Pericardial Disease

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12 Pericardial Disease

Introduction

Background

image

Figure 12-1 Normal pericardial anatomy.

From Gray H. Anatomy of the Human Body. Philadelphia: Lea & Febiger, 1918; Bartleby.com, 2000.

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

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.

Pericardial versus Pleural Effusion

In contrast, PEs are generally found between the descending thoracic aorta and the LA (Figure 12-6A). On occasion, an effusion may be first appreciated surrounding the left atrial appendage (LAA; see Figure 12-6B).

Cardiac Tamponade

Anatomic Imaging

Constrictive Pericarditis

Background

TABLE 12-4 PATHOPHYSIOLOGY OF PERICARDIAL CONSTRICTION

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.

Anatomic Imaging

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.

Alternative Approaches

Other Pericardial Diseases

Surgical Considerations

Pericardiectomy

Suggested Readings

1 Goldstein JA. Cardiac tamponade, constrictive pericarditis, and restrictive cardiomyopathy. Curr Probl Cardiol. 2004;29:503-567.

A comprehensive review of the normal anatomy and function of the human pericardium. The pathophysiology and clinical diagnosis of cardiac tamponade and pericardial constriction are meticulously described and illustrated with a number of useful figures.

2 Khandaker MH, Espinosa RE, Nishimura RA, et al. Pericardial disease: Diagnosis and management. Mayo Clin Proc. 2010;85:572-593.

A nicely illustrated overview on the clinical management of pericardial disease including several flow charts and diagnostic algorithms.

3 Wann S, Passen E. Echocardiography in pericardial disease. J Am Soc Echocardiogr. 2008;21:7-13.

A concise review on pericardial diseases with the focus on echocardiography as the diagnostic method. It contains explanations of different imaging techniques, matching illustrations, and echocardiographic images.

4 D’Cruz IA, Kanuru N. Echocardiography of serous effusions adjacent to the heart. Echocardiography. 2001;18:445-456.

This article is dedicated to the anatomic imaging and differentiation of pericardial effusion, pleural effusions, and ascites using echocardiography.

5 Reddy PS. Spectrum of hemodynamic changes in cardiac tamponade. Am J Cardiol. 1990;66:1487-1491.

This study in 77 patients with pericardial effusion is a great example for the hemodynamic impact of tamponade with respect to pressure equalization and the response to pericardiocentesis.

6 Yared K, Baggish AL, Picard MH, et al. Multimodality imaging of pericardial disease. J Am Coll Cardiol Imaging. 2010;3:650-660.

A good review looking at different imaging modalities for the diagnosis of pericardial diseases. An emphasis is put on the comparison of echocardiography with other imaging studies.

7 Hatle LK, Appleton CP, Popp RL. Differentiation of constrictive pericarditis and restrictive cardiomyopathy by Doppler echocardiography. Circulation. 1989;79:357-370.

An excellent study focused on the pathophysiology of pericardial constriction. Patients with constrictive pericarditis showed respiratory variation of ventricular inflow velocities, whereas patients with restrictive cardiomyopathy did not. These findings are also illustrated using ventricular pressure tracings.

8 Schwefer M, Aschenbach R, Heidemann J, et al. Constrictive pericarditis, still a diagnostic challenge: Comprehensive review of clinical management. Eur J Cardiothorac Surg. 2009;36:502-510.

A review of the pathophysiology and clinical presentation of constrictive pericarditis, but the focus is on the clinical management, especially the surgical aspects of pericardiectomy and associated outcomes.