Pericardial disease Flashcards
(139 cards)
1
Q
Pericardial disease, effusions, and masses: The reported caused of pericardial effusion (PE) in animals include
A
- Pericardioperitoneal hernias,
- congestive heart failure,
- LA rupture,
- infection,
- neoplasia,
- trauma,
- benign idiopathic causes.
The pericardial effusion may lead to tamponade.
2
Q
…….. is the most common cause of pericardial effusion in the cat and is often accompanied by pleural effusion and ascites.
A
FIP is the most common cause of pericardial effusion in the cat and is often accompanied by pleural effusion and ascites.
3
Q
HCM is the most frequent frequent form of heart disease leading to pericardial effusion in cats. Other less-encountered forms of heart disease resulting in PE in the cat include?
A
Dilated and restrictive cardiomyopathies and mitral valve abnormalities.
4
Q
……………………are the most common causes of pericardial effusion in the dog, with ……………………. heading the list.
A
-Intrapericardial neoplasia, -idiopathic hemorragic pericarditis, and
-LA rupture secondary to chronic MR
are the most common causes of pericardial effusion in the dog, with intracardiac and pericardial tumors heading the list.
5
Q
Which tumors lead the list for highest incidence for PE?
A
Hemangiosarcoma
Chemodectoma
Mesothelioma
6
Q
PE: There is a high incidence of pericardial effusion in large breed dogs with the highest incidence seen in?
A
Golden retrievers, German shepherd dogs, Saint Bernards, Labrador retrievers, and Newfoundlands.
7
Q
Most dogs that present with pericardial effusions with echo evidence of a mass are older (median 9-11 years) than dogs that present without echo evidence of a mass (median 7-9 years) The exception is the … breed
A
Saint Bernard, which presented at a much younger median age of 2,3 years.
8
Q
Congestive heart failure may also cause pericardial effusion in both dogs and cats, although the incidence is less common and the amount of effusion is typically small. Occasionally atrial rupture causes pericardial effusion in dogs.
A
Congestive heart failure may also cause pericardial effusion in both dogs and cats, although the incidence is less common and the amount of effusion is typically small. Occasionally atrial rupture causes pericardial effusion in dogs.
9
Q
Pericardial effusion in the cat is relatively rare. When present, however, several studies have shown that congestive heart failure secondary to ……………………. are the most common underlying causes of pericardial effusion in cats.
A
hypertrophic, restrictive, and unclassified cardiomyopathy are the most common underlying causes of pericardial effusion in cats.
10
Q
FIP, neoplasia, pericardial peritoneal diaphragmatic hernia, systemic infections, and uremia, are other reported causes of pericardial effusion in cats.
Of these, neoplasia, primarily …………and……………, and FIP are reported as the next most common causes of effusion in the cat.
A
Of these, neoplasia, primarily lymphoma, and adenocarcinoma, and FIP are reported as the next most common causes of effusion in the cat.
11
Q
Echo features of pericardial effusion?
A
Presence of an echo free or hypo echoic space between the epicardium and the pericardial sac, swinging motion of the heart when the amount of effusion is significant, and if tamponade is present; diastolic collapse of the right atrium or ventricle
12
Q
What helps differentiate pleural from pericardial effusions?
A
Pericardial effusion is typically not seen behind the left and right atrium on echo images because the parietal and visceral pericardiums are more adherent to each other at the base of the heart. This helps differentiate pleural from pericardial effusions
Fig 8.1, 8.2, 8.3, 8.4, 8.5
13
Q
The boundaries of pericardial effusion are typically ……… and conform to the shape of the heart while pleural effusion is seen as more ………….. with ill-defined boundaries.
A
The boundaries of pericardial effusion are typically smooth and conform to the shape of the heart while pleural effusion is seen as more irregular with ill-defined boundaries.
14
Q
In man, an echo-free space of less than ……… mm is considered to be a mild effusion, a space between ……….. mm is moderate in amount, and an anechoic space of greater than ….. mm is classified as a severe amount of fluid accumulation.
A
In man, an echo-free space of less than 5 mm is considered to be a mild effusion, a space between 5 and 10 mm is moderate in amount, and an anechoic space of greater than 10 mm is classified as a severe amount of fluid accumulation.
15
Q
Pericardial effusion is typically not seen at the heart base below the atria while pleural fluid is present.
A
Pericardial effusion is typically not seen at the heart base below the atria while pleural fluid is present.
16
Q
M-mode images show an echo-free space between the LV wall and the pericardial sac. The epicardium on these images will be very bright simply because of?
A
The epicardium on these images will be very bright simply because of the difference in acoustical impedance between the epicardium and fluid.
Fig 8.6
17
Q
When the fluid space is not seen during …………… of the LV chamber, the fluid accumulation is not clinically significant.
A
When the fluid space is not seen during systolic contraction of the LV chamber, the fluid accumulation is not clinically significant.
18
Q
Large amounts of thoracic or mediastinal fat have sometimes been misdiagnosed as pericardial effusion and care should be taken to set the ………… correctly and to image multiple cardiac planes.
