Pericardial disease Flashcards
Pericardium consists of:
- 2 serous surfaces
- One potential space
What are the two serous surfaces of the pericardium?
- Visceral pericardium
- Parietal pericardium
How much fluid does the pericardial space normally contain?
< 50 mL
What are the roles of the pericardium?
- Maintaining heart w/in place in thorax
- Lubricates heart to avoid friction w/surrounding organs
- Protects heart from spreading infection
- Prevents acute dilation of chambers
- May also prevent hypertrophy under conditions of strenuous exercise
- Ventricular interdependence
- Responsible for drop in intrapericardial pressure during ventricular systole
Pericarditis
Symptomatic inflammation of the pericardium
Pericarditis can be acute, chronic, or
recurrent pericarditis
What is the most common manifestation of pericardial disease
acute pericarditis
Myopericarditis
Implies associated inflammation, often with coinciding tissue necrosis of the myocardium
Causes of pericarditis
- Infectious
- Autoimmune
- Reactive
- Metabolic
- Traumatic
- Neoplastic
What are most cases of pericarditis in Western Europe and North America pressumed to be
Viral etiology (aka idiopathic)
Pericardial irritation can also be due to:
- Cardiothoracic surgery
- Percutaenous device implantation
- Endocardial and epicardial catheter based ablation procedures
To be clinically diagnosed with acute pericarditis you need to have two of the four symptoms:
- Pericarditic chest pain
- Pericardial friction rub
- ECG features
- New or worsening PE
Pericarditis can be confused w/more fatal etiologies:
- Acute coronary syndrome
- Pulmonary thromboembolic events
- Aortic dissection
Pericardial rub
A rubbing sound due to the friction of visceral and parietal pericardial layers
Pericardial thickening
Increased echogenicity and thickness of pericardial reflector (thicker than 5mm)
Symptoms of pericarditis
- Chest pain is the most common
- May be sudden or gradual
- Sharp and similar to pleurisy
- Radiates to the trapezius ridge
- Aggravated by lying down
- Fells better when sitting and leaning forward
Treatment for pericarditis
- Nonsteroidal anti-inflammatory drugs (NSAIDs)
- NSAIDs and colchicine together
- Aspirin
Pericardial effusions are usually:
- Diffuse
- Symmetric
- Clear space between parietal and visceral pericardium
M-mode w/small effusions:
- Flat posterior pericardial echo reflection
- Moving epicardial echo
- Seperation between the above echoes in systole and diastole
Fibrous strands
Strands w/in the fluid on the epicardial surface of the heart
- Common in pts w/recurrent or long-standing pericardial disease
Causes of pericardial disease
- Infections
- Malignant
- Inflammatory
- Intracardiac - pericardial communications
Metastatic disease can help differentiate from fibrin strands by looking for:
- Nodular appearance
- Evidence of extensions into myocardium
- Other clinical signs
Pericardial seperation: Echolucent space < 10mm seen only in systole =
Trivial PE
Pericardial seperation: Echolucent space < 10mm seen in systole and diastole =
Small PE
Pericardial seperation: Echolucent space 10-20mm =
Moderate PE
Pericardial seperation: Echolucent space > 20mm =
Large PE
Loculated effusion is more common in patients with
recurrent pericardial disease or post op
Loculated effusion is localized by
adhesions to one or several small areas in the pericardial space
Hemodynamic compromise can happen w/small fluid pocket if it is in a sensitive spot
Difference between PE and pleural effusion
- PE anterior to desc Ao - pleural posterior to it
- PE gradually tapers at atrioventricular groove - pleural normally behind LA & LV
- PE doesnt change w/respirations - pleural effusion may change
Tamponade:
Abnormal accumulation of fluid and/or blood in the pericardial space
Tamponade increases the pressure in the ____ and compresses the cardiac chambers
pericardium
Development and severity of tamponade depends on:
- Volume and rate of fluid accumulation (ranging from slow to very fast)
- Pericardial compliance/elasticity
Acute tamponade is
- Rapid accumulation of as little as 150mL of fluid
- Abrupt bleeding into stiff pericardial space
- Results in rapidly rising intrapericardial pressure, chamber compression, and hypotension leading to cardiogenic shock
Causes of acute tamponade:
- Penetrating chest wound
- Iatrogenic chamber perforation
- LV free wall rupture
- Proximal aortic dissection rupture
Subacute tamponade is
- PE develops gradually
- Pericardium stretches and can allow for large amounts of fluid (>1000mL) w/o increase in intrapericardial pressure
- Eventually filling will be compromised and tamponade will result
Causes of subacute tamponade:
Seen mostly with:
- Neoplasms
- Uremia
- Idiopathic situations
Compression w/tamponade is seen more when chamber pressures are at their ____
____ for atria
____ for ventricles
Lowest
