PERICARDIAL DISEASE Flashcards
What is the single most useful parameter to exclude hemodynamically significant pericardial disease?
A plethoric inferior vena cava is a specific marker of raised central venous pressure. Although this sign may not manifest if the patient has undergone brisk diuresis or is severely dehydrated, its absence usually makes the diagnosis of advanced or hemodynamically significant pericardial diseases unlikely.
Note: RA , RV collapse and transmitral inflow gradient are useful but IVC size is the most important to exclude hemodynamically significant pericardial disease/
Class I recommendations for using echocardiography in which pericardial disease scenarios?
- Patients with suspected pericardial disease, including effusion, constriction, or effusive–constrictive process.
- Patients with suspected bleeding in the pericardial space (e.g., trauma, perforation).
- Follow-up study to evaluate recurrence of effusion or to diagnose early constriction. Repeat studies may be goal d
directed to answer a specific clinical question. - Pericardial friction rub developing in acute myocardial infarction accompanied by symptoms such as persistent
pain, hypotension, and nausea.
Note:
Pericardial friction rub in early uncomplicated myocardial infarction or in the early postoperative period after cardiac surgery. routine follow up of a small effusion in clinically stable patients is not a class I indication.
Two-Dimensional (2D) echocardiographic features of congenital complete absence of the pericardium resemble which of the following conditions?
Congenital complete absence of the pericardium is associated with the enlargement of the right ventricle, excessive motion of the posterior left ventricular (LV) wall, and shift of the heart to the left, resulting in more of the right ventricle being seen on the routine left parasternal echocardiogram; these changes may result in paradoxical motion of the interventricular septum. All of these findings mimic right ventricular volume overload as seen in atrial septal defect.
What feature can be seen in both constriction and tamponade?
Increase in tricuspid valve and decrease in mitral valve Doppler velocities on inspiration occurs in both CP and tamponade. In both CP and tamponade, the cardiac chambers operate in a fixed noncompliant space preventing the normal inspiratory decrease in intrathoracic pressure from being transmitted fully to the heart chambers. As the pressure in the extrapericardial pulmonary veins decreases normally with inspiration, a reduced pulmonary venous-to-left atrial gradient also contributes to the inspiratory decrease in LV filling. Opposite changes in the filling of the two ventricles are seen on expiration.
Note: RV diastolic collapse occurs only in tamponade, while continuous LV septal flattening during inspiration and expiration is associated with any cause of increased right-sided pressures and pulmonary hypertension.
Clinical and echocardiographic features of tamponade?
In the presence of a dilated inferior vena cava (IVC), which echocardiographic combination of findings would yield the highest sensitivity and specificity in diagnosing constrictive pericarditis (CP)?
Recently, new criteria for diagnosis of CP were published using five conventional echocardiographic findings. The three most important seemed to be the presence of respiration-related ventricular septal shift, preserved or increased medial mitral annular e′ velocity, and prominent hepatic vein expiratory diastolic flow reversal. Inferior vena cava plethora (maximum diameter ≥21 mm and degree of inspiratory collapse <50%), was found to be a prerequisite. The addition of a combination of ventricular septal shift and either medial e′ velocity ≥9 cm/s or hepatic vein expiratory diastolic flow reversal ratio ≥0.79 corresponded to the highest combination of sensitivity (87%) and specificity (91%).
Which echocardiographic technique is best for evaluating pericardial thickness?
TEE !.
Pericardial thickness of ≥3 mm on transesophageal echocardiography has 95% sensitivity and 86% specificity for the detection of thickened pericardium. Figure shows a transesophageal echocardiogram (4-chamber transverse plane view) and the corresponding transaxial electron beam computed tomographic scan from a patient with a markedly thickened pericardium (up to 18 mm) over the right side of the heart. White arrows point to the thickened pericardium (P).
What may prevent right ventricular free wall diastolic collapse in a patient with a pericardial effusion?
