Question 2 : Pericardial disease

Question 2.

Discuss the use and value of echocardiography in evaluating pericardial disease of various types

Value is to look at the pericardium for structural abnormalities (thickening/calcification), assess associated pericardial effusions (may have strands suggesting inflammatory more chronic problem, may be anechoic, may show swirling cells) , look for haemodynamic signs of pericardial constriction. Pericardial disease can either be restrictive (affecting the myocardium) or constrictive (affecting the pericardium)

Criteria to differentiate constrictive from restrictive cardiomyopathy . In constrictive pericardial disease there is

  • Respiration-related ventricular shift (septal bounce)
  • Respiratory variation in mitral inflow velocity
  • Preserved or exaggerated medial mitral annulus early diastolic (e’) velocity (³9 cm/s)
  • Medial e’ equal to or greater than lateral mitral annulus e’ velocity (annulus reversus)
  • Constrained circumferential and preserved longitudinal myocardial deformation (strain)
  • Marked hepatic vein diastolic flow reversal with expiration

Causes of pericardial disease:
• Inflammatory
• Post radiation
• Post cardiac surgery
• CT disease
• Idiopathic

ECHO can show

1. Associated pericardial effusion :

  • Anechoic, echoic, associated with fibrin strands.
  • The size of the effusion can be measured in end diastole if present.
  • Haemodynamic effects of pericardial effusion can be assessed

2. Thickening of pericardium +/- calcification (if in plaques “eggshell ” pericardium). Poorly image quality . Normal pericardium is 2mm or less (3)

3. Signs of pericardial constriction

  • Fixed and dilated IVC and dilated hepatic veins
  • Septal shift towards LV on inspiration
  • Septal bounce (respirophasic respiratory  shift)
  • Increase in the size of the right ventricle on inspiration
  • Exaggerated trans- tricuspid flow during inspiration  > 40%
  • > 25% respiratory variation of mitral valve inflow velocity (decrease in peak mitral E-wave velocity by >25% during the first beat of inspiration)
  • Expiratory flow reversal in hepatic veins (PW Doppler)

Explanation  of interventricular interdependence (2) :

The rigid, noncompliant fibrous pericardial sac couples both ventricles. Consequently, an increase in filling on one side of the heart impedes contralateral filling throughthe motion of the interventricular septum (IVS), thereby making both ventricles markedly interdependent.15-17 The inspiratory reduction in LV filling is therefore associated with a simultaneous increase in right ventricular (RV) diastolic filling and an IVS shift toward the left chamber. The opposite physiologic effects on filling gradients and IVS shift are seen in expiration, with increased pulmonary venous pressure and an attendant increase in LV diastolic inflow. This is associated with simultaneous decrease in right-sided filling.”

4. Small ventricle /atria
5. Pleural effusion/ ascites
6. Distorted heart contour in forms of regional constriction

References

  1. 123 sonography
  2. Journal of the American Society of Echocardiography January 2009:   STATE OF THE ART REVIEW Role of Echocardiography in the Diagnosis of Constrictive Pericarditis
    Jacob P. Dal-Bianco, MD,* Partho P. Sengupta, MBBS, MD, DM,*
  3. ESC  Constrictive pericarditis: role of echocardiography and magnetic resonance imaging
    Vol.15,N°23 – 22 Nov 2017

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