Pericardial Diseases Smonporn Boonyaratavej, MD Division of Cardiology, Department of Medicine Chulalongkorn University Cardiac Center, King Chulalongkorn Memorial Hospital 21 AUGUST 2016
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
Echo Findings in Pericardial Diseases Pericardial effusion Tamponade physiology Constrictive physiology & Pericardial constriction
Pericardial Disease Pericardial Effusion Normal pericardial fluid = 20-30 ml Intrapericardial pressure -5 to +5 mmhg Pericardial effusion Separation of visceral and parietal pericardium with echo-free space
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
Small Pericardial Effusion
Large Pericardial Effusion Pe eff Pl eff * Pl eff Pe eff
Pericardial Effusion Pleural vs. Pericardial effusion Pleural vs. Pericardial effusion * A B * *
From Netter F. Atlas of Human Anatomy. Ciba-Geigy 1995.
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.
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
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
Transverse Sinus www.uwanesthesiology.org/echo
Anterior view J Am Soc Echocardiogr 2013;26:965-1012
Right lateral & Left Lateral views of the pericardium Phrenic n. J Am Soc Echocardiogr 2013;26:965-1012
Coronal section epicardial fat RV LV epipericardial fat J Am Soc Echocardiogr 2013;26:965-1012
Epicardial Fat http://www.massgeneral.org/imaging/news/cv-newsletter/october_2010/
Cardiac Tamponade Abnormal rise in intrapericardial pressure Impairment of diastolic filling
Cardiac Tamponade Beck s triad low arterial blood pressure distended neck veins distant, muffled heart sounds https://www.pinterest.com/pin/120963939965796206/
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;113:1622-1632 Copyright American Heart Association
Grading of Hemodynamic Compromise Caused by Pericardial Effusion Sagristà-Sauleda. World J Cardiol 2011; 3(5): 135-143
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
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
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
RV diastolic collapse
RV diastolic collapse M-mode
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 %
Swinging Heart
Cardiac Tamponade 2-D Echocardiographic diagnosis RA inversion & RV collapse False negative Pace rhythm (RA inversion) Adhesion Loculated effusion Increase chamber stiffness
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
LV inflow PW Doppler
Cardiac Tamponade Transmitral Doppler
Pericardial effusion?
Pericardial effusion?
Pericardial effusion? Subcostal View
LV Free Wall Rupture Hemopericardium
BMJ Case Rep Published online: doi:10.1136/bcr-2013-009861
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
Echo-guided pericardiocentesis Jung HK. Korean Circ J. 2012 November; 42(11): 725 734.
2015ESCGuidelines for the diagnosis and management of pericardial diseases
2015ESCGuidelines for the Dx and management of pericardial diseases(2)
2015ESCGuidelines for the Dx and management of pericardial diseases(3)
Loculated cardiac hematoma Rev Port Cardiol 2015;34:561.e1-3
Loculated cardiac hematoma Rev Port Cardiol 2015;34:561.e1-3
http://www.echocardiographer.org/ Pericardial Cyst
Constrictive Pericarditis
Constrictive pericarditis Physiology Dissociation of intrathoracic and intracardiac pressures Enhanced ventricular interaction (exaggerated ventricular interdependence)
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%)
Constrictive pericarditis 2-D Echocardiography Increase pericardial thickness Myocardial tethering Inspiratory septal shift (septal bounce) Abnormal septal motion (septal shudder) IVC plethora
Constrictive pericarditis Pericardial Thickness
Constrictive pericarditis Pericardial Thickness
Constrictive pericarditis Pericardial Thickness
Constrictive pericarditis Pericardial Thickness Pericardial thickness from TTE usually NOT reliable Thickness from TEE correlates better with EBCT
Pericardial thickness CT scan Normal Increase pericardial thickness
Pericardial Thickness MRI Normal Increase pericardial thickness 60
Constrictive pericarditis Pericardial Thickness Pericardial thickness does NOT mean Constriction