One of the features of a hemodynamically significant pericardial effusion is right ventricular diastolic collapse and/or right atrial late diastolic collapse. This 2D echocardiographically appreciated sign usually reflects that pericardial fluid has accumulated to the elastic limit of the pericardial sac, causing a significant increase in pericardial pressure. Increasing the pressure beyond this point will be at the expense of the cardiac chambers with the lowest pressures, and will be reflected as indentation of right-sided chambers during diastole. However, when right-sided pressures are abnormally high, as in severe pulmonary hypertension, pressures of the RV and RA might increase to a pressure equal to or even higher than that of the pericardial pressure, thus preventing right-sided diastolic collapse. R
Which condition is characterized by marked diastolic flow reversal in the hepatic veins that increases in expiration compared with inspiration?
Constriction
Hepatic vein diastolic flow reversal, which increases with expiration, is a classical feature of CP. There is reversal of forward flow during expiration, since the right ventricular cavity size is reduced due to right-sided shift of the interventricular septum, becoming less compliant as the left ventricle fills more. In contrast, reversal of hepatic vein flow occurs during inspiration in restrictive cardiomyopathy.
What is the suggested cut-off value of longitudinal early diastolic annular velocities for differentiating CP from restrictive cardiomyopathy?
8 m/s
An e′ of >8 cm/s has approximately 95% sensitivity and 96% specificity for the diagnosis of CP. In normal subjects, mitral lateral e′ velocity is higher than the medial e′ velocity. The presence of relatively normal lateral and/or septal mitral annular velocities suggests the presence of CP. However, the lateral e′ velocity is usually lower than the medial e′ velocity, resulting in annulus reversus. This finding is likely due to the tethering of the adjacent fibrotic and scarred pericardium, which influences the lateral mitral annulus of patients with CP.
Enhanced respiratory variation of ventricular filling represents which pathophysiologic feature of pericardial disease?
Abnormal septal motion.
In patients with CP, the pulmonary capillary wedge pressure (PCWP) is influenced by the inspiratory fall in thoracic pressure, whereas the LV pressure is shielded from respiratory pressure variations by the pericardial scar. Thus, inspiration lowers the PCWP and presumably left atrial pressure, but not LV diastolic pressure, thereby decreasing the pressure gradient for ventricular filling. The less favorable filling pressure gradient during inspiration explains the decline in filling velocity. Reciprocal changes occur in the velocity of right ventricular filling. These changes are mediated by the ventricular septum, not by increased systemic venous return and represent features of exaggerated interventricular dependence.
What is seen in CP but is not necessarily a specific sign for constriction?
Abnormal interventricular septal motion.
In CP, total cardiac volume is fixed by the noncompliant pericardium. The septum is not involved and can therefore bulge toward the left ventricle (Fig. 25-15, arrow 1), when LV volume is less than that on the right. As a result, ventricular interaction is greatly enhanced. This periodic bulging may be seen on echocardiography and represents an abnormal pattern of septal motion. In addition, the rapid filling in early diastole gives rise to additional brisk motion of the septum, which is also referred to as “septal shudder” or septal bounce (Fig. 25-15, arrow 2). It is important to differentiate septal bounce from respirophasic septal shift. A septal bounce is defined as an abrupt displacement of the interventricular septum in early diastole during each cardiac cycle. A respirophasic septal shift is defined as a posterior shift of the interventricular septum during inspiration. Hemodynamic data from the Mayo Clinic shows that the septal bounce is related to an abrupt increase in early diastolic right ventricular pressure, which surpasses left ventricular diastolic pressure during the cardiac cycle. Abnormal septal motion, however, is not specific for constriction and is also seen following cardiac surgery, in the presence of left bundle branch block or pulmonary hypertension. Tissue Doppler imaging of the ventricular septum can be used to show the polyphasic fluttering motion in constrictive pericarditis compared to the other causes of abnormal ventricular septal motion.
Demonstration of what is obligatory for the diagnosis of CP?