- Systole
- Diastole
W/tamponade filling pressures increase to maintain ___
CO
- Eventually all 4 chambers are equally elevated from pericardial pressure on the entire heart
Tamponade clinical symptoms
- Low CO symptoms
- Hypotension
- Tachycardia
- Elevated JVP
- Pulsus paradoxus on exam (inspiratory decline >10mmHg in systemic BP)
What are the three medical signs (Beck’s triad) associated with acute cardiac tamponade:
- Low arterial BP
- Distended neck veins
- Distant muffled heart sounds
Echo approach to tamponade
- Intrapericardial pressure exceeds RA pressure
- Ra free wall inversion or collapse occurs
- Longer RA inversion relative to cycle length, the greater teh chance of tamponade
- Inversoin > 1/3 systole is 94% sensitive and 100% specific for tamponade
- RV collapse when intracardial pressure exceeds RV diastolic pressure
- RV free wall collapse is not as sensitive or specific as RA collapse
Respiratory variation w/tamponade
- Inspirations increases RV volume
- Septum shifts toward LV in diastole and RV during systole
- During expiration septal flow normalizes
- This motion is responsible for physical finding of pulsus paradoxus
Pulsus Paradoxus
The exaggerated drop in systemic blood pressure during inspiration
Reciprocal respiratory variation resaon for changes:
- Total pericardial volume (chambers + pericardial fluid) is fixed in tamponade
- As intrathoracic pressure is more negative w/inspiration, increaseed RV filling limits LV filling
- The opposite occurs during expiration
- > ## 25% variation is considered marked
Diastolic fillining - Inspiration:
- Augmented RV filling
- LV filling diminishes
- PA flow velocity integral increases
- Aortic flow velocity integral decreases
Dilated IVC (≥2.1cm) with <50% inspiratory reduction in diameter reflects
elevated intrapericardial pressure transmitted to the Rt heart
Surgical treatments for tamponade:
- Pericardiocentesis
- Pericardial window
- Total/limited pericardectomy
Constrictive pericarditis
Visceral and parietal pericardium are adherent, thickened, and fibrotic, resulting in impairment of diastolic ventricular filling
constrictive pericarditis can occur after:
- Repeated episodes of pericarditis
- Cardiac surgery
- Radiation therapy
- Variety of other causes
Symptoms of constrictive pericarditis are nonspecific:
- Fatigue and malaise from low CO
- Subtle increase in jugular venous pressure
- Distant heart sounds
- Ascites and peripheral edema in late disease course
Constrictive pericarditis is characterized by:
- Impaired diastolic filling
- Rapid early diastoli filling
- Abrupt cessation of ventricular fillin
Echo appearance of constrictive pericarditis:
- Normal values (LV wall thickness, chamber size, systolic function)
- LAE
- Pericardial thickening
Constrictive pericarditis Doppler:
-Hepatic flow
-Pulmonary vein flow
-RV and LV diastolic filling
-Short DT
-Small A wave
Hepatic flow:
- prominent A wave
- deep Y descent
P vein flow:
- prominent A wave
- prominent Y descent
- blunting of systolic phase atrial filling
RV and LV diastolic filling:
- high E velocity
Shot DT:
- abrupt filling cessation
Small A wave:
- little late diastolic filling
Constrictive pericarditis respiratory variation: Inspiration
- Augmented RV filling
- Lv filling velocities decrease w/inspiration and increase w/expiration (look for > 25% respiratory variation using 25 mm/s sweep speed)
- IVRT increases by approximately 20% w/inspiration
Differential diagnosis for constrictive pericarditis:
- Difference between tamponade and pericardial constriction is presence of PE
- It is more difficult to differentiate bettween restrictive cardiomyopathy and constrictive pericarditis
Constrictive pericarditis M-mode
- Multiple dense echoes (posterior to LV epicardium, moves parallel w/eachother, are visible even at low gain settings)
- Abrupt posterior motion of IVS in early diastole
- Flat IVS motion in mid diastole
- Abrupt anterior motion of IVS after atrial contraction
- LV posterior wall endocardium shows little posterior motion during diastole (< 2 mm)
- IVC and hepatic veins are dilated
Pts w/restrictive cardiomyopathy usually have moderate to severe ____
Pts w/constrictive pericarditis usually have only mild elevation in ____ pressures
- Pulmonary HTN
- Pulmonary
What is the treatment for constrictive pericarditis?
Pericardectomy
What is the most uncommon of the pericadialconstraint syndromes?
Effusive constrictive pericarditis
McConnell’s sign is a
distinct echo feature of acute massive pulmonary embolism
What are the three distinct features of McConnell’s sign?
- A regional pattern of Rt ventricular dysfunction
- Akinesia of the mid free wall
- Normokinesia or hyperkinesia of the apical segment
60/60 sign of pulmonary embolism
- RV ejection Acceleration Time < 60 msec
- TR jet < 60 mmHg
- Mid systolic notching can also be an indication
