12 Pericardial Disease
Introduction
Background
Overview of Echocardiographic Approach
Pericardial Effusion
Background
TABLE 12-1 OVERVIEW OF PERICARDIAL DISEASE ETIOLOGIES AND ASSOCIATED SYNDROMES
Etiology | Clinical Endpoints |
---|---|
Idiopathic | |
Infectious | |
Bacterial | Acute pericarditis |
Tuberculous | Acute pericarditis, constrictive pericarditis |
Viral | Acute pericarditis |
Parasitic | Acute pericarditis |
Connective tissue disease | |
Systemic lupus erythematosus | Pericarditis, pericardial effusion |
Scleroderma | Pericarditis |
Rheumatoid arthritis | Pericarditis, pericardial effusion |
Wegener’s granulomatosis | Pericarditis, pericardial effusion |
Post-myocardial infarction | |
Dressler’s syndrome | Acute pericarditis, pericardial effusion |
Ventricular rupture | Pericardial effusion, cardiac tamponade |
Metabolic | |
Uremia | Pericardial effusion |
Myxedema | Pericardial effusion |
Trauma | Pericardial effusion, cardiac tamponade |
Postradiation | Acute pericarditis, constrictive pericarditis |
Postoperatively after cardiac surgery | Pericardial effusion, cardiac tamponade, constrictive pericarditis |
Neoplastic | |
Primary pericardial and cardiac tumors | Pericardial effusion, cardiac tamponade |
Metastatic disease | Pericardial effusion, cardiac tamponade |
Congestive heart failure | Pericardial effusion |
Aortic dissection, left ventricular rupture | Pericardial effusion, cardiac tamponade |
Postoperatively after cardiac catheter or electrophysiologic procedures | Pericardial effusion, cardiac tamponade |
Overview of Echocardiographic Approach
Anatomic Imaging
Step 1: 2D Image Acquisition
TABLE 12-2 TRANSTHORACIC VERSUS TRANSESOPHAGEAL ECHOCARDIOGRAPHY VIEWS FOR THE IMAGING OF PERICARDIAL EFFUSIONS
TTE | TEE | |
---|---|---|
Useful echocardiographic views | Parasternal long axis | ME four-chamber |
Parasternal short axis | ME RV inflow-outflow | |
Apical four-chamber subcostal | Transgastric mid short axis | |
Benefits and limits | Less invasive technique | Better detection of posterior effusion |
Poor image quality after cardiac surgery | More invasive |
ME, midesophageal; RV, right ventricular; TEE, transesophageal echocardiography; TTE, transthoracic echocardiography.
Step 2: Image Analysis
TABLE 12-3 ECHOCARDIOGRAPHIC GRADING OF PERICARDIAL EFFUSIONS
Location of the Effusion | Distance between Pericardial Layers | |
---|---|---|
Small | Posterior only | <0.5 cm |
Moderate | Anterior and posterior | 0.5-2 cm |
Large | Anterior and posterior | >2 cm |
Pitfalls
Pericardial versus Pleural Effusion
Cardiac Tamponade
Background
Overview of Echocardiographic Approach
Anatomic Imaging
Step 1: Image Acquisition
Step 2: Image Analysis
Pitfalls
Step 1: Acquisition of Physiologic Data
Step 2: Analysis of Physiologic Data
Pitfalls
Alternative Approaches
Key Points
Constrictive Pericarditis
Background
1 | High atrial pressures increase early filling of the ventricles |
2 | Ventricular filling is quickly offset by the constriction resulting in a rapid rise of the intraventricular pressure in diastole |
3 | RV systolic pressure is only mildly elevated, whereas RV diastolic pressures are markedly increased (usually more than one third of systolic pressure) |
4 | In classic constrictive pericarditis, there is equalization and elevation of diastolic pressures in all cardiac chambers |
5 | Ventricular volume is limited by pericardial constraint |
6 | Increased early diastolic RV filling goes along with decreased early diastolic LV filling, which is referred to as exaggerated ventricular interdependence |
LV, left ventricular; RV, right ventricular.
Overview of Echocardiographic Approach
Anatomic Imaging
Step 1: Image Acquisition
Pitfalls
Step 1: Acquisition of Physiologic Data
Step 2: Analysis of Physiologic Data
TABLE 12-5 COMPARISON OF CONSTRICTIVE PERICARDITIS AND RESTRICTIVE CARDIOMYOPATHY
Constrictive Pericarditis | Restrictive Cardiomyopathy | |
---|---|---|
Hemodynamics | ||
RA pressure | Elevated | Elevated |
Pulmonary artery pressures | Mildly elevated | At least moderately elevated |
2D | ||
Pericardial thickening and fusion of both layers, no effusion | LV hypertrophy, normal systolic function | |
Septal bounce | Usually normal septal motion | |
Spectral Doppler | ||
Transmitral and transtricuspid inflow E > a Increased E-wave velocity Shortened deceleration time Respiratory variation of E-wave velocity and IVRT |
Transmitral and transtricuspid inflow E < A (early stage) E >> A (late stage) No respiratory variations |
|
Pulmonary veins Blunted S-wave, large D-wave |
||
Hepatic veins Large A-wave Prominent y descent |
||
Tissue Doppler | ||
E′ > 8 cm/s | E′ < 8 cm/s | |
Color M-mode | ||
Flow propagation > 45 cm/s | Flow propagation < 45 cm/s |
IVRT, isovolumic relaxation time; LV, left ventricular; RA, right atrial; 2D, two-dimensional.
Pitfalls
Differential Diagnosis of Constrictive Pericarditis
Alternative Approaches

Figure 12-14 Thickened and calcified pericardium (arrows) seen with TEE (A), CT scan (B), chest x-ray (C), and MRI (D).
Key Points
Other Pericardial Diseases
Acute Pericarditis
Epicardial Fat
Congenital Absence of the Pericardium
Pericardial Cysts and Tumors
Surgical Considerations
Pericardiocentesis
Pericardial Window
Pericardiectomy
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