Pericardial Disease Flashcards
The two layers of the pericardium are:
A. Epicardium; endocardium
B. Epicardium; fibrous pericardium
C. Myocardium; parietal pericardium
D. Visceral pericardium; myocardium
B. The pericardium is made up of two layers. The epicardium (visceral pericardium) is a serous membrane which lies directly adherent to the heart and the outer layer is called the fibrous (parietal) pericardium.
The normal thickness of the parietal pericardium is approximately 2 mm. There is approximately 10 to 50 mL of fluid normally between the epicardium and fibrous pericardium.
The most common presenting symptom of acute pericarditis is:
A. Chest pain
B. Cachexia
C. Hemoptysis
D. Fatigue
A. Other symptoms of pericarditis include dyspnea, fever and cough.
The chest pain associated with acute pericarditis may be relieved by the patient sitting up and leaning forward.
All of the following are associated findings for pericarditis EXCEPT:
A. Pericardial friction rub
B. Pericardial effusion by echocardiography
C. Fever
D. Tachycardia
B. The expected echocardiographic finding for pericarditis is a pericardial effusion but patients may have pericarditis without pericardial effusion (dry pericarditis). Additionally pericardial effusion can occur in the absence of pericardial inflammation such as in post-operative cardiac surgery, chronic renal disease, collagen vascular disease, cardiac trauma, malignancy, AIDS and hypothyroidism.
The best guideline for differentiating pericardial effusion from pleural effusion by two-dimensional echocardiography is:
A. Pericardial effusion is located anterior to the descending aorta; pleural effusion is present posterior to the descending aorta.
B. Pericardial effusion is present posterior to the descending aorta; pleural effusion is located anterior to the descending aorta.
C. Pericardial effusion is usually seen as an anterior clear space; pleural effusion is usually seen as a posterior clear space.
D. Pericardial effusion is usually seen as a posterior clear space; pleural effusion is usually seen as an anterior clear space.
A. In addition, a large pericardial effusion usually surrounds the heart.
A posterior echo-free space is detected during the systolic phase only by M-mode/two-dimensional echocardiography. This is considered a:
A. Normal finding
B. Small pericardial effusion
C. Moderate pericardial effusion
D. Large pericardial effusion
A. The pericardial space is normally filled with between 10 to 50 mL of fluid. This normal pericardial fluid may be seen as an echo-free space during ventricular systole. When the echo-free space persists throughout the cardiac cycle, a pericardial effusion is considered present. When quantitating the amount of pericardial fluid by echocardiography the fluid should be measured during ventricular diastole.
An anterior clear space is noted in the parasternal long-axis view.
The diagnosis is most likely:
A. Adipose tissue
B. Pericardial effusion
C. Cardiac tamponade
D. Constrictive pericarditis
A. Adipose tissue surrounds the normal adult heart and can appear as an echo-free space on an echocardiogram. Most of the adipose tissue is located anterior although it can surround the entire heart. In the echocardiography laboratory, a clear space located only anterior is assumed to be adipose tissue. Exceptions include loculated pericardial effusion, hematoma (especially post-cardiac surgery and may result in regional cardiac tamponade) and tumor.
Fibrin within the pericardial effusion most likely indicates:
A. Cardiac tamponade
B. Constrictive pericarditis
C. Acute myocardial infarction
D. Long-standing pericardial effusion
D. Intrapericardial strands or fibrin strands indicate inflammation or longstanding pericardial effusions.
Pulsed-wave Doppler evidence of cardiac tamponade from diastolic hepatic vein flow is:
A. Expiratory decrease
B. Expiratory increase
C. Inspiratory increase
D. Inspiratory reversal
A. Hepatic vein flow in cardiac tamponade mimics the flow changes of the tricuspid valve. The hepatic vein will have a reduction (or reversal) of diastolic flow with expiration.
The most effective treatment for cardiac tamponade is:
A. Aspirin
B. Bed rest
C. Pericardiectomy
D. Pericardiocentesis
D. Removal of the pericardial fluid in cardiac tamponade is life saving.
Two dimensional echocardiography may guide pericardiocentesis by locating the optimal puncture site, determine the depth of pericardial effusion and monitoring the results of the pericardiocentesis.
A thickened, inflamed, adherent or calcific pericardium is associated with:
A. Cardiac tamponade
B. Constrictive pericarditis
C. Mitral stenosis
D. Pulmonary embolism
B. Constrictive pericarditis results in the impairment of diastolic filling of the heart which may result in diastolic heart failure. Diastolic filling is impaired because of the constraint the pericardium places on the heart. Intracardiac filling pressures are usually increased in patients with constrictive pericarditis. Constrictive pericarditis should be a differential diagnosis in patients who present with congestive heart failure and normal global ventricular systolic function.