Abnormal hemodynamics
Demonstration of constrictive physiology and elevated filling pressure are key requisites for the diagnosis of CP and can occur in the absence of a thickened pericardium. Significant pulmonary hypertension and more than mild atrial enlargement are not typical features of CP.
Which echocardiographic feature can differentiate CP from chronic obstructive pulmonary disease (COPD)?
In COPD, the mitral inflow pattern is not restrictive.
Respiratory variation in mitral E velocity of ≥25% is the main diagnostic criterion for CP on Doppler echocardiography but it can also be present in patients with COPD. However, transmitral filling is usually never restrictive in COPD. In an attempt to further distinguish between these disorders, the pulsed-wave Doppler recordings of mitral and superior vena cava flow velocities can be compared. Patients with pulmonary disease have a marked increase in inspiratory superior vena cava systolic flow velocity , which is not seen in those with CP (Fig. 25-16B). DR = diastolic reversal.
What the most common primary neoplasm of the heart associated with a pericardial effusion?
The most common primary neoplasm of the heart associated with pericardial effusion is angiosarcoma. Nearly 80% of cardiac angiosarcomas arise as mural masses in the right atrium. Typically, they completely replace the atrial wall and fill the entire cardiac chamber. They may invade adjacent structures (e.g., vena cava, tricuspid valve). These tumors are both symptomatic and rapidly fatal. Extensive pericardial spread and encasement of the heart often occur.
What is the cause of chest pain in a 43 year old patient with this echo?
Absent pericardium
Complete absence of the pericardium is associated with the enlargement of the right ventricle and shift of the heart to the left, resulting in more of the right ventricle being seen on the routine left parasternal echocardiogram. Unusual windows for obtaining traditional appearing images of the left ventricle are often needed.
The labeled portion (white arrow) of the two-dimensional echocardiographic image is consistent with:
Pleural effusion
Left pleural effusions can present as large echo-free spaces that resemble pericardial effusions. These can be recognized because they appear as very large posterior spaces without any anterior component. Generally, in the parasternal long-axis view, pleural effusions are located posterior to the descending aorta, whereas pericardial effusions are located anterior to the aorta.
The labeled portion (white arrow) of the two-dimensional echocardiographic image is consistent with:
Loculated effusion
Pericardial fluid can become loculated or compartmentalized. Loculated fluid in the pericardium or surrounding mediastinum under pressure may produce severe hemodynamic instability. Small effusions are generally confined to the region behind the left ventricle when the patient is in a supine position and may appear to vanish when the patient sits up, as they drain to the apical region.
The labeled portion (white arrow) of the two-dimensional echocardiographic image is consistent with:
Pericardial effusion
There is a large loculated anterior pericardial effusion. Pericardial fluid typically appears as an anterior echo-free space on two-dimensional imaging. Pericardial fat usually can be distinguished from fluid because of subtle echogenicity resulting from the presence of fibrous material within the fat. In addition, pericardial fat remains constant in size throughout the cardiac cycle.
The M-mode echocardiographic features shown are suggestive of:
Tamponade
shows M-mode features of early diastolic collapse of the right ventricular free wall in cardiac tamponade. The yellow arrows point to right ventricular diastolic collapse. The * denotes the pericardial effusion. The primary abnormality is compression of all cardiac chambers due to increased pericardial pressure. The pericardium has some degree of elasticity; but once the elastic limit is reached, the ventricles must compete with each other for the fixed volume determined by the increased intrapericardial pressure.