A
Large amounts of thoracic or mediastinal fat have sometimes been misdiagnosed as pericardial effusion and care should be taken to set the gain correctly and to image multiple cardiac planes.
19
Q
The diagnosis of pericardial fat is typically made when an anechoic space is seen in the near field of the sector image, and although it may be present in the far field, it usually is not. Therefore, an echo-free space in both the near field and far field usually supports the diagnosis of?
A
True pericardial effusion.
However, this is not foolproof as pericardial fat can occasionally be seen in both areas.
20
Q
Fat when present typically moves with the heart during contraction, and is somewhat ……………; features that can help differentiate fat from pericardial effusion.
A
Fat when present typically moves with the heart during contraction, and is somewhat echogenic, features that can help differentiate fat from pericardial effusion.
21
Q
Cardiac tamponade:
Pericardial fluid accumulation that causes intrapericardial pressure results in:?
A
Diastolic collapse of the right ventricle and atrium,
Decreased cardiac output, and Signs of forward failure.
22
Q
The amount of pericardial fluid does not determine if tamponade is present or not. Intrapericardial pressure is determined by?
A
- Pericardial compliance
- The rate of fluid accumulation
- The amount of fluid accumulation.
23
Q
The compliance of the pericardial sac decreases with?
A
- age,
- with chronic pericardial inflammation,
- with pericardial neoplasia
So smaller amounts of fluid are needed to generate large amount of pressure on the cardiac chambers.
24
Q
Additionally, a chronic slow developing effusion is less likely to develop…..
A
tamponade
25
Dogs that present with the clinical sign of collapse typically have tamponade and have a high incidence of being positive for the presence of cardiac neoplasia.
The collapse is thought to occur because of a ....?
The collapse is thought to occur because of a rapid accumulation of fluid secondary to the neoplastic lesion.
26
Dogs that are diagnosed with idiopathic effusions tend to accumulate larger volumes of effusion before tamponade develops. Why?
Presumably because of the slow and chronic nature of fluid accumulation, which allows the pericardial sac to expand slowly, delaying the development of high pressure within the pericardial space.
27
Signs of right heart failure including jugular dissension and ascites instead of collapse typically suggest ............?
Signs of right heart failure including jugular dissension and ascites instead of collapse typically suggest slow fluid accumulation.
28
The size of the effusion does not determine if tamponade is present. ............ collapse of the right atrium and/or ventricle confirms the presence of tamponade.
The size of the effusion does not determine if tamponade is present. Diastolic collapse of the right atrium and/or ventricle confirms the presence of tamponade.
29
The ....................... collapse of the right ventricle secondary to tamponade is displayed on M-mode images as downward motion of the right ventricular wall during diastole.
The diastolic collapse of the right ventricle secondary to tamponade is displayed on M-mode images as downward motion of the right ventricular wall during diastole. This is a sensitive and specific finding.
30
When right ventricular hypertrophy is present, increased loading conditions .............. ............. of the right ventricular chamber even in the presence of high intrapericardial pressure.
When right ventricular hypertrophy is present, increased loading conditions prevent collapse of the right ventricular chamber even in the presence of high intrapericardial pressure.
31
Abnormal diastolic downward motion of the RA wall is 100% sensitive for?
The presence of tamponade but is less specific.
32
LA collapse though not common is a very specific finding for tamponade in man after cardiac surgery.
LA collapse though not common is a very specific finding for tamponade in man after cardiac surgery.
33
2D imaging is superior to M-mode in identifying both pericardial effusion and the presence of tamponade. Real-time images will show the collapse of the right side of the heart.
2D imaging is superior to M-mode in identifying both pericardial effusion and the presence of tamponade. Real-time images will show the collapse of the right side of the heart.
34
Right parasternal long-axis images may be used to view the collapse since the heart is displaced from the thoracic wall and ..............-sided structures are easier to visualize, but multiple planes should be interrogated for diagnostic accuracy and for identification of an underlying cause.
Right parasternal long-axis images may be used to view the collapse since the heart is displaced from the thoracic wall and right-sided structures are easier to visualize, but multiple planes should be interrogated for diagnostic accuracy and for identification of an underlying cause. Figures 8.7, 8.8
35
Tapping the pericardial fluid results in visible increased chamber sizes. Rarely a sudden increase in venous return and volume overload of the heart resulting in acute pulmonary edema has been associated with pericardiocentesis in several animals and man.
Rarely a sudden increase in venous return and volume overload of the heart resulting in acute pulmonary edema has been associated with pericardiocentesis in several animals and man.
36
There are reports of clinical signs related to cardiac tamponade without echo evidence of diastolic collapse of the right-sided chambers. This is seen when there is increased right-sided pressure secondary to other cardiac disease such as .....?
pulmonary hypertension, Tetralogy of Fallot, intracardiac tumors and pulmonic stenosis.
37
Cardiac tamponade has been reported in man secondary to large pleural effusion without the presence of pericardial effusion.
Evidence of ............... is visible in these patients.
Evidence of diastolic collapse on the right side of the heart is visible in these patients.
