Pericardial Disease

1. Pericardial Disease Susan A. Raaymakers, MPAS, PA-C, RDCS (AE)(PE) Radiologic and Imaging Sciences - Echocardiography Grand Valley State University, Grand Rapids, Michigan raaymasu@gvsu.edu

2. Normal PericardiumFor ARDMS Exam • Three layers: • Fibrous pericardium – thick outer sack • Serous parietal – bound to fibrous pericardium smooth, ‘the wall of a cavity’ • Serous visceral – bound to epicardium smooth, ‘toward the organ’ • 5 to 10 ml pericardial fluid found in between the two serous layers

3. Normal Pericardium • Pericardial fluid is often appreciated as a very small echo-free space in the posterior atrioventricular groove. • Echo-free space between visceral and parietal pericardium (epicardium and fibrous pericardium) • Visualized as a small anechoic space in the posterior AV groove that may be visible only in systole 09-001a-1b Feigenbaum

4. Pericardial Diseases • Can present as several different clinical scenarios • Pericardial effusions can accumulate in any infectious or inflammatory process involving the pericardium • Most infectious and inflammatory process involve both layers of the pericardium (visceral and parietal)

5. Pericardial Diseases • Pericardial space is limited • Accumulation of significant pericardial fluid reduces the space that the heart may occupy Non-dynamic

6. Pericardial Diseases • Hemodynamic compromise is related to intrapericardial pressure • Intrapericardial pressure is related to the volume of pericardial fluid and the COMPLIANCE OR DISTENSIBILITY of the pericardium

7. Pericardial Diseases • Slowly developing large effusions are better tolerated than a smaller but more rapidly developing effusion • More rapidly developing effusion does not allow the heart to compromise 09-004a Feigenbaum

8. Difference in pericardial pressures - Rapid vs slow accumulation ACUTE CHRONIC PRESSURE VOLUME

9. Detection and Quantification of Pericardial Fluid

10. Detection and Quantification of Pericardial Fluid M-Mode • Appears as anechoic space both anterior and posterior to the heart. • Note: An isolated anterior free space is not specific for pericardial fluid. • Isolated anterior anechoic space may be due to mediastinal fat

11. Detection and Quantification of Pericardial Fluid M-Mode • Size of anechoic space is directly proportional to the amount of fluid • No accurate M-mode techniques for quantifying absolute volume of pericardial fluid

12. Detection and Quantification of Pericardial Fluid 2D • Most often used for screening • Seen between Descending Ao and CS • Most echocardiographic labs visually quantify pericardial effusion as: • Minimal • Small • Moderate • Large • Further characterize: • Either free or loculated • Presence or absence of hemodynamic compromise

13. Detection and Quantification of Pericardial Fluid Small Pericardial Effusion- 1 cm of posterior anechoic space with or w/out fluid accumulation elsewhere 09-003 Feigenbaum Minimal Pericardial Fluid - Normal 09-001a-1b Feigenbaum

14. Detection and Quantification of Pericardial Fluid Large Pericardial Effusion – more than 2 cm of maximal separation 09-004b Feigenbaum Moderate Pericardial Effusion – 1 to 2 cm of anechoic space 09-004a Feigenbaum

15. Minimal Pericardial Fluid Small Pericardial Effusion Large Pericardial Effusion Moderate Pericardial Effusion

16. Large pericardial effusion: signs • Soft heart sounds • Reduced intensity of friction rub • Ewart’s sign: Dullness and decreased breath sounds, over posterior L lung due to compression by large pericardial sac • Electrical alternans on ECG

17. Large pericardial effusion: signs • Electrical alternans on ECG

18. Large Pericardial Effusion and a Swinging Heart • Large pericardial effusion • In this image also a large pleural effusion 09-010a-10b Feigenbaum

19. Detection and Quantification of Pericardial Fluid • On 2D echo: pericardial effusion typically appears maximal in the posterior atrioventricular groove • Use multiple views to reliably assess fluid including PSAX, Apicals, and Subcostals 09-004a Feigenbaum

20. Detection and Quantification of Pericardial Fluid Small Pericardial Effusion – PSAX PM Large Pericardial Effusion – PSAX PM 09-007 Feigenbaum 09-006 Feigenbaum

21. Detection and Quantification of Pericardial Fluid Moderate, predominately lateral pericardial effusion (PEF) Note PEF behind RA Mod to Large PEF w/greatest dimension lateral to LV free wall 09-009 Feigenbaum 09-008 Feigenbaum

22. Detection and Quantification of Pericardial Fluid • PEF may be localized or loculated rather than circumferential • May occur after cardiac surgery or cardiac trauma Non-dynamic

23. Loculated effusion at apex Non-dynamic

24. Stranding and Fluid Accumulation • Presence of fluid accumulation, masses and stranding • Occur either on the visceral pericardium or the interior aspect of the parietal pericardium • Fibrin strands are commonly seen in long-standing effusions or effusions from metastatic diseases 09-016 Feigenbaum

25. Direct Visualization of the Pericardium 09-017 Feigenbaum

26. Detection and Quantification of Pericardial Fluid • Several schemes have been used for actual quantification of pericardial volume • None have had universal clinical acceptance • 3D echo may provide the most accurate technique for quantification and assessment • 3D volume of entire pericardial space is calculated • Overall total volume of the entire heart is calculated • Pericardial fluid is calculated as the difference between entire pericardial space and overall total volume • Little significance due to lack of 3D availability and lack of clinical need to determining precise pericardial volume

