and usually do not require treatment
• They can be associated with innocent heart murmurs or ventricular arrhythmias in rare cases
• Proper identification is crucial to avoid misdiagnosis and unnecessary interventions
• Additional cardiac testing is only necessary if symptoms or abnormal cardiac findings are present.

From the Research

Clinical Significance of False Tendons

The presence of a false tendon in the apex of the heart on an echocardiogram can have various clinical implications.

• False tendons are anomalous structures that can be found in the left ventricle and are often incidentally detected on echocardiography 2.
• They are more frequently found in male patients and are associated with left ventricular dilatation, hypertrophy, and systolic dysfunction 2.
• The presence of false tendons can sometimes be confused with other conditions such as left ventricular apical cardiac tumors, left ventricular apical thrombus, isolated ventricular non-compaction, endomyocardial fibrosis, and coronary artery disease 3.
• False tendons themselves do not necessarily cause systolic murmurs, even in a dilated left ventricle 4, 5.

Diagnostic Considerations

• Echocardiography, particularly two-dimensional echocardiograms, can be useful in demonstrating the presence of false tendons and differentiating them from other abnormal linear echoes in the outflow tract of the left ventricle 4, 5.
• In some cases, further diagnostic testing such as cardiac MRI or invasive hemodynamic testing may be necessary to establish or rule out the diagnosis of apical hypertrophic cardiomyopathy, which can present similarly to false tendons on echocardiography 6.
• The clinical significance of false tendons should be considered in the context of the patient's overall clinical presentation and other echocardiographic findings 2.

Association with Apical Hypertrophic Cardiomyopathy

• Apical hypertrophic cardiomyopathy (AHCM) is a rare form of hypertrophic cardiomyopathy that classically involves the apex of the left ventricle 3, 6.
• AHCM can be an incidental finding or patients may present with symptoms such as chest pain, palpitations, dyspnea, syncope, atrial fibrillation, myocardial infarction, embolic events, ventricular fibrillation, and congestive heart failure 3.
• The presence of a false tendon in the apex of the heart on an echocardiogram should prompt consideration of AHCM as a potential diagnosis, particularly if there are other echocardiographic findings suggestive of this condition 3, 6.