Pericarditis and Cardiomyopathy

Question 1

Class 1 recommendations for pericardial disease echo

Answer 1

pts with suspected pericardial disease including effusion, constriction
pations with suspected bleeding in pericardium
follow up for recurrence
pericardial friction rub in MI with symptoms like pain nausea and hypotension

Question 2

Thickened pericardium measurement

Answer 2

greater than 4mm

Question 3

Pericardial anatomy

Answer 3

normally contains 5-30mL serous fluid
reflections create oblique and transverse sinus
fused with diaphragm

congenital absence of pericardium
mulibrey nanism
leads to CHF, constrictive pericarditis

Question 4

normal spontaneous respirophasic variation

Answer 4

transtricuspid inflow increase by 20% on inspiration and decrease by 20% on expiration
transmitral inflow increase by 10% on expiration and decrease by 10% on inspiration

intrathoracic pressure from -3 to -6 with normal respirations

gradient for filling RV is RAP - negative intrathoracic pressure. Increased RV filling, decreased LV filling during inspiration

increased LV filling , decreased RV filling during expiration

Septum shifts to left

Question 5

negative pressure inspiration

Answer 5

less rv afterlaod
increased rv filling
decreased lv filling
increased lv afterload

Question 6

negative pressure expiration

Answer 6

decreased systemic venous return
decreased rv filling
increased rv afterload
increased LV filling
decreased LV afterload

Question 7

CP and tamponade with spontaneous variation

Answer 7

changes of inspiration and expiration exaggerated in both with spontaneous ventilation

Question 8

Tamponade changes with ppv

Answer 8

decrease in variation. So much that you can end up causing arrest

Question 9

Constrictive pericarditis

Answer 9

increased resp variation with both spont and ppv
elevated and equalized CVP , Pulm vein and LVEDP
prominent early filling (exagerrated Y descent)
pulus paradoxus uncommon but kussmauls sign common

Question 10

tamponade

Answer 10

increased resp variation with spontaneous
decreased resp variation with ppv
elevated and equalized cvp, pulm vein and LVEDP pressures
prominent systolic filling (loss of y descent)
pulsus paradoxus common
kussmauls sign uncommon

Question 11

congenital pericardial problems

Answer 11

rare
partial or total absence
mulibery nanism (muscle liver brain eye nanism) = chf and CP

Question 12

pericarditis

Answer 12

inflammation of pericardium
Triad : chest pain, ekg changes (diffuse st elevation) , friction rub at left sternal border with pt leaning forward. Pain better leaning forward
Chronic can lead to constrictive

Often idiopathic / viral
infection
neoplastic
autoimmune
post surgical
post radiation
drugs/ trauma/ uremia

thickness usually greater than 4mm but not always. Use MRI>CT=TEE>TTE

Question 13

CP vs RICM

Answer 13

peak velocity pulm vein D wave variation > 18%
peak velocity TM E wave variation >10% in CP
color m mode Vp >100cm/sec in CP
Tissue doppler e’<8 cm/sec in RICM
Tissue doppler septal velocity > lateral velocity in CP
pericardial knock in cp, s3 in RICM
BNP <100 pg/ml in CP but elevated in RICM
thickness >4mm favors CP

Question 14

tissue doppler cp vs ricm

Answer 14

e’<8cm/sec in ricm
e’>10 cm/sec in cp
annulus reversus lat e’<sep e’ in CP
annulus paradoxus E/e’ <15 in CP

Question 15

hepatic venous reversal spontaneous

Answer 15

cp- reversal during expiration
ricm- reversal during inspiration

Question 16

pulm venous resp variation spontaneous

Answer 16

peak velocity d wave variation >18% in cp

Question 17

MRI comparison of cp vs ricm

Answer 17

late gad enhancement of pericardium and thick - cp
lge of sub endocardium - ricm
LA : RA volume CP»RICM
Max septal excurtion b/w in and ex cp>RICM

Question 18

speckle tracking differences

Answer 18

cp- ratio of LV free wall strain to septal wall strain and RV were less in CP than RICM

Question 19

Vp

Answer 19

<50 cm/sec = ricm
>100 cm/sec=cp

Question 20

cardiac cath cp vs ricm

Answer 20

elevation and equalization of diastolic pressures in cp

lvedp>rvedp in ricm

Question 21

dip and plateau sign

Answer 21

square root sign seen in both cp and ricm that indicates rapid early filling

Question 22

tamponade findings

Answer 22

tachycardia
chest pain/fullness
dyspnea, tachypnea
peripheral edema
hypotension
Elevated JvP without kussmaul
pulsus paradoxus but may be absent if regional/loculated

Question 23

chamber collapse for tamponade

Answer 23

absence = very unlikely there is tamponade
RA collapse >1/3 cycle is nearly 100% sens and specific
RV collapse occurs iin diastole
RA collapse in diastole can be normal

