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PTE Masters + A Practical Approach to Transesophageal Echocardiography > Pericardial Disease > Flashcards

Pericardial Disease Flashcards

1
Q

What are the 4 Class 1 indications for TEE for pericardial disease?

A
  1. Suspected pericardial disease
  2. Suspected bleeding in the pericardial space
  3. Follow up study to evaluate for effusion or to diagnose constriction
  4. Pericardial friction rub develpping in acute MI accompanied by pain, hypotension and nausea
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2
Q

What are the two pericardial layers?

A
  1. Pariental pericardium (outer)
  2. Visceral Pericardium (inner)
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3
Q

What is the function of the parietal pericardium?

A

1. Restraint role and prevents heart from dilating

2. AV valve stabilization with improved valve functions

3. Secretory functions

  • Prostacyclin
  • Sympathetic neuronal regulation
  • Coronary Vascular Tone & Cardiac Contractility
    4. Fibrinolytic Function (If clot develops)
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4
Q

What is the cutoff for pericardial thickness?

A

>4 mm = thickened

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5
Q

What does the parietal pericardium blend with inferiorly?

A

Diaphragm

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6
Q

What does the parietal pericardium apposed to laterally?

A

Pleural Spaces

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7
Q

What is the term where the pericardial layers meet?

A

Reflections

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8
Q

Reflections that surround the vena cava and pulmonary veins create a pocket behind the LA are called what?

A

Oblique Sinus

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9
Q

What is the pericardial reflection around the great vessels called?

What great vessels are these?

A

Transverse Sinus

Pulmonary Artery and Aorta

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10
Q

What is the normal amount of fluid in the pericardium?

A

25 - 50 mL

(5-30 mL in some sources)

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11
Q

What is at the arrow?

A

Oblique Sinus

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12
Q

Where on your omniplane will you see the oblique sinus?

A

~70 degrees near the LAA

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13
Q

What is seen at the pointer?

A

Transverse sinus in the Ascending Aorta Short Axis

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14
Q

What is seen at the blue arrow and also at the vessel at the top and middle of the image?

A

RPA = Top

Transverse Sinus = At blue arrow

Large vessel = Aorta

View = Mid Esophageal Ascending Aorta in long axis

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15
Q

What is Mulibrey Nanism?

A

Congential disease - Overgrowth of the fibrous sac surrounding the heart (constrictive pericarditis).

Finnish population (Autosomal recessive)

Causing CHF

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16
Q

For negative pressure spontaneous ventilation:

What is the Intrathoracic pressure End of expiration?

A

-3 = End Expiration

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17
Q

For negative pressure spontaneous ventilation:

What is the Intrathoracic pressure End of inspiration?

A

-6 at end of inspiration

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18
Q

How much do transtricuspid inflow velocities change during spontaneous negative ventilation?

A

~20%

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19
Q

How much do transmitral inflow velocities change during spontaneous negative ventilation?

A

~10%

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20
Q

How does the transtricuspid PWD inflow velocities change during spontaneous expiration compared to spontaneous inspiration?

A

~20% increase in inflow velocities (see images)

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21
Q

How do you calculate the gradient for RV filling?

A

Intracardiac pressure - pericardial pressure

Ex: if right atrial pressure is 6 and PP is -6 then the gradient is 12

(RV filling is enhanced by spontaneous inspiration)

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22
Q

How does the RV vs. LV fill during spontaneous inspiration?

A

RV fills due to increased gradient

Decreased LV filling (pulmonary venous pooling)

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23
Q

How does the septum shift during inspiration?

A

Shifts towards LV due to RV filling* and *decreased LV filling

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24
Q

How does the RV vs. LV fill during spontaneous expiration?

