pericardial diseases. pericardial anatomy pericardial effusion (etiology) viral (most common) uremic...

Pericardial diseasesPericardial diseases

Pericardial anatomyPericardial anatomy

PERICARDIAL EFFUSION PERICARDIAL EFFUSION (ETIOLOGY)(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

HIVHIV

PERICARDIAL DISEASESPERICARDIAL DISEASES(CLINICAL PRESENTATION)(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 FLUIDPERICARDIAL FLUID

• Serosanguinous (clear, pale yellow)

- not echogenic

• Bloody (consider metastatic, trauma)

- may be echogenic

• Infectious (brown,milky colored)

PERICARDIAL EFFUSIONPERICARDIAL EFFUSION (M Mode Echocardiography) (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 EFFUSIONPERICARDIAL EFFUSION(2D Echocardiography)(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 Parasternal long axis long axis

LA

LV AO

DAO

Effus

ParasternalParasternalShort AxisShort Axis

Apical 4CApical 4C

Subcostal viewSubcostal view

Fibrous StrandsFibrous Strands

Unequal distributionUnequal distribution

M Mode echoM Mode echo

M-ModeM-Mode

RV collapse/ Delayed RV Relaxation

PERICARDIAL EFFUSION: PERICARDIAL EFFUSION: SIZESIZE

• 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 EffusionSmall Pericardial Effusion

Moderate Pericardial EffusionModerate Pericardial Effusion

Large Pericardial EffusionLarge Pericardial Effusion

PERICARDIAL EFFUSION: POSSIBLE PERICARDIAL EFFUSION: POSSIBLE

SOURCES OF FALSE POSITIVESSOURCES OF FALSE POSITIVES

• Pleural effusion

• Pericardial tumor or cyst

• Dilated coronary sinus

• LV pseudoaneurysm

• Large hiatal hernia

LSVC Dilated Coronary SinusLSVC Dilated Coronary Sinus

Pericardial Cyst SubcostalPericardial Cyst Subcostal

2C: Posterior echo free space2C: Posterior echo free space

DOPPLERDOPPLER

• 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 StudyTamponade Case Study

PericardiocentesisPericardiocentesis

• 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 subcostalLittle effusion available from subcostal

Differentiation with AscitesDifferentiation with Ascites

Case 2Case 2

• 56 year old female

• transferred from outside hospital

• know breast cancer

• possible malignant pericardial effusion

• Pericardiocentesis

- injected into the pericardial space for verification of needle placement

Agitated SalineAgitated Saline

Before

After pericardiocentesis

Case 4Case 4

• Patient presents post MI

• New pericardial effusion

• What is the differential?

EP applicationEP 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 TEEPericardial Effusion by TEE

Pericardial Disease:Pericardial Disease:Constriction versus RestrictionConstriction versus Restriction

Constrictive Pericardial Diseases: Constrictive Pericardial Diseases: EtiologiesEtiologies

• Idiopathic/recurrent pericarditis

• Post cardiac surgery

• Prior chest radiation

• Infectious (Tuberculosis)

• Metastatic process

• Difficult diagnosis to establish

Less Common EtiologiesLess Common Etiologies

• Infectious (Fungal)• Neoplasms• Uremia• Connective tissue disorders (SLE,

Scleroderma)• Drug Induced (Procainamide, hydralazine)• Trauma• Post MI (Dressler’s)

Clinical SignsClinical 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

PhysiologyPhysiology

• 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 Imaging2D 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 EvaluationM-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 EvaluationDoppler 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 Decreased Mitral Inflow with InspirationInspiration

Tricuspid Inflow Increased with Tricuspid Inflow Increased with InspirationInspiration

Tissue DopplerTissue 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 DopplerConstrictive Tissue Doppler

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

E/E’ and PCWP are inversely correlated in patients with constrictive disease

Ha et al, Circulation. 2001;104:976-978

Additional Doppler findingsAdditional Doppler findings

• Expiratory decrease in hepatic diastolic forward flow and increases in hepatic vein flow reversals

Normal Hepatic FlowNormal Hepatic Flow

Systolic and diastolic phasic flow

Constrictive Hepatic Vein FlowConstrictive Hepatic Vein Flow

Increased forward flow with inspiration, backflow with expiration

Adapted from Haley et al JACC, 2004;43;271-275

Technical ConcernsTechnical 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 CaseConstriction Case

Mitral InflowMitral Inflow

Tissue DopplerTissue Doppler

Medial Lateral

Apical 4 Chamber viewApical 4 Chamber view

Reciprocal LV changes in size with respiration

Cardiac Cardiac CatheterizationCatheterization

Calcification

LV function

Infiltrative/Restrictive Infiltrative/Restrictive Systemic DiseasesSystemic Diseases

EtiologyEtiology• Noninfiltrative

– Idiopathic– Familial– HCM– Scleroderma– Diabetic

• Infiltrative– Amyloidosis– Sarcoidosis

• Storage– Hemochromatosis– Fabry’s

• Hypereosinophilic Syndrome• Carcinoid

2D Findings2D 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 LongAmyloid Parasternal Long

Amyloid Apical 4Amyloid Apical 4

Doppler FindingsDoppler 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 Restrictive fillingfilling

Hepatic VeinsHepatic Veins

Prominent diastolic reversal (Y decent)

Indices of patients with elevated LV Indices of patients with elevated LV filling pressuresfilling 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 InflowMitral / Tricuspid InflowConstriction vs RestrictionConstriction vs Restriction

I E I E I E

Normal Constriction Restriction

Mitral

Tricuspid

Tissue DopplerTissue Doppler

Constrictive• Average velocities

14.8 cm/sec• Normal or enhanced

longitudinal expansion

Restrictive• Average velocities 4.1

cm/sec• Restricted myocardial

motion

Garcia, et al. JACC 1996 Jan;27(1):108-14, Sengupta et al. Am J Cardiol. 2004 Apr 1;93(7):886-90

• Increases sensitivity to detect Constriction to 98.4%• except in pts with MAC, LV dysfunction

Mixed Constrictive/ Restrictive Mixed Constrictive/ Restrictive PhysiologyPhysiology

• Incidence varies, but around 20% of patients

• May be found in Radiation Induced, CABG

• Increased Mortality in Mixed physiology

ComparisonComparison

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 IncreasedPalka et al. Circulation 2000;102;655-662.

Normal Restrictive Constrictive

Mitral

Tissue

Pulmonary Vein

Tricuspid

Hepatic Veins

Adapted From Hoit, Management of Effusive and Constrictive Pericardial Heart Disease Circulation 2002;105;2939-2942

S S

S S S

S D D D

DD

D

Case 1 Restrictive vs. ConstrictiveCase 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