Pericardial Diseases. Smonporn Boonyaratavej, MD. Division of Cardiology, Department of Medicine Chulalongkorn University

Transcription

1 Pericardial Diseases Smonporn Boonyaratavej, MD Division of Cardiology, Department of Medicine Chulalongkorn University Cardiac Center, King Chulalongkorn Memorial Hospital 21 AUGUST 2016

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4 Pericardial Diseases Etiologic Dx Clinical Dx/ conditions Echo findings Purulent Acute pericarditis Pericardial effusions Tuberculous Recurrent pericarditis Tamponade physiology Viral Cardiac tamponade Constrictive physiology Autoimmune Constrictive pericarditis Pericardial Masses (Tumors,Cysts, and Diverticulum) Post surgery Idiopathic Congenital Malignancy Trauma Effusive constrictive pericarditis Congenital Absence of the Pericardium

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6 Echo Findings in Pericardial Diseases Pericardial effusion Tamponade physiology Constrictive physiology & Pericardial constriction

7 Pericardial Disease Pericardial Effusion Normal pericardial fluid = ml Intrapericardial pressure -5 to +5 mmhg Pericardial effusion Separation of visceral and parietal pericardium with echo-free space

8 Reporting amount of pericardial effusion Trivial, small (<10 mm), moderate (10 20 mm), large (>20 mm) size of the echo-free space seen end-diastole Klein. JASE 2013

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10 Small Pericardial Effusion

11 Large Pericardial Effusion Pe eff Pl eff * Pl eff Pe eff

12 Pericardial Effusion Pleural vs. Pericardial effusion Pleural vs. Pericardial effusion * A B * *

13 From Netter F. Atlas of Human Anatomy. Ciba-Geigy 1995.

14 Pericardial Attachments SVC Transverse sinus Pulmonary veins Aorta Pulmonary a. Oblique sinus IVC Visceral pericardium Parietal pericardium From Netter F. Atlas of Human Anatomy. Ciba-Geigy 1995.

15 Pericardial Attachments 1-5 Transverse sinus 1. Anterior portions of superior aortic recess 2. Posterior portions of superior aortic recess 3. Inferior aortic recess 4. Left pulmonic recess 5. Right pulmonic recess 6 Oblique sinus 7. Postcaval recess 8. Left pulmonary venous recess 9. Right pulmonary venous recess From Kodama et al. AJR 2003; 181:1101

16 Pericardial Attachments 1-5 Transverse sinus 1. Anterior portions of superior aortic recess 2. Posterior portions of superior aortic recess 3. Inferior aortic recess 4. Left pulmonic recess 5. Right pulmonic recess 6 Oblique sinus 7. Postcaval recess 8. Left pulmonary venous recess 9. Right pulmonary venous recess From Kodama et al. AJR 2003; 181:1101

17 Transverse Sinus

18 Anterior view J Am Soc Echocardiogr 2013;26:

19 Right lateral & Left Lateral views of the pericardium Phrenic n. J Am Soc Echocardiogr 2013;26:

20 Coronal section epicardial fat RV LV epipericardial fat J Am Soc Echocardiogr 2013;26:

21 Epicardial Fat

22 Cardiac Tamponade Abnormal rise in intrapericardial pressure Impairment of diastolic filling

23 Cardiac Tamponade Beck s triad low arterial blood pressure distended neck veins distant, muffled heart sounds

24 Figure 1. Pericardial pressure-volume relations determined in pericardium obtained from a normal experimental animal and from an animal with chronic cardiac dilation produced by volume loading. Little W C, and Freeman G L Circulation 2006;113: Copyright American Heart Association

25 Grading of Hemodynamic Compromise Caused by Pericardial Effusion Sagristà-Sauleda. World J Cardiol 2011; 3(5):

26 Role of Echocardiography: in Cardiac Tamponade A Diagnosis of tamponade and evaluation of the size of pericardial effusion B Assessment of the distribution of pericardial effusion C Detection of intrapericardial adhesions D Diagnosis of intrapericardial clot E Assessment of the suitability for pericardiocentesis F Assist in monitoring pericardiocentesis G Diagnosis of effusive constrictive pericarditis Chandraratna, Echocardiography 2014

27 Cardiac Tamponade M mode/2d echocardiogram Diastolic collapse of the anterior RV free wall, RA collapse, LA and very rarely LV collapse increased LV diastolic wall thickness pseudohypertrophy IVC dilatation Swinging heart Doppler Exaggerated respiratory variation of LV and RV inflow

