Pericardial Effusion & Tamponade Flashcards
Pericardial Effusion
definition
presence of an abnormal amount/or type of fluid between the parietal and visceral layers of pericardium
Pericardial Effusion
What are the layers of heart wall?
PE Size & Etiology
Trivial pericardial effusion is only visible during ______
systole
PE Size & Etiology
Small PE is ______ mm ( _____ mL) by echo
&
the causes are:
< 10mm, 50-100 mL
acute pericaditis
idiopathic
infectious (usually viral)
PE Size & Etiology
Moderate PE is ______ cm ( _____ mL) by echo
&
the causes are:
1-2 cm
100-500 mL
various causes
PE Size & Etiology
Large PE is ______ mm / very large is ____ mm (____ mL) by echo
&
the causes are:
- >20 mm
- >25 mm, >500 mL
- hypothyroidism
- neoplasia (abnormal growth/atypical proliferation of tissue)
- tubeculosis
PE Size & Etiology
Rapid accumulation
the causes are:
- acute MI with cardiac rupture
- Asc aortic dissection
- blunt trauma
- cardiac ;perforation (cath procedure or other)
PE other causes
- auto immune/inflammatory/connective tissue disorders
- benign/malignant tumor or metastatic cancer to pericardium
- drug induced
- infectious (viral/bacterial/fungal/HIV/AIDS/tubeculosis)
- kidney failure (excessive nitrogen blood levels)
- post MI (*Dressler’s syndrome) or surgery
- radiation/chemotherapy
PE Signs & Symptoms
small PE is usually ______ and found accidentally on chest x-ray or echo
asymptomatic
PE Signs & Symptoms
Symptoms are often due to:
compression of the heart, stomach, lungs, or peripheral nerve
PE Signs & Symptoms
- CP/pressure/discomfort
- palpitation
- cough
- hoarseness
- SOB
- dysphagia
- nausea
- feeling of abdominal fullness
- light headed
- anxiety
- confusion
- syncope
PE Differential Diagnosis
PE is sometimes confused with _____ or _______
pleural effusion
epicardial fat
PE Differential Diagnosis
_______ is the ideal view to differentiate a pericardial effusion from a pleural effusion.
PLAX
PE Differential Diagnosis
A pleural effusion is positioned ________, appears very large, and may change with _____.
posterior to DAO
respiration
PE Differential Diagnosis
If both pleural effusion and pericardial effusion are present, visualize _______ between them
pericardium
PE Differential Diagnosis
______ is a measure of visceral fat and has been linked to increased risk for CAD, metabolic syndrome, and insulin resistance.
epicardial fat
PE Differential Diagnosis
By echo, epicardial fat is best visualized on the ______, usually in _____ or ____ views.
RVFW
PLAX
Sub
PE Differential Diagnosis
epicardial fat is seen as an echo free space between the ________ and ________
the outer wall of myocardium
the visceral layer of the pericardium
PE Differential Diagnosis
Epicardial fat appears _____ than the myocardium and moves _______.
brighter/gelatinous
with the heart
PE Differential Diagnosis
epicardial fat measurements have been acquired from _______ mm
1-23
PE
PE frequently originates near _____ because it has the ______ pressure of the four chambers; therefore the other chambers tend to squeeze the effusion to the area of the least resistance.
RA
lowest
PE
It is unusual for a PE to be positioned solely ______ to the heart, unless it is loculated. A loculated effusion is more common _________ or ________
anterior
post cardiac surgery
metastatic disease
*note: loculated: the compartmentalization of a fluid-filled cavity into smaller spaces (locules) by fibrous septa
PE
________ may contain fibrin strands, adhesions, or uneven distribution.
exudative pericardial effusion
Exudative effusions are caused by an inflammatory or malignant process affecting the pleura, causing increased capillary permeability and fluid accumulation. Common causes of exu-dates include pneumonia, cancer, tuberculosis and pulmonary embolism
PE
Fibrin strands are frequently present with a long standing PE or one associated with metastatic disease.
T or F ?
