Pericardial Disease

1
Pericardial Disease

• Susan A. Raaymakers, MPAS, PA-C, RDCS (AE)(PE)
• Radiologic and Imaging Sciences -
  Echocardiography
• Grand Valley State University, Grand Rapids,
  Michigan
• raaymasu_at_gvsu.edu

2
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

3
Normal Pericardium

• Pericardial fluid is often appreciated as a very
  small echo-free 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
4
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)

5
Pericardial Diseases

• Pericardial space is limited
• Accumulation of significant pericardial fluid
  reduces the space that the heart may occupy

Non-dynamic
6
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

7
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
8
Difference in pericardial pressures - Rapid vs
slow accumulation
ACUTE
CHRONIC
PRESSURE
VOLUME
9
Detection and Quantification of Pericardial Fluid
10
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

11
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

12
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

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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
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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
15
Minimal Pericardial Fluid
Small Pericardial Effusion
Large Pericardial Effusion
Moderate Pericardial Effusion
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Large pericardial effusion signs

• Soft heart sounds
• Reduced intensity of friction rub
• Ewarts sign Dullness and decreased breath
  sounds, over posterior L lung due to compression
  by large pericardial sac
• Electrical alternans on ECG

17
Large pericardial effusion signs

• Electrical alternans on ECG

18
Large Pericardial Effusion and a Swinging Heart

• Large pericardial effusion
• In this image also a large pleural effusion

09-010a-10b Feigenbaum
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Detection and Quantification of Pericardial Fluid

• On 2D echo pericardial effusion typically
  appears maximal in the posterior atrioventricular
  groove
• Use multiple views to reliably assess fluid
  including PSAX, Apicals, and Subcostals

09-004a Feigenbaum
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Detection and Quantification of Pericardial Fluid
Small Pericardial Effusion PSAX PM
Large Pericardial Effusion PSAX PM
09-007 Feigenbaum
09-006 Feigenbaum
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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
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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
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Loculated effusion at apex
Non-dynamic
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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 long-standing
  effusions or effusions from metastatic diseases

09-016 Feigenbaum
25
Direct Visualization of the Pericardium
09-017 Feigenbaum
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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

27
Detection and Quantification of Pericardial Fluid

• 3D Pericardial Effusion

09-013b Feigenbaum
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Direct Visualization of the Pericardium
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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

30
Direct Visualization of the Pericardium
09-010a-10b Feigenbaum
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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
32
Differentiation of Pericardial from Pleural
Effusion
33
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

34
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
35
Hierarchy of Significant Pericardial Effusions
36
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

37
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

38
Cardiac Tamponade
39
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

40
Cardiac TamponadeClinical 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
• Becks triad
• Elevated venous pressure
• Hypotension
• Quiet heart

41
Respiration VariationReview
42
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

43
Respiration Variation

• Review
• Expiration
• Intrathoracic pressure and intrapericardial
  pressure ?
• Mild ? in RV diastolic filling
• ? in LV filling

44
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

45
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 gtnormal filling
  pressure, filling is determined by
  intrapericardial pressure

46
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

47
Pericardial TamponadePathophysiology

• Increased intra-pericardial pressure
• Exceeds ventricular diastolic pressure
• Causing impaired diastolic filling
• Elevated venous pressure
• JVP, hepatomegaly, edema
• Dyspnea
• Decreased filling ? decreased stroke volume
• Reflex tachycardia, hypotension

48
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

49
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

50
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
51
Respiratory variation of tricuspid inflow gt 50
52
Respiratory variation of mitral inflow gt 30
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Cardiac Tamponade- Doppler Findings

• Reciprocal and phasic variation respiration
  physiologic evidence of exaggerated
  intraventricular interdependence
• Results pulsus paradoxus

Pulmonic
Aortic
54
Pulsus paradoxus

• Exaggerated (gt10mmHg) 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.