Transmitral and transtricuspid flow profiles shown in a patient with a large pericardial effusion is suggestive of:
Tamponade
The respiratory variation of mitral and tricuspid flow velocities in cardiac tamponade is greatly increased and out of phase, reflecting the increased ventricular interdependence in which the hemodynamics of the left and right heart chambers are directly influenced by each other to a much greater degree than normal. The pathophysiology of tamponade relates to the effect of the excessive pericardial fluid limiting cardiac filling as the cardiac chambers compete with the pericardial fluid in the “fixed” and noncompliant space. Ventricular diastolic filling is reduced because of reduced inflow pressure gradients. Inspiration increases venous return to the right heart, with a simultaneous decrease in left heart filling, while expiration increases left heart filling with decrease in right heart filling. This explains the opposite respiratory variation of mitral and tricuspid inflow by Doppler echocardiography. For peak mitral E inflow velocity, the maximal drop occurs with the first beat of inspiration and the first beat of expiration and usually exceeds >30% respiratory variation. For peak tricuspid E inflow velocity, the maximal drop is on the first beat in expiration at the same time as the hepatic vein atrial reversal and usually exceeds >60% respiratory variation. Significant respiratory variation of the mitral and tricuspid inflows should not be used as a stand-alone criterion for tamponade without the presence of other features suggestive of tamponade, for example, chamber collapse, because in CP the pattern of mitral and tricuspid flow variation with respiration is comparable to that observed in cardiac tamponade; however, less in intensity (e.g., mitral inflow velocity usually not >25%–40%, and tricuspid velocity greatly increases 40%–60%) in the first beat after inspiration
The M-mode echocardiogram shown refers to the early diastolic motion of the interventricular septum and LV posterior wall. This unique motion pattern is seen in which of the following pericardial diseases?
Chronic constriction
In CP, when intracardiac volume is less than that defined by the stiff pericardium, diastolic filling is unimpeded, and early diastolic filling occurs abnormally rapidly because venous pressure is elevated. The rapid early diastolic filling, which is halted abruptly when intracardiac volume reaches the limit set by the noncompliant pericardium, is reflected by the abrupt displacement of the interventricular septum into the left ventricle during early diastole (i.e., the septal bounce).
Similarities and Differences between tamponade and constriction?
Figure shows velocities from the medial corner of the mitral annulus in a patient with CP. What relationship would be expected to be seen between pulmonary capillary wedge pressure (PCWP) and the E/e′ ratio?
Varies inversely proportional to the PCWP.
Paradoxical to the positive correlation between E/e′ and PCWP in patients with myocardial disease, an inverse relationship is seen in patients with CP. The likely explanation for this finding is the exaggerated longitudinal motion of the mitral annulus, despite high filling pressures in patients with CP. This is because the lateral expansion of the entire heart is limited by the constricting pericardium. The more severe the constriction with a higher filling pressure, the more accentuated is the longitudinal motion of the mitral annulus. However, a study from the Cleveland Clinic showed that this inverse relationship of annulus paradoxus in constriction was not seen possibly due to the heterogeneity of patients with constriction.
Following figure shows hepatic vein pulsed wave Doppler. The features are consistent with?
Expiratory diastolic flow reversals seen in chronic CP.
Hepatic vein diastolic flow reversal with expiration suggests CP, even when the transmitral flow velocity pattern may not be diagnostic. The absence of typical respiratory flow velocity changes in transmitral flow should not exclude the diagnosis, because up to 50% of patients with constriction may not meet these criteria. In such a situation, hepatic vein flow reversal that increases with expiration may still be seen and reflect the ventricular interaction and dissociation of intracardiac and intrathoracic pressures. The white arrow in Figure refers to hepatic vein diastolic reversal.
The two-dimensional echocardiogram of this 82-year-old woman in Figure (with white arrow pointing to a key finding), is consistent with?
Pericardial metastasis.
Although a pericardial effusion generally appears as an echo-free space encircling the heart, sometimes echogenic materials such as fibrinous strands and shaggy exudative coating are found in pericardial effusion. Tuberculous pericardial effusion shows the highest prevalence of echogenic material, followed by malignant and idiopathic pericardial effusions.
Following echocardiogram of a 35 year old patient with shortness of breath for 1 week and cardiomegaly on chest X ray. What is the echocardiogram consistent with?
Injection of agitated saline.