27. Detection and Quantification of Pericardial Fluid • 3D Pericardial Effusion 09-013b Feigenbaum

28. Direct Visualization of the Pericardium

29. Direct Visualization of the Pericardium • Pleural effusion creates a fluid layer on either side of the pericardium • In absence of pleural effusion exterior potion of parietal pericardium abuts the normal intrathoracic structures • Therefore, thickness and character of the pericardium cannot be separated from the surrounding tissues • When both pericardial and pleural effusions are present, thickness of pericardium in hat area can be assessed

30. Direct Visualization of the Pericardium 09-010a-10b Feigenbaum

31. Direct Visualization of the Pericardium • Presence of calcific pericarditis may be marked shadowing seen posterior to pericardium • Normal pericardium is highly reflective • Hyperechoic pericardium alone should not be used to diagnose constrictive pericarditis 09-015 Feigenbaum

32. Differentiation of Pericardial from Pleural Effusion

33. Differentiation of Pericardial from Pleural Effusion • Pleural effusion can be mistaken for pericardial effusion • Fluid appearing exclusively behind the LA is more likely to represent pleural than pericardial effusion • Pericardial reflections surround the pulmonary veins and tend to limit the potential space behind the LA

34. Differentiation of Pericardial from Pleural Effusion • Location of fluid-space with respect to descending thoracic aorta • Pericardial reflection is typically anterior to the descending aorta • Fluid appearing posterior to descending aorta more likely pleural Non-dynamic

35. Hierarchy of Significant Pericardial Effusions

36. Hierarchy of Hemodynamically Significant Pericardial Effusions • Exaggerated respiratory variation of tricuspid inflow • Exaggeration in mitral inflow • Right atrial collapse occurs at lower levels of intrapericardial pressure elevations than RVOT collapse • Right ventricular free wall collapse (may be seen in expiration but not inspiration with RV filling is increased) • When intrapericardial pressure is elevated and consistently exceeds intravascular pressures the above findings will be present simultaneously

37. Hierarchy of Hemodynamically Significant Pericardial Effusions Instances with changes may not be seen: • Significant RVH usually d/t pulmonary hypertension • Thick, noncompliant RV wall is not compressed by modest elevation in pericardial pressure • Thickening of the ventricular wall d/t malignancy, an overlying inflammatory respoinse or an overlying thrombus in a hemhorrhagic pericarditis • Hypovolumia causing a low pressure tamponade

38. Cardiac Tamponade

39. Cardiac Tamponade • Clinical diagnosis made at the bedside; • Echo helps determine the amount and location of fluid • Occurs mostly with moderate-to-large effusions although small, rapidly accumulated effusions may also cause tamponade

40. Cardiac TamponadeClinical Features • Symptoms • dyspnea, fatigue, cough, agitation and restlessness, syncope, and shock • Physical examination • pulsusparadoxus (may also be present in COPD patients or patients on ventilators) • ECG may shows electrical alternans • increased jugular venous pressure • Beck’s triad • Elevated venous pressure • Hypotension • Quiet heart

41. Respiration VariationReview

42. Respiration Variation Review: • Inspiration: intrathoracic and intrapericardial pressures ↓ • ↑flow into right heart • ↑right ventricular filling and stroke volume • ↓ flow to pulmonary veins • Compensatory decrease in left ventricular stroke volume in early inspiration

43. Respiration Variation Review: • Expiration: • Intrathoracic pressure and intrapericardial pressure ↑ • Mild ↓ in RV diastolic filling • ↑ in LV filling

44. Respiration Variation • Cyclic variation of LV and RV filling is sufficient to create mild changes in stroke volume (SV) and blood pressure • Normal respiratory variation of SV results in ≤ 10 mmHg ↓ in systolic arterial systolic pressure with inspiration • Processes that alter the respiratory cycle (i.e. COPD) ↑ work of breathing ↑intrathoracic pressure swings • Alter variation of SV and arterial pulse pressure

45. Cardiac Tamponade • ↑ accumulation of pericardial fluid ↑ intrapericardial pressure and affects RV filling • Overall effect of ↑volume of pericardial fluid limits total blood volume within four cardiac chambers • Exaggerate the respiration-dependent ventricular volume • If intrapericardial pressure >normal filling pressure, filling is determined by intrapericardial pressure

46. Cardiac Tamponade • LV has stiffer wall and diastolic filling is determined largely by active relaxation LV filling is relatively unaffected compared to RV filling • In large pericardial effusions, elevation of interpericardial pressure inspiration results in disproportionately greater filling of RV than normal and leads to greater compromise of LV filling

47. Pericardial Tamponade:Pathophysiology • Increased intra-pericardial pressure • Exceeds ventricular diastolic pressure • Causing impaired diastolic filling • Elevated venous pressure • JVP, hepatomegaly, edema • Dyspnea • Decreased filling  decreased stroke volume • Reflex tachycardia, hypotension

48. Cardiac Tamponade • Marked exaggeration in phasic changes with respiration • Greater decrease in systolic arterial blood pressure with inspiration • Variation of BP with respiration called pulses paradoxus

49. Cardiac Tamponade- Doppler Findings • Under normal circumstances, peak velocity of mitral inflow varies by 15% with respiration and tricuspid by 25% • Variation of aortic and pulmonary flow velocities vary less than 10%

50. Cardiac Tamponade- Doppler Findings Tricuspid • In presence of hemodynamically significant pericardial effusion: • Respiratory variation is exaggerated above normal variation and therefore velocities are exaggerated • Inspiration: ↑right↓left • Expiration: ↓right ↑left Mitral