A

Decreased gradient for RV filling (Decreased venous return)

Increased LV filling due to compressed lungs

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25
Q

How does spontaneous inspiration affect:

Intrathoracic pressure

A

Becomes more negative

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26
Q

How does spontaneous inspiration affect:

Pulmonary Veins

A

Dilates pulmonary veins

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27
Q

How does spontaneous inspiration affect:

venous return

A

Increases venous return

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28
Q

How does spontaneous inspiration affect:

RV filling and RV stroke volume

A

Increased RV filling and RV stroke volume

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29
Q

How does spontaneous inspiration affect:

RV afterload

A

Decreased RV afterload

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30
Q

How does spontaneous inspiration affect:

LA filling

A

Decreased LA filling

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31
Q

How does spontaneous inspiration affect:

LV stroke volume

A

Decreased LV stroke volume

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32
Q

How does spontaneous inspiration affect:

LV afterload

A

Increased LV afterload

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33
Q

How does spontaneous expiration affect:

Intrathoracic pressure?

A

More positive intrathoracic pressure

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34
Q

How does spontaneous expiration affect:

Pulmonary Vein Tone

A

Compressed pulmonary veins

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35
Q

How does spontaneous expiration affect:

Venous Return

A

Decreased Venous Return

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36
Q

How does spontaneous expiration affect:

RV FIlling and RV stroke Volume

A

Decreased RV FIlling and RV stroke Volume

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37
Q

How does spontaneous expiration affect:

RV afterload

A

Increased RV afterload

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38
Q

How does spontaneous expiration affect:

LA Filling

A

Increased LA filling

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39
Q

How does spontaneous expiration affect:

LV Stroke Volume

A

Increased LV Stroke Volume

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40
Q

How does spontaneous expiration affect:

LV Afterload

A

Decreased LV afterload

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41
Q

During spontaneous ventilation, how does Trans Mitral inflow velocities change during expiration?

A

Increase 10%

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42
Q

During spontaneous ventilation, how does Trans Tricuspid inflow velocities change during expiration?

A

Decrease 20%

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43
Q

During positive pressure ventilation, how does Trans Mitral inflow velocities change during expiration?

A

Decrease

44
Q

During positive pressure ventilation, how does Trans Tricuspid inflow velocities change during expiration?

A

Increase

45
Q

What changes are exaggerated with constrictive pericarditis and Tamponade?

A

Spontaneously ventilating patients havae exaggeratad changes in TM and TT inflow velocities

i.e. Exaggerated respiro-phasic variation

46
Q

How does tamponade physiology change with resp variation?

A

PPV respiratory variation decrease

47
Q

What changes are exaggerated with constrictive pericarditis that make it unique?

A

Exaggerated Respiratory variation with spontaneous ventilation and PPV.

48
Q

How does respirophasic variation change in a tamponade patient with:

Spontaneously breathing patient?
Positive pressure applied to patient?

A

Spont = Increase in respirophasic variation

PPV = Decrease in respirophasic variation

49
Q

What is the major difference with positive pressure with tamponade vs. constrictive pericarditis?

A

Tamponade = Decrease variation with PPV

Constrictive pericarditis = Increase variation with PPV

50
Q

What is the difference in Y descents (CVP) of Tamponade vs. Constrictive pericarditis?

A

Tamponade = Attenuated Y descent (Prominent systolic filling)

Constrictive Pericarditis = Exaggerated Y descent (Prominent early filling)

51
Q

How does pulsus paradoxus differ in tamponade vs. constrictive pericarditis?

A

Tamponade = Pulsus Paradoxus is common

CP = Pulsus Paradoxus is not common

52
Q

How does Kussmaul’s sign differ in tamponade vs. constrictive pericarditis?

A

Not present in Tamponade

Present in CP

Kussmaul’s sign is the paradoxical increase in JVP that occurs during inspiration.

53
Q

What is Mulberry Nonism important to note on echo?

A

CHF and Constrictive Pericarditis

54
Q

What is the triad of pericarditis?

A
  1. Chest Pain
  2. EKG changes
  3. Pericardial Friction Rub
55
Q

What is the etiology % of viral pericarditis that results in constrictive pericarditis?

A

42-49%

56
Q

What are the other etiologies of pericarditis?