A cross-sectional contrast echocardiogram showing pericardial space containing a cloud of echogenic microbubbles is seen. Although pericardiocentesis is a relatively safe procedure, there are hazards particularly suspected when hemorrhagic fluid is aspirated. Having the opportunity to outline the space from which the fluid is withdrawn is of particular interest in this situation. A current technique of echocardiography with contrast enhancement involves injection of a few milliliters of agitated saline solution. In the pericardium, contrast movement is slow and swirling and has a longer half-life. Performing this procedure helps in ensuring that the catheter is within the pericardial cavity and not within the cardiac chambers.
Needle and transducer are best placed remote and orthogonal to each other
During pericardiocentesis, a proposed entry point is marked on the patient’s skin where the percutaneous needle should penetrate the chest wall. The transducer angle is noted as this will need to be replicated by the pericardiocentesis needle. The distance from the chest wall to the effusion and the distance to the nearest cardiac structure are determined, as this will determine the maximum distance that the pericardial needle can be safely advanced. It is best to locate an acoustic window remote to the proposed puncture site. The transducer, if possible, is held in an orthogonal direction so that needle puncture can be directly visualized. If not, the imaging probe should be covered with a sterile cover and available for the physician performing the procedure to use if needed.
Note: Contrast echocardiography is a simple, effective technique that aids localization of catheter position during pericardiocentesis.
What do doppler images suggest in a 38 year old man with history of weight gain, shortness of breath and leg edema?
Note: A lack of typical respiratory flow velocity changes should not exclude the diagnosis of CP because up to 50% of patients with CP may not meet these criteria.
The upper panel in Figure shows respiratory changes in hepatic vein flow Doppler velocity profile. The presence of exaggerated diastolic flow reversals suggests possible CP. The lower panel in Figure shows lack of significant respiratory changes in transmitral flow velocities. In patients with symptoms and signs of right ventricular failure, Doppler echocardiography can be diagnostic for constriction if mitral inflow and hepatic vein flow velocities show characteristic respiratory changes. However, in the absence of significant respiratory changes, Doppler echocardiographic study should be repeated with maneuvers such as tilting, sitting, or diuresis.
Head up tilting, sitting, or diuresis helps in reducing preload in an effort to determine whether the characteristic Doppler velocity changes with respiration can be demonstrated.
In a patient with a febrile syndrome who presents with shortness of breath, leg edema, orthopnea and JVP along with pleural effusions and pericardial thickness of 20 mm on CT with following doppler findings, what should be the management?
In the absence of symptoms that suggest chronicity of disease (e.g., cachexia, atrial fibrillation, hepatic dysfunction, or pericardial calcification), patients with newly diagnosed CP who are hemodynamically stable and some evidence of inflammation using biomarkers (CRP, WSR) or imaging may be given a trial of conservative management for 3–6 months before pericardiectomy is recommended.
Figure shows respiratory variations in mitral E velocity and hepatic veins that are consistent with the diagnostic criteria for CP on Doppler echocardiography. The clinical presentation in this patient implies the presence of acute inflammatory pericarditis with constriction. CP in such a situation may resolve either spontaneously or in response to various combinations of nonsteroidal anti-inflammatory agents, steroids, and antibiotics or sometimes triple anti-inflammatory therapy. Specific antibiotic (e.g., antituberculous) therapy should be initiated in presence of a confirmed tubercular etiology. Diuretics can be used sparingly with the goal of reducing, not eliminating, elevated jugular pressure, edema, and ascites. The central venous pressure may take weeks to months to return to normal.
Note: The resolution of edema and pleural effusion with documentation of reduction in pericardial thickening on computed tomography scan is consistent with the diagnosis of transient pericardial constriction.
In a patient who is hemodynamically stable, without symptoms or JVP but with following echo and doppler what is the diagnosis?
Apical 2-chamber and short-axis views of the left ventricle i show marked thickening of the parietal and visceral pericardium with a small loculated pericardial effusion. The Figure increased respiratory variation of transmitral flow. Both these features suggest the presence of occult effusive CP.