T
Tamponade
definition
a potentially life-threatening PE with significant hemodynamic compromise on cardiac filling and function
Tamponade
signs/symptoms
- excessive pericardial fluid accumulates - the effusion compresses the heart and limits cardiac filling
- dyspnea *improves when the patient sit up
- SOB
- altered mental status/anxiety
- cold extremities/peripheral cyanosis
- blue lips/skin
- dysphagia
- cough
- fatigue/weakness
- hypotension
- lightheaded/dizziness/syncope
- tachycardia
- cardiogenic shock
- impaired diastolic filling (progressively worsens)
- elevation and equalization of diastolic and pericardial pressures
- reduced CO
- insufficient preload - unable to sustain cardiac filling - result in a dramatic decrease in coronary and systemic perfusion
- cardiac arrest/death
Tamponade
can be acute, subacute, or chronic; mild to severe, and potentially life-threatening. Low-pressure tamponade is possible due to hypovolemia or over-diuresis.
T or F ?
T
Tamponade
Regional tamponade affects selected chambers, usually _______ heart due to a loculated effusion or precordial blood clot post cardiac surgery or MI
left
Tamponade
It is important to remember that tamponade is a clinical diagnosis; echo determines:
- size, location of the PE
- presence and degree of hemodynamic comprise on the cardiac filling and function
Tamponade
Clinical Presentation
- Beck’s Triad
- Pulsus paradoxus: an exaggerated decrease in systolic BP with inspiration
- pericardial friction rub
- tachycardia
- dyspnea *may improve when the patient is upright
- hepatomegaly *enlarged liver due to increased venous pressure
Tamponade
What is Beck’s Triad?
- hypotension and weak pulse due to low CO
- muffled heart sound due to fluid around the heart
- elevated venous pressure and extended neck veins because it is difficult to return blood to the heart
Tamponade
causes
- asc aortic dissection
- autoimmune/connective tissue/inflammatory disease
- cardiac surgery
- cardiac perforation (cath procedure or other)
- CM
- hypothyroidism
- infectious (viral, bacterial, fungal, HIV/AIDS, tuberculosis)
- kidney failure/uremia (urea in blood)
- large PLE
- malignant disease
- MI
- pericarditis
- radiation therapy/chemotherapy
Tamponade
Treatment
- O2, fluids, medical therapy
- pericardiocentesis (aka: pericardial trap): the physician/surgeon taps (drains) the pericardial effusion via aspiration *quick bubble study can verify catheter location & fluid sample sent to the lab for culture
- pericardial window: open pericardial drainage via a window made by the surgeon
- pericardiectomy: removal of pericardium by the surgeon
Tamponade
2D Echo presentation
- swinging heart is possible for a large PE
- decreased LV diastolic/systolic dimensions
- wall may appear hypertrophied
- ventricular respiratory variation
- LV diastolic dimension - decreases with inspiration
- RV diastolic dimension - i_ncreases_ with inspiration
- IVS inspiratory bounce
- RA late diastolic collapse
-
RV diastolic collapse
- early on, RV diastolic collapse is present during inspiration
- as the tamponade severity increases, the collapse remains throughout the respiratory cycle. the longer the collapse = the more severe the tamponade *tip: compare RV wall motion to the MV/TV motion - diastolic collapse occurs while these valves are open
- paradoxical septal motion - the walls move parallel to one another than their normal contraction (toward) and relaxation (away).
- dilated hepatic veins/IVC with a lack of respiratory collapse - reflects elevated systemic venous pressure
- Pericarditis/ Pericardial Effusion is an infiltration of inflammatory cells into the pericardium*
- List 4 causes:*
- acute injury
- post MI
- autoimmune/collagen vascular disease
- cancer
- HIV/AIDS
- infections
- kidney failure
- radiation therapy
- tuberculosis
- congenital anomaly
- idiopathic
List 4 complications of infective endocarditis.
- cusps/leaflet rupture frail
- perforation
- abscess
- aneurysm
- fistula
- Dehiscence of prosthetic valve
- PE
List 4 signs/symptoms of the clinical presentation of pericarditis.
- CP
- dyspnea
- fever
- palpitation
- odynophagia (painful swalloing)
- elevated cardiac enzyme
This structure may mimic infective endocarditis. What is it?
