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Pericardial Disease
Susan A. Raaymakers, MPAS, PA-C, RDCS (AE)(PE)
Radiologic and Imaging Sciences - Echocardiography
Grand Valley State University, Grand Rapids, Michigan
[email protected]
Normal Pericardium
For ARDMS Exam


Three layers:

Fibrous pericardium – thick
outer sack

Serous parietal – bound to
fibrous pericardium smooth,
‘the wall of a cavity’

Serous visceral – bound to
epicardium smooth, ‘toward
the organ’
5 to 10 ml pericardial fluid
found in between the two
serous layers
Normal Pericardium

Pericardial fluid is often appreciated as a very small echofree space in the posterior atrioventricular groove.


Echo-free space between visceral and parietal pericardium
(epicardium and fibrous pericardium)
Visualized as a small anechoic space in the posterior AV
groove that may be visible only in systole
09-001a-1b
Feigenbaum
Pericardial Diseases

Can present as several
different clinical scenarios

Pericardial effusions can
accumulate in any infectious
or inflammatory process
involving the pericardium

Most infectious and
inflammatory process involve
both layers of the
pericardium (visceral and
parietal)
Pericardial Diseases


Pericardial space is
limited
Accumulation of
significant pericardial
fluid reduces the space
that the heart may
occupy
Non-dynamic
Pericardial Diseases

Hemodynamic
compromise is related
to intrapericardial
pressure

Intrapericardial pressure
is related to the volume
of pericardial fluid and
the COMPLIANCE OR
DISTENSIBILITY of
the pericardium
Pericardial Diseases

Slowly developing large
effusions are better
tolerated than a smaller
but more rapidly
developing effusion

More rapidly developing
effusion does not allow the
heart to compromise
09-004a
Feigenbaum
Difference in pericardial pressures Rapid vs slow accumulation
ACUTE
PRESSURE
VOLUME
CHRONIC
Detection and
Quantification of
Pericardial Fluid
Detection and Quantification of
Pericardial Fluid
M-Mode
 Appears as anechoic space
both anterior and posterior
to the heart.

Note: An isolated anterior
free space is not specific for
pericardial fluid.

Isolated anterior anechoic
space may be due to
mediastinal fat
Detection and Quantification of Pericardial Fluid
M-Mode
 Size of anechoic space is directly
proportional to the amount of fluid

No accurate M-mode techniques for quantifying
absolute volume of pericardial fluid
Detection and Quantification of Pericardial Fluid
2D
 Most often used for screening
 Seen between Descending Ao and CS
 Most echocardiographic labs visually
quantify pericardial effusion as:
Minimal
 Small
 Moderate
 Large
 Further characterize:

Either free or loculated
 Presence or absence of hemodynamic compromise

Detection and Quantification of
Pericardial Fluid
Small Pericardial Effusion- 1 cm of
posterior anechoic space with or
w/out fluid accumulation
elsewhere
09-003 Feigenbaum
Minimal Pericardial Fluid - Normal
09-001a-1b Feigenbaum
Detection and Quantification of
Pericardial Fluid
Large Pericardial Effusion – more
than 2 cm of maximal separation
09-004b Feigenbaum
Moderate Pericardial Effusion – 1
to 2 cm of anechoic space
09-004a Feigenbaum
Minimal Pericardial Fluid
Moderate Pericardial Effusion
Small Pericardial Effusion
Large Pericardial Effusion
Large pericardial effusion: signs




Soft heart sounds
Reduced intensity of friction rub
Ewart’s sign: Dullness and decreased breath
sounds, over posterior L lung due to
compression by large pericardial sac
Electrical alternans on ECG
Large pericardial effusion: signs

Electrical alternans on ECG
Large Pericardial Effusion and a
Swinging Heart

Large pericardial effusion

In this image also a large
pleural effusion
09-010a-10b Feigenbaum
Detection and Quantification of Pericardial Fluid

