Pericardial Diseases

Pericardium =

2 layers that surround the heart and proximal great vessels

visceral pericardium =

epicardium; inner layer where coronaries sit underneath

parietal pericardium

outer layer, fibrous structure providing mechanical support

• between fibrous pericardium and pericardial cavity

reflections of pericardium =

the 2 layers form a closed space with finger-like projections. this “pocket” creates sinuses

Oblique sinus

around IVC and Pulmonary veins

Transverse sinus

around Aorta and Pulmonary Artery

pericardial fluid

between 2 layers - lubricates heart so it can beat in a friction-free space

epicardial fat pad

present on anterior aspect, speckled/granular appearance

• elderly, obese, diabetic, female pts

What are the 2 functions of the pericardium?

1. Mechanical - allows heart to beat with minimal friction

2. Passive restraint - controls how much heart may expand in diastole

How does the pericardium work as a passive restraint?

The fibrous parietal pericardium contributes to resting diastolic pressures and limits acute dilation

How does the mechanical restraint of the pericardium influence ventricular interdependence?

LV and RV share the IVS and is surrounded by the noncompliant pericardium → volume in one ventricle can influence pressure & filling in the other

acute pericarditis clinical presentation

• dyspnea

• tachypnea

• palpitations

• fever

In acute pericarditis, how is the positional chest pain increased/decreased?

increases with inspiration

decreases with sitting up and leaning foward

acute pericarditis EKG

• reduced QRS voltage

• concave ST elevation

acute pericarditis EKG stage 1

ST elevation and PR depression

acute pericarditis EKG stage 2

J points flatten

acute pericarditis EKG stage 3

T-wave inversion

acute pericarditis EKG stage 4

Normal!

Acute pericarditis auscultation

• pericardial friction rub

• Ewart’s sign

Ewart’s sign

dullness on left lung

Acute pericarditis 2D echo findings

• swinging heart

• IVC plethora = ↑RAp

• effusion

• loculated effusion

• increased echogenicity (blood)

Constrictive Pericarditis pathophysiology

impaired LATE diastolic filling due to noncompliant case = ↑diastolic pressures

Constrictive Pericarditis causes cessation of mid-late ventricular filling due to physical limitation of expansion. This causes what sign on the atrial and ventricular pressure maps?

rapid “y” descent and “dip and plateau”

Constrictive Pericarditis clinical presentation

• jugular venous distension

• Kussmaul’s sign

• weakness, fatigue

• dyspnea, PND, orthopnea

• peripheral edema

• hepatomegaly + ascites

Kussmaul’s sign

rise in jugular pressures in inspiration

Constrictive Pericarditis ausultation

pericardial knock (low diastolic sound)

Constrictive Pericarditis EKG signs

• diffuse T-wave flattening

• low QRS voltage

• afib

• tachycardia

Constrictive Pericarditis 2D echo findings

• thickened pericardium >3 mm

• septal bounce

• IVC plethora

Septal bounce

IVS bulges to left during inspiration due to abrupt cessation of diastolic filling

IVC plethora

dilated IVC with lack of variation (↑RAp)

Constrictive Pericarditis M-MODE echo findings

• Railroad track sign

• Posterior wall flattening

• Spanish notch

Railroad track sign

parallel but separated epicardial & pericardial echoes

Posterior wall “flattening”

outward movement during mid-late diastole

Spanish notch

sudden anterior displacement and bisk posterior rebound of IVS

Constrictive Pericarditis Doppler (PW) echo findings

• Trans mitral flow - increases 25% with expiration

• Trans tricuspid flow - increases 40% with inspiration

• hepatic venous flow - ↑diastolic reversal with expiration

• TDI - annulus reversus

Annulus Reversus

septal E’ > lateral E’ due to tethering of lateral wall by pericardium

Cardiac Tamponade pathophysiology

injury to pericardium → pericardial effusion → increased intrapericardial pressures → cardiac chamber compression

Cardiac Tamponade: The increase in intrapericardial pressures causes the chamber pressures to equalize, and impairment of venous return, causing a _____ on the atrial tracing

blunted “y”

3 stages of tamponade

1. intrapericardial pressure rises < RVp and PCWP

2. intrapericardial pressure = RV but < PCWP

3. intrapericardial pressure = RV + PCWP

Cardiac Tamponade clinical presentation

• Beck’s triad

• dyspnea

• shock

• Pulsus Paradoxus

• Total Paradoxus

• peripheral cyanosis (↓CO)

• Kussmaul’s sign

• Ewart’s sign

Beck’s triad

1. Hypotension

2. Distended jugular veins (↑ venous pressure)

3. muffled heart sounds

Pulsus Paradoxus

>10 mmHg fall in systolic BP in inspiration

Total Paradoxus

complete absence of pulse with inspiration

Cardiac Tamponade EKG signs

• reduced QRS voltage

• ST elevation with upright T wave

• electrical alternans

• total alternans

• tachy/bradycardia

Electrical alternans

alternating QRS amplitude

Cardiac Tamponade 2D echo findings

• pericardial effusion

• presystolic collapse of RA

• RV + LV early diastolic collapse

• LA late diastolic collapse

• swinging heart

• IVC plethora

• dilated HpV + SVC

• inspiratory bounce of IVS toward LV

What are the most significant echo findings of Cardiac Tamponade?

chamber collapse & swinging heart

Cardiac Tamponade Doppler echo findings

abnormal diastolic biventricular flow with respiration

• MV ↑ in expiation

• TV ↑ in inspiration

• ↑diastolic HpV reversal

Mitral Flow _____ with expiration and ______ with inspiration

increases (expiration)

decreases (RV fills more and IVS compresses LV)

Tricuspid Flow _____ with expiration and ______ with inspiration

• decrease

• INcrease with INspiration (more blood to RA → ↑volume in RV → IVS moves to left → less filling in LV)