Pericardial diseases

Pericardial anatomy

PERICARDIAL EFFUSION (ETIOLOGY) Viral (most common) Uremic (chronic renal failure) Metastatic (breast or lung CA) Post MI (Dresslers syndrome) Post cardiac surgery (regional) CHF, systemic diseases (lupus, AIDS) Trauma Infectious

HIV

PERICARDIAL DISEASES (CLINICAL PRESENTATION) Chest pain with respiration, fever Shortness of breath Enlarged cardiac silhouette on chest X ray EKG changes with diffuse ST elevation Pulsus paradoxus, tachycardia, hypotension, neck vein distention, decreased heart sounds

PERICARDIAL FLUID Serosanguinous (clear, pale yellow) - not echogenic Bloody (consider metastatic, trauma) - may be echogenic Infectious (brown,milky colored)

PERICARDIAL EFFUSION (M Mode Echocardiography) may overestimate amount and not useful if loculated or localized useful for timing of RV wall motion relative to mitral valve opening Caution when only anterior echo free space present

PERICARDIAL EFFUSION (2D Echocardiography) Superior to M Mode for extent and localization by use of multiple views Assess for diastolic collapse of right heart chambers, IVC size and change with inspiration/expiration Identify intrapericardial process (clot, tumor, fibrin strands) Differentiate pericardial from pleural effusion by recognition of descending aorta Non diagnostic for pericardial thickness

Parasternal long axis LV AO Effus LA DAO

Parasternal Short Axis

Apical 4C

Subcostal view

Fibrous Strands

Unequal distribution

M Mode echo

RV collapse/ Delayed RV Relaxation M-Mode RV collapse/ Delayed RV Relaxation

PERICARDIAL EFFUSION: SIZE SMALL: echo free space present posterior and < 1 cm. MODERATE: echo free space present anterior and posterior < 1 cm. LARGE: echo free space anterior and posterior > 1 cm.

Small Pericardial Effusion

Moderate Pericardial Effusion

Large Pericardial Effusion

PERICARDIAL EFFUSION: POSSIBLE SOURCES OF FALSE POSITIVES Pleural effusion Pericardial tumor or cyst Dilated coronary sinus LV pseudoaneurysm Large hiatal hernia

LSVC Dilated Coronary Sinus

Pericardial Cyst Subcostal

2C: Posterior echo free space

DOPPLER Assessment of flow velocities across mitral/tricuspid valves, LV outflow, and hepatic veins Presence of respiratory variation > 20% in left heart flow velocities and more marked in right heart Should be performed in all patients with suspicion or evidence of pericardial disease

Tamponade Case Study

Pericardiocentesis Needle aspiration of the pericardial effusion Usually performed with needle entering subxiphoid Echo guided Evaluate fluid initially from subcostal Imaging performed from the apical position

Little effusion available from subcostal

Differentiation with Ascites

Case 2 56 year old female transferred from outside hospital know breast cancer possible malignant pericardial effusion Pericardiocentesis

Agitated Saline - injected into the pericardial space for verification of needle placement

After pericardiocentesis Before After pericardiocentesis

Case 4 Patient presents post MI New pericardial effusion What is the differential?

EP application 56 year old female comes into the hospital after being discharged from outside hospital after pacemaker insertion Continued severe chest pain When pacer activated, diaphragm stimulated

Pericardial Effusion by TEE

Pericardial Disease: Constriction versus Restriction

Constrictive Pericardial Diseases: Etiologies Idiopathic/recurrent pericarditis Post cardiac surgery Prior chest radiation Infectious (Tuberculosis) Metastatic process Difficult diagnosis to establish

Less Common Etiologies Infectious (Fungal) Neoplasms Uremia Connective tissue disorders (SLE, Scleroderma) Drug Induced (Procainamide, hydralazine) Trauma Post MI (Dressler’s)

Clinical Signs Shortness of breath Peripheral edema Increased jugular venous pressure Normal heart size on chest X ray Similar in presentation to CHF Often confused with restrictive cardiomyopathy

Physiology Dissociation between intrathoracic and intracardiac pressures Normally with inspiration, intrathoracic pressure falls and intrathoracic structures fall In constriction, the pressure change is not transmitted to intrapericardial structures and cavities

2D Imaging Pericardial thickening Paradoxical septal motion TEE more reliable than TTE, but CT or MRI is the better method for thickness evaluation Paradoxical septal motion Respiratory Variable Septal shift leftward with inspiration Increased IVC diameter, lack of resp change

M-mode Evaluation Parietal pericardial tracking with epicardial/endocardial motion M Mode posterior LV wall motion is flat during mid and late diastole Respiratory variation in ventricular chamber size

