pericardial disease

Question 1

Visceral Pericardium

Answer 1

epicardium

moist outer cardiac membrane

Question 2

Parietal Pericardium

Answer 2

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

Question 3

Atelectasis

Answer 3

collapsed portion of lung (seen in pleural effusion)

Question 4

Clinical Signs of Pericarditis

Answer 4

• 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)

Question 5

Otto Rating Scale for Pericardial Effusion

Answer 5

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

Question 6

What quantifies tamponade?

Answer 6

RA collapse and swinging motion (A4)

Question 7

Reynolds Rating Scale for Pericardial Effusion

Answer 7

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

Question 8

Pericardial Effusion VS Pleural Effusion

Answer 8

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

Question 9

Loculated Pericardial Effusion

Answer 9

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

Question 10

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

Answer 10

epicardial fat pad

Question 11

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

Answer 11

pleural effusion

Question 12

pericardial cysts

Answer 12

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

Question 13

hematoma

Answer 13

common against RA post surgery

Question 14

pseudoaneurysm

Answer 14

from myocardial rupture

Question 15

Cardiac Tamponade

Answer 15

• 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)

Question 16

Signs and Symptoms of Cardiac Tamponade

Answer 16

• 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)

Question 17

Auscultations of Cardiac Tamponade

Answer 17

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

Question 18

Echo Findings for Cardiac Tamponade

Answer 18

• 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)

Question 19

Using Doppler to rule in Cardiac Tamponade

Answer 19

• 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

Question 20

Treatment for Cardiac Tamponade

Answer 20

• 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

Question 21

Constrictive Pericarditis

Answer 21

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

Question 22

Signs and Symptoms of Constrictive Pericarditis

Answer 22

• 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)

Question 23

Auscultations in Constrictive Pericarditis

Answer 23

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

Question 24

Treatment for Constrictive Pericarditis

Answer 24

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

Question 25

2D Echo Findings for Constrictive Pericarditis

Answer 25

- 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)

Question 26

M-Mode Echo Findings for Constrictive Pericarditis

Answer 26

- 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

Question 27

Doppler Echo Findings for Constrictive Pericarditis

Answer 27

- 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