On 2D echo: pericardial effusion typically
appears maximal in the posterior
atrioventricular groove
09-004a Feigenbaum

Use multiple views to reliably assess fluid
including PSAX, Apicals, and Subcostals
Detection and Quantification of Pericardial Fluid
Small Pericardial Effusion – PSAX PM
Large Pericardial Effusion – PSAX PM
09-007 Feigenbaum
09-006 Feigenbaum
Detection and Quantification of Pericardial Fluid
Moderate, predominately lateral pericardial
effusion (PEF) Note PEF behind RA
Mod to Large PEF w/greatest dimension
lateral to LV free wall
09-009 Feigenbaum
09-008 Feigenbaum
Detection and Quantification of Pericardial Fluid

PEF may be
localized or loculated
rather than
circumferential

May occur after
cardiac surgery or
cardiac trauma
Non-dynamic
Loculated effusion at apex
Non-dynamic
Stranding and Fluid Accumulation

Presence of fluid
accumulation, masses
and stranding

Occur either on the
visceral pericardium or
the interior aspect of the
parietal pericardium

Fibrin strands are
commonly seen in longstanding effusions or
effusions from metastatic
diseases
09-016 Feigenbaum
Direct Visualization of the Pericardium
09-017 Feigenbaum

Detection and Quantification of Pericardial Fluid
Several schemes have been used for actual
quantification of pericardial volume


None have had universal clinical acceptance
3D echo may provide the most accurate technique
for quantification and assessment



3D volume of entire pericardial space is calculated
Overall total volume of the entire heart is calculated
Pericardial fluid is calculated as the difference between
entire pericardial space and overall total volume

Little significance due to lack of 3D availability and lack of
clinical need to determining precise pericardial volume
Detection and Quantification of Pericardial Fluid

3D Pericardial Effusion
09-013b Feigenbaum
Direct Visualization of
the Pericardium
Direct Visualization of the Pericardium

Pleural effusion creates a fluid layer on either side of
the pericardium

In absence of pleural effusion exterior potion of
parietal pericardium abuts the normal intrathoracic
structures


Therefore, thickness and character of the pericardium
cannot be separated from the surrounding tissues
When both pericardial and pleural effusions are present,
thickness of pericardium in hat area can be assessed
Direct Visualization of the Pericardium
09-010a-10b Feigenbaum
Direct Visualization of the Pericardium

Presence of calcific
pericarditis may be
marked shadowing
seen posterior to
pericardium

Normal pericardium is
highly reflective

Hyperechoic
pericardium alone
should not be used to
diagnose constrictive
pericarditis
09-015 Feigenbaum
Differentiation of
Pericardial from
Pleural Effusion
Differentiation of
Pericardial from Pleural Effusion


Pleural effusion can be mistaken for pericardial
effusion
Fluid appearing exclusively behind the LA is
more likely to represent pleural than pericardial
effusion

Pericardial reflections surround the pulmonary veins
and tend to limit the potential space behind the LA
Differentiation of
Pericardial from Pleural Effusion

Location of fluid-space
with respect to
descending thoracic
aorta

Pericardial reflection is
typically anterior to the
descending aorta

Fluid appearing
posterior to descending
aorta more likely pleural
Non-dynamic
Hierarchy of
Significant Pericardial
Effusions
Hierarchy of Hemodynamically
Significant Pericardial Effusions
1.
Exaggerated respiratory variation of tricuspid inflow
2.
Exaggeration in mitral inflow
3.
Right atrial collapse occurs at lower levels of
intrapericardial pressure elevations than RVOT collapse
4.
Right ventricular free wall collapse (may be seen in
expiration but not inspiration with RV filling is
increased)
5.
When intrapericardial pressure is elevated and
consistently exceeds intravascular pressures the above
findings will be present simultaneously
Hierarchy of Hemodynamically
Significant Pericardial Effusions
Instances with changes may not be seen:

Significant RVH usually d/t pulmonary
hypertension

Thick, noncompliant RV wall is not compressed by
modest elevation in pericardial pressure

