Pericardial Disease Flashcards
1
Q
What are the 4 Class 1 indications for TEE for pericardial disease?
A
- Suspected pericardial disease
- Suspected bleeding in the pericardial space
- Follow up study to evaluate for effusion or to diagnose constriction
- Pericardial friction rub develpping in acute MI accompanied by pain, hypotension and nausea
2
Q
What are the two pericardial layers?
A
- Pariental pericardium (outer)
- Visceral Pericardium (inner)
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)
4
Q
What is the cutoff for pericardial thickness?
A
>4 mm = thickened
5
Q
What does the parietal pericardium blend with inferiorly?
A
Diaphragm
6
Q
What does the parietal pericardium apposed to laterally?
A
Pleural Spaces
7
Q
What is the term where the pericardial layers meet?
A
Reflections
8
Q
Reflections that surround the vena cava and pulmonary veins create a pocket behind the LA are called what?
A
Oblique Sinus
9
Q
What is the pericardial reflection around the great vessels called?
What great vessels are these?
A
Transverse Sinus
Pulmonary Artery and Aorta
10
Q
What is the normal amount of fluid in the pericardium?
A
25 - 50 mL
(5-30 mL in some sources)
11
Q
What is at the arrow?
A
Oblique Sinus
12
Q
Where on your omniplane will you see the oblique sinus?
A
~70 degrees near the LAA
13
Q
What is seen at the pointer?
A
Transverse sinus in the Ascending Aorta Short Axis
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
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
16
Q
For negative pressure spontaneous ventilation:
What is the Intrathoracic pressure End of expiration?
A
-3 = End Expiration
17
Q
For negative pressure spontaneous ventilation:
What is the Intrathoracic pressure End of inspiration?
A
-6 at end of inspiration
18
Q
How much do transtricuspid inflow velocities change during spontaneous negative ventilation?
A
~20%
19
Q
How much do transmitral inflow velocities change during spontaneous negative ventilation?
A
~10%
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)
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)
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)
23
Q
How does the septum shift during inspiration?
A
Shifts towards LV due to RV filling* and *decreased LV filling
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
25
How does spontaneous inspiration affect:
## Footnote
**Intrathoracic pressure**
Becomes more negative
26
How does spontaneous inspiration affect:
## Footnote
**Pulmonary Veins**
**Dilates** pulmonary veins
27
How does spontaneous inspiration affect:
## Footnote
**venous return**
**Increases** venous return
28
How does spontaneous inspiration affect:
## Footnote
**RV filling and RV stroke volume**
**Increased** RV filling and RV stroke volume
29
How does spontaneous inspiration affect:
## Footnote
**RV afterload**
**Decreased** RV afterload
30
How does spontaneous inspiration affect:
## Footnote
**LA filling**
**Decreased** LA filling
31
How does spontaneous inspiration affect:
## Footnote
**LV stroke volume**
**Decreased** LV stroke volume
32
How does spontaneous inspiration affect:
## Footnote
**LV afterload**
**Increased** LV afterload
33
How does spontaneous **expiration** affect:
## Footnote
**Intrathoracic pressure?**
**More positive** intrathoracic pressure
34
How does spontaneous **expiration** affect:
## Footnote
**Pulmonary Vein Tone**
**Compressed** pulmonary veins
35
How does spontaneous **expiration** affect:
## Footnote
**Venous Return**
**Decreased** Venous Return
36
How does spontaneous **expiration** affect:
## Footnote
**RV FIlling and RV stroke Volume**
**Decreased** RV FIlling and RV stroke Volume
37
How does spontaneous **expiration** affect:
## Footnote
**RV afterload**
**Increased** RV afterload
38
How does spontaneous **expiration** affect:
## Footnote
**LA Filling**
**Increased** LA filling
39
How does spontaneous **expiration** affect:
LV Stroke Volume
**Increased** LV Stroke Volume
40
How does spontaneous **expiration** affect:
## Footnote
**LV Afterload**
**Decreased** LV afterload
41
During spontaneous ventilation, how does **Trans Mitral inflow** velocities change during **expiration**?
Increase 10%
42
During spontaneous ventilation, how does **Trans Tricuspid inflow** velocities change during **expiration**?
