Download Two-dimensional Echocardiography and B-mode

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VOL 60, No 7, DECEMBER 1979
CI RCULATION
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Disturbances of the transitional circulation: spectrum of
pulmonary hypertension and myocardial dysfunction. J Pediatr
89: 622, 1976
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Nadas AS: Persistent pulmonary hypertension in a newborn
with congenital diaphragmatic hernia: successful management
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Two-dimensional Echocardiography and
B-mode Ultrasonography for the Diagnosis
of Loculated Pericardial Effusion
MARK J. FRIEDMAN, M.D., DAVID J. SAHN, M.D.,
AND
KAI HABER, M.D.
SUMMARY Two cases of loculated pericardial effusion resulting in cardiac tamponade are presented. The
loculated nature and extent of the effusion was best defined by two-dimensional echocardiography or B-mode
ultrasonography. Cross-sectional images should probably be obtained in all cases of suspected loculated
pericardial effusion and in patients in whom the interpretation of the M-mode echocardiogram is equivocal as
to the presence or absence of pericardial effusion.
M-MODE ECHOCARDIOGRAPHY is a sensitive
and specific technique for the detection of nonloculated pericardial effusion.1 2 Recent reports of
two-dimensional echocardiography suggest that this
method is also clinically useful for evaluating pericardial effusion.3 In contrast to the positive experience
with these techniques for the detection of nonloculated
pericardial effusion, loculated pericardial effusions
have frequently resulted in false-negative M-mode
echocardiographic studies.4 6 This report demonstrates the usefulness of two-dimensional echocardiography and B-mode ultrasonography in two
patients with loculated pericardial effusion.
From the Departm-lenit of Internal Medicine, Section of Cardiology, the Department of Pediatrics, Section of Cardiology, and
the Department of Radiology, Arizona Health Sciences Center,
Tucson, Arizona.
Supported in part by Clinical Pharmacology Research Training
grant 5T32GM07533-02, NIH.
Address for correspondence: David J. Sahn, M.D., Department
of Pediatrics, University of Arizona Health Sciences Center, Tucson, Arizona 85724.
Received April 16, 1979; revision accepted July 2, 1979.
Circulation 60, No. 7, 1979.
Case 1
A 28-year-old Mexican male was admitted to the
University of Arizona Health Sciences Center for
evaluation of sharp, substernal chest pain, shortness of
breath and cardiomegaly. On physical examination,
the blood pressure was 92/70 mm Hg with 14 mm Hg
pulsus paradoxus. The jugular veins were distended to
the angle of the jaw with the patient sitting upright.
The first and second heart sounds were normal and a
three-component pericardial friction rub was heard
over the anterior precordium. A chest radiograph
showed marked enlargement of the cardiac silhouette,
but was otherwise unremarkable. The diagnosis of
pericarditis with cardiac tamponade was made and an
M-mode echocardiogram was obtained using a SmithKline Ekoline 20A ultrasonoscope with a 2.25-MHz
transducer. Standard sweeps from the aortic root to
the left ventricle were attempted using previously
described techniques,7 however, a limited echo window
resulted in a suboptimal M-mode echocardiogram.
The M-mode echocardiogram (fig. 1) demonstrated a
large, echo-free space posterior to the left ventricular
wall extending behind the left atrium. A small anterior
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DIAGNOSIS OF PERICARDIAL EFFUSION/Friedman et al.
FIcGURE 1. M-mode echocardiograms from case 1. Panel A) Sweep from the mitral valve to the aortic root
at a paper speed of 25 mm/sec. Panel B is taken from the mitral valve level, first at a paper speed of 25
mm/sec and then at 50 mm/sec. Adjustment of the gain allows identification of the pericardium. A large
pericardial effusion located posterior to the left ventricle is identified. A small, echo-free space anterior to
the heart is also seen. A O aortic root; EFF pericardial effusion; IVS interventricular septum; MV
mitral valve; PERI pericardium.
=
=
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effusion was also observed. A right-heart catheterization was performed that revealed equilibration of
mean pulmonary wedge, right ventricular enddiastolic, and mean right atrial pressure, confirming
the impression of cardiac tamponade (table 1). A
pericardiocentesis under fluoroscopic guidance was
attempted from the subxiphoid approach; however,
only 2 ml of serosanguinous fluid could be extracted
from the pericardial sac. A two-dimensional echocardiogram was performed using a high-resolution, 32element linear array ultrasound device (Toshiba SAL
IOA). A large, echo-free space located posterior and
lateral to the left ventricle was identified. The left ventricle appeared to be compressed by the posterior effusion and the right ventricle was compressed behind the
sternum. No anterior fluid was found (fig. 2). These
findings suggested a loculated pericardial effusion and
a B-mode ultrasound examination of the mediastinum
was performed using a water-delay multitransducer
automated B scanner (Octoson).8 Pericardial fluid was
identified posterior and lateral to the heart, but no
effusion was identified anterior to the heart (fig. 3). At
surgery, the chest was entered through a left lateral
thoracotomy incision. A large mass was found behind
TABLE 1. Hemodynamic Data From the Right-Heart Cat heterization.
