1. Pericardial diseases

2. Pericardial anatomy

3. 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

4. HIV

5. 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

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

7. 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

8. 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

9. Parasternal long axis LV AO
Effus LA
DAO

10. Parasternal Short Axis

11. Apical 4C

12. Subcostal view

13. Fibrous Strands

14. Unequal distribution

15. M Mode echo

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

17. 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.

18. Small Pericardial Effusion

19. Moderate Pericardial Effusion

20. Large Pericardial Effusion

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

22. LSVC Dilated Coronary Sinus

24. Pericardial Cyst Subcostal

25. 2C: Posterior echo free space

26. 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

28. Tamponade Case Study

33. 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

34. Little effusion available from subcostal

35. Differentiation with Ascites

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

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

39. After pericardiocentesis
Before
After pericardiocentesis

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

44. 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

49. Pericardial Effusion by TEE

50. Pericardial Disease: Constriction versus Restriction

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

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

53. 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

54. 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

55. 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

56. 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

57. 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

58. Decreased Mitral Inflow with Inspiration

59. Tricuspid Inflow Increased with Inspiration

60. 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:

61. 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:

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

63. Normal Hepatic Flow
Systolic and diastolic phasic flow

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

65. 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

66. Constriction Case

67. Mitral Inflow

68. Tissue Doppler
Medial
Lateral

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

70. Cardiac Catheterization
Calcification
LV function

71. Infiltrative/Restrictive Systemic Diseases

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

73. 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”

74. Amyloid Parasternal Long

75. Amyloid Apical 4

76. 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

77. Restrictive filling

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

79. 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

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

81. 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 Apr 1;93(7):886-90

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

83. 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;

84. 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;

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

90. INS EXP

91. INS EXP

92. INS EXP

93. INS EXP