All of the following are possible etiologies of constrictive pericarditis EXCEPT:
A. Prior pericardiotomy
B. Tuberculosis
C. Radiation therapy to the chest region
D. Atherosclerosis
D. Causes of constrictive pericarditis include prior pericardiotomy, idiopathic, pericarditis, radiation, infection and collagen vascular disease. Tuberculosis was at one time considered the leading cause of constrictive pericarditis but idiopathic and prior pericardiotomy are the most common reasons for constrictive pericarditis currently.
Cardiac catheterization findings for constrictive pericarditis include:
A. Absent “a” wave
B. Dip-and-plateau
C. Increased “v” wave
D. Increased peak-to-peak pressure gradient
B. In constrictive pericarditis virtually all filling of the ventricle occurs in very early ventricular diastole. This abnormal pattern of diastolic filling is reflected in the characteristic dip-and-plateau (“square root” sign) waveforms in both the right and left ventricles. The rapid rise in pressure after the early diastolic corresponds to the period of rapid diastolic filling while the plateau phase corresponds to the period of mid and late diastole when there is little additional expansion of ventricular volume.
This can be expressed by the inflow patterns of the mitral valve and tricuspid valve with increased E/A ratio (> 1.5) and shortened deceleration time (< 140 msec).
Echocardiographic signs associated with constrictive pericarditis include all of the following EXCEPT:
A. Increased EPSS
B. Inferior vena cava plethora
C. Railroad track sign
D. Septal bounce
A. A thickened pericardium (> 2 mm), interventricular/inter-atrial septal bounce (shudder), “bound-down” appearance of the ventricular walls with lack of pericardial slide, inferior vena cava plethora (dilatation), normal atrial dimensions, normal ventricular dimensions and normal global ventricular systolic function are the echocardiographic findings associated with constrictive pericarditis.
The most likely pulsed-wave Doppler mitral flow pattern in constrictive pericarditis is:
A. Impaired relaxation
B. Pseudonormal
C. Restrictive
D. Normal for age
C. The restrictive pattern (increased E/A ratio, shortened deceleration time) is expected because of rapid early diastolic filling which will abruptly be impeded by the constriction. In addition, respiratory variation (e.g., increased mitral E wave peak velocity with expiration, decreased with inspiration) may be present the same restrictive flow pattern may be seen on the pulsed-wave Doppler of the tricuspid valve. Respiratory variation of the tricuspid E wave velocity (increased E wave velocity with inspiration; decreased with expiration) may be present.
Pulsed-wave Doppler evidence of constrictive pericarditis includes:
A. Increased peak velocity across the mitral valve with inspiration
B. Increased peak velocity across the aortic valve with inspiration
C. Increased peak velocity across the mitral valve with expiration
D. Increased peak velocity across the tricuspid valve with expiration
C. In constrictive pericarditis diastolic filling of the ventricles is impaired. Doppler evidence of respiratory variation (> 25%) across the atrioventricular valves is helpful in evaluating constrictive pericarditis.
It is important to note that this finding is present in only 50% of patients presenting with constrictive pericarditis. Maneuvers such as having the patient change position may improve the sensitivity of this finding.
Doppler evidence of constrictive pericarditis from diastolic hepatic vein flow is:
A. Expiratory decrease
B. Expiratory increase
C. Inspiratory increase
D. Systolic flow reversal
A. Respiratory variation of 25% or more of the mitral valve or tricuspid valve inflow peak velocity/velocity time integral with hepatic vein diastolic flow decrease or reversal with expiration are two important signs of the presence of constrictive pericarditis.
The tissue Doppler finding for constrictive pericarditis is mitral valve annulus:
A. Increased S’ wave peak velocity
B. Normal E’ wave peak velocity
C. E/A’ ratio reversal
D. Absent A’ wave
B. The tissue Doppler of the mitral annulus can be useful in evaluating patients with constrictive pericarditis. The E’ wave peak velocity is normal (≥ 8 cm/s) and the E/E’ ratio is normal (< 8). In a patient with preserved global ventricular systolic function in congestive heart failure with a restrictive mitral valve inflow pattern, respiratory variation, hepatic vein diastolic flow reversal with expiration, a normal mitral annular E’ peak velocity and a normal E/E’ ratio, constrictive pericarditis should be included in the differential diagnosis.