A

Idiopathic (Often viral)

Infection

Neoplastic

Autoimmune / Inflammatory

Post Cardiac Surgery / Intervention (11-37%)

Post-radiation

Drugs

Traum

Uremia

57
Q

What is the chest pain described as with pericarditis?
What is the palliative/provoking symptoms?

A

Sharp, radiates to the back

Position:

Worse when flat

Better when forward

58
Q

What is seen on Cardiac MRI for Pericarditis?

A

Late Gadolinium Enhancement

59
Q

What inflammatory markers are elevated in pericarditis?

A

Elevated CRP

Elevated Westergren Sedimentation Rate

60
Q

What is a sensitive indicator for pericarditis?

A

>4mm thickness

Highly sensitive

61
Q

How would you rank best modalities to measure pericardium thickness in pericarditis?

A

MRI & CT > TEE > TTE

62
Q

What is the time cutoff for acute vs. chronic pericarditis?

A

3 months

<3 months = Acute

>6 months = Chronic

63
Q

What is normal thickness of the pericardium?

A

1-2 mm

64
Q

Can constrictive pericarditis happen with normal pericardial thickness?

A

Yes; Doesnt exclude CP to have a normally thick pericardium

65
Q

What are the distinguishing echo features that differentiate Constrictive Pericarditis vs. Restrictive infiltrative Cardiomyopathy? (4)

A
  1. Peak Velocity Pulmonay Venous D wave variation >18% in CP
  2. Peak Velocity TM E Wave variation >10% in CP
  3. Color M-mode prop velocity (VP) slope >100 cm/sec in CP
  4. Tissue doppler e’ <8 cm/sec in RICM
66
Q

What are the distinguishing physical exam that differentiate Constrictive Pericarditis vs. Restrictive infiltrative Cardiomyopathy?

A

Pericardial Knock in CP

S3 in RICM

67
Q

What are the distinguishing lab finding that differentiate Constrictive Pericarditis vs. Restrictive infiltrative Cardiomyopathy?

A

CP - BNP <100

RICM - BNP elevated

68
Q

What is a distinguishing factors for CP vs. RICM regarding pulmonary venous waves?

A

Peak velocity pumonary D wave variation >18% in CP

69
Q

What is charactersitics of Constrictive Pericarditis vs. RICM with Transmitral waves?

A

Peak Velocity TM E wave variation >10%

70
Q

For constrictive pericarditis vs. RICM, what is the color M-mode prop velocity (VP) slope for CP?

A

>100 cm/sec

71
Q

What is the tissue doppler e’ in RICM?

A

e’ < 8cm/sec

72
Q

What is the tissue doppler e’ in Constrictive Pericarditis?

A

e’ > 10

73
Q

What is the Annular reversus in Constrictive Pericarditis?

A

Lateral e’ < Septal e’

(Lateral annulus is tethered to the pericardial sac and restricted)

74
Q

What is annulus paradoxus?

What is seen in CP vs. RICM

A

E/e’ <15 in Constrictive Pericarditis (despite elevated LAP)

(E/e’ >15 in RICM)

75
Q

For pericardial diseases, when is reversal of forward flow during expiration seen?

A

Constrictive Pericarditis

76
Q

For pericardial diseases, when is reversal of forward flow during inspiration seen?

A

RICM

77
Q

How do you differentiate CP vs. RICM on MRI?

(Hint: Where is the Late Gadolinium enhancement?)

A

CP = Late Gadolinium enhancement of Pericardium and Thick Pericardium

RICM = Late Gadolinium enhancement of Subendocardium

78
Q

How do you differentiate CP vs. RICM on Left Atrial volume?

A

LA Volume / RA volume greater in CP > RICM

79
Q

For CP vs. RICM

Max Septal Excursion between inspiration and expiration is greater in which one?

A

CP > RICM

80
Q

What is speckle tracking echocardiography?