Pressure
IlA
ltVEI)P
PA
PAW
(mm Jlg)
20
Case 1
20
20
25/20
16
14
Case 2
14
20/14
Abbreviations: PA = pulm-nonary artery; PAW
mean
rneani right atrial; ItVEI)P
pulmoniary artery wedge; 11A m
right venitricular enid-diastolic.
=
=
,LA
Chest Wall
- ,
LV-Papillary Muscle
i
0, ;Effusion
Ant
R
JL
Post
FIGURE 2. Short-axis view of the left ventricle from the
two-dinmensional echocardiogram of case 1. The left ventricle is compressed by a large pericardial effusion located
posterior and lateral to the left ventricle. L V left ventricle;
RV right ventricle.
=
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CIRCULATION
VOL 60, No 7, DECEMBER 1979
-Chest Wall
RV
PA2I
-LV
-
Effusion
Ant
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Supp
Inf
Post
FIGURE 3. Long-axis, B-mode ultrasound image from case 1. The left ventricle is compressed by the
posterior effusion and the right ventricle is compressed behind the sternum. L V = left ventricle; PA
pulmonary artery; RV = right ventricle.
=
the heart, which was compressing the heart against the
sternum. The mass involved the pericardium and extended into the left chest. No extension into the
anterior mediastinum was appreciated. Upon opening
the mass and pericardium, a large amount of thick
fluid as well as solid tumor was encountered.
Pathologic analysis of the pericardium and tumor
tissue revealed an undifferentiated seminoma as the
etiology of the effusion.
Case 2
A 21-year-old Mexican male was admitted to Tucson Medical Center with a history of chronic renal
failure and recent onset of shortness of breath. On
physical examination, the blood pressure was 140/80
mm Hg with 18-mm Hg pulsus paradoxus. The
jugular veins were distended to the angle of the jaw
with the patient sitting upright. The first and second
heart sounds were diminished in intensity. A pericardial friction rub was not heard. A chest radiograph
revealed a right pleural effusion, obscuring the right
heart border, and cardiomegaly. An M-mode echocardiogram was obtained using a Smith Kline Ekoline
20A ultrasonoscope with a 2.25-MHz transducer. The
M-mode echocardiogram (fig. 4) showed a large,
echo-free space between the anterior chest wall and
A
EFF¾
EFF
RV
IVs
IVs
LV
=
MV
PERI
PERt ~ ~ ~ ~~~,,
FIGURE 4. M-mode echocardiogram from
case 2. Panel A is at the mitral valve level
and panel B is at the level of the left ventricle. A large, echo-free space is identified
anterior to the heart. No effusion is identified posterior to the left ventricle. EFF =
effusion; I VS = interventricular septum; L V
= left ventricle, MV = mitral valve, PERI
= pericardium, P W = posterior wall; RV
right ventricle; R VA W =-right ventricular
anterior wall.
PERI
DIAGNOSIS OF PERICARDIAL EFFUSION/Friedman et al.
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the right ventricular anterior wall. The right ventricle
appeared to be compressed and paradoxical septal
motion was noted. An echo-free space posterior to the
left ventricle was not identified. A two-dimensional
echocardiogram was performed using a dynamically
focused, phased-array, wide-angle sector scanner.
This study demonstrated a large, echo-free space
located between the chest wall and the right ventricle
that resulted in marked compression of the right ventricle (fig. 5). Several septations were noted within the
anterior echo free space. No space between the left
ventricle and posterior pericardium was noted. A Bmode ultrasound examination of the mediastinum was
performed using the Octoson B-scanner.8 A large multiloculated anterior pericardial effusion, compressing
the right ventricle, and a right pleural effusion were
found (fig. 6). No posterior pericardial effusion was
detected. A right-heart catheterization revealed
equilibration of the mean pulmonary wedge, right ventricular end-diastolic and mean right atrial pressure
confirming the impression of cardiac tamponade
(table 1). At surgery, the chest was opened through a
median sternotomy incision. A tense, distended
pericardial sac was encountered which was incised,
yielding 300 ml of hemorrhagic fluid and degenerating
clot. The pericardium was markedly thickened with
adhesions between the visceral and parietal pericardium. The posterior aspect of the heart was free of
pericardial fluid, but some thickening of the pericardium was appreciated. Pathologic analysis of the
pericardium revealed only chronic inflammation.
