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Echo > Pericardial disease > Flashcards

Pericardial disease Flashcards

1
Q

Pericardium consists of:

A
  • 2 serous surfaces
  • One potential space
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2
Q

What are the two serous surfaces of the pericardium?

A
  • Visceral pericardium
  • Parietal pericardium
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3
Q

How much fluid does the pericardial space normally contain?

A

< 50 mL

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4
Q

What are the roles of the pericardium?

A
  • Maintaining heart w/in place in thorax
  • Lubricates heart to avoid friction w/surrounding organs
  • Protects heart from spreading infection
  • Prevents acute dilation of chambers
  • May also prevent hypertrophy under conditions of strenuous exercise
  • Ventricular interdependence
  • Responsible for drop in intrapericardial pressure during ventricular systole
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5
Q

Pericarditis

A

Symptomatic inflammation of the pericardium

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6
Q

Pericarditis can be acute, chronic, or

A

recurrent pericarditis

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7
Q

What is the most common manifestation of pericardial disease

A

acute pericarditis

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8
Q

Myopericarditis

A

Implies associated inflammation, often with coinciding tissue necrosis of the myocardium

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9
Q

Causes of pericarditis

A
  • Infectious
  • Autoimmune
  • Reactive
  • Metabolic
  • Traumatic
  • Neoplastic
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10
Q

What are most cases of pericarditis in Western Europe and North America pressumed to be

A

Viral etiology (aka idiopathic)

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11
Q

Pericardial irritation can also be due to:

A
  • Cardiothoracic surgery
  • Percutaenous device implantation
  • Endocardial and epicardial catheter based ablation procedures
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12
Q

To be clinically diagnosed with acute pericarditis you need to have two of the four symptoms:

A
  • Pericarditic chest pain
  • Pericardial friction rub
  • ECG features
  • New or worsening PE
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13
Q

Pericarditis can be confused w/more fatal etiologies:

A
  • Acute coronary syndrome
  • Pulmonary thromboembolic events
  • Aortic dissection
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14
Q

Pericardial rub

A

A rubbing sound due to the friction of visceral and parietal pericardial layers

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15
Q

Pericardial thickening

A

Increased echogenicity and thickness of pericardial reflector (thicker than 5mm)

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16
Q

Symptoms of pericarditis

A
  • Chest pain is the most common
  • May be sudden or gradual
  • Sharp and similar to pleurisy
  • Radiates to the trapezius ridge
  • Aggravated by lying down
  • Fells better when sitting and leaning forward
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17
Q

Treatment for pericarditis

A
  • Nonsteroidal anti-inflammatory drugs (NSAIDs)
  • NSAIDs and colchicine together
  • Aspirin
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18
Q

Pericardial effusions are usually:

A
  • Diffuse
  • Symmetric
  • Clear space between parietal and visceral pericardium
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19
Q

M-mode w/small effusions:

A
  • Flat posterior pericardial echo reflection
  • Moving epicardial echo
  • Seperation between the above echoes in systole and diastole
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20
Q

Fibrous strands

A

Strands w/in the fluid on the epicardial surface of the heart
- Common in pts w/recurrent or long-standing pericardial disease

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21
Q

Causes of pericardial disease

A
  • Infections
  • Malignant
  • Inflammatory
  • Intracardiac - pericardial communications
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22
Q

Metastatic disease can help differentiate from fibrin strands by looking for:

A
  • Nodular appearance
  • Evidence of extensions into myocardium
  • Other clinical signs
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23
Q

Pericardial seperation: Echolucent space < 10mm seen only in systole =

A

Trivial PE

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24
Q

Pericardial seperation: Echolucent space < 10mm seen in systole and diastole =

A

Small PE

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25
Q

Pericardial seperation: Echolucent space 10-20mm =

A

Moderate PE

26
Q

Pericardial seperation: Echolucent space > 20mm =

A

Large PE

27
Q

Loculated effusion is more common in patients with

A

recurrent pericardial disease or post op

28
Q

Loculated effusion is localized by

A

adhesions to one or several small areas in the pericardial space

Hemodynamic compromise can happen w/small fluid pocket if it is in a sensitive spot

29
Q

Difference between PE and pleural effusion

A
  • PE anterior to desc Ao - pleural posterior to it
  • PE gradually tapers at atrioventricular groove - pleural normally behind LA & LV
  • PE doesnt change w/respirations - pleural effusion may change
30
Q

Tamponade:

A

Abnormal accumulation of fluid and/or blood in the pericardial space

31
Q

Tamponade increases the pressure in the ____ and compresses the cardiac chambers

A

pericardium

32
Q

Development and severity of tamponade depends on:

A
  • Volume and rate of fluid accumulation (ranging from slow to very fast)
  • Pericardial compliance/elasticity
33
Q

Acute tamponade is

A
  • Rapid accumulation of as little as 150mL of fluid
  • Abrupt bleeding into stiff pericardial space
  • Results in rapidly rising intrapericardial pressure, chamber compression, and hypotension leading to cardiogenic shock
34
Q

Causes of acute tamponade:

A
  • Penetrating chest wound
  • Iatrogenic chamber perforation
  • LV free wall rupture
  • Proximal aortic dissection rupture
35
Q

Subacute tamponade is

A
  • PE develops gradually
  • Pericardium stretches and can allow for large amounts of fluid (>1000mL) w/o increase in intrapericardial pressure
  • Eventually filling will be compromised and tamponade will result
36
Q

Causes of subacute tamponade:

A

Seen mostly with:
- Neoplasms
- Uremia
- Idiopathic situations

37
Q

Compression w/tamponade is seen more when chamber pressures are at their ____
____ for atria
____ for ventricles

