Pericardial Disease: Constriction and Tamponade Rory B. Weiner, MD

Cardiac Ultrasound Laboratory Massachusetts General Hospital Assistant Professor of Medicine Harvard Medical School

American Society of Echocardiography Echo Florida October 15, 2013

Pericardium • Pericardial space typically contains 10 – 50 mL of fluid. • Pericardial space not visualized on echo in most normal

subjects. – Small amount of physiologic pericardial fluid may be

seen in the posterior pericardial space during ventricular systole. • Pericardial thickness: – CT or MRI preferable to measure pericardial thickening.

Pericardium: Echo Evaluation •

Full 2D examination with emphasis on location, volume, and characteristics of pericardial fluid and pericardium. – Views of RA and RV free walls. – Long loops to capture changes related to respiratory cycle.

•

M-mode examination (RV free wall).

•

PW Doppler of tricuspid and mitral inflow, pulmonary vein flow, and hepatic vein flow.

•

Tissue Doppler imaging of medial and lateral mitral annulus

•

IVC imaging.

•

Post-operative patients: search for localized effusions.

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Pericardial Constriction • Etiology: – Infectious (i.e. tuberculosis) – Trauma (including prior cardiac surgery) – Prior acute pericarditis – Autoimmune (i.e. SLE, RA) – Malignancy • Including prior radiation – Metabolic (i.e. renal disease, hypothyroidism)

– Idiopathic

Pathophysiology • Mid- and late-diastolic filling is impeded as end-

diastolic volume is impeded by the thickened / fibrotic pericardium. • Early diastolic filling typically not impaired

(can be supra-normal due to elevated atrial pressure). • Dynamic changes in filling throughout the

respiratory cycle.

Case • 60-year-old woman with a history of breast cancer and

prior mediastinal radiation (1991). • Several years of progressive dyspnea on exertion and

lower extremity swelling. • Now admitted with worsening functional status and clinical

evidence of heart failure. • Transthoracic echocardiogram.

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M-Mode and 2D: IVS Motion

Movement of the septum posteriorly with inspiration and anteriorly with inspiration.

Septal “Bounce”

Abrupt bouncing motion toward the LV during inspiration, followed by a shift in the opposite direction during diastole.

Posterior LV wall “Flattening” • Due to abrupt cessation of flow in mid/late-diastole.

Voelkel AG et al. Circulation 1978;58:871-5.

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Trans-mitral Flow

•

Rapid early diastolic flow: –

High E wave velocity

–

Short deceleration time

–

Low A wave velocity

Respiratory Changes in Cardiac Filling •

Two physiologic phenomena 1. Dissociation of intracardiac from intrathoracic

pressures: –

Fall in PV pressure with inspiration but not in LV diastolic pressure.

–

Driving pressure across the mitral valve is reduced.

2. Ventricular interdependence: –

Reduction in LV filling with inspiration allows for compensatory increase in right heart filling.

Trans-mitral Flow Variation

>25% reduction in E velocity (typically on the first inspiratory beat).

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Hepatic Vein Flow

Expiratory flow reversal

Inferior Vena Cava (IVC)

Dilated with blunting of the normal inspiratory collapse (consistent with elevated RA pressure).

Tissue Doppler Imaging (TDI)

E’ Septal

>

E’ Lateral

“Annulus reversus”

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Constriction vs. Restriction Parameter

Constrictive Pericarditis

Restrictive Cardiomyopathy

Pericardium

Thickened

Normal

LV

Septal bounce

↑ Wall thickness

Atria

Normal size

Dilated

Mitral inflow

E/A increased, short DT

E/A increased, short DT

>25% E inspiratory ↓

No significant resp. var.

Tissue Doppler

E’ sept > E’ lat

Reduced

Hepatic veins

Expiratory flow reversal

Blunted S/D ratio

Invasive Hemodynamics

Constriction: discordance in LV and RV pressures with respiration.

Hurrell DG et al. Circulation 1996;93:2007-13.

Pericardial Effusion •

Echolucent zone corresponding to greater than physiologic volume of fluid in the pericardial space. – Accumulates first in the posterior pericardial space (oblique sinus) – Size:

• Minimal: 2 mm (>500 mL) •

Differentiate normal anatomic variants and nonpericardial processes: – Pleural effusion – Pericardial / epicardial fat • Generally more prominent anteriorly

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Rate of Fluid Accumulation

Spodick DH et al. N Engl J Med 2003;349:684-90.

Case • 54-year-old man with rheumatoid arthritis (steroid

dependent) presents with increasing fatigue and dyspnea on exertion. • ECG shows sinus rhythm with decreased QRS voltage.

• Transthoracic echocardiogram.

RV Diastolic Collapse

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M-Mode: RV Diastolic Collapse

RV collapse may not occur in pulmonary HTN, RVH, or RV volume overload.

RA Inversion

RA Inversion Index

0.34

Gillam L et al. Circulation 1983;68:294-301.

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TEE: Post-cardiac surgery

Classic findings of tamponade may not be present in localized, regional cardiac compression after cardiac surgery.

Other Findings • LA inversion / compression / collapse: – May be useful in patients with high right-sided

pressures or post-operative patients. • LV diastolic collapse: – Typically seen with localized effusion (post-cardiac

surgery). Chuttani et al. Circulation 1991;83:1999-2006.

Doppler Echocardiography

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Echo-guided Pericardiocentesis • Confirm location / size of the effusion. • Determine if effusion is loculated. • Determination of optimal access site and approach.

Tsang T et al. Mayo Clin Proc 1998;73:647-52.

Effusive-Constrictive Pericarditis • Small percentage of pericardial effusion patients have

persistence of constrictive physiology after removal of the pericardial fluid.

Sauleda JS et al. N Engl J Med 2004;350:469-75.

Conclusions • Respiratory variation in intracardiac flows and ventricular

interdependence are key physiologic hallmarks of pericardial disease. • Echocardiographic evaluation of pericardial disease

requires integration of M-mode, 2D, and Doppler findings. • Tissue Doppler is a useful adjunct for constriction. • Tamponade is a clinical diagnosis, although echo provides

information regarding hemodynamic impact and guidance of pericardiocentesis.

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