Thickening of the ventricular wall d/t
malignancy, an overlying inflammatory respoinse
or an overlying thrombus in a hemhorrhagic
pericarditis

Hypovolumia causing a low pressure tamponade
Cardiac Tamponade
Cardiac Tamponade

Clinical diagnosis made at the bedside;


Echo helps determine the amount and location of
fluid
Occurs mostly with moderate-to-large effusions
although small, rapidly accumulated effusions
may also cause tamponade
Cardiac Tamponade
Clinical Features

Symptoms


dyspnea, fatigue, cough, agitation and restlessness,
syncope, and shock
Physical examination




pulsus paradoxus (may also be present in COPD patients
or patients on ventilators)
ECG may shows electrical alternans
increased jugular venous pressure
Beck’s triad



Elevated venous pressure
Hypotension
Quiet heart
Respiration Variation
Review
Respiration Variation
Review:
 Inspiration: intrathoracic
and intrapericardial
pressures ↓

↑flow into right heart


↑right ventricular filling and
stroke volume
↓ flow to pulmonary veins

Compensatory decrease in left
ventricular stroke volume in
early inspiration
Respiration Variation
Review:
 Expiration:

Intrathoracic pressure and
intrapericardial pressure ↑
Mild ↓ in RV diastolic filling
 ↑ in LV filling

Respiration Variation

Cyclic variation of LV and RV filling is
sufficient to create mild changes in
stroke volume (SV) and blood pressure

Normal respiratory variation of SV
results in ≤ 10 mmHg ↓ in systolic
arterial systolic pressure with
inspiration

Processes that alter the respiratory
cycle (i.e. COPD) ↑ work of breathing
↑intrathoracic pressure swings
 Alter variation of SV and arterial
pulse pressure
Cardiac Tamponade

↑ accumulation of pericardial fluid ↑
intrapericardial pressure and affects RV
filling

Overall effect of ↑volume of pericardial fluid
limits total blood volume within four cardiac
chambers
Exaggerate the respiration-dependent
ventricular volume
 If intrapericardial pressure >normal filling
pressure, filling is determined by intrapericardial
pressure

Cardiac Tamponade

LV has stiffer wall and
diastolic filling is determined
largely by active relaxation
LV filling is relatively
unaffected compared to RV
filling

In large pericardial effusions,
elevation of interpericardial
pressure inspiration results in
disproportionately greater
filling of RV than normal and
leads to greater compromise
of LV filling
Pericardial Tamponade:
Pathophysiology

Increased intra-pericardial pressure



Causing impaired diastolic filling
Elevated venous pressure



Exceeds ventricular diastolic pressure
JVP, hepatomegaly, edema
Dyspnea
Decreased filling  decreased stroke volume

Reflex tachycardia, hypotension
Cardiac Tamponade

Marked
exaggeration in
phasic changes with
respiration
Greater decrease in
systolic arterial blood
pressure with
inspiration
 Variation of BP with
respiration called

pulses paradoxus
Cardiac Tamponade- Doppler Findings


Under normal circumstances, peak velocity of
mitral inflow varies by 15% with respiration
and tricuspid by 25%
Variation of aortic and pulmonary flow
velocities vary less than 10%
Cardiac Tamponade- Doppler Findings

In presence of
hemodynamically
significant pericardial
effusion:

Respiratory variation is
exaggerated above
normal variation and
therefore velocities are
exaggerated
Inspiration: ↑right↓left
 Expiration: ↓right ↑left

Tricuspid
Mitral
Respiratory variation of tricuspid inflow > 50%
Respiratory variation of mitral inflow > 30%
Cardiac Tamponade- Doppler Findings

Reciprocal and phasic
variation respiration:
physiologic evidence of
exaggerated
intraventricular
interdependence
Pulmonic
Aortic

Results: pulsus
paradoxus
Pulsus paradoxus

Exaggerated (>10mmHg) cyclic decrease in
systolic BP during normal inspiration
Inspiration: increased venous return increased
RV volume.
 Interventricular septum shifts left, decreased
LV volume decreased stroke volume systolic
pressure falls.