A

Lowest
- Systole
- Diastole

38
Q

W/tamponade filling pressures increase to maintain ___

A

CO
- Eventually all 4 chambers are equally elevated from pericardial pressure on the entire heart

39
Q

Tamponade clinical symptoms

A
  • Low CO symptoms
  • Hypotension
  • Tachycardia
  • Elevated JVP
  • Pulsus paradoxus on exam (inspiratory decline >10mmHg in systemic BP)
40
Q

What are the three medical signs (Beck’s triad) associated with acute cardiac tamponade:

A
  • Low arterial BP
  • Distended neck veins
  • Distant muffled heart sounds
41
Q

Echo approach to tamponade

A
  • Intrapericardial pressure exceeds RA pressure
  • Ra free wall inversion or collapse occurs
  • Longer RA inversion relative to cycle length, the greater teh chance of tamponade
  • Inversoin > 1/3 systole is 94% sensitive and 100% specific for tamponade
  • RV collapse when intracardial pressure exceeds RV diastolic pressure
  • RV free wall collapse is not as sensitive or specific as RA collapse
42
Q

Respiratory variation w/tamponade

A
  • Inspirations increases RV volume
  • Septum shifts toward LV in diastole and RV during systole
  • During expiration septal flow normalizes
  • This motion is responsible for physical finding of pulsus paradoxus
43
Q

Pulsus Paradoxus

A

The exaggerated drop in systemic blood pressure during inspiration

44
Q

Reciprocal respiratory variation resaon for changes:

A
  • Total pericardial volume (chambers + pericardial fluid) is fixed in tamponade
  • As intrathoracic pressure is more negative w/inspiration, increaseed RV filling limits LV filling
  • The opposite occurs during expiration
  • > ## 25% variation is considered marked
45
Q

Diastolic fillining - Inspiration:

A
  • Augmented RV filling
  • LV filling diminishes
  • PA flow velocity integral increases
  • Aortic flow velocity integral decreases
46
Q

Dilated IVC (≥2.1cm) with <50% inspiratory reduction in diameter reflects

A

elevated intrapericardial pressure transmitted to the Rt heart

47
Q

Surgical treatments for tamponade:

A
  • Pericardiocentesis
  • Pericardial window
  • Total/limited pericardectomy
48
Q

Constrictive pericarditis

A

Visceral and parietal pericardium are adherent, thickened, and fibrotic, resulting in impairment of diastolic ventricular filling

49
Q

constrictive pericarditis can occur after:

A
  • Repeated episodes of pericarditis
  • Cardiac surgery
  • Radiation therapy
  • Variety of other causes
50
Q

Symptoms of constrictive pericarditis are nonspecific:

A
  • Fatigue and malaise from low CO
  • Subtle increase in jugular venous pressure
  • Distant heart sounds
  • Ascites and peripheral edema in late disease course
51
Q

Constrictive pericarditis is characterized by:

A
  • Impaired diastolic filling
  • Rapid early diastoli filling
  • Abrupt cessation of ventricular fillin
52
Q

Echo appearance of constrictive pericarditis:

A
  • Normal values (LV wall thickness, chamber size, systolic function)
  • LAE
  • Pericardial thickening
53
Q

Constrictive pericarditis Doppler:
-Hepatic flow
-Pulmonary vein flow
-RV and LV diastolic filling
-Short DT
-Small A wave

A

Hepatic flow:
- prominent A wave
- deep Y descent
P vein flow:
- prominent A wave
- prominent Y descent
- blunting of systolic phase atrial filling
RV and LV diastolic filling:
- high E velocity
Shot DT:
- abrupt filling cessation
Small A wave:
- little late diastolic filling

54
Q

Constrictive pericarditis respiratory variation: Inspiration

A
  • Augmented RV filling
  • Lv filling velocities decrease w/inspiration and increase w/expiration (look for > 25% respiratory variation using 25 mm/s sweep speed)
  • IVRT increases by approximately 20% w/inspiration
55
Q

Differential diagnosis for constrictive pericarditis:

A
  • Difference between tamponade and pericardial constriction is presence of PE
  • It is more difficult to differentiate bettween restrictive cardiomyopathy and constrictive pericarditis
56
Q

Constrictive pericarditis M-mode

A
  • Multiple dense echoes (posterior to LV epicardium, moves parallel w/eachother, are visible even at low gain settings)
  • Abrupt posterior motion of IVS in early diastole
  • Flat IVS motion in mid diastole
  • Abrupt anterior motion of IVS after atrial contraction
  • LV posterior wall endocardium shows little posterior motion during diastole (< 2 mm)
  • IVC and hepatic veins are dilated
57
Q

Pts w/restrictive cardiomyopathy usually have moderate to severe ____
Pts w/constrictive pericarditis usually have only mild elevation in ____ pressures

A
  • Pulmonary HTN
  • Pulmonary
58
Q

What is the treatment for constrictive pericarditis?

A

Pericardectomy

59
Q

What is the most uncommon of the pericadialconstraint syndromes?

A

Effusive constrictive pericarditis

60
Q

McConnell’s sign is a

A

distinct echo feature of acute massive pulmonary embolism

61
Q

What are the three distinct features of McConnell’s sign?

A
  • A regional pattern of Rt ventricular dysfunction
  • Akinesia of the mid free wall
  • Normokinesia or hyperkinesia of the apical segment
62
Q

60/60 sign of pulmonary embolism

A
  • RV ejection Acceleration Time < 60 msec
  • TR jet < 60 mmHg
  • Mid systolic notching can also be an indication

Echo (3 decks)

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