28 Cardiac Tamponade 2-D Echocardiographic diagnosis RV diastolic collapse persistent inward motion of RV free wall after mitral valve opening Most common (supine) anterior free wall and proximal infundibulum

29 RV diastolic collapse

30 RV diastolic collapse M-mode

31 Tamponade 2-D Echocardiographic RA inversion Normally rounded throughout cardiac cycle Sensitivity 90 + % Specificity 82% Predictive value 50% RA inversion lasting > 1/3 cardiac cycle Sensitivity 94 % Specificity 100 %

32 Swinging Heart

33 Cardiac Tamponade 2-D Echocardiographic diagnosis RA inversion & RV collapse False negative Pace rhythm (RA inversion) Adhesion Loculated effusion Increase chamber stiffness

34 Cardiac Tamponade Echocardiographic features suggesting cardiac tamponade Early diastolic collapse of the right ventricle Late diastolic right atrial inversion Plethora of the inferior vena cava with blunted respiratory change Suggestive but indirect Doppler echocardiography more sensitive

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36 LV inflow PW Doppler

37 Cardiac Tamponade Transmitral Doppler

38 Pericardial effusion?

39 Pericardial effusion?

40 Pericardial effusion? Subcostal View

41 LV Free Wall Rupture Hemopericardium

42 BMJ Case Rep Published online: doi: /bcr

43 Role of Echocardiography: in Cardiac Tamponade A Diagnosis of tamponade and evaluation of the size of pericardial effusion B Assessment of the distribution of pericardial effusion C Detection of intrapericardial adhesions D Diagnosis of intrapericardial clot E Assessment of the suitability for pericardiocentesis F Assist in monitoring pericardiocentesis G Diagnosis of effusive constrictive pericarditis

44 Echo-guided pericardiocentesis Jung HK. Korean Circ J November; 42(11):

45 2015ESCGuidelines for the diagnosis and management of pericardial diseases

46 2015ESCGuidelines for the Dx and management of pericardial diseases(2)

47 2015ESCGuidelines for the Dx and management of pericardial diseases(3)

48 Loculated cardiac hematoma Rev Port Cardiol 2015;34:561.e1-3

49 Loculated cardiac hematoma Rev Port Cardiol 2015;34:561.e1-3

50 Pericardial Cyst

51 Constrictive Pericarditis

52 Constrictive pericarditis Physiology Dissociation of intrathoracic and intracardiac pressures Enhanced ventricular interaction (exaggerated ventricular interdependence)

53 Constrictive pericarditis 2-D Echocardiography Increase pericardial thickness Myocardial tethering Inspiratory septal shift (septal bounce) Abnormal septal motion (septal shudder) IVC plethora (max diameter 21 mm and degree of inspiratory collapse <50%)

54 Constrictive pericarditis 2-D Echocardiography Increase pericardial thickness Myocardial tethering Inspiratory septal shift (septal bounce) Abnormal septal motion (septal shudder) IVC plethora

55 Constrictive pericarditis Pericardial Thickness

56 Constrictive pericarditis Pericardial Thickness

57 Constrictive pericarditis Pericardial Thickness

58 Constrictive pericarditis Pericardial Thickness Pericardial thickness from TTE usually NOT reliable Thickness from TEE correlates better with EBCT

59 Pericardial thickness CT scan Normal Increase pericardial thickness

60 Pericardial Thickness MRI Normal Increase pericardial thickness 60

61 Constrictive pericarditis Pericardial Thickness Pericardial thickness does NOT mean Constriction

62 Constrictive pericarditis Pericardial Thickness

63 Constrictive pericarditis 2-D Echocardiography Increase pericardial thickness Myocardial tethering Inspiratory septal shift (septal bounce) Abnormal septal motion (septal shudder) IVC plethora

64 Constrictive pericarditis Myocardial Tethering RA RA No tethering

65 Constrictive pericarditis Myocardial Tethering

66 Constrictive pericarditis 2-D Echocardiography Increase pericardial thickness Myocardial tethering Inspiratory septal shift (septal bounce) Abnormal septal motion (septal shudder) IVC plethora

67 Constrictive pericarditis Inspiratory Septal Shift LV RV

68 Constrictive pericarditis Inspiratory Septal Shift

69 Constrictive pericarditis 2-D Echocardiography Increase pericardial thickness Myocardial tethering Inspiratory septal shift (septal bounce) Abnormal septal motion (septal shudder) IVC plethora