38
Experimental models in man of pleural effusion have shown that pleural effusion can cause echo signs of cardiac tamponade, with both right atrial and right ventricle diastolic collapse. Signs of tamponade have been reported in a dog with pleural effusion and no echo evidence of pericardial effusion or cardiac pathology
Experimental models in man of pleural effusion have shown that pleural effusion can cause echo signs of cardiac tamponade, with both right atrial and right ventricle diastolic collapse. Signs of tamponade have been reported in a dog with pleural effusion and no echo evidence of pericardial effusion or cardiac pathology
39
Flow alterations with tamponade can be documented with spectral Doppler. .............. and ................... inflow velocities increase with ..................... in the presence of tamponade.
Flow alterations with tamponade can be documented with spectral Doppler. Pulmonary artery and right ventricular inflow velocities increase with inspiration in the presence of tamponade.
40
Pulmonary artery and right ventricular inflow velocities increase with inspiration in the presence of tamponade. Flow velocities in the left side of the heart at the aorta and mitral valve ............. accordingly with inspiration.
Flow velocities in the left side of the heart at the aorta and mitral valve decrease accordingly with inspiration.
41
Cardiac tamponade: Vena caval flow into the right atrial chamber will show increased systolic .................. with inspiration and increased diastolic .................. of flow with expiration.
Vena caval flow into the right atrial chamber will show increased systolic velocities with inspiration and increased diastolic reversal of flow with expiration.
42
Cardiac function with pericardial effusion: Pericardial fluid with or without tamponade reduced the amount of filling and output from the right side of the heart. This will ............. left-sided volume and output. Function is reduced when a significant volume of pericardial fluid is present, and the diagnosis of myocardial failure should wait until after resolution of the effusion.
This will reduce left-sided volume and output. Function is reduced when a significant volume of pericardial fluid is present, and the diagnosis of myocardial failure should wait until after resolution of the effusion.
43
Often adequate assessment of function is not possible simply because the heart motion is too erratic as it swings within the pericardial sac. These changes all disappear after pericardiocentesis. What else can impair cardiac function in these patients?
Presence of cardiac tumors: if they are infiltrative in nature or produce arrhythmias.
44
Neoplasia as a cause of pericardial effusion:
| Cardiac neoplasia has a reported incidence of.... of all canine cases presented to institutions.
0.19-3.1%
45
Hemangiosarcoma is reported with the highest frequency:....%
40-69%
46
.....are reported in 5-17%
Chemodectomas
47
..............., ................, and various less common neoplasias make up the rest of the cardiac tumors seen in dogs.
Thyroid carcinomas, lymphosarcomas, and various less common neoplasias make up the rest of the cardiac tumors seen in dogs.
48
Cardiac neoplasia is not common in cats, but of the reported cases, .................is the most common intrapericardial neoplasia
lymphosarcoma (up to 30%)
Other carcinomas, hemangiosarcomas, chemodectomas, and fibrosarcomas representing a low percentage.
49
Echocardiography cannot acutely identify the actual histological tyoe of neoplasia, but the location and the appearance of the mass tends to be highly suggestive of particular types of tumors.
Echocardiography cannot acutely identify the actual histological tyoe of neoplasia, but the location and the appearance of the mass tends to be highly suggestive of particular types of tumors.
50
The search for cardiac masses is easier when pericardial effusion is present. Masses may be found where?
within the cardiac chambers, within the myocardium, or associated with the pericardial sac.
51
The following intracardiac tumors have been reported:
```
Chondrosarcoma
Fibroma
Fibrosarcoma
Hemangiosarcoma
Hamartoma
Mesenchymal tumor
Myxoma
Osteosarcoma
Rhabdomyoma
Rhabdomyosarcoma
Ectopic thyroid tumor
Spindle cell sarcoma
Undifferentiated sarcoma
```
52
The right side of the heart is the most common location for masses in the dog while LV and LA masses are much less common.
The right side of the heart is the most common location for masses in the dog while LV and LA masses are much less common.
53
Occasionally tumors may also be associated with the right and LV outflow tracts. Diligently search in very possible cardiac plane for a potential mass.
Occasionally tumors may also be associated with the right and LV outflow tracts. Diligently search in very possible cardiac plane for a potential mass.
54
Heart tumors: Animals should be scanned lying down as well as in a standing position.
Animals should be scanned lying down as well as in a standing position (if not seen lying down).
masses have been found simply by repositioning the animal into a standing position when no evidence of a mass was seen in lateral recumbency. Even then, the absence of a mass does not rule out its presence especially when there is no pericardial effusion to highlight the auricular chambers and other structures at the base of the heart.
55
Detection of masses with echo has a sensitivity between...........%
between 16.7 and 80%.
This variation may be dependent upon the presence of pericardial effusion and/or the skill of the echocardiography. Discrete masses like hemangiosarcoma and chemodectoma are much easier to identify with echo than more diffuse neoplasia such as mesothelioma and lymphosarcoma.
56
Serial echo exams are sometimes necessary with recurrent pericardial effusion before some masses are large enough to be visualized. It is important to point out that the echo appearance of intracardiac tumors and intracardiac ........ are very similar, and they cannot be differentiated using this imaging modality.
It is important to point out that the echo appearance of intracardiac tumors and intracardaic thrombi are very similar, and they cannot be differentiated using this imaging modality.
