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S4 W2 Cardiac Tamponade > Echo in Cardiac Tamponade > Flashcards

Echo in Cardiac Tamponade Flashcards

1
Q

Evidence of decreased transmural filling pressure?

A
  • Collapse of right heart chambers (RA diastolic inversion, RV early diastolic collapse)
  • Plethora of IVC
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2
Q

RA diastolic inversion in tamponade?

A
  • Seen when IPP exceeds RAP
  • Inversion seen during late ventricular diastole or early ventricular systole when RAP at its lowest point
  • RA inversion lasting > 1/3 cardiac cycle highly sensitive and specific to tamponade
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3
Q

RV early diastolic collapse in tamponade?

A
  • RV collapse occurs when IPP exceeds RV pressure
  • Usually occurs early-mid diastole when RV pressure is at its lowest point
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4
Q

IVC plethora in tamponade?

A
  • IVC plethora reflects impaired systemic venous return to RA caused by increased RAP and/or RA compression secondary to increased IPP
  • Dilated IVC + < 50% collapse
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5
Q

Absence of RA or RV collapse or IVC plethora?

A

Virtually excludes tamponade*

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6
Q

When may RADC and/or RVDC be absent in tamponade?

A
  • Located PE (of left heart chambers)
  • Pulmonary hypertension (very high right heart pressures)
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7
Q

Other than tamponade, when else may a dilated IVC be seen?

A
  • Dilated IVC = elevated central venous pressures; also seen with:
  • RV failure
  • Elevation in RAP due to other causes
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8
Q

Evidence of exaggerated right and left heart filling with respiration?

A
  • LA and LV inflow
  • RA and RV inflow
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9
Q

Formula for calculating respiratory change?

A

% change = (first beat exp. - first beat insp.) / exp. x 100

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10
Q

Mitral significance of respiratory change (%)?

A

Mitral E > 30%

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11
Q

Tricuspid significance of respiratory change (%)?

A

Tricuspid > 60%

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12
Q

Normal mitral inflow?

A

Barely any noticeable change in mitral E velocity
(ITP falls with inspiration = fall in pulmonary venous pressure = fall in IPP = filling gradient only changes slightly)

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13
Q

Mitral inflow with tamponade?

A
  • Smaller E velocity with inspiration, larger E velocity with expiration
  • Prolonged IVRT
    (IPP elevated = diastolic filling gradient between pulmonary veins and left heart falls during inspiration = smaller E velocity)
    (Reduced diastolic filling gradient with inspiration = MV opens later prolonging IVRT)
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14
Q

Normal tricuspid inflow?

A

Slight increase in tricuspid inflow velocities with inspiration
(Inspiration = reduced IPP = augmentation of systemic venous return and filling to the right heart)

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15
Q

Tricuspid inflow with tamponade?

A
  • Higher E velocity with inspiration compared to expiration
    (Inspiration = increased early diastolic filling = increased venous return and reduced LV filling = IVS shift to left = increased inflow with inspiration)
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15
Q

Mitral/Tricuspid/Hepatic Venous/Pulmonary Venous flow with inspiration in tamponade?

A
  • Mitral E velocity reduced with inspiration
  • Tricuspid E increased
  • Hepatic D velocity increased
  • Pulmonary D velocity reduced
16
Q

Mitral/Tricuspid/Hepatic Venous/Pulmonary Venous flow with expiration in tamponade?

A
  • Mitral E increased
  • Tricuspid E decreased
  • Hepatic D velocity decreased, plus increase in flow reversal (AR velocity)
  • Pulmonary D velocity increased
17
Q

IVRT with tamponade?

A

Increased IVRT > 20% on 1st beat of inspiration compared with 1st beat of expiration

18
Q

SVC flow in tamponade?

A
  • Lack of normal increase in SVC flow with inspiration
  • Loss of expiratory D velocity (i.e. no D wave)
19
Q

Summary of LV filling on 1st beat of inspiration?

A

Reduced LV filling:
- Reduced mitral E velocity (< 30%
- Reduced pulmonary D velocity
- Increased IVRT (> 20%)

20
Q

Summary of LV filling on 1st beat of expiration?

A

Increased LV filling:
- Increased mitral E velocity
- Increased pulmonary D velocity
- Reduced IVRT

21
Q

Summary of RV filing on 1st beat of inspiration?

A

Increased RV filling:
- Increased tricuspid E velocity (> 60%)
- Normal increase in hepatic D velocity
- Normal increase, or reduced S & D +/- lack of inspiratory increase in SVC D velocity

22
Q

Summary of RV filling on 1st beat of expiration?

A

Reduced RV filling:
- Reduced tricuspid E velocity
- Reduced, absent or reversed D hepatic D velocity with increase in AR
- Reduced SVC D velocity (absent in severe tamponade), increased AR

23
Q

Evidence of enhanced ventricular interdependence?

A
  • IVS bounce: change in LV/RV size
  • Reduced stroke volume
24
Q

Enhanced ventricular interdependence with inspiration?

A
  • IVS shifts to the left
  • RV cavity increases in size, LV cavity decrases
25
Q

Enhanced ventricular interdependence with expiration?

A
  • IVS shifts to the right
  • LV cavity size increases, RV cavity decreases
26
Q

Stroke volume with inspiration in tamponade?

A

Leftwards shift of IVS = decreased LV volume = reduced LV SV during inspiration

27
Q

How is reduced stroke volume in tamponade identified?

A

Reduced transmitral inflow velocities

28
Q

Formula to calculate stroke volume?

A

SV = CSA x VTI
CSA = 0.785 x d2

29
Q

Normal range for stroke volume?

A

70 - 100mL

30
Q

Challenges in cardiac tamponade?

A
  • Pulmonary hypertension
  • Chronic obstructive airways disease (COAD)
  • Ventilated patients
  • Low pressure cardiac tamponade
  • Pleural effusion causing tamponade (pleural effusions can cause tamponade physiology)
31
Q

Effect of COAD?

A
  • Exaggerated increase in respiratory variation (mitral/tricuspid inflow) due to exaggerated ITP changes
  • Hard to tell if respiratory changes are COAD or tamponade
32
Q

How to distinguish COAD from tamponade?

A
  • Use SVC profile
33
Q

SVC profile in tamponade vs COAD?

A
  • COAD: SVC shows marked increased of forward flow velocities with inspiration
  • Tamponade: Loss of normal inspiratory increase in SVC flow, especially of diastolic forward flow velocities
34
Q

Tamponade in ventilated patients?

A
  • Respiratory changes opposite…
  • MV increase E with inspiration
  • TV decrease E with inspiration
  • ITP increases during inspiration (increases rather than decreases as ventilator pushing air into lungs)
35
Q

Identifying tamponade when low-pressure cardiac tamponade?

A
  • Tamponade in setting of low ICP and low IPP
  • Typical clinical findings are absent
  • Echo findings are the same

S4 W2 Cardiac Tamponade (2 decks)

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