Constrictive pericarditis Pericardial Thickness
Constrictive pericarditis 2-D Echocardiography Increase pericardial thickness Myocardial tethering Inspiratory septal shift (septal bounce) Abnormal septal motion (septal shudder) IVC plethora
Constrictive pericarditis Myocardial Tethering RA RA No tethering
Constrictive pericarditis Myocardial Tethering
Constrictive pericarditis 2-D Echocardiography Increase pericardial thickness Myocardial tethering Inspiratory septal shift (septal bounce) Abnormal septal motion (septal shudder) IVC plethora
Constrictive pericarditis Inspiratory Septal Shift LV RV
Constrictive pericarditis Inspiratory Septal Shift
Constrictive pericarditis 2-D Echocardiography Increase pericardial thickness Myocardial tethering Inspiratory septal shift (septal bounce) Abnormal septal motion (septal shudder) IVC plethora
Constrictive pericarditis Abnormal Septal motion (Septal Shudder)
Interventricular Septal Diastolic Motion (IVSDM) J Candell-Riera. Circulation 1978
Constrictive pericarditis 2-D Echocardiography Increase pericardial thickness Myocardial tethering Inspiratory septal shift (septal bounce) Abnormal septal motion (septal shudder) IVC plethora
Constrictive pericarditis IVC Plethora
Pericardial thickness CT scan Normal Increase pericardial thickness
Pericardial Thickness MRI Normal Increase pericardial thickness
Constrictive pericarditis 2D echo Pericardial thickness Inspiratory septal shift Abnormal septal motion IVC plethora
Inspiratory Septal Shift Expiration Inspiration
Constrictive Pericarditis Doppler echo with respirometer
Constrictive Pericarditis Doppler echo
Constrictive Pericarditis Doppler echo
http://www.nature.com/doifinder/10.1038/nrcardio.2014.100
Mitral Doppler
Pulmonary vein Doppler
Hepatic Vein Doppler
Hepatic Vein Doppler Diastolic reversal ratio = reversal velocity forward velocity 0.79
Mitral PW Doppler
Pulmonary vein Doppler LV LA S D AR TTE TEE
Hepatic Vein Doppler Subcostal window Color-Flow Doppler AR S D
Superior Vena Cava Dopper Right supraclavicular window Color-Flow Doppler AR S 1 D S 2
Constrictive Pericarditis Doppler echocardiography Mitral = 100 * (Expiration Inpiration) / Inpiration > 25% Tricuspid = 100 * (Inspiration Expiration) / Expiration > 30%
Constriction and Restriction Normal 1. Mitral inflow E vel.< 10% respiratory variation DT > 160 2. Hepatic vein flow Systolic forward > Diastolic forward Diastolic reversal < 20% forward flow From: Oh JK et al. The Echo Manual. Little, Brown. 1994.
Constriction and Restriction Constrictive Physiology 1. Mitral inflow > 25% increase E vel. with expiration DT usually < 160 2. Hepatic vein flow Diastolic reversal > 25% diastolic forward flow From: Oh JK et al. The Echo Manual. Little, Brown. 1994.
Constriction and Restriction Restrictive physiology 1. Mitral inflow E/A usually > 1.5 E vel.< 10% respiratory variation DT < 160 2. Hepatic vein flow Diastolic forward > Systolic forward Increase reversals with inspiration From: Oh JK et al. The Echo Manual. Little, Brown. 1994.
Constriction vs Restriction Annulus Paradoxus E/E < 15 E/E > 15
Constrictive pericarditis TDI Medial Mitral annulus
Constrictive Pericarditis Doppler echocardiography (expiration inspiration) x 100% inspiration
Constrictive Pericarditis Mitral Pulmonary V
Doppler Mitral Inflow
Constrictive pericarditis Hepatic vein SVC
Restriction vs. Constriction SVC ins exp HV Restrictive Cardiomyopathy Constrictive pericarditis Appleton et al. JACC 1988;11:757-68.
Echocardiographic Diagnosis of Constrictive Pericarditis: Mayo Clinic Criteria Welch et al. Circ Cardiovasc Imaging. 2014;7:526-534
Echocardiography diagnostic criteria algorithm for constrictive pericarditis Syed, F. F. et al. Nat. Rev. Cardiol. 11, 530 544 (2014);
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
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
COPD vs. Constriction Boonyaratavej S et al. JACC 1998:2043-8
COPD vs. Constriction Boonyaratavej S et al. JACC 1998:2043-8
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
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