57
Unless the heart is scanned from both sides of the thorax when the animal is lying down and standing up, masses will be missed.
Unless the heart is scanned from both sides of the thorax when the animal is lying down and standing up, masses will be missed.
58
There are many reports of aortic body tumors in dogs, but reports are rare in cats. These tumors develop from ?
These tumors develop from the chemoreceptor cells located at the heart base, around the aorta, and carotid bifurcation and are chemodectomas or nonchromaffin paragangliomas.
59
At times chemodectomas are an incidental finding since dogs are symptomatic only when there is significant pericardial effusion, invasion into adjacent structures, or compression of adjacent structures.
At times chemodectomas are an incidental finding since dogs are symptomatic only when there is significant pericardial effusion, invasion into adjacent structures, or compression of adjacent structures.
60
chemodectomas: When pericardial effusion is present, it may be small or quite large i volume. These tumors are typically seen at the level of the aorta or pulmonary artery on long-axis or transverse views.
When pericardial effusion is present, it may be small or quite large i volume. These tumors are typically seen at the level of the aorta or pulmonary artery on long-axis or transverse views.
61
chemodectomas: On transverse views, the mass is seen around the ............ or ............. artery and between the ..........artery and right ............ or along the aortic arch.
On transverse views, the mass is seen around the aorta or pulmonary artery and between the pulmonary artery and right atrium, or along the aortic arch.
62
chemodectomas: It may be seen between the right auricular appendage and ascending aorta making it difficult to differentiate from a .....................
It may be seen between the right auricular appendage and ascending aorta making it difficult to differentiate from a right auricular mass.
63
The presence of a large tumor along the aortic arch will allow visualization of the arch and possibly the .................... trunk as the mass wraps around these structures.
The presence of a large tumor along the aortic arch will allow visualization of the arch and possibly the brachycephalic trunk as the mass wraps around these structures.
64
Do chemoreceptors metastasize?
Chemoreceptors rarely metastasize and are only locally invasive. Often it appears to invade the atria or the great vessels, but it may simply be in the filed of view or compressing the atria.
Fig 8.9
65
Deciding whether a mass is within the cardiac chambers or compressing the chambers is sometimes not possible. Heart base tumors on long-axis views are seen at the ........... of the heart around the ............. pushing into either atrium
Deciding whether a mass is within the cardiac chambers or compressing the chambers is sometimes not possible. Heart base tumors on long-axis views are seen at the base of the heart around the aorta pushing into either atrium
66
Heart base tumors are generally homogeneous in appearance with no hypo echoic areas within them, but there are exceptions. Small masses are usually oval or circular in shape, well .........., and localized. Large heart bass masses have ............boundaries and may diffusely invade the adjacent atria and ventricles.
Small masses are usually oval or circular in shape, well defined, and localized. Large heart bass masses have irregular boundaries and may diffusely invade the adjacent atria and ventricles. Fig 8.10, 8.11.
67
Some heart base tumors may be impossible to detect since they manifest themselves as thin small masses spread out over the surface of the ...............
Some heart base tumors may be impossible to detect since they manifest themselves as thin small masses spread out over the surface of the aorta.
The entire mass is rarely seen since the mass beyond the immediate cardiac boundaries is usually obscured by lung.
68
Heart base tumors: The location of masses large enough to see are usually well defined however, and their accessibility for surgical removal can usually be determined.
The location of masses large enough to see are usually well defined however, and their accessibility for surgical removal can usually be determined.
69
Do not confuse collapsed lung with a mass at the heart base or mediastinum. How to differentiated from heart base tumor?
The lung will maintain a wedge shape, float within the pleural fluid, and may contain small hyper echoic areas.
Fig 8.12, 8.13
70
Other heart base masses:
| RV tumor associated with the pulmonic valve and pulmonary artery has been reported. These have been identified as?
Myxomas, thyroid carcinomas, neurofibromas, chondrosarcomas, and fibrosarcomas. Fig 8.14
71
Other heart base masses: When associated with the pulmonary valve and RV outflow tract, they have created RV outflow obstruction to varying degrees. Right heart failure as well as decreased preload to the LV may develop if occlusion is severe.
When associated with the pulmonary valve and RV outflow tract, they have created RV outflow obstruction to varying degrees. Right heart failure as well as decreased preload to the LV may develop if occlusion is severe.
72
Hemangiosarcoma arise from vascular ................ and can be found anywhere in the body, but the heart is a frequent site where it is typically associated with the right atrium or auricle.
Hemangiosarcoma arise from vascular endothelium and can be found anywhere in the body, but the heart is a frequent site where it is typically associated with the right atrium or auricle.
73
Hemangiosarcoma is commonly found within the right atrial wall or as an auricular mass extending into the pericardial space or into the auricular lumen.
Fig 8.15-8.21
Hemangiosarcoma may also involve the right ventricular wall, invade the pericardial sac, or rarely the LV chamber.
Fig 8.22-8.23
74
Hemangiosarcomas usually have smooth, well-defined boundaries; rarely are they irregular masses. They are typically heterogenous congaing many hypoechoic areas
Fig 8.24
75
.............. transducers are necessary to resolve diffuse hemangiosarcoma involving just the wall of the ventricle or atrium.
