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Echo > Pericardial Effusion & Tamponade > Flashcards

Pericardial Effusion & Tamponade Flashcards

1
Q

Pericardial Effusion

definition

A

presence of an abnormal amount/or type of fluid between the parietal and visceral layers of pericardium

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2
Q

Pericardial Effusion

What are the layers of heart wall?

A
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3
Q

PE Size & Etiology

Trivial pericardial effusion is only visible during ______

A

systole

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4
Q

PE Size & Etiology

Small PE is ______ mm ( _____ mL) by echo

&

the causes are:

A

< 10mm, 50-100 mL

acute pericaditis

idiopathic

infectious (usually viral)

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5
Q

PE Size & Etiology

Moderate PE is ______ cm ( _____ mL) by echo

&

the causes are:

A

1-2 cm

100-500 mL

various causes

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6
Q

PE Size & Etiology

Large PE is ______ mm / very large is ____ mm (____ mL) by echo

&

the causes are:

A
  • >20 mm
  • >25 mm, >500 mL
  • hypothyroidism
  • neoplasia (abnormal growth/atypical proliferation of tissue)
  • tubeculosis
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7
Q

PE Size & Etiology

Rapid accumulation

the causes are:

A
  • acute MI with cardiac rupture
  • Asc aortic dissection
  • blunt trauma
  • cardiac ;perforation (cath procedure or other)
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8
Q

PE other causes

A
  • 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
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9
Q

PE Signs & Symptoms

small PE is usually ______ and found accidentally on chest x-ray or echo

A

asymptomatic

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10
Q

PE Signs & Symptoms

Symptoms are often due to:

A

compression of the heart, stomach, lungs, or peripheral nerve

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11
Q

PE Signs & Symptoms

A
  • CP/pressure/discomfort
  • palpitation
  • cough
  • hoarseness
  • SOB
  • dysphagia
  • nausea
  • feeling of abdominal fullness
  • light headed
  • anxiety
  • confusion
  • syncope
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12
Q

PE Differential Diagnosis

PE is sometimes confused with _____ or _______

A

pleural effusion

epicardial fat

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13
Q

PE Differential Diagnosis

_______ is the ideal view to differentiate a pericardial effusion from a pleural effusion.

A

PLAX

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14
Q

PE Differential Diagnosis

A pleural effusion is positioned ________, appears very large, and may change with _____.

A

posterior to DAO

respiration

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15
Q

PE Differential Diagnosis

If both pleural effusion and pericardial effusion are present, visualize _______ between them

A

pericardium

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16
Q

PE Differential Diagnosis

______ is a measure of visceral fat and has been linked to increased risk for CAD, metabolic syndrome, and insulin resistance.

A

epicardial fat

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17
Q

PE Differential Diagnosis

By echo, epicardial fat is best visualized on the ______, usually in _____ or ____ views.

A

RVFW

PLAX

Sub

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18
Q

PE Differential Diagnosis

epicardial fat is seen as an echo free space between the ________ and ________

A

the outer wall of myocardium

the visceral layer of the pericardium

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19
Q

PE Differential Diagnosis

Epicardial fat appears _____ than the myocardium and moves _______.

A

brighter/gelatinous

with the heart

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20
Q

PE Differential Diagnosis

epicardial fat measurements have been acquired from _______ mm

A

1-23

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21
Q

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.

A

RA

lowest

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22
Q

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 ________

A

anterior

post cardiac surgery

metastatic disease

*note: loculated: the compartmentalization of a fluid-filled cavity into smaller spaces (locules) by fibrous septa

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23
Q

PE

________ may contain fibrin strands, adhesions, or uneven distribution.

A

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

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24
Q

PE

Fibrin strands are frequently present with a long standing PE or one associated with metastatic disease.

T or F ?

A

T

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25
Q

Tamponade

definition

A

a potentially life-threatening PE with significant hemodynamic compromise on cardiac filling and function

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26
Q

Tamponade

signs/symptoms

A
  • 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
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27
Q

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 ?

A

T

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28
Q

Tamponade

Regional tamponade affects selected chambers, usually _______ heart due to a loculated effusion or precordial blood clot post cardiac surgery or MI

A

left

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29
Q

Tamponade

It is important to remember that tamponade is a clinical diagnosis; echo determines:

A
  • size, location of the PE
  • presence and degree of hemodynamic comprise on the cardiac filling and function
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30
Q

Tamponade

Clinical Presentation

A
  • 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
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31
Q

Tamponade

What is Beck’s Triad?

A
  • 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
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32
Q

Tamponade

causes

A
  • 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
33
Q

Tamponade

Treatment

A
  • 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
34
Q

Tamponade

2D Echo presentation

A
  • 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
35
Q
A
36
Q
  • Pericarditis/ Pericardial Effusion is an infiltration of inflammatory cells into the pericardium*
  • List 4 causes:*
A
  • acute injury
  • post MI
  • autoimmune/collagen vascular disease
  • cancer
  • HIV/AIDS
  • infections
  • kidney failure
  • radiation therapy
  • tuberculosis
  • congenital anomaly
  • idiopathic
37
Q

List 4 complications of infective endocarditis.

A
  • cusps/leaflet rupture frail
  • perforation
  • abscess
  • aneurysm
  • fistula
  • Dehiscence of prosthetic valve
  • PE
38
Q

List 4 signs/symptoms of the clinical presentation of pericarditis.