Decrease 20%
43
During *_positive pressure ventilation_*, how does **Trans Mitral inflow** velocities change during expiration?
Decrease
44
During *_positive pressure ventilation_*, how does Trans Tricuspid inflow velocities change during expiration?
**Increase**
45
What changes are exaggerated with **constrictive pericarditis** and **Tamponade**?
**Spontaneously** ventilating patients havae exaggeratad changes in TM and TT inflow velocities
i.e. Exaggerated respiro-phasic variation
46
How does tamponade physiology change with resp variation?
**PPV** respiratory variation **decrease**
47
What changes are exaggerated with constrictive pericarditis that make it unique?
*_Exaggerated Respiratory variation_* with **spontaneous** ventilation and **PPV**.
48
How does **respirophasic variation change** in a tamponade patient with:
Spontaneously breathing patient?
Positive pressure applied to patient?
Spont = **Increase** in respirophasic variation
PPV = **Decrease** in respirophasic variation
49
What is the major difference with positive pressure with tamponade vs. constrictive pericarditis?
Tamponade = **Decrease** variation with PPV
Constrictive pericarditis = **Increase** variation with PPV
50
What is the difference in Y descents (CVP) of Tamponade vs. Constrictive pericarditis?
Tamponade = **Attenuated** Y descent (Prominent systolic filling)
Constrictive Pericarditis = **Exaggerated** Y descent (Prominent early filling)
51
How does **pulsus paradoxus** differ in tamponade vs. constrictive pericarditis?
**Tamponade** = Pulsus Paradoxus is **common**
**CP** = Pulsus Paradoxus is **not common**
52
How does **Kussmaul's sign** differ in tamponade vs. constrictive pericarditis?
Not present in **Tamponade**
Present in **CP**
Kussmaul's sign is the paradoxical increase in JVP that occurs during inspiration.
53
What is Mulberry Nonism important to note on echo?
CHF and Constrictive Pericarditis
54
What is the triad of pericarditis?
1. Chest Pain
2. EKG changes
3. Pericardial Friction Rub
55
What is the etiology % of viral pericarditis that results in constrictive pericarditis?
42-49%
56
What are the other etiologies of pericarditis?
Idiopathic (Often viral)
Infection
Neoplastic
Autoimmune / Inflammatory
Post Cardiac Surgery / Intervention (11-37%)
Post-radiation
Drugs
Traum
Uremia
57
What is the chest pain described as with pericarditis?
What is the palliative/provoking symptoms?
*Sharp, radiates to the back*
*_Position:_*
**Worse** when **flat**
**Better** when **forward**
58
What is seen on Cardiac MRI for Pericarditis?
Late Gadolinium Enhancement
59
What inflammatory markers are elevated in pericarditis?
Elevated **CRP**
Elevated **Westergren Sedimentation Rate**
60
What is a sensitive indicator for pericarditis?
**\>4mm thickness**
Highly sensitive
61
How would you rank best modalities to measure pericardium thickness in pericarditis?
MRI & CT \> TEE \> TTE
62
What is the time cutoff for acute vs. chronic pericarditis?
3 months
\<3 months = Acute
\>6 months = Chronic
63
What is normal thickness of the pericardium?
1-2 mm
64
Can constrictive pericarditis happen with normal pericardial thickness?
**Yes**; Doesnt exclude CP to have a normally thick pericardium
65
What are the distinguishing *_echo features_* that differentiate **Constrictive Pericarditis** vs. **Restrictive infiltrative Cardiomyopathy**? (4)
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
What are the distinguishing *_physical exam_* that differentiate **Constrictive Pericarditis** vs. **Restrictive infiltrative Cardiomyopathy**?
**Pericardial Knock** in CP
**S3** in RICM
67
What are the distinguishing *_lab finding_* that differentiate **Constrictive Pericarditis** vs. **Restrictive infiltrative Cardiomyopathy**?
CP - BNP \<100
RICM - BNP elevated
68
What is a distinguishing factors for CP vs. RICM regarding **pulmonary venous waves?**
Peak velocity pumonary D wave variation \>18% in CP
69
What is charactersitics of Constrictive Pericarditis vs. RICM with Transmitral waves?
Peak Velocity TM E wave variation \>10%
70
For constrictive pericarditis vs. RICM, what is the color M-mode prop velocity (VP) slope for CP?