55
Pulsus Paradoxus
an exaggerated drop in SBP with inspiration
(gt10mmHg)
Berliner Klinische Wochenschrift 1878 10461
56
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

57
Cardiac Tamponade Echocardiographic Findings
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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
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RV Diastolic Collapse
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Cardiac Tamponade- Echocardiographic Findings

• Moderate Pericardial Effusion with hemodynamic
  compromise and diastolic RV collapse

9-22a b Feigenbaum
61
RV Compression With Large Pericardial Effusion
Non-dynamic image
62
Cardiac Tamponade- Echocardiographic Findings

• Hemodynamic significant pericardial effusion and
  right ventricular outflow tract collapse

9-23a b Feigenbaum
63
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
64
IVC collapse

• IVC diameter decreases by gt 50 if RA pressure
  normal
• Lack of IVC collapse indicates RA pressure gt 20
  mm Hg and restriction to diastolic filling

65
No change in IVC diameter with inspiration
Non-dynamic
66
Evaluation of the inferior vena cava

• Other causes of IVC dilatation and failure to
  collapse
• Positive pressure ventilation
• Right heart failure
• Constrictive pericarditis

67
Cardiac Tamponade

• Early stage
• mild to moderate elevation of central venous
  pressure
• Advanced stage
• ? intrapericardial pressure? ventricular
  filling, ? stroke volume
• hypotension
• impaired organ perfusion

68
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

69
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
70
Subacute Tamponade

• Neoplasm, uremia, infection
• Gradual onset chest pain, SOB, cough
• Effort intolerance due to limited cardiac output
• Can progress to cardiac arrest

71
When to Treat Pericardial Effusion
72
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

73
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

74
Treatment Options

• Nonsurgical
• pericardiocentesis
• blind
• ECG guided
• Echo guided
• CT guided
• balloon pericardiotomy

• Surgical
• subxiphoid
• video-assisted thoracoscopy
• pericardial-peritoneal
• pericardial window
• pericardiectomy

75
Pericardiocentesis

• Diagnostic tap
• not always indicated
• Pericardial biopsy may be more definitive
• Therapeutic drainage
• indicated for tamponade

76
Is this tamponade

• http//www.echojournal.org/video/64/Tamponade

77
Pericardiocentesis

• 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

Non-dynamic
http//www.youtube.com/watch?vkoD2mEDoXSY
78
Pericardiocentesis

• 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

Nn-dynamic
79
Pericardiocentesis

• Contrast injection
• Non-dynamic images

Contrast
80
Pericardial effusion
L
Pre and post-pericardiocentesis
81
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

82
Constrictive Pericarditis
83
Pericarditis
84
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)

85
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
  anti-inflammatory 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

86
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

87
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

88
Acute Pericarditis Electrocardiogram
Diffuse ST elevation PR depression
89
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 50-85 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

90
Viral Pericarditis

• The echo is usually normal especially during the
  first presentation
• Pericardial thickening, effusions and
  constriction are UNCOMMON

91
(No Transcript)
92
TB Pericarditis

• Uncommon in US, except AIDS population
• Often bloody effusion
• Infection usually spread from chest lymph nodes
• Often progresses to constriction, calcification

93
Bacterial Pericarditis

• Multiple Gram and Gram- bacteria 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

94
Uremic PericarditisUremia 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

95
Malignant Pericarditis - Neoplastic

• Tumor or fluid may cause tamponade
• Lung, breast, lymphoma most common
• Overall mean survival 4 months
• Percutaneous drainage vs surgical window

96
Large tumor fills pericardial space
PL - pleural effusion T - tumor
Non-dynamic
97
Radiation Pericarditis

• Usually after treatment for Hodgkins, NHL and
  Breast CA
• Acutely sub-clinical
• Chronic - pain
• Constriction
• Restriction
• Drainage of fluid may not relieve symptoms

98
Subcostal view - severely thickened pericardium
A- ascites
Non-dynamic
99
Post-MI Pericarditis

• Dresslers syndrome
• Acute illness occurring weeks to months after an
  MI
• Not Dresslers if occurs early after MI
• Difficult to distinguish from recurrent MI in
  either case
• Cause unknown ?autoimmune
• Can be recurrent
• Can cause constriction