High-resolution transducers are necessary to resolve diffuse hemangiosarcoma involving just the wall of the ventricle or atrium.
76
Although hemangiosarcoma may be found in many different planes, and each view should be interrogated, the ................. view of the right auricular appendage is probably the most useful one for identifying cardiac hemangiosarcoma.
Although hemangiosarcoma may be found in many different planes, and each view should be interrogated, the left cranial long-axis view of the right auricular appendage is probably the most useful one for identifying cardiac hemangiosarcoma.
77
Echo detection of hemangiosarcoma in the dog has a reported sensitivity of 48-69%. This includes repeat examinations in several dogs when no mass was found on initial exams.
Echo detection of hemangiosarcoma in the dog has a reported sensitivity of 48-69%. This includes repeat examinations in several dogs when no mass was found on initial exams.
78
Is effusion necessary for the diagnosis of hemangiosaromca?
No, but effusion does help highlight the areas of interest especially the right auricle, which are the most difficult to visualize. Small tumors may only be identified ehn effusion is present and the right auricle floats within the pericardial fluid on left cranial long-axis views of the right atrium and auricle.
79
Hemangiosarcomas are best seen on left parasternal cranial long-axis views of the right atrium and auricle.
Hemangiosarcomas are best seen on left parasternal cranial long-axis views of the right atrium and auricle.
80
Lymphosarcoma: An infiltrative type of cardiac neoplasia seen most often in cats and cows, but is occasionally reported in the dog and horse.
An infiltrative type of cardiac neoplasia seen most often in cats and cows, but is occasionally reported in the dog and horse.
81
Although cardiac neoplasia is rare in the cat, it is reported to be present in 10-15% of cats with ............. and even higher in cats with feline leukemia virus.
Although cardiac neoplasia is rare in the cat, it is reported to be present in 10-15% of cats with lymphoma and even higher in cats with feline leukemia virus.
82
Infiltrative diseases in man are usually associated with restrictive cardiomyopathy with the most common underlying cause being amyloid deposition. Infiltrative disease resulting in restrictive physiology has been documented in the cat secondary to ................ and ..............
Infiltrative disease resulting in restrictive physiology has been documented in the cat secondary to lymphosarcoma and endomyocardial fibrosis.
83
Lymphosarcoma involving the heart is perceived on echo images as hypertrophied .................muscle with or without areas of increased ................
Lymphosarcoma involving the heart is perceived on echo images as hypertrophied hypokinetic muscle with or without areas of increased echogenicity.
84
There ay be associated pericardial effusion resulting in tamponade.
Lymphosarcoma involving only the pericardium is reported with resulting tamponade and no visible echo abnormalities of the pericardial sac.
There ay be associated pericardial effusion resulting in tamponade.
Lymphosarcoma involving only the pericardium is reported with resulting tamponade and no visible echo abnormalities of the pericardial sac.
Fig 8.25, 8.26
85
Lymphosarcoma is usually an infiltrative disease. The myocardium appears hypertrophied and hypokinetic.
Lymphosarcoma is usually an infiltrative disease. The myocardium appears hypertrophied and hypokinetic.
86
Other intracardiac neoplasia: Lipomas have also been seen within the heart and pericardial sac of dogs and horses, although generally founding subcutaneous tissues.
Other intracardiac neoplasia: Lipomas have also been seen within the heart and pericardial sac of dogs and horses, although generally founding subcutaneous tissues.
87
Lipomas: can infiltrate the walls of the heart and create thrombosis within the vessels entering or leaving the heart.
can infiltrate the walls of the heart and create thrombosis within the vessels entering or leaving the heart.
88
Lipomas within the pericardial sac may be attached to the surface of the heart by a stalk and can become quite large without elevating pressure significantly presumably due to their slow growth and soft consistency.
Lipomas within the pericardial sac may be attached to the surface of the heart by a stalk and can become quite large without elevating pressure significantly presumably due to their slow growth and soft consistency.
In man, patients with cardiac lipomas are usually asymptomatic, but there are occasional reports of arrhythmia, obstruction of flow into or out of the heart.
89
Rhabdomyosarcoma: ...........muscle tumors, are rare in all species. They are usually infiltrative in nature, but can extend into the cardiac chambers as polyp-like growth.
Striated muscle tumors, are rare in all species. They are usually infiltrative in nature, but can extend into the cardiac chambers as polyp-like growth.
90
Rhabdomyosarcoma in the dog has been seen in the right ventricular and atrial walls with partial obstruction of the right ventricular inflow and outflow tracts. They can have irregular borders.
Rhabdomyosarcoma in the dog has been seen in the right ventricular and atrial walls with partial obstruction of the right ventricular inflow and outflow tracts. They can have irregular borders.
91
Myxoma:
Myxomas, though not common in dogs, are .......... masses typically found within the LA chamber of the heart. They are attached to the wall of the LA by a pedicle and are easily removed.
Myxomas, though not common in dogs, are benign masses typically found within the LA chamber of the heart. They are attached to the wall of the LA by a pedicle and are easily removed.
