Pericardial Diseases

Atul Jaidka | Echo Rounds

Objectives

• Anatomy
• Tumours
• Pericardial Cyst
• Congenital
• Pericardial Fat
• Pericardial Effusion
• Tamponade
• Pericarditis
• Constriction

Case!

Code Stemi

• Cath: Non-obstructive CAD
• Admitted to CCU
• High O2 Requirements
• Please do echo for HF

Conclusion

• History of laryngeal SCC
• CT also shows pulmonary nodules
• Biopsy pending to confirm diagnosis
• Likely Metastatic SCC

Anatomy

Anatomy

• Double layers structure with visceral and parietal
• Visceral (serosal) is attached to epicardium and parietal (fibrous) surrounds the heart
• Normally 20-50mL of fluids present

Echo Protocol

Echo Protocol

• 2D echocardiography
  • PEff (size, location, free flowing vs organizing, suitability for pericardiocentesis vs window)
  • Pericardial thickness (particularly TEE)
  • Collapse of right-sided chambers (duration of diastole and relation with respiration)
  • Early diastolic septal bounce, respiratory shift of the ventricular septum
  • IVC plethora
  • Pleural effusion/ascites
  • RA tethering (best seen by TEE)
  • Stasis of agitated saline contrast in right atrium (sluggish flow)

Echo Protocol

• Doppler with Respirometry
  • Restrictive mitral inflow pattern
  • Reciprocal respiratory changes of mitral (and tricuspid) inflow
  • Reciprocal respiratory changes of diastolic forward flow velocity and end diastolic flow reversal in hepatic veins
  • Tissue Doppler velocities of mitral annulus, color Doppler M-mode of mitral inflow
  • 2D strain of longitudinal and circumferential deformation
• M-Mode
  • Flattening of the posterior wall during diastole
  • Respiratory variation of ventricular size

Tumours

Pericardial Masses

https://www.acc.org/latest-in-cardiology/articles/2016/07/12/13/06/cmr-and-pericardial-masses

• Masses can be from primary tumour, metastases, or mass encroaching on pericardium
• Almost always effusion
• Metastatic disease most commonly to pericardium

Case - Pericardial Lipoma

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5128889/

Pericardial Cysts

Pericardial Cyst

• Usually along right heart border
  • can be anywhere
• Generally asymptomatic unless compressing structure (ie coronary)
• Important to distinguish from mass
• Appear as echo free space, localized and spherical (vs pericardial effusion)
• Further imaging needed

UTD

Case

https://academic.oup.com/ehjcimaging/article/12/11/E43/2396998

Case

https://academic.oup.com/ehjcimaging/article/12/11/E43/2396998

Case

https://academic.oup.com/ehjcimaging/article/12/11/E43/2396998

Congenital Absence of Pericardium

Congenital Absence of Pericardium (CPA)

• Pericardium stabilizes the heart and limits dilation
• Absence of pericardium is rare
• Can be complete bilateral (9%), complete left (70%), complete right (17%), or partial (3-4%)
  • Partial can be life threatening due to possible herniation  (strangulate cardiac structure or compress coronaries)
• 50% of cases have associated findings
  • ASD, PDA, ToF, etc
• Complete usually asymptomatic
• Partial can have trepopnea (dyspnea on one side or chest pain (compression of coronaries)

ECG

• Normal in complete
• Left CPA can have RAD, RBBB, poor transition

CXR

• Left CPA heart can shift posterior and left causing straightening and elongation of heart (levorotation and levoposition)
• "Snoopy" Sign

ECHO

• Complete CPA better imaged supine give heart shift posterior and leftward
• Exaggerated movement of heart in chest
• Outward bulging of LV inferior wall seen best on 2 Chamber (tear drop shape)
• Need further imaging to confirm
  • CMR gold standard

Case 1

ECG: incomplete RBBB, poor R wave progression, right axis deviation

29M presented with atypical chest pain

Case 1

A4C Medial

A4C Lateral

Note posteriorly directed apex and exaggerated mobility. "Teardrop" ventricles. Usual apical location shows RV predominance requiring supine positioning

https://www.cvcasejournal.com/article/S2468-6441(19)30165-3/fulltext

Case 2

Right ventricle appears enlarged, teardrop-shaped heart, and hypermobile heart

https://www.cvcasejournal.com/article/S2468-6441(19)30165-3/fulltext

"Pericardial Fat"

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3998169/

Epicardial and Paracardial Fat

https://www.jacc.org/doi/pdf/10.1016/j.jacc.2011.05.052

Epicardial and Paracardial Fat

UTD

• dashed arrow: "paracardial fat"
• arrowhead: epicardial fat
• arrow: visceral pericardium
• thick arrow: parietal pericardium

Epicardial and Paracardial Fat

https://www.journal-of-cardiology.com/article/S0914-5087(14)00203-2/pdf#:~:text=On%20the%20other%20hand%2C%20the,(pericardi%2Dal%20fat).

Epicardial Fat vs Pericardial Effusion

• Epicardial fat is often brighter than myocardium
• Moves in