Pulsus Paradoxus
an exaggerated drop in SBP with inspiration (>10mmHg)
Berliner Klinische Wochenschrift 1878; 10:461
Cardiac Tamponade- Doppler Findings



Hepatic vein flow pattern may reflect exaggerated respiratory
phase dependence of RV filling
Note loss of forward flow in hepatic veins during expiratory
phase (E) of respiratory cycle
Flow is confined exclusively to early inspiratory (I) phase
Cardiac Tamponade –
Echocardiographic
Findings
Cardiac Tamponade- Echocardiographic Findings
Signs of elevated intrapericardial pressure
 Diastolic right ventricular collapse
 Exaggerated right atrial collapse during atrial systole
(ventricular diastole)
ES: End-systole
DC: Diastolic collapse
RV Diastolic Collapse
Cardiac Tamponade- Echocardiographic Findings

Moderate Pericardial
Effusion with
hemodynamic
compromise and
diastolic RV collapse
9-22a & b Feigenbaum
RV Compression With Large Pericardial Effusion
Non-dynamic image
Cardiac Tamponade- Echocardiographic Findings

Hemodynamic
significant
pericardial effusion
and right ventricular
outflow tract collapse
9-23a & b Feigenbaum
Cardiac Tamponade- Echocardiographic Findings

Large pericardial
effusion and evidence of
right atrial collapse
occurring immediately
after normal atrial
systolic contraction

In the presence of
marked elevation of
intrapericardial
pressure, right atrial wall
will remain collapsed
throughout atrial
diastole
9-24 Feigenbaum
IVC collapse


IVC diameter decreases by > 50% if RA
pressure normal
Lack of IVC collapse indicates RA pressure >
20 mm Hg and restriction to diastolic filling
No change in IVC diameter with
inspiration
Non-dynamic
Evaluation of the inferior vena cava

Other causes of IVC dilatation and failure to
collapse
Positive pressure ventilation
 Right heart failure
 Constrictive pericarditis

Cardiac Tamponade

Early stage


mild to moderate elevation of central venous
pressure
Advanced stage
 intrapericardial pressure
 ventricular filling,  stroke volume
 hypotension
 impaired organ perfusion

Acute Tamponade

Blood in pericardial space

Complication of catheter or pacemaker procedures

Post-surgical or traumatic

Rupture heart or aorta into pericardial space

Acute chest pain and dyspnea

Volume of pericardial fluid may be low

Life threatening
Postoperative Effusions

May occur post cardiac
surgery, not uncommon

Can range from small and
self-limited to larger effusions

Most often localized to the
posterior and lateral aspects
of the heart and may be
loculated

Complication of assessment:
postoperative status of
patient, pericardial fluid most
likely is hemorrhagic and
intrapericardial hematoma
may be present
9-41 Feigenbaum
Subacute Tamponade

Neoplasm, uremia, infection

Gradual onset chest pain, SOB, cough

Effort intolerance due to limited cardiac
output

Can progress to cardiac arrest
When to Treat
Pericardial Effusion
When to treat pericardial effusion?

Tamponade is not an all-or-none-phenomena

Echo more sensitive than clinical criteria

Limited data exist with respect to the optimal
timing of intervention for pericardial effusion

Cardiogenic shock must be aggressively addressed

Infusion of large volume of IV fluids may
temporarily stabilize the patient
Echo-guided Pericardiocentesis
SAFE and EFFECTIVE
 Locating the optimal site of puncture

Determining the depth of the pericardial
effusion and the distance form the puncture
site to the effusion

Monitoring the results of the
pericardiocentesis
Treatment Options
Nonsurgical
 pericardiocentesis