Doppler Evaluation Pulsed Doppler respiratory flow velocity variation at mitral valve, pulmonary veins Variation greater than 25% Left side velocities decrease with inspiration Diastolic Decrease in PV velocities Right side increases with inspiration Shortened mitral deceleration time that decreases more with inspiration

Decreased Mitral Inflow with Inspiration

Tricuspid Inflow Increased with Inspiration

Tissue Doppler In 20 to 40% of patients, Mitral filling may not meet criteria Sitting patient reduces preload and may reveal variation Tissue Doppler provides best marker for detection of constriction TDI velocity >8-15 cm/sec is diagnostic to rule out restriction Ha et al. JASE 2002; 15:1468-71.

Constrictive Tissue Doppler E/E’ and PCWP are inversely correlated in patients with constrictive disease Mitral -Increased E/A ratio Tissue Doppler –Increased Tissue Velocities Note E/e’ is “normal” despite increased filling pressures due to increased longitudinal annular motion in Constrictive processes Ha et al, Circulation. 2001;104:976-978

Additional Doppler findings Expiratory decrease in hepatic diastolic forward flow and increases in hepatic vein flow reversals

Normal Hepatic Flow Systolic and diastolic phasic flow

Constrictive Hepatic Vein Flow Increased forward flow with inspiration, backflow with expiration Adapted from Haley et al JACC, 2004;43;271-275

Technical Concerns COPD May cause respiratory variability but not usually at the onset of inspiration/expiration Mitral Inflow pattern is not necessarily increased E/A ratio as in constriction SVC flow varies in COPD, not in constriction

Constriction Case

Mitral Inflow

Tissue Doppler Medial Lateral

Reciprocal LV changes in size with respiration Apical 4 Chamber view Reciprocal LV changes in size with respiration

Cardiac Catheterization Calcification LV function

Infiltrative/Restrictive Systemic Diseases

Etiology Noninfiltrative Infiltrative Storage Idiopathic Familial HCM Scleroderma Diabetic Infiltrative Amyloidosis Sarcoidosis Storage Hemochromatosis Fabry’s Hypereosinophilic Syndrome Carcinoid

2D Findings Bilateral Atrial Enlargement Normal LV cavity size and function Hyperechoic Myocardium Possible Pericardial Effusion Dilated Hepatic Veins Granular appearance of the myocardium “Ground glass”

Amyloid Parasternal Long

Amyloid Apical 4

Doppler Findings Mitral Filling (Late) Pulmonary and Hepatic Veins Increased E to A Shortened Deceleration Time Pulmonary and Hepatic Veins Prominent Early Diastolic Filling Increased Reversed Flow during Atrial Contraction Pulmonary Hypertension

Restrictive filling

Prominent diastolic reversal (Y decent) Hepatic Veins Prominent diastolic reversal (Y decent)

Indices of patients with elevated LV filling pressures Enlarged LA size (> 28 ml/m2) E/A ratio > 2 DT <150 Pulmonary Vein S/D < 40% Pulmonary Vein A wave velocity > 25 cm/s E/e’ ratio > 15 Vp flow propagation < 40 cm/sec

Mitral / Tricuspid Inflow Constriction vs Restriction Normal Constriction Restriction I E I E I E Mitral Tricuspid

Tissue Doppler Constrictive Average velocities 14.8 cm/sec Normal or enhanced longitudinal expansion Restrictive Average velocities 4.1 cm/sec Restricted myocardial motion Increases sensitivity to detect Constriction to 98.4% except in pts with MAC, LV dysfunction Garcia, et al. JACC 1996 Jan;27(1):108-14, Sengupta et al. Am J Cardiol. 2004 Apr 1;93(7):886-90

Mixed Constrictive/ Restrictive Physiology Incidence varies, but around 20% of patients May be found in Radiation Induced, CABG Increased Mortality in Mixed physiology

Palka et al. Circulation 2000;102;655-662. Comparison Restrictive Constrictive LV wall thickness Increased Normal LA diameter E/A ratio Decel time Shortened IVRT LV diameter Decreased Peak E wave Palka et al. Circulation 2000;102;655-662.

Normal Restrictive Constrictive Mitral Tissue D S S D D S Pulmonary Vein Tricuspid Hepatic Veins S D S D S D Adapted From Hoit, Management of Effusive and Constrictive Pericardial Heart Disease Circulation 2002;105;2939-2942

Case 1 Restrictive vs. Constrictive 68 year old male Admitted with shortness of breath Known history of Amyloidosis

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