1647
Effusion
RV
Septum LA
MV
Ant
Inf +
Sup
Post
Discussion
Using ultrasound techniques, most large pericardial
effusions have fluid demonstrated in the anterior as
well as posterior pericardial spaces.1 3Case I had a
large pericardial effusion located posterior and lateral
to the heart with little fluid present in the anterior
pericardial space, while case 2 had a large multiloculated pericardial effusion localized to the
anterior surface of the heart with no effusion present
posterior to the left ventricle. The M-mode echocardiogram from case 1 demonstrated a large, posterior,
echo-free space that extended behind the left atrium
and a small anterior clear space. The inability to obtain fluid by pericardiocentesis, in the presence of pericardial tamponade, necessitated further evaluation
which was accomplished noninvasively using two-dimensional echocardiography and B-mode ultrasonography. These studies confirmed that the major portion of the pericardial effusion was located posterior
Papillary
Muscle
,
FIGURE 5. Long-axis (A) and short-axis (B) views from
the two-dimensional echocardiogram from case 2. A large,
anterior pericardial effusion is identified. No posterior effusion is noted. A single septation is evident in the short-axis
view. A o aortic root; LA left atrium; L V - left ventricle; M V = m i t ral val ve; R V = righ t ven tricle; s ep ta = septation.
=
=
RV-
Ant
R+L
Post
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VOL 60, No 7, DECEMBER 1979
ClIRCU LATION
_'- Chest Wall
Peri Eff-
-RV
-LV
PilEff
Ant
L
R
Post
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FIGURE 6. Short-axis, B-mode ultrasound image from case 2. A large, multiloculated, anterior pericardial
effusion conmpressing the right ventricle is identified. A right pleural effusion is also visible. No effusion
posterior to the left ventricle is identified. L V left ventricle; Peri. Eff pericardial effusion; Pl. Eff
pleural effusion; RV = right ventricle.
=
=
=
and lateral to the left ventricle. This aided in the planning for the prompt surgical evacuation and relief of
the cardiac tamponade. Other possible explanations
for the posterior echo-free space noted on the M-mode
echocardiogram include the misdiagnosis of a left
pleural effusion as a pericardial effusion,9 a giant left
atrium simulating a pericardial effusion,1 or tumor,"1 13 or fibrosis'2 simulating pericardial effusion.
The two-dimensional echocardiograms and B-mode
ultrasound examination excluded most of these
possibilities.
The small anterior clear space identified on the Mmode echocardiogram (fig. 1) was not detected by the
other ultrasound techniques. This is probably because
M-mode echocardiography is primarily an axial
technique and damping controls can be used effectively to image structures in the near field. Although
the pericardial effusion and tumor mass was not noted
to extend anteriorly at the time of surgery, the
anterior pericardial space was not fully explored once
the cardiac tamponade was relieved and the malignant
nature of the tumor was identified. Thus, a small
amount of pericardial fluid may have been present in
the anterior pericardial space.
The M-mode echocardiogram from case 2
demonstrated a large, echo-free space anterior to the
right ventricular wall with no echo free space behind
the left ventricle. This M-mode echo pattern is considered to be nonspecific for pericardial effusion; it has
been reported with pericardial cysts'4 and noncardiac
mediastinal cysts" and tumors.5 16 Tajik'7 speculated
that an echocardiogram demonstrating a large,
anterior, echo-free space without any significant
posterior echo-free space might be found in a patient
with loculated anterior pericardial effusion. However,
he had not seen such an example. We believe this case
demonstrates that an echo-free space isolated to the
anterior surface of the heart may be related to a
loculated pericardial effusion.
The etiology of the effusion in the second case is
probably related to chronic pericarditis secondary to
the patient's chronic renal failure. Although pericardial effusion is common in patients with chronic renal
failure on hemodialysis,18-20 pericardial tamponade is
unusual2' and many of the effusions are silent.'9 We
believe this is the first documented case of pericardial
tamponade secondary to a loculated pericardial effusion in a patient with chronic renal failure diagnosed
by ultrasound.
The distinction by ultrasound between pericardial
cysts, noncardiac mediastinal cysts and loculated
pericardial effusion is not always possible. The multiloculated nature of the effusion in patient 2 helped
distinguish it from a pericardial cyst since pericardial
cysts are rarely multiloculated.2 However, this finding would not be helpful in distinguishing pericardial
effusion from thymic cysts, which are frequently multiloculated.23 We recently used ultrasound to assist in
the differential diagnosis between pericardial effusion,
tumor and mediastinal (bronchogenic) cyst in a
patient who had the latter diagnosis. Even with
thickened intracystic fluid, the boundaries and extent
of the cystic mass could be localized with both the Bscan and real-time, cross-sectional echo systems.
We believe that two-dimensional echocardiography or B-mode ultrasonography should be used in
all cases of suspected loculated pericardial effusion
and in all cases where the interpretation of the Mmode echocardiogram is equivocal as to the presence
or absence of pericardial effusion.
DIAGNOSIS OF PERICARDIAL EFFUSION/Friedman et al.
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Two-dimensional echocardiography and B-mode ultrasonography for the diagnosis of
loculated pericardial effusion.
M J Friedman, D J Sahn and K Haber
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Circulation. 1979;60:1644-1649
doi: 10.1161/01.CIR.60.7.1644
Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright © 1979 American Heart Association, Inc. All rights reserved.
Print ISSN: 0009-7322. Online ISSN: 1524-4539
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