A
  • CP
  • dyspnea
  • fever
  • palpitation
  • odynophagia (painful swalloing)
  • elevated cardiac enzyme
39
Q

This structure may mimic infective endocarditis. What is it?

A

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

40
Q

List 3 common locations for endocarditis in the heart

A
  • atrial side of MV & TV
  • ventricular side of AoV & PV
  • secondary jet lesions
41
Q

List 3 less common locations for endocarditis in the heart

A
  • chordae
  • Eustachian valve
  • pacemaker wire
42
Q

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*
A

Minor criteria

43
Q

The following are considered ______________________ on the Duke list.

A

major criteria

44
Q

The marks on the finger nail of this patient could indicate infective endocarditis. What are they called?

A

splinter hemorrhages

reddish, thin lines appearing under nails

45
Q
  • TEE is superior to 2D echo for detection of vegetations or ring abscess.*
  • T or F ?*
A

T

TEE is superior to 2D echo for detection of vegetations or ring abscess

46
Q

The parietal pericardium is fused to the __________________ pericardium.

A

fibrous

47
Q

Patients with infective endocarditis may present with these symptoms. These are ______________________________.

A
  • Fever – usually low grade
  • Fatigue / weakness
  • “Flu-like” symptoms
  • Weight loss
48
Q

Infective Endocarditis Etiology

_______________________ , usually seen as a right sided infection in IV drug users is a (skin flora)

A

Staphylococcus aureus

49
Q

Infective Endocarditis Etiology

A
  • streptococcus (mouth flora) *most common
  • staphylococcus (skin flora)
50
Q

The pericardium is divided into two layers, the fibrous (outer) and serous (inner) which is divided into two layers, the ___________ and ___________ layers.

A

parietal

visceral

51
Q

The pericardial space lies between the ________1_____________ and __________2________ pericardium.

A
  1. parietal
  2. visceral
52
Q

The epicardium is immediately outside of the myocardium and is a part of the ________

A

visceral pericardium

53
Q

List 4 physical findings of infective endocarditis.

A
  • Petechiae
  • splinter hemorrhages
  • Osler’s nodes
  • Janeway’s lesions
54
Q

what is this?

A

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.

55
Q

What is this?

A

Osler’s node

ed, tender, raised, tender lesions located in pulp of fingers and toes

56
Q

What is this?

A

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.

57
Q

What is this?

A

Roth Spots are defined as a white centered retinal hemorrhage and are associated with multiple systemic illnesses, most commonly bacterial endocarditis.

58
Q

List 4 Doppler features of Constrictive Pericarditis.

A
  • 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)
59
Q

List 4 of the categories for individuals at higher risk for infective endocarditis.

A
  1. Prosthetic heart valve
  2. Native valve disease
  3. Congenital heart disease
  4. IV drug users
60
Q
  • Streptococcus viridians is the least common mouth flora.*
  • T or F ?*
A

F

most common

61
Q

Discuss the Doppler findings in Cardiac Tamponade in 25 words or less.

A
  • 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
62
Q

Cardiac Tamponade Echo Features

A
  • 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
63
Q

List 4 vascular phenomenon found in patients with infective endocarditis

A
  • 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
64
Q
  • Constrictive pericarditis may develop in the aftermath of virtually any pericardial injury or inflammation.*
  • T or F ?*
A

T

65
Q

clinical presentation of constrictive pericarditis

A
  • 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
66
Q
  • The serious pericardium is immediately outside of the myocardium and is a part of the visceral pericardium.*
  • T or F ?*
A

F

67
Q

Briefly describe the Modified Duke Criteria for Diagnosis of Infective Endocarditis in 25 words or less.

A

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
68
Q

negative infective endocarditis

A
69
Q

3 components of Beck’s triad

A
  1. Hypotension/weak pulse due to low CO 2. Muffled heart sound due to fluid around heart 3. Elevated venous pressure/Jagular vein distention
70
Q

Regional tamponade affects selected chamber, typically ________ due to loculated effusion or blood clot post cardiac surgery

A

Left heart

71
Q

Ventricular respiratory variation is detected when the LV diastolic dimension ______ with inspiration and the RV diastolic dimension ______ with inspiration

A

Decrease Increase

72
Q

As tamponade increases in severity, the RV diastolic collapse remains throughout the respiratory cycle. T or F ?

A

T

73
Q

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

A

4

74
Q

In order to evaluate the MV and/or TV for respiratory variations, the sonography should ______

A

Decrease PW speed to 25mm/s in order to appreciate the variation

75
Q

Respiratory variation is seen as a wavelike motion across the top of Doppler waveforms where the _______

A

MV waveform decreases with respiration

76
Q

Loculated PE is rare except for patients with _______

A

Post-op cardiac surgery or metastatic disease

77
Q

A PE associated with metastatic disease frequently has fibrin strands. T or F ?

A

T *fibrin strands frequently associated with long standing PE or metastatic diseases

78
Q

A circumferential PE is best visualized from the ______

A

PLAX PSAX Sub

79
Q

Tamponade causes a(n) ______ and equalization of diastolic and pericardial pressures; resulting in reduced CO

A

Elevation

Echo (35 decks)

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