Lambl’s excrescences
Lambl’s excrescences (LE) are filiform fronds that occur at sites of valvular closure. They may be found without any other evidence of cardiac disease. 1,2. They originate as small thrombi on endocardial surfaces where the valve margins make contact. These are the sites of minor endothelial damage, due to wear and tear
List 3 common locations for endocarditis in the heart
- atrial side of MV & TV
- ventricular side of AoV & PV
- secondary jet lesions
List 3 less common locations for endocarditis in the heart
- chordae
- Eustachian valve
- pacemaker wire
The following are considered ______________________ on the Duke list.
- 1.Predisposition, predisposing heart condition, or injection drug use*
- 2.Fever, temperature > 38ºC*
- 3.Vascular phenomena, major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and Janeway lesions*
- 4.Immunologic phenomena: glomerulonephritis, Osler nodes, Roth spots, and rheumatoid factor*
- 5.Microbiological evidence: positive blood culture, but does not meet a major criterion as noted previously; or serologic evidence of active infection with organism consistent with IE*
Minor criteria
The following are considered ______________________ on the Duke list.
major criteria
The marks on the finger nail of this patient could indicate infective endocarditis. What are they called?
splinter hemorrhages
reddish, thin lines appearing under nails
- TEE is superior to 2D echo for detection of vegetations or ring abscess.*
- T or F ?*
T
TEE is superior to 2D echo for detection of vegetations or ring abscess
The parietal pericardium is fused to the __________________ pericardium.
fibrous
Patients with infective endocarditis may present with these symptoms. These are ______________________________.
- Fever – usually low grade
- Fatigue / weakness
- “Flu-like” symptoms
- Weight loss
Infective Endocarditis Etiology
_______________________ , usually seen as a right sided infection in IV drug users is a (skin flora)
Staphylococcus aureus
Infective Endocarditis Etiology
- streptococcus (mouth flora) *most common
- staphylococcus (skin flora)
The pericardium is divided into two layers, the fibrous (outer) and serous (inner) which is divided into two layers, the ___________ and ___________ layers.
parietal
visceral
The pericardial space lies between the ________1_____________ and __________2________ pericardium.
- parietal
- visceral
The epicardium is immediately outside of the myocardium and is a part of the ________
visceral pericardium
List 4 physical findings of infective endocarditis.
- Petechiae
- splinter hemorrhages
- Osler’s nodes
- Janeway’s lesions
what is this?
Petechiae are tiny purple, red, or brown spots on the skin. They usually appear on your arms, legs, stomach, and buttocks. You might also find them inside your mouth or on your eyelids. These pinpoint spots can be a sign of many different conditions — some minor, others serious. They can also appear as a reaction to certain medications.
What is this?
Osler’s node
ed, tender, raised, tender lesions located in pulp of fingers and toes
What is this?
Janeway’s lesions
rregular, nontender hemorrhagic macules located on the palms, soles, thenar and hypothenar eminences of the hands, and plantar surfaces of the toes. They typically last for days to weeks. They are usually seen with the acute form of bacterial endocarditis.
What is this?
Roth Spots are defined as a white centered retinal hemorrhage and are associated with multiple systemic illnesses, most commonly bacterial endocarditis.
List 4 Doppler features of Constrictive Pericarditis.
- Respirator variation in velocities
- Mitral inflow pattern typically restrictive
- Inspiration – Decreased mitral E velocity; Decreased pulmonary venous diastolic forward flow; Increased tricuspid E velocity
- Expiration – Increased mitral E velocity; Increased pulmonary venous diastolic forward flow; Decreased tricuspid E velocity; Decreased or loss of diastolic filling with marked expiratory reversal
- Tissue Doppler – e’ velocity relative normal or accentuated in constriction (> 12 cm/sec)
List 4 of the categories for individuals at higher risk for infective endocarditis.
- Prosthetic heart valve
- Native valve disease
- Congenital heart disease
- IV drug users
- Streptococcus viridians is the least common mouth flora.*
- T or F ?*
F
most common
Discuss the Doppler findings in Cardiac Tamponade in 25 words or less.