\>100 cm/sec
71
What is the tissue doppler e' in **RICM**?
e' \< 8cm/sec
72
What is the tissue doppler e' in Constrictive Pericarditis?
e' \> 10
73
What is the Annular reversus in Constrictive Pericarditis?
**Lateral e'** \< **Septal e'**
(Lateral annulus is tethered to the pericardial sac and restricted)
74
What is annulus paradoxus?
What is seen in CP vs. RICM
**E/e' \<15** in Constrictive Pericarditis (despite elevated LAP)
(E/e' \>15 in RICM)
75
For pericardial diseases, when is reversal of forward flow during **expiration** seen?
Constrictive Pericarditis
76
For pericardial diseases, when is reversal of forward flow during **inspiration** seen?
RICM
77
How do you differentiate **CP vs. RICM on MRI**?
(Hint: Where is the Late Gadolinium enhancement?)
CP = Late Gadolinium enhancement of *_Pericardium_* and Thick **Pericardium**
RICM = Late Gadolinium enhancement of *_Subendocardium_*
78
How do you differentiate CP vs. RICM on **Left Atrial volume**?
**LA Volume / RA volume** greater in CP \> RICM
79
For CP vs. RICM
**Max Septal Excursion** between inspiration and expiration is greater in which one?
**CP** \> RICM
80
What is speckle tracking echocardiography?
***_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
What is the Color M Mode Flow Propagation Velocities seen in CP vs. RICM?
Vp \<**50** cm/sec = **RICM**
Vp \>**100** cm/sec = **CP**
82
How does cardiac catheterization appear in CP?
Elevation and Equalization of diastolic pressures (oversimplification)
83
How do the filling pressures differ in RICM?
**LVEDP** \> RVEDP
84
What is the dip and plateau sign seen in CP and RICM?
85
Is Kussmall's sign seen in tamponade?
**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
What is pulsus paradoxus?
Pulsus paradoxus is defined as a **fall of systolic blood pressure of \>10 mmHg during the inspiratory phase.**
87
How does **respirophasic variation** change with tamponade under:
1. Spontaneous ventilation?
2. Positive Pressure ventilation?
1. SV = Exagerrated variation
2. PPV = Decreased variation
88
How does the IVC appear in **tamponade**?
IVC = Plethoric
89
How do the **Hepatic Veins** appear in tamponade?
Enlarged
90
When is there RA collapse in Tamponade?
Systole and Diastole
91
What is more specific for tamponade;
RA collapse in systole vs. RA collapse in diastole
RA collapse in systole = Tamponade
92
What is seen in the septum during cardiac tamponade on echo?
**Septal Shift** & **Bounce** (From the respiratory variation and ventricular interdependence)
93
What is seen in the pulmonic valve during cardiac tamponade?
Premature Mid-Diastolic Pulmonic Valve Opening (M-mode)
94
What does a plethoric IVC mean during cardiac tamponade?
\>20 mm in width
\<50% decrease with inspiration
95
What is the negative predictive value (NPV) of cardiac tamponade with absence of chamber collapse?
Absence of any collapse = 90% NPV
96
What finding is 100% sensitive and specific for cardiac tamponade?
RA collapse \>1/3 of the cardiac cycle
97
When does the RV collapse in diastole occur in cardiac tamponade?
Pericardial Pressure \> RVDBP (RV diastolic pressure)
98
What is electrical alternans?
This EKG rhythm is typically associated with pericardial effusion via the “swinging heart” from the fluid surrounding the heart
99
What is the sensitivity and specificity of **Atrial Systolic Collapse** for Cardiac Tamponade?
**Atrial Systolic Collapase \> 1/3 of systole**
94% sensitive
100% specific
100
What is the sensitivity and specificity of **RV Diastolic Collapse** for Cardiac Tamponade?
60-90% sensitivity
85-100% specificity
101
When would you have cardiac tamponade **without** pulses paradoxus?
Intrapericardial Clot
102
How do we quantify a **small** pericardial fluid?
0.5 cm (100-200 mL)
103
How do we quantify a **moderate** pericardial fluid?
0.5 - 2 cm
(200 - 500 mL) = Moderate
104
How do we quantify a **large** pericardial fluid?
\>2 cm (\>500 mL)
105