Surgical
 subxiphoid
 blind
 video-assisted
 ECG guided
thoracoscopy
 Echo guided
 pericardial-peritoneal
 CT guided
 pericardial window
balloon pericardiotomy
 pericardiectomy
Pericardiocentesis

Diagnostic tap
not always indicated
 Pericardial biopsy may be more definitive


Therapeutic drainage

indicated for tamponade
Is this tamponade

http://www.echojournal.org/video/64/Tampo
nade
Pericardiocentesis
Non-dynamic

Note approximately 1.5cm
distance between the
pericardium and RV free wall
implying a significant distance
between the pericardium and
heart

A significant distance may
indicate a decreased risk of
pericardiocentesis if
approached from the subcostal
position
http://www.youtube.com/watch?v=koD2mEDoXSY
Pericardiocentesis
Nn-dynamic

Many labs use echo guided
pericardiocentesis and
attempt to visualize needle
as it enters the pericardial
cavity

Helpful to avoid cardiac
damage in a relatively small
effusion but may not play a
big role in larger effusions
Pericardiocentesis

Contrast injection
Non-dynamic images
Contrast
Pericardial effusion
L
Pre and post-pericardiocentesis
Focal Tamponade




Most often occurs after cardiac surgery
May be difficult to diagnose on TTE
Respiratory variation may also be focal
TEE often necessary to make the diagnosis
Constrictive
Pericarditis
Pericarditis
Acute Pericarditis

Infectious
viral
 tuberculosis
 pyogenic bacterial (AKA bacterial pericarditis)


Several different bacteria can cause this disease.
Examples include staphylococci, group A
streptococci (strept throat, scarlet fever), and the
bacteria that cause Lime disease (tick)
Acute Pericarditis

Non-infectious

Post-myocardial infarction

Uremia


Condition resulting from advanced stages of kidney failure in
which urea and other nitrogen-containing wastes are found in
the blood.

Uremia can be caused by NSAIDs (nonsteroid antiinflammatory drugs), especially in older patients treated
primarily with ibuprofen for arthritis.

Treatment of uremia, which is directed at the underlying kidney
disease, is usually with dialysis and renal transplantation.
Neoplastic disease
Acute Pericarditis

Non-infectious – Continued…

Radiation induced

Connective tissue diseases


Rheumatoid arthritis, Systemic Lupis Erythematous,
Sclerodoma etc.
Drug induced

procainamide, hydralazine, isoniazid, methysergide,
phenytoin, or anticoagulants
Acute pericarditis: clinical findings

Chest pain

Pleuritic, positional, may mimic MI

Fever, tachycardia, dyspnea

Pericardial friction rub


3 component “scratchy” sound
Abnormal ECG


Diffuse ST elevation
PR depression
*
Acute Pericarditis:
Electrocardiogram
Diffuse ST elevation
PR depression
Viral Pericarditis

Coxsackievirus and Echovirus
 Enterovirus: found in alimentary canal (the intestines) of
infected people
 Often diagnosed as idiopathic
 Seasonal variation

Can occur with AIDS as a result of Cytomegalovirus (CMV)
 CMV: Common virus in the herpes virus family that affects 5085% of adults in the US by age 40.
 Found in saliva, urine, and other body fluids and can be spread
through sexual contact or other more casual forms of physical
contact such as kissing.
 Usually self-limited
 Complications: myocarditis, recurrence, tamponade,
constriction

Treat underlying disorder
Viral Pericarditis

The echo is usually normal especially during
the first presentation

Pericardial thickening, effusions and
constriction are UNCOMMON
TB Pericarditis

Uncommon in US, except AIDS population

Often bloody effusion

Infection usually spread from chest lymph nodes

Often progresses to constriction, calcification
Bacterial Pericarditis

Multiple Gram+ and Grambacteria can cause

Previously complication from
pneumonia, now more
commonly seen post-op, with
endocarditis, remote GI abscess
or bacteremia

Treatment is antibiotics tailored
to organism

Survival is only 30%

Early surgical drainage is
essential
Uremic Pericarditis
Uremia is a buildup of urea and other waste material in the
blood due to kidney failure.