92
Myxoma: echocardiographically they appear uniform in tissue character with smooth borders. ........... has been found within the LA chamber of the dog and echo cannot be differentiated from myxoma.
Paraganglioma has been found within the LA chamber of the dog and echo cannot be differentiated from myxoma.
They may obstruct flow into or out of the LA chamber.
93
Myxosarcomas are a rare malignant often infiltrative endocardial growths of mesenchymal origin that may involve the pulmonary artery, RV and RA, RV outflow tract, LV and pericardial sac. They are common in rabbits and poultry but rare in dogs. Echocardiographical features?
Usually multi lobed and heterogeneous in appearance, congaing many small hypo echoic areas. Despite this heterogeneous appearance, they are difficult to differentiate from benign myxomas.
94
Echo cannot identify tumor types. Location and appearance provide info as to the most likely type of tumor, but many tumors look alike and are found in similar places within the heart.
Echo cannot identify tumor types. Location and appearance provide info as to the most likely type of tumor, but many tumors look alike and are found in similar places within the heart.
95
Pericardial disease:
| Pericarditis is classified into 3 broad categories with some overlap: Which ones?
Effusive
Fibrinous
Constrictive
96
Pericarditis. Large fluid accumulation characterize ........... pericarditis, fibrinous tissue within the pericardial fluid characterizes ............... pericarditis, and when the fibrinous tissue matures and consolidates causing fibrosis of the pericardial sat it has advanced to ............. pericarditis.
Large fluid accumulation characterize effusive pericarditis, fibrinous tissue within the pericardial fluid characterizes fibrinous pericarditis, and when the fibrinous tissue matures and consolidates causing fibrosis of the pericardial sat it has advanced to constrictive pericarditis.
97
Idiopathic effusion: The diagnosis of a thickened pericardium is sometimes possible on echo images, but there are many false positives unless there is .............. to help define both boundaries of the sac.
The diagnosis of a thickened pericardium is sometimes possible on echo images, but there are many false positives unless there is pleural effusion to help define both boundaries of the sac.
98
Idiopathic pericardial is an uncommon occurrence in dogs, is even rarer in large animals, and is referred to as?
chronic proliferative pericarditis, benign idiopathic pericardial effusion, idiopathic hemorrhagic pericardial effusion, or idiopathic pericardial hemorrhage.
99
The diagnosis of idiopathic pericardial effusion is one of exclusion after ........... and ............ have been ruled out as
causes.
The diagnosis of idiopathic pericardial effusion is one of exclusion after neoplasia and infection have been ruled out as
causes.
100
Idiopathic pericardial effusion: there is generally a ........... amount of pericardial effusion. The fluid accumulates slowly, and signs of tamponade ara a late sequela.
there is generally a large amount of pericardial effusion. The fluid accumulates slowly, and signs of tamponade ara a late sequela. Fig 8.5
101
Idiopathic pericardial effusion: ............ is usually present as well, and this allows better imaging of the pericardial sac itself. fig 8.5
Pleural effusion is usually present as well, and this allows better imaging of the pericardial sac itself. fig 8.5
102
The sac is usually thickened and irregular by the chronic accumulation of fibrin on the ............ side of the sac, and undulating fibrin tags may be seen within the ......... space and adhered to the sac.
The sac is usually thickened and irregular by the chronic accumulation of fibrin on the pleural side of the sac, and undulating fibrin tags may be seen within the pleural space and adhered to the sac.
103
At times the fibrin accumulation may appear to be masses. A thorough exam to rule out masses still does not lead to a definitive diagnosis of idiopathic effusion since small masses may bot be seen. Massive effusions however do make it easier to identify neoplasia. Surgical and histological examination is necessary for the definitive diagnosis.
At times the fibrin accumulation may appear to be masses. A thorough exam to rule out masses still does not lead to a definitive diagnosis of idiopathic effusion since small masses may bot be seen. Massive effusions however do make it easier to identify neoplasia. Surgical and histological examination is necessary for the definitive diagnosis.
104
Idiopathic effusion typically have very large volumes.
Idiopathic effusion typically have very large volumes.
105
Pericardial neoplasia:
Pericardial disease may be secondary to metastatic disease involving the sac with ........... being the most common of these.
Pericardial disease may be secondary to metastatic disease involving the sac with lymphosarcoma being the most common of these.
106
Other cancers (besides lymphosarcoma) found to metastasize to the pericardial sac in dogs and cats include?
Melanomas
| Mammary and pulmonary adenoma, mesothelioma, and rarely hemangiosarcoma.
107
Pericardial tumors are difficult to diagnose. When no effusion is present, the pericardial sac cannot be defined well and when pericardial effusion is present, the sac may still appear to be normal in appearance because the tumor is so diffuse in nature.
When no effusion is present, the pericardial sac cannot be defined well and when pericardial effusion is present, the sac may still appear to be normal in appearance because the tumor is so diffuse in nature.
108
Pericardial tumors: Pericardial effusion is typically present and is usually a significant volume.
Pericardial effusion is typically present and is usually a significant volume.
