Date post: | 29-Dec-2015 |
Category: |
Documents |
Upload: | gordon-phillips |
View: | 234 times |
Download: | 4 times |
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
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
Unequal distributionUnequal distribution
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
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
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
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