The tissue Doppler finding of the mitral annulus in constrictive pericarditis is called:
A. Pulsus paradoxus
B. Annulus paradoxus
C. Beck’s triad
D. Kussmaul’s sign
B. Generally in patients with congestive heart failure the mitral annulus tissue Doppler E/E’ ratio is increased (> 15). In patients with constrictive pericarditis and congestive heart failure the mitral annulus tissue Doppler may be normal (< 8). This apparent paradox is referred to as “annulus paradoxus.”
Another reported mitral annular tissue Doppler finding for constrictive pericarditis is respiratory variation of the mitral E’ wave in the opposite direction of the pulsed-wave Doppler mitral inflow.
The combination of pericardial effusion and constrictive pericarditis is called:
A. Cardiac tamponade
B. Pericardial cyst
C. Effusive-constrictive pericarditis
D. Libman-Sacks
C. Effusive-constrictive pericarditis is the combination of a moderate to large pericardial effusion and pericardial thickening. Constrictive hemodynamics may persist even after the pericardial effusion has been removed or resolves.
The most common location for a pericardial cyst is the:
A. Hilum
B. Left costophrenic angle
C. Right costophrenic angle
D. Superior mediastinum
C. Pericardial cyst is a benign structural abnormality. It is usually seen as an echo-free structure on two-dimensional echocardiography.
Air in the pericardial sac is known as:
A. Cardiac tamponade
B. Effusive-contrictive pericardium
C. Hemopericardium
D. Pneumopericardium
D. Because of esophageal perforation air may enter the pericardium. Transthoracic and transesophageal cardiac imaging are very difficult because ultrasound will not penetrate air.
An echocardiographic finding for congenital absence of the pericardium is volume overload of the:
A. Left atrium
B. Left ventricle
C. Right atrium
D. Right ventricle
D. Congenital absence of the pericardium usually involves the left side of the pericardium. Because of the shift of the heart to the left, the right ventricular cavity is more prominent and interventricular septal motion is abnormal. This condition is associated with bicuspid aortic valve, atrial septal defect and bronchogenic cysts.
The pulse associated with cardiac tamponade is:
A. Pulsus alternans
B. Pulsus bisfierens
C. Pulsus paradoxus
D. Pulsus parvus et tardus
C. Pulsus paradoxus is present when there is an exaggerated inspiratory decline in arterial blood pressure of more than 10 mm Hg. Pulsus paradoxus is associated with cardiac tamponade for two reasons:
(1) filling of both ventricles against a common stiffness and
(2) respiratory changes in the venous pressure differential (systemic versus pulmonary) alternately favoring right and left ventricular filling. Respiratory variation of the cardiac Doppler signals of the atrioventricular valves suggests pulsus paradoxus.
All of the following are associated M-mode/two-dimensional echocardiography findings for cardiac tamponade EXCEPT:
A. Pericardial effusion (usually moderate to large)
B. Right atrial diastolic collapse
C. Right ventricular systolic collapse
D. Inferior vena cava plethora
C. Right ventricular diastolic collapse occurs in early diastole when the right ventricular volume and pressure are at their lowest levels in patients with cardiac tamponade. Right ventricular diastolic collapse can be observed in the parasternal long-axis-view, parasternal short-axis-view, apical four-chamber view and the subcostal four-chamber view.
The swinging heart syndrome is associated with:
A. Pericardial effusion
B. Cardiac trauma
C. Constrictive pericarditis
D. Mitral valve prolapse
A. With a large anterior and posterior pericardial effusion the heart may move freely within the pericardial cavity. This type of motion called the swinging heart syndrome tends to occur in large pericardial effusions. The swinging may cause the phenomenon of electrical alternans.
Pulsed-wave Doppler evidence of cardiac tamponade includes:
A. Systolic flow reversal in the pulmonary veins
B. Systolic flow reversal in the hepatic veins
C. Inspiratory increase in peak velocity across the mitral valve with an inspiratory decrease in the tricuspid valve
D. Inspiratory decrease in peak velocity across the mitral valve with an inspiratory increase in peak velocity across the tricuspid valve
D. Marked (> 25% respiratory variation of tricuspid valve (increase in inspiration; decrease with expiration) and mitral valve (decrease in inspiration; increase with expiration) peak flow velocities and/or velocity time integrals is a strong indicator for the presence of cardiac tamponade.
In cardiac tamponade the order in which changes occur are fairly predictable. Changes in the tricuspid valve occur first, followed by changes in the mitral valve with right atrial collapse being the next change and right ventricular diastolic collapse occurring last.