Usually responds to aggressive hemodialysis

Occasionally causes tamponade


Usually accumulates slowly allowing
pericardium to accommodate volume
Large effusion not always be present on
echo
Malignant Pericarditis - Neoplastic




Tumor or fluid may cause tamponade
Lung, breast, lymphoma most common
Overall mean survival 4 months
Percutaneous drainage vs surgical window
Large tumor fills pericardial
space
PL - pleural effusion
T - tumor
Non-dynamic
Radiation Pericarditis

Usually after treatment for Hodgkin’s, NHL
and Breast CA

Acutely sub-clinical
Chronic - pain
 Constriction
 Restriction


Drainage of fluid may not relieve symptoms
Subcostal view - severely thickened
pericardium
A- ascites
Non-dynamic
Post-MI Pericarditis

Dressler’s syndrome
Acute illness occurring weeks to months after an
MI
 Not Dressler’s if occurs early after MI


Difficult to distinguish from recurrent MI in either
case
Cause unknown ?autoimmune
 Can be recurrent
 Can cause constriction

Recurrent Pericarditis

Incidence ~25%

Treatment

NSAID’s (non-steroidal anti-inflammatory) initially

Steroids Rarely

Colchicine

Used to prevent or treat attacks of gout (also called gouty
arthritis).




People with gout have too much uric acid in their blood and joints. An
attack of gout occurs when uric acid causes inflammation (pain, redness,
swelling, and heat) in a joint. It prevents or relieves gout attacks by
reducing inflammation
Well Tolerated
60% effective long-term, more effective if taken chronically
Fewer side effects than long-term steroids
Constrictive pericarditis

Fibrous thickening, adhesion, calcification of the
pericardium

Most common etiologies:





TB
Idiopathic
Radiation therapy
Long-term steroid use
Chronic pericarditis (see etiologies for effusion)
Constriction



Fibrosis and/or calcification of pericarium
results in restriction of diastole
Equalization of RV and LV diastolic pressures
by catheterization
Treatment involves pericardiectomy
Constrictive pericarditis: clinical
findings



Dyspnea
Kussmaul’s sign (inspiration rise in venous
pressure)
Pericardial “knock”



Abrupt cessation of early diastolic inflow (classic
in constrictive pericarditis)
Ascites
Edema
Constrictive pericarditis: Diagnosis



Calcified pericardium on Xray
Image thickened pericardium:
CT scan, MRI
Cardiac cath:
Elevated, equalized diastolic pressures
 Restricted filling pattern in RV (“dip and
plateau”)

Calcified pericardium
ANT
MRI- Constriction
RV
LV
Restriction of diastolic filling
Brief rapid, fall of ventricular pressure in
early diasotle, followed by
•High early diastolic pressure plateau
•Rapid descent of right atrial
pressure with the onset of ventricular
filling
•Only modest elevation of RV and PA
systolic pressures
•RV diastolic plateau that is a third or
more of systolic pressure
•Equalizaiton of diastolic pressures
in the RV and LV even after volume
loading
Echocardiographic signs of constriction







Normal systolic function
Thickened pericardium
Flat LV posterior wall motion in diastole
Early diastolic “notching” of the IVS
Right and left atrial enlargement
Dilated IVC – no inspiratory collapse
Premature opening of the PV
Constrictive pericarditis

Posterior pericardium is
adherent to posterior
wall
Diastolic septal bounce with inspiration
•
•
•
Non-dynamic
Venous return increases
leading to increased RV
volume
Total cardiac volume
constrained by pericardium
Interventricular dependence
leads to septal shift
Constrictive Pericarditis - Doppler

Mitral and tricuspid
regurgitation is usually
present

Mitral inflow has prominent
E velocity, rapid deceleration
and a small A wave

Respiratory variation >25%
in RV/LV diastolic filling
Respiration and Constrictive Pericarditis