- Respiratory variation in velocities
- inspiration - Decreased mitral E velocity; Decreased pulmonary venous diastolic forward flow; Increased tricuspid E velocity
- Expiration - reciprocal changes
- Decrease or loss of hepatic vein diastolic filling with marked expiratory reversal
Cardiac Tamponade Echo Features
- Pericardial effusion
- RV or RA chamber collapse during early diastole
- IVC plethora: n cardiac tamponade, IVC plethora (defined as a decrease in the proximal venal caval diameter by <50% during deep inspiration) is often the first echocardiographic sign to appear
- Reciprocal changes in ventricular volumes (septal shift)
- “Swinging Heart” if large effusion
List 4 vascular phenomenon found in patients with infective endocarditis
- Petechiae – subcutaneous dermal flat red spots
- Splinter hemorrhages – reddish, thin lines appearing under nails
- Osler’s nodes - red, raised, tender lesions on palms and soles
- Janeway’s lesions - purplish lesions on the palmer surface of hands and/or feet
- Constrictive pericarditis may develop in the aftermath of virtually any pericardial injury or inflammation.*
- T or F ?*
T
clinical presentation of constrictive pericarditis
- Dyspnea/Chest pain
- Jugular venous distention
- Edema
- Ascites
Kussmaul sign ( A paradoxical rise in jugular venous pressure (JVP) on inspiration, or failure in the appropriate fall of the JVP with inspiration. Causes include: right ventricular infarction, severe right ventricular failure, restrictive cardiomyopathy, constrictive pericarditis, tricuspid stenosis)
Pulsus Paradoxus (An abnormally large decrease in stroke volume, systolic blood pressure and pulse wave amplitude during inspiration. The normal fall in pressure is less that 10 mmHg. Pulsus paradoxus = a drop > 10mmHg.)
- Hepatosplenomegaly
- Auscultatory findings ( pericardial knock – caused by rapid diastolic filling followed by a prominent halt of flow)
- ECG findings ( flat or inverted T waves, low voltage QRS complexes in all leads, A fib, Sinus Tachycardia, Pathologic Q waves, AV or Bundle branch block
- The serious pericardium is immediately outside of the myocardium and is a part of the visceral pericardium.*
- T or F ?*
F
Briefly describe the Modified Duke Criteria for Diagnosis of Infective Endocarditis in 25 words or less.
Definite infective endocarditis - one of the followings:
- culture/histologic examination of a vegetation
- intracardiac abscess specimen
- 2 major criteria
- 1 major criterion & 3 minor criteria
- 5 minor criteria
Possible infective endocarditis - one of the followings:
- 1 major criterion & 1 minor criterion
- 3 minor criteria
negative infective endocarditis
3 components of Beck’s triad
- Hypotension/weak pulse due to low CO 2. Muffled heart sound due to fluid around heart 3. Elevated venous pressure/Jagular vein distention
Regional tamponade affects selected chamber, typically ________ due to loculated effusion or blood clot post cardiac surgery
Left heart
Ventricular respiratory variation is detected when the LV diastolic dimension ______ with inspiration and the RV diastolic dimension ______ with inspiration
Decrease Increase
As tamponade increases in severity, the RV diastolic collapse remains throughout the respiratory cycle. T or F ?
T
Upon echo, a moderate to severe PE is detected with slight swinging of the heart; an excellent method to rule out RV diastolic collapse with… 1. CFD in the RV 2. Doppler of the AV valves 3. Eye-ball it with 2D echo 4. M-mode at the level of the PE, RVFW and MV
4
In order to evaluate the MV and/or TV for respiratory variations, the sonography should ______
Decrease PW speed to 25mm/s in order to appreciate the variation
Respiratory variation is seen as a wavelike motion across the top of Doppler waveforms where the _______
MV waveform decreases with respiration
Loculated PE is rare except for patients with _______
Post-op cardiac surgery or metastatic disease
A PE associated with metastatic disease frequently has fibrin strands. T or F ?
T *fibrin strands frequently associated with long standing PE or metastatic diseases
A circumferential PE is best visualized from the ______
PLAX PSAX Sub
Tamponade causes a(n) ______ and equalization of diastolic and pericardial pressures; resulting in reduced CO
Elevation
