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Pericardial diseases Pericardial anatomy PERICARDIAL EFFUSION (ETIOLOGY) • • • • • • • • 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) • • • • • 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 • • • • • 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 • • • • • 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 • • • • • • Idiopathic/recurrent pericarditis Post cardiac surgery Prior chest radiation Infectious (Tuberculosis) Metastatic process Difficult diagnosis to establish Less Common Etiologies • • • • Infectious (Fungal) Neoplasms Uremia Connective tissue disorders (SLE, Scleroderma) • Drug Induced (Procainamide, hydralazine) • Trauma • Post MI (Dressler’s) Clinical Signs • • • • • • 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 – – – – 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 – – – – – Idiopathic Familial HCM Scleroderma Diabetic • Infiltrative – Amyloidosis – Sarcoidosis • Storage – Hemochromatosis – Fabry’s • Hypereosinophilic Syndrome • Carcinoid 2D Findings • • • • • • 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 • • • • • • • 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 I Mitral Tricuspid Constriction E I E Restriction I 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