Inspiration
LVIT decreased >25%
 RVIT increased


LVIT
Expiration
RVIT decreased >25%
 LVIT increased

RVIT
Constriction Treatment

Medical management-palliative



Diuretics to minimize edema
Anti TB drugs x 4 weeks before surgery
Surgical management-Pericardiectomy



Mortality ~10%
Symptomatic improvement 90%
Poor Prognostic Indicators:



NYHA class III or IV
Incomplete resection
Radiation induced
Quiz
8 Questions
All of the following may result in
jugular venous distension EXCEPT:
1.
2.
3.
4.
5.
Cardiac tamponade
Pulmonary hypertension
Tricuspid stenosis
Hypovolemia
Constrictive pericarditis
All of the following may result in
jugular venous distension EXCEPT:
1.
2.
3.
4.
5.
Cardiac tamponade
Pulmonary hypertension
Tricuspid stenosis
Hypovolemia
Constrictive pericarditis
An enlarged heart on chest x-ray
could be all of the following
EXCEPT:
1.
2.
3.
4.
Pericardial effusion
Pleural effusion
Aortic stenosis
Hypertrophic cardiomyopathy
An enlarged heart on chest x-ray
could be all of the following
EXCEPT:
1.
2.
3.
4.
Pericardial effusion
Pleural effusion
Aortic stenosis
Hypertrophic cardiomyopathy
What do you do if tamponade is
suspected?
What do you do if tamponade is
suspected?

Immediate interpretation. Do not let the patient
leave the hospital/doctor’s office
What causes a pericardial knock?
What causes a pericardial knock?

Abrupt cessation of early diastolic inflow (classic
in constrictive pericarditis)
Other than tamponade, what pericardial
abnormality causes impaired ventricular
filling?
Other than tamponade, what pericardial
abnormality causes impaired ventricular
filling?

Constrictive pericarditis
A pericardial effusion can often be
seen in patients with:
1.
2.
3.
4.
Aortic stenosis
Atrial flutter
Myocardial infarction
Renal failure
A pericardial effusion can often be
seen in patients with:
1.
2.
3.
4.
Aortic stenosis
Atrial flutter
Myocardial infarction
Renal failure
Challenging Case Studies
What would the cardiologist
do?
Susan A. Raaymakers, BS, RDCS (AE)(PE)
Coordinator of Radiologic and Imaging Sciences - Echocardiography
Grand Valley State University, Grand Rapids, Michigan
[email protected]
Echo-free Space
75 year old man with previous history of coronary
artery disease and bypass surgery complained of
dyspnea.

Workup reviewed severe mitral regurgitation, and
the patient underwent mitral valve replacement with
a tissue prosthesis.

There was no immediate postoperative problems.

On the seventh post-operative day he developed
dyspnea at rest and weakness. Physical examination
was unremarkable.
Echo-free Space
A transthoracic echocardiogram was obtained.
Based on these findings, you should order:
1.
Follow-up echo in one week; drain if
effusion increases or if more symptoms
appear
2.
Urgent needle pericardiocentesis (apical
approach)
3.
Urgent needle pericardiocentesis
(parasternal approach)
4.
Contrast echo
5.
Anticoagulation with heparin, followed by
warfarin (international normalized ratio =
2 to 3)
Echo-free Space
A transthoracic echocardiogram was obtained.
Based on these findings, you should order:
1.
Follow-up echo in one week; drain if
effusion increases or if more symptoms
appear
2.
Urgent needle pericardiocentesis (apical
approach)
3.
Urgent needle pericardiocentesis
(parasternal approach)
4.
Contrast echo
5.
Anticoagulation with heparin, followed by
warfarin (international normalized ratio =
2 to 3)
If you chose answers
1,2,3 or 5, you are in big
trouble because the
echo-free space between
the left ventricle apex and
the chest wall is a
pseudoaneurysm of the
LV.