Download Constrictive

Pericardial diseases
Pericardial anatomy
PERICARDIAL EFFUSION
(ETIOLOGY)
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Viral (most common)
Uremic (chronic renal failure)
Metastatic (breast or lung CA)
Post MI (Dresslers syndrome)
Post cardiac surgery (regional)
CHF, systemic diseases (lupus, AIDS)
Trauma
Infectious
HIV
PERICARDIAL DISEASES
(CLINICAL PRESENTATION)
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Chest pain with respiration, fever
Shortness of breath
Enlarged cardiac silhouette on chest X ray
EKG changes with diffuse ST elevation
Pulsus paradoxus, tachycardia, hypotension,
neck vein distention, decreased heart sounds
PERICARDIAL FLUID
• Serosanguinous (clear, pale yellow)
- not echogenic
• Bloody (consider metastatic, trauma)
- may be echogenic
• Infectious (brown,milky colored)
PERICARDIAL EFFUSION
(M Mode Echocardiography)
• may overestimate amount and not useful if
loculated or localized
• useful for timing of RV wall motion relative
to mitral valve opening
• Caution when only anterior echo free space
present
PERICARDIAL EFFUSION
(2D Echocardiography)
• Superior to M Mode for extent and localization by
use of multiple views
• Assess for diastolic collapse of right heart
chambers, IVC size and change with
inspiration/expiration
• Identify intrapericardial process (clot, tumor,
fibrin strands)
• Differentiate pericardial from pleural effusion by
recognition of descending aorta
• Non diagnostic for pericardial thickness
Parasternal
long axis
LV
Effus
DAO
AO
LA
Parasternal
Short Axis
Apical 4C
Subcostal view
Fibrous Strands
Unequal distribution
M Mode echo
M-Mode
RV collapse/ Delayed RV Relaxation
PERICARDIAL EFFUSION:
SIZE
• SMALL: echo free space present posterior
and < 1 cm.
• MODERATE: echo free space present
anterior and posterior < 1 cm.
• LARGE: echo free space anterior and
posterior > 1 cm.
Small Pericardial Effusion
Moderate Pericardial Effusion
Large Pericardial Effusion
PERICARDIAL EFFUSION: POSSIBLE
SOURCES OF FALSE POSITIVES
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Pleural effusion
Pericardial tumor or cyst
Dilated coronary sinus
LV pseudoaneurysm
Large hiatal hernia
LSVC Dilated Coronary Sinus
Pericardial Cyst Subcostal
2C: Posterior echo free space
DOPPLER
• Assessment of flow velocities across
mitral/tricuspid valves, LV outflow, and
hepatic veins
• Presence of respiratory variation > 20% in
left heart flow velocities and more marked
in right heart
• Should be performed in all patients with
suspicion or evidence of pericardial disease
Tamponade Case Study
Pericardiocentesis
• Needle aspiration of the pericardial effusion
• Usually performed with needle entering
subxiphoid
• Echo guided
– Evaluate fluid initially from subcostal
– Imaging performed from the apical position
Little effusion available from subcostal
Differentiation with Ascites
Case 2
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56 year old female
transferred from outside hospital
know breast cancer
possible malignant pericardial effusion
Pericardiocentesis
Agitated Saline
- injected into the pericardial space for verification of needle placement
Before
After pericardiocentesis
Case 4
• Patient presents post MI
• New pericardial effusion
• What is the differential?
EP application
• 56 year old female comes into the hospital
after being discharged from outside hospital
after pacemaker insertion
• Continued severe chest pain
• When pacer activated, diaphragm
stimulated
Pericardial Effusion by TEE
Pericardial Disease:
Constriction versus Restriction
Constrictive Pericardial Diseases:
Etiologies
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Idiopathic/recurrent pericarditis
Post cardiac surgery
Prior chest radiation
Infectious (Tuberculosis)
Metastatic process
Difficult diagnosis to establish
Less Common Etiologies
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Infectious (Fungal)
Neoplasms
Uremia
Connective tissue disorders (SLE,
Scleroderma)
• Drug Induced (Procainamide, hydralazine)
• Trauma
• Post MI (Dressler’s)
Clinical Signs
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Shortness of breath
Peripheral edema
Increased jugular venous pressure
Normal heart size on chest X ray
Similar in presentation to CHF
Often confused with restrictive
cardiomyopathy
Physiology
• Dissociation between intrathoracic and
intracardiac pressures
• Normally with inspiration, intrathoracic
pressure falls and intrathoracic structures
fall
• In constriction, the pressure change is not
transmitted to intrapericardial structures and
cavities
2D Imaging
• Pericardial thickening
– TEE more reliable than TTE, but CT or MRI is the
better method for thickness evaluation
• Paradoxical septal motion
– Respiratory Variable
– Septal shift leftward with inspiration
• Increased IVC diameter, lack of resp change
M-mode Evaluation
• Parietal pericardial tracking with
epicardial/endocardial motion
• M Mode posterior LV wall motion is flat
during mid and late diastole
• Respiratory variation in ventricular chamber
size
Doppler Evaluation
• Pulsed Doppler respiratory flow velocity
variation at mitral valve, pulmonary veins
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Variation greater than 25%
Left side velocities decrease with inspiration
Diastolic Decrease in PV velocities
Right side increases with inspiration
• Shortened mitral deceleration time that
decreases more with inspiration
Decreased Mitral Inflow with
Inspiration
Tricuspid Inflow Increased with
Inspiration
Tissue Doppler
• In 20 to 40% of patients,
Mitral filling may not
meet criteria
• Sitting patient reduces
preload and may reveal
variation
• Tissue Doppler provides
best marker for detection
of constriction
• TDI velocity >8-15
cm/sec is diagnostic to
rule out restriction
Ha et al. JASE 2002; 15:1468-71.