100
Recurrent Pericarditis

• Incidence 25
• Treatment
• NSAIDs (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

101
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)

102
Constriction

• Fibrosis and/or calcification of pericarium
  results in restriction of diastole
• Equalization of RV and LV diastolic pressures by
  catheterization
• Treatment involves pericardiectomy

103
Constrictive pericarditis clinical findings

• Dyspnea
• Kussmauls sign (inspiration rise in venous
  pressure)
• Pericardial knock
• Abrupt cessation of early diastolic inflow
  (classic in constrictive pericarditis)
• Ascites
• Edema

104
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)

105
Calcified pericardium
ANT
106
MRI- Constriction
RV
LV
107
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

108
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

109
Constrictive pericarditis

• Posterior pericardium is adherent to posterior
  wall

110
Diastolic septal bounce with inspiration

• Venous return increases leading to increased RV
  volume
• Total cardiac volume constrained by pericardium
• Interventricular dependence leads to septal shift

Non-dynamic
111
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 gt25 in RV/LV diastolic
  filling

112
Respiration and Constrictive Pericarditis

• Inspiration
• LVIT decreased gt25
• RVIT increased
• Expiration
• RVIT decreased gt25
• LVIT increased

LVIT
RVIT
113
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

114
Quiz8 Questions
115
All of the following may result in jugular venous
distension EXCEPT

1. Cardiac tamponade
2. Pulmonary hypertension
3. Tricuspid stenosis
4. Hypovolemia
5. Constrictive pericarditis

116
All of the following may result in jugular venous
distension EXCEPT

1. Cardiac tamponade
2. Pulmonary hypertension
3. Tricuspid stenosis
4. Hypovolemia
5. Constrictive pericarditis

117
An enlarged heart on chest x-ray could be all of
the following EXCEPT

1. Pericardial effusion
2. Pleural effusion
3. Aortic stenosis
4. Hypertrophic cardiomyopathy

118
An enlarged heart on chest x-ray could be all of
the following EXCEPT

1. Pericardial effusion
2. Pleural effusion
3. Aortic stenosis
4. Hypertrophic cardiomyopathy

119
What do you do if tamponade is suspected?
120
What do you do if tamponade is suspected?

• Immediate interpretation. Do not let the patient
  leave the hospital/doctors office

121
What causes a pericardial knock?
122
What causes a pericardial knock?

• Abrupt cessation of early diastolic inflow
  (classic in constrictive pericarditis)

123
Other than tamponade, what pericardial
abnormality causes impaired ventricular filling?
124
Other than tamponade, what pericardial
abnormality causes impaired ventricular filling?

• Constrictive pericarditis

125
A pericardial effusion can often be seen in
patients with

1. Aortic stenosis
2. Atrial flutter
3. Myocardial infarction
4. Renal failure

126
A pericardial effusion can often be seen in
patients with

1. Aortic stenosis
2. Atrial flutter
3. Myocardial infarction
4. Renal failure

127
Challenging Case StudiesWhat 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
• raaymasu_at_gvsu.edu

128
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.

129
Echo-free Space

• A transthoracic echocardiogram was obtained.
• Based on these findings, you should order
• Follow-up echo in one week drain if effusion
  increases or if more symptoms appear
• Urgent needle pericardiocentesis (apical
  approach)
• Urgent needle pericardiocentesis (parasternal
  approach)
• Contrast echo
• Anticoagulation with heparin, followed by
  warfarin (international normalized ratio 2 to 3)

130
Echo-free Space

• A transthoracic echocardiogram was obtained.
• Based on these findings, you should order
• Follow-up echo in one week drain if effusion
  increases or if more symptoms appear
• Urgent needle pericardiocentesis (apical
  approach)
• Urgent needle pericardiocentesis (parasternal
  approach)
• Contrast echo
• 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.