70 Constrictive pericarditis Abnormal Septal motion (Septal Shudder)

71 Interventricular Septal Diastolic Motion (IVSDM) J Candell-Riera. Circulation 1978

72 Constrictive pericarditis 2-D Echocardiography Increase pericardial thickness Myocardial tethering Inspiratory septal shift (septal bounce) Abnormal septal motion (septal shudder) IVC plethora

73 Constrictive pericarditis IVC Plethora

74 Pericardial thickness CT scan Normal Increase pericardial thickness

75 Pericardial Thickness MRI Normal Increase pericardial thickness

76 Constrictive pericarditis 2D echo Pericardial thickness Inspiratory septal shift Abnormal septal motion IVC plethora

77 Inspiratory Septal Shift Expiration Inspiration

78 Constrictive Pericarditis Doppler echo with respirometer

79 Constrictive Pericarditis Doppler echo

80 Constrictive Pericarditis Doppler echo

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82 Mitral Doppler

83 Pulmonary vein Doppler

84 Hepatic Vein Doppler

85 Hepatic Vein Doppler Diastolic reversal ratio = reversal velocity forward velocity 0.79

86 Mitral PW Doppler

87 Pulmonary vein Doppler LV LA S D AR TTE TEE

88 Hepatic Vein Doppler Subcostal window Color-Flow Doppler AR S D

89 Superior Vena Cava Dopper Right supraclavicular window Color-Flow Doppler AR S 1 D S 2

90 Constrictive Pericarditis Doppler echocardiography Mitral = 100 * (Expiration Inpiration) / Inpiration > 25% Tricuspid = 100 * (Inspiration Expiration) / Expiration > 30%

91 Constriction and Restriction Normal 1. Mitral inflow E vel.< 10% respiratory variation DT > Hepatic vein flow Systolic forward > Diastolic forward Diastolic reversal < 20% forward flow From: Oh JK et al. The Echo Manual. Little, Brown

92 Constriction and Restriction Constrictive Physiology 1. Mitral inflow > 25% increase E vel. with expiration DT usually < Hepatic vein flow Diastolic reversal > 25% diastolic forward flow From: Oh JK et al. The Echo Manual. Little, Brown

93 Constriction and Restriction Restrictive physiology 1. Mitral inflow E/A usually > 1.5 E vel.< 10% respiratory variation DT < Hepatic vein flow Diastolic forward > Systolic forward Increase reversals with inspiration From: Oh JK et al. The Echo Manual. Little, Brown

94 Constriction vs Restriction Annulus Paradoxus E/E < 15 E/E > 15

95 Constrictive pericarditis TDI Medial Mitral annulus

96 Constrictive Pericarditis Doppler echocardiography (expiration inspiration) x 100% inspiration

97 Constrictive Pericarditis Mitral Pulmonary V

98 Doppler Mitral Inflow

99 Constrictive pericarditis Hepatic vein SVC

100 Restriction vs. Constriction SVC ins exp HV Restrictive Cardiomyopathy Constrictive pericarditis Appleton et al. JACC 1988;11:

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102 Echocardiographic Diagnosis of Constrictive Pericarditis: Mayo Clinic Criteria Welch et al. Circ Cardiovasc Imaging. 2014;7:

103 Echocardiography diagnostic criteria algorithm for constrictive pericarditis Syed, F. F. et al. Nat. Rev. Cardiol. 11, (2014);

104 Constrictive pericarditis Differential Diagnosis Respiratory variation of mitral E velocity Acute dilatation of the heart Pulmonary embolism RV infarct Pleural effusion Chronic obstructive lung disease

105 Constrictive pericarditis Differential Diagnosis Respiratory variation of mitral inflow velocities Acute dilatation of the heart Pulmonary embolism RV infarct Pleural effusion Clinical 2-D echo Chronic obstructive lung disease

106 COPD vs. Constriction Boonyaratavej S et al. JACC 1998:2043-8

107 COPD vs. Constriction Boonyaratavej S et al. JACC 1998:2043-8

108 Pericardial Diseases Etiologic Dx Clinical Dx/ conditions Echo findings Purulent Acute pericarditis Pericardial effusions Tuberculous Recurrent pericarditis Tamponade physiology Viral Cardiac tamponade Constrictive physiology Autoimmune Constrictive pericarditis Pericardial Masses (Tumors,Cysts, and Diverticulum) Post surgery Idiopathic Congenital Malignancy Effusive constrictive pericarditis Congenital Absence of the Pericardium

109 Thank You