A

Ratio of LV free wall systolic strain/septal wall strain & RV free wall

Speckle-tracking echocardiography has recently emerged as a quantitative ultrasound technique for accurately evaluating myocardial function by analyzing the motion of speckles identified on routine 2-dimensional sonograms. It provides non-Doppler, angle-independent, and objective quantification of myocardial deformation and left ventricular systolic and diastolic dynamics.

By tracking the displacement of the speckles during the cardiac cycle, strain and the strain rate can be rapidly measured offline after adequate image acquisition.

81
Q

What is the Color M Mode Flow Propagation Velocities seen in CP vs. RICM?

A

Vp <50 cm/sec = RICM

Vp >100 cm/sec = CP

82
Q

How does cardiac catheterization appear in CP?

A

Elevation and Equalization of diastolic pressures (oversimplification)

83
Q

How do the filling pressures differ in RICM?

A

LVEDP > RVEDP

84
Q

What is the dip and plateau sign seen in CP and RICM?

A
85
Q

Is Kussmall’s sign seen in tamponade?

A

No

Kussmaul’s sign is the paradoxical increase in JVP that occurs during inspiration. Jugular venous pressure normally decreases during inspiration because the inspiratory fall in intrathoracic pressure creates a “sucking effect” on venous return.

Said another way; Absence of an inspiatory drop in JVP (Spontaneous ventilation)

86
Q

What is pulsus paradoxus?

A

Pulsus paradoxus is defined as a fall of systolic blood pressure of >10 mmHg during the inspiratory phase.

87
Q

How does respirophasic variation change with tamponade under:
1. Spontaneous ventilation?

  1. Positive Pressure ventilation?
A
  1. SV = Exagerrated variation
  2. PPV = Decreased variation
88
Q

How does the IVC appear in tamponade?

A

IVC = Plethoric

89
Q

How do the Hepatic Veins appear in tamponade?

A

Enlarged

90
Q

When is there RA collapse in Tamponade?

A

Systole and Diastole

91
Q

What is more specific for tamponade;

RA collapse in systole vs. RA collapse in diastole

A

RA collapse in systole = Tamponade

92
Q

What is seen in the septum during cardiac tamponade on echo?

A

Septal Shift & Bounce (From the respiratory variation and ventricular interdependence)

93
Q

What is seen in the pulmonic valve during cardiac tamponade?

A

Premature Mid-Diastolic Pulmonic Valve Opening (M-mode)

94
Q

What does a plethoric IVC mean during cardiac tamponade?

A

>20 mm in width

<50% decrease with inspiration

95
Q

What is the negative predictive value (NPV) of cardiac tamponade with absence of chamber collapse?

A

Absence of any collapse = 90% NPV

96
Q

What finding is 100% sensitive and specific for cardiac tamponade?

A

RA collapse >1/3 of the cardiac cycle

97
Q

When does the RV collapse in diastole occur in cardiac tamponade?

A

Pericardial Pressure > RVDBP (RV diastolic pressure)

98
Q

What is electrical alternans?

A

This EKG rhythm is typically associated with pericardial effusion via the “swinging heart” from the fluid surrounding the heart

99
Q

What is the sensitivity and specificity of Atrial Systolic Collapse for Cardiac Tamponade?

A

Atrial Systolic Collapase > 1/3 of systole

94% sensitive

100% specific

100
Q

What is the sensitivity and specificity of RV Diastolic Collapse for Cardiac Tamponade?

A

60-90% sensitivity

85-100% specificity

101
Q

When would you have cardiac tamponade without pulses paradoxus?

A

Intrapericardial Clot

102
Q

How do we quantify a small pericardial fluid?

A

0.5 cm (100-200 mL)

103
Q

How do we quantify a moderate pericardial fluid?

A

0.5 - 2 cm

(200 - 500 mL) = Moderate

104
Q

How do we quantify a large pericardial fluid?

A

>2 cm (>500 mL)

105
Q
A

PTE Masters + A Practical Approach to Transesophageal Echocardiography (55 decks)

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