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Flashcards in pericardial disease Deck (27)
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1

Visceral Pericardium

epicardium
moist outer cardiac membrane

2

Parietal Pericardium

Has two layers:
-Fibrous: outer layer, adjacent to pleura and diaphragm
-Parietal Serous: moist membrane that lines the outer fibrous layer
Fluid generally collects between the parietal and the epicardium

3

Atelectasis

collapsed portion of lung (seen in pleural effusion)

4

Clinical Signs of Pericarditis

-Chest Pain (typically worse when supine and with inspiration)
-Widespread ST elevation on EKG
-Pericardial friction rub on auscultation
-New or increasing pericardial effusion

Other possible signs: dyspnea, tachy, palpitations, fever
Increased troponin seen in 50% of cases (especially if young, male, ST elevation, and associated effusion)

5

Otto Rating Scale for Pericardial Effusion

Based on the degree of separation between the parietal and visceral layer
-Small <0.5 cm
-Moderate 0.5 - 2.0 cm
-Large >2.0 cm

6

What quantifies tamponade?

RA collapse and swinging motion (A4)

7

Reynolds Rating Scale for Pericardial Effusion

-Small S/D posterior <1 cm
-Moderate S/D posterior/anterior <1 cm
-Large S/D posterior/anterior >1 cm

8

Pericardial Effusion VS Pleural Effusion

Pericardial: anterior to the DA
Pleural: posterolateral to the DA

9

Loculated Pericardial Effusion

Localized by adhesions to a small area of pericardial sac (or several small areas)
-look in multiple windows
-common post-op and in recurrent pericardial disease
-can be hemodynamically significant, percutaneous pericardiocentesis may not be possible

10

If echo free space is small and anterior to RV (PLAX) it is likely _________

epicardial fat pad

11

if isolated echo free space is superior to RA in A4 it is most likely ____________

pleural effusion

12

pericardial cysts

benign, echo free shell can compress atria leading to arrhythmia, syncope

13

hematoma

common against RA post surgery

14

pseudoaneurysm

from myocardial rupture

15

Cardiac Tamponade

-occurs when pericardial effusion causes pressure in pericardium to exceed pressure in chambers impairing cardiac filling
-can occur with small amount accumulating quickly (perforations) or large amounts occurring over period of time (metastatic responsible for 32% of tamponades)

16

Signs and Symptoms of Cardiac Tamponade

-signs of low CO: dyspnea and tachy most common
-cough (overload to lungs)
-JVD (overload to venous)
-Hoarseness, difficulty swallowing (nerve compression)
-low voltage EKG, electrical alternans
-possible signs of pericarditis (CP, EKG changes, rub)

17

Auscultations of Cardiac Tamponade

-Distant heart sounds
-Pulsus Paradoxus: an inspiratory decline in systolic BP >10 mmHg; by palpation this is a weakening of the pulse during inspiration

18

Echo Findings for Cardiac Tamponade

-Large PE and swinging heart
-RA systolic collapse
-RV diastolic collapse
-LV may appear hyperkinetic as it seeks volume to circulate
-Reciprocal respiratory changes in ventricular volumes
-Reciprocal respiratory changes in ventricular inflow velocities
-Enlarged nonpulsatile IVC (plethora)

19

Using Doppler to rule in Cardiac Tamponade

-We look for respiratory variation in diastolic inflow velocities >25%
-WHY; total pericardial volume (heart chambers plus pericardial volume) is fixed so that respiratory changes are exaggerated
-PW at RVIT and LVIT; caliper many peak inflow velocities (sweep speed 25)
-changes will be similar at other heart locations

20

Treatment for Cardiac Tamponade

-Treat etiology of tamponade
-Volume expansion (IV fluids)
-Pericardiocentesis (echo guided to reduce complications) needle is in sack when bayonet sign is seen; can inject contrast to determine if in pericardial sack
-Pericardial Window

21

Constrictive Pericarditis

Visceral and Parietal layers become adherent, thickening and fibrotic impairing diastolic filling "acting like a rigid box" leading to decreased cardiac output

22

Signs and Symptoms of Constrictive Pericarditis

-Dx is often delayed, Sx subtle or occur late
-Fatigue
-Malaise (generalized feeling of discomfort, illness, weakness)
-Dyspnea
-JVD
-Ascites
-Peripheral Edema
-Tachycardia
-Low voltage EKG (more common in tamponade)

23

Auscultations in Constrictive Pericarditis

-Distant heart sounds
-Diastolic pericardial knock (as inflow abruptly stops)
-Pulsus Paradoxus (more common in tamponade)

24

Treatment for Constrictive Pericarditis

Pericardiectomy: stripping of pericardium with 5-15% early surgical mortality

25

2D Echo Findings for Constrictive Pericarditis

-Normal to dilated atria (due to chronic atrial pressure elevation)
-Dilated IVC/hepatic veins due to elevated atrial pressures
-Echogenic pericardial thickening may be evident
-Bouncing appearance at ventricular/pericardial border with lack of "pericardial slide"
-Septal shift with inspiration (bouncing)

26

M-Mode Echo Findings for Constrictive Pericarditis

-Multiple dense echoes posterior to LV "railroad track sign"
-Diastolic septal or "Spanish" notch
-LVPW: early diastolic descent followed by flattening (AKA square root sign)
-Exaggerated premature opening of PV

27

Doppler Echo Findings for Constrictive Pericarditis

-As in tamponade, respiratory variations in diastolic filling velocities >25%
-Respiratory changes will be similar at other right and left heart locations
-LV and RV inflow shows prominent E, rapid decal slope, and small A
-IVRT demonstrates respiratory changes with increased time in inspiration