Constrictive Tissue Doppler
E/E’ and PCWP are inversely correlated in patients with constrictive disease
Mitral -Increased E/A ratio
Tissue Doppler –Increased Tissue Velocities
•Note E/e’ is “normal” despite increased filling
pressures due to increased
longitudinal annular motion in
Constrictive processes
Ha et al, Circulation. 2001;104:976-978
Additional Doppler findings
• Expiratory decrease in hepatic diastolic
forward flow and increases in hepatic vein
flow reversals
Normal Hepatic Flow
Systolic and diastolic phasic flow
Constrictive Hepatic Vein Flow
Increased forward flow with inspiration, backflow with expiration
Adapted from Haley et al JACC, 2004;43;271-275
Technical Concerns
• COPD
– May cause respiratory variability but not
usually at the onset of inspiration/expiration
– Mitral Inflow pattern is not necessarily
increased E/A ratio as in constriction
– SVC flow varies in COPD, not in constriction
Constriction Case
Mitral Inflow
Tissue Doppler
Medial
Lateral
Apical 4 Chamber view
Cardiac
Catheterization
Calcification
LV function
Infiltrative/Restrictive
Systemic Diseases
Etiology
• Noninfiltrative
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Idiopathic
Familial
HCM
Scleroderma
Diabetic
• Infiltrative
– Amyloidosis
– Sarcoidosis
• Storage
– Hemochromatosis
– Fabry’s
• Hypereosinophilic Syndrome
• Carcinoid
2D Findings
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Bilateral Atrial Enlargement
Normal LV cavity size and function
Hyperechoic Myocardium
Possible Pericardial Effusion
Dilated Hepatic Veins
Granular appearance of the myocardium
“Ground glass”
Amyloid Parasternal Long
Amyloid Apical 4
Doppler Findings
• Mitral Filling (Late)
– Increased E to A
– Shortened Deceleration Time
• Pulmonary and Hepatic Veins
– Prominent Early Diastolic Filling
– Increased Reversed Flow during
Atrial Contraction
• Pulmonary Hypertension
Restrictive
filling
Hepatic Veins
Prominent diastolic reversal (Y decent)
Indices of patients with elevated LV
filling pressures
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Enlarged LA size (> 28 ml/m2)
E/A ratio > 2
DT <150
Pulmonary Vein S/D < 40%
Pulmonary Vein A wave velocity > 25 cm/s
E/e’ ratio > 15
Vp flow propagation < 40 cm/sec
Mitral / Tricuspid Inflow
Constriction vs Restriction
Normal
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Mitral
Tricuspid
Constriction
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E
Restriction
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E
Tissue Doppler
Constrictive
• Average velocities
14.8 cm/sec
• Normal or enhanced
longitudinal expansion
Restrictive
• Average velocities 4.1
cm/sec
• Restricted myocardial
motion
• Increases
sensitivity to detect Constriction to 98.4%
• except in pts with MAC, LV dysfunction
Garcia, et al. JACC 1996 Jan;27(1):108-14, Sengupta et al. Am J Cardiol. 2004 Apr 1;93(7):886-90
Mixed Constrictive/ Restrictive
Physiology
• Incidence varies, but around 20% of
patients
• May be found in Radiation Induced, CABG
• Increased Mortality in Mixed physiology
Comparison
Restrictive
Constrictive
LV wall
thickness
Increased
Normal
LA diameter
Increased
Increased
E/A ratio
Increased
Increased
Decel time
Shortened
Shortened
IVRT
Shortened
Shortened
LV diameter
Decreased
Normal
Peak E wave
Increased
Increased
Palka et al. Circulation 2000;102;655-662.
Normal
Restrictive
Constrictive
Mitral
Tissue
S D
D
S D
S
Pulmonary Vein
Tricuspid
Hepatic Veins
S
D
S
D
S
Adapted From Hoit, Management of Effusive and Constrictive Pericardial Heart Disease Circulation 2002;105;2939-2942
D
Case 1 Restrictive vs. Constrictive
• 68 year old male
• Admitted with shortness of breath
• Known history of Amyloidosis
INS
EXP
INS
EXP
INS
EXP
INS
EXP