109
Pericardial tumors: When the sac is thick and irregular, pericardial neoplasms cannot be differentiated echocardiographically from other pericardial ................ or .............. on the sac.
When the sac is thick and irregular, pericardial neoplasms cannot be differentiated echocardiographically from other pericardial disease or fibrin deposition on the sac.
110
Infectious pericarditis:
Is rare in small animals, but traumatic fibrinous pericarditis is frequently seen in the bovine and less commonly in the horse. This form of pericarditis is usually the result of?
Foreign body penetration
| Other trauma such as bite wounds or systemic infections
111
It is generally easy to differentiate fibrinous pericarditis from other forms of pericardial disease because of?
Of the extensive amount of fibrin adhered to the epicardial surface and moving around within the pericardial space. Fig 8.29, 8.30
112
Constrictive pericarditis:
2D findings:
Not all pericarditis is fibrinous in nature, and there are no specific echo changes to help differentiate idiopathic effusions from infectious pericarditis.
Constructive pericarditis however involves a ...?
Involves a thickened scarred pericardium, which limits diastolic filling of the heart.
113
Constrictive pericarditis is typically ..............., but can be, and there are usually no visible adhesions connecting the sac to the epicardium.
Constrictive pericarditis is typically not effusive, but can be, and there are usually no visible adhesions connecting the sac to the epicardium.
When effusion is present, the term effusive-constrictive pericarditis is used.
114
Constrictive pericarditis is thought to start with an episode of .................... This usually goes undetected, and fluid is resorbed. The pericardial sac then becomes thick and fibrotic during a chronic phase.
Constrictive pericarditis is thought to start with an episode of acute pericarditis. This usually goes undetected, and fluid is resorbed. The pericardial sac then becomes thick and fibrotic during a chronic phase.
115
Causes of the acute subclinical phase may be..?
idiopathic effusion, mycotic infections, neoplasia, and foreign bodies
116
Differentiating effusive constrictive pericarditis from acute cardiac tamponade is sometimes only possible after....?
After a centesis
Cardiac pressures do not return to normal in constrictive pericarditis.
117
The pericardium may appear normal in thickness echocardiographically, during surgery, and with histological examination. The diagnosis of a thick pericardium is tricky using. echo.
When a small amount of effusion is present, ............ of the the parietal pericardium and epicardium can be seen with a thick sac.
When a small amount of effusion is present, parallel motion of the the parietal pericardium and epicardium can be seen with a thick sac.
Transthoracic imaging however is very insensitive to increases in pericardial thickness, and both false positives and negatives are common.
Pericardial thickness assessed by transeophageal echo in man correlates well with thicknesses obtained from CT.
118
When the pericarditits leads to constrictive physiology, the cardiac chambers are typically .......... than normal as the pericardial sac constricts the heart and prevents adequate ventricular filling.
When the pericarditits leads to constrictive physiology, the cardiac chambers are typically smaller than normal as the pericardial sac constricts the heart and prevents adequate ventricular filling.
Fig 8.31.
119
Constr pericarditis: Both sides of the heart are affected by the increased pressures applied to it by the thickened sac, but the signs of right-sided heart failure predominates because of ...........?
Both sides of the heart are affected by the increased pressures applied to it by the thickened sac, but the signs of right-sided heart failure predominates because of the thinner right ventricular wall.
120
Constr pericarditis: 2D imaging will show ...............
biatrial dilation, increased mitral and tricuspid valve excursions, and an abnormal contour to the junction between the ventricular and atrial chambers.
The atrial chamber appears to balloon out this junction as opposed to the smooth transition usually seen when the atrium and ventricular chamber both dilate.
121
Constr pericarditis: .............. areas within the myocardium may be seen after resolution of the pericarditis on follow-up exams. These areas are though to be areas of .............. secondary to myocarditis, which was probably present in addition to the pericarditis.
Echogenic areas within the myocardium may be seen after resolution of the pericarditis on follow-up exams. These areas are though to be areas of fibrosis secondary to myocarditis, which was probably present in addition to the pericarditis.
122
M-mode findings:
When constrictive pericarditis exists, the ventricles stop filling early in diastole; typically by the end of the first third of diastole. This is sometimes seen on M-mode images as a...?
As a decrease in the normal gradual downward motion seen on the LV free wall throughout diastole.
M-mode images of the LV may also show early diastolic notching on the left side of the inter ventricular septum or later in diastole with atrial contraction. These are not specific, and even the presence of all of these M-mode findings does not confirm the diagnosis of constrictive pericarditis. The lack of any of them definitely rules out the diagnosis.
123
LA dilation is commonly seen with constrictive pericarditis secondary to .......
Secondary to increased LV filling pressures.
124
Spectral Doppler findings: Inspiration decreases ......................., which normally increases flow into the right side of the heart.
There is enhanced ventricular interaction with constrictive pericarditis however, and expansion of the right heart during inspiration reduced .............
Spectral Doppler findings: Inspiration decreases intrathoracic pressure, which normally increases flow into the right side of the heart.
There is enhanced ventricular interaction with constrictive pericarditis however, and expansion of the right heart during inspiration reduced LV filling.
125
There is enhanced ventricular interaction with constrictive pericarditis however, and expansion of the right heart during inspiration reduced LV filling.
