Pericardial Disease Flashcards
What are the 4 Class 1 recommendations for use of echo in evaluating pericardial disease?
- Patients with suspected pericardial disease, including effusion
- Patients with suspected bleeding into the pericardial space
- Follow up to evaluate recurrence of effusion or to diagnose early constriction
- Pericardial friction rub in acute MI w/ symptoms such as persistent pain, HoTN, nausea
What is the threshold for thickened pericardium in mm?
> 4mm
What is the pericardial reflection around the vena cavae and pulmonary veins behind the LA called?
The oblique sinus
What is the pericardial reflection around the great vessels called?
The transverse sinus
What is the normal amount of pericardial fluid?
5-30cc
What is the normal % change in transtricuspid inflow velocity with negative pressure inspiration?
~20% INCREASE in transtricuspid inflow with negative pressure inspiration
What is the normal % change in transmitral inflow velocity with negative pressure inspiration?
~10% DECREASE in transmitral inflow with negative pressure inspiration
What is normal intrathoracic pressure with negative pressure inspiration and expiration?
-3 at end-expiration and -6 at end-inspiration
What is the transmural gradient for RV filling?
Intracardiac pressure minus pericardial pressure
e.g. if intracardiac pressure is 5 and intrathoracic pressure is -6, transmural gradient = 5-(-6)=11
In spontaneous ventilation, why does RV stroke volume increase with inspiration?
Negative intrathoracic pressure -> increased venous return to RA -> increased RV filling -> increased RV SV
In spontaneous ventilation, why does LV stroke volume decrease with inspiration?
Negative intrathoracic pressure -> pulmonary venous pooling -> decreased LA filling -> decreased LV filling -> decreased LV SV
In spontaneous ventilation, why does RV stroke volume decrease with expiration?
Less negative intrathoracic pressure -> decreased venous return to RA -> decreased RV filling -> decreased RV SV
In spontaneous ventilation, why does LV stroke volume increase with expiration?
Less negative intrathoracic pressure -> compression of pulmonary vasculature -> increased pulmonary venous return -> increased LA filling -> increased LV filling -> increased LV SV
In constrictive pericarditis, how do the respirophasic changes in spontaneous and PPV change?
Exaggerated respirophasic changes with both spontaneous ventilation and PPV
In tamponade, how do the respirophasic changes in spontaneous and PPV change?
Exaggerated respirophasic changes with spontaneous ventilation
DIMINISHED respirophasic changes with PPV
In a normal patient, how do the respirophasic changes differ between spontaneous ventilation and PPV?
They are opposite
Transmitral inflow: decreased during spontaneous inspiration, increased during positive pressure inspiration (vice versa for expiration)
Transtricuspid inflow: increased during spontaneous inspiration, decreased during positive pressure inspiration (vice versa for expiration)
Is pulsus paradoxus seen in tamponade or constrictive pericarditis?
More common in tamponade
Is Kussmaul’s sign seen in tamponade or constrictive pericarditis?
More common in constrictive pericarditis
What is pulsus paradoxus?
Decrease in systolic pressure >10mmHg with negative pressure inspiration
(Can use to detect presence of tamponade by palpating pulse and asking patient to take a deep breath in)
- May be absent if s/p pericardiectomy or if loculated effusion
What is Kussmaul’s sign?
Absence of inspiratory drop in JVP with spontaneous inspiration
How does tamponade affect the Y descent on CVP?
Attenuated Y descent
“Lose your Y, then you die”
How does constrictive pericarditis affect the Y descent on CVP?
Exaggerated Y descent
What is mulibrey nanism?
Mu=muscle
li=liver
br=brain
ey=eye
Nanism = dwarfed, unusually small
Rare autosomal recessive condition seen in Finland, results in CHF and constrictive pericarditis. <200 cases to date.
What is the normal thickness for pericardium?
<4mm
(values range from 1-2mm to 2-3mm depending on resource)
Doppler distinguishing features of constrictive pericarditis vs. restrictive infiltrative cardiomyopathy
- Peak pulmonary venous D wave velocity variation >18% in CP
- Peak transmitral E wave variation >10% in CP
- Vp >100cm/sec in CP, Vp<50 in RICM
- lateral e’ <8 in RICM, lateral e’ >10 in CP
What is annular reversus?
Lateral e’ < septal e’
(seen in constrictive pericarditis)
Note: lateral e’ still expected to be >10cm/sec in CP
What is annulus paradoxus?
E/e’ <15 despite elevated LAP
(seen in constrictive pericarditis)
RA collapse is sensitive and specific for tamponade when it occurs during which part of the cardiac cycle?
When there is both systolic and diastolic collapse (>1/3 of the cardiac cycle)
Nearly 100% sensitive and specific
When does diastolic RV collapse occurs?
When pericardial pressure > RV pressure
Pericardial effusion sizing
0.5cm (100-200cc) = small
0.5-2cm (200-500cc) = moderate
>2cm (>500cc) = large
Tamponade depends on both volume and fluid and speed of accumulation.
What % decrease in transmitral peak E wave velocity with spontaneous inspiration is diagnostic of tamponade?
> 30% decrease in peak E velocity with spontaneous inspiration
(due to increased RV filling bowing septum to left and reducing LV filling)
Is Vp normal or abnormal in tamponade?
Vp is normal in tamponade
Is lateral mitral e’ normal or abnormal in tamponade?
Lateral mitral e’ is normal in tamponade
What is the square root sign?
Seen in constrictive pericarditis on the ventricular pressure tracing (steep dip followed by plateau with little pressure change during diastasis)
How much pericardial fluid is present in a normal healthy patient?
25-50cc
What is the normal lateral e’ to septal e’ ratio?
> 1.3 (seen in normal patients and restrictive infiltrative cardiomyopathy)
<1 in constrictive pericarditis