Question 24

pericardial effusion

Answer 24

0.5 and less is small
.5-2 cm moderate (200-500 mL)
>2cm large

Question 25

tamponade doppler changes

Answer 25

prolongation IVRT decrease or reversal of hepatic d waves w expiration

Question 26

when is pulsus paradoxus seen besides tamponade

Answer 26

copd, asthma, vigorous positive pressure ventilation

Question 27

mitral inflow patterns for tamponade and constrictive pericarditis

Answer 27

tamponade - impaired relaxation with a >e cp - restrictive pattern with e>>a

Question 28

pericardial tumors

Answer 28

not high yield primary: benign more comon. teratoma, lipoma, fibroma ,hemangioma, lymphangioma malignant-mesothelioma, angiosarcoma Secondary: metastatic, more common than primary. Lymphoma, melanoma, lung ,breast carcinoma. usually present with pericardial effusion

Question 29

pericardial cysts

Answer 29

congenital or infectious enclosed spaces taht do not communicate with pericardial space. manage conservatively

Question 30

How much fluid is normal in pericardium?

Answer 30

25-50 mL

Question 31

Does VSD typically cause RV or LV enlargement

Answer 31

usually LV , especially at first. All flow goes from LV to RV and out pulmonic valve during systole

Question 32

what is pulsus alternans

Answer 32

alternating strong and weak beats seen on arterial line. Associated with severe LV systolic dysfunction

Question 33

what is kussmaul sign

Answer 33

paradoxical rise in RAP during inspiration. Commonly seen in constrictive pericarditis and RICM as there is a decrease in RV compliance.

Question 34

E/e' ratio for CP

Answer 34

usually less than 15 Annulus paradoxus

Question 35

LVDP in CP

Answer 35

unchanged. LV is shielded from decrease in pressure due to constrictive pericarditis. There is an exaggerated decrease in LV filling

Question 36

3 major types of cardiomyopathy

Answer 36

Dilated- not enough stuff. 100% have systolic dysfunction. Carpentier 3B. Most common cardiomyopathy Hypertrophic-Too much stuff. AD variable penetrance and expresivity. LVOT obstruction 25% pts. 100% have diastolic dysfunction. Have subendocardial ischemia and vtach. Get pacemakers that cause RBBB to reduce obstruction. Associated with cardiac death sudden RICM- the wrong stuff. Amyloidosis most common. 100% have diastolic dysfunction. Prognosis related to thickness of walls and diastolic dysfunciton. Systolic function also eventually gets worse. ONce symptoms appear 2-3 year survival is less than 50%

Question 37

Dilated cardiomyopathy

Answer 37

causes 3b carpentier mitral motion. Caused by: idopathic, peripartum, infectious, toxin, genetics. Associated with low EF, low flow leading to LAA clot / LV clot

Question 38

Toxic causes of dilated cardiomyopathy

Answer 38

cobalt, doxorubicin, alcohol, snake bites

Question 39

infectious causes of dilated cardiomyopathy

Answer 39

chagas, post viral Children can get severe acute form after virus that can improve and return to basically normal

Question 40

Higher mortality in D CM

Answer 40

EDD of >4cm/m2

Question 41

HOCM / HCM

Answer 41

Obstuction occurs in 25%. AD with variable penetrance and expressivity 4 types based on pattern of hypertrophy. Basal inferolateral wall is spared in all usually normal systolic function but 100% have diastolic dysfunction Reguritant jet is posteriorly directed (y sign)

Question 42

CWD of HOCM

Answer 42

Late systolic peaking , dagger shaped

Question 43

M mode of HOCM aortic valve

Answer 43

Early systolic closure and fluttering

Question 44

RICM

Answer 44

Infiltration of myocardium from abnormal substances. Leading to stiff myocardium. Primary; loefflers hypereosinophillic, endomyocardial fibrosis, idiopathic Secondary: amyloid, sarcoid, glycogen storage disease, hemochromotosis, Drugs, radiation

Question 45

Echo appearance of RICM

Answer 45

granular speckled , starry sky appearance of myocardium

Question 46

Transmitral inflow velocities in ricm

Answer 46

restrictive pattern like CP but also has reduced tissue doppler

Question 47

4 types of HCM

Answer 47

sigmoidal (most common basal septal ) reverse curve - entire septum apical neutral-concentric

Question 48

other findings often seen in addition to enlarged septum in HCM

Answer 48

elongated leaflet and apically displaced papillary muscle

Question 49

Different gradients seen in HCM

Answer 49

LVOT (web, SAM) Mid Cavitary Diastolic apical gradient

Question 50

Gradient of LVOT at rest that pt need to go on for surgical consult

Answer 50

greater than 50

Question 51

LVOT gradient with exercise or provocation (dobutamine) indicating SAM/MR

Answer 51

greater than 30