Pulmonary venous pressure .................. during inspiration as a result, but there is no decrease in LV ............., which additionally limits LV filling. The ............... occurs during expiration with constrictive physiology.
Pulmonary venous pressure decreases during inspiration as a result, but there is no decrease in LV pressure, which additionally limits LV filling. The reverse occurs during expiration with constrictive physiology.
126
Constrictive pericarditis: The ........... in pulmonary venous pressure during inspiration ................... pulmonary vein diastolic flow velocity, and with expiration there is a very pronounced ............. in diastolic flow into the LA chamber.
The decrease in pulmonary venous pressure during inspiration decreases pulmonary vein diastolic flow velocity, and with expiration there is a very pronounced increase in diastolic flow into the LA chamber.
127
Constrictive pericarditis: Expiration also decreases the pulmonary venous S:D ratio since diastolic flow into the LA chamber is ..................
Expiration also decreases the pulmonary venous S:D ratio since diastolic flow into the LA chamber is enhanced.
128
Constrictive pericarditis: The enhanced interdependence between the right and left ventricular chambers and the changes in pulmonary venous flow cause ............. respiratory changes in flow through the atrioventricular valves.
exaggerated
129
Constrictive pericarditis: During the beat just after inspiration while there is negative intrathoracic pressure, trans tricuspid flow velocity ............while transmitral flow velocity is d.............. by 25-40% and the reverse happens during expiration.
During the beat just after inspiration while there is negative intrathoracic pressure, trans tricuspid flow velocity increases while transmitral flow velocity is decreased by 25-40% and the reverse happens during expiration.
Fig 8.32
130
In the normal heart, there will be variation in trans tricuspid flow velocities with respiration, but there is little ventricular interdependence, and respiratory changes are not noted during LV filling.
In the normal heart, there will be variation in trans tricuspid flow velocities with respiration, but there is little ventricular interdependence, and respiratory changes are not noted during LV filling.
131
Constrictive pericarditis: Lower LA pressure during inspiration will ..................isovolumic relaxation time, while increased pulmonary venous return and higher LA pressure with expiration ................ isovolumic relaxation
Lower LA pressure during inspiration will increase isovolumic relaxation time, while increased pulmonary venous return and higher LA pressure with expiration decreases isovolumic relaxation
132
Constrictive pericarditis: Since expiration results in ....... flow into the right side of the heart, there is also ........... hepatic flow reversal during this respiratory time period.
Since expiration results in poor flow into the right side of the heart, there is also increased hepatic flow reversal during this respiratory time period.
133
Constricitve pericarditis:
Trans tricuspid flow
- .............. with inspiration
- .............. with expiration
- Increases with inspiration
| - Decreases with expiration
134
Constricitve pericarditis:
Transmitral flow:
- ................ with inspiration
- ................ with expiration
Decreases with inspiration
| Increases with expiration
135
Abscesses:
Rarely abscesses may involve the pericardial sac. They appear to ave thin walls with large hypo echoic areas within them and are adhered to the pericardial sac instead of the heart as other cardiac masses are. Large abscesses may compress the cardiac chamber next to it.
Rarely abscesses may involve the pericardial sac. They appear to ave thin walls with large hypo echoic areas within them and are adhered to the pericardial sac instead of the heart as other cardiac masses are. Large abscesses may compress the cardiac chamber next to it.
136
Pericardial cysts:
Fluid-filled cystic structures within the pericardial sac have occasionally been reported in the dog and cat. The cyst may be located, and some have been attached to the parietal pericardium by a stalk.
An association with pericardial peritoneal diaphragmatic hernia is reported in several cases, and it is hypothesized that abdominal viscera become confined into the pericardial space in conjunction the hernia.
These cystic structures may elevate intrapericardial pressure resulting in compression of cardiac chambers and possibly tamponade.
Fluid-filled cystic structures within the pericardial sac have occasionally been reported in the dog and cat. The cyst may be located, and some have been attached to the parietal pericardium by a stalk.
An association with pericardial peritoneal diaphragmatic hernia is reported in several cases, and it is hypothesized that abdominal viscera become confined into the pericardial space in conjunction the hernia.
These cystic structures may elevate intrapericardial pressure resulting in compression of cardiac chambers and possibly tamponade.
137
Thrombus: Organized thrombi appear as free-floating layers or strands of echogenic material within the pericardial space. This may be seen secondary to ....?
This may be seen secondary to acute bleeding from hemangiosarcoma, ruptured atrium, idiopathic hemorrhagic effusion, or after a pericardiocentesis if the heart was penetrated. Fig 5.22, 5.23
138
While thrombus occurrences within the cardiac chambers are ball or oval shaped, soft tissue structures found within the pericardial sac are almost always ............. of some sort and are not typical of thrombus within the sac.
While thrombus occurrences within the cardiac chambers are ball or oval shaped, soft tissue structures found within the pericardial sac are almost always neoplasm of some sort and are not typical of thrombus within the sac.
139
Bleeding into the pericardial sac results in long layers of organized clot.
Bleeding into the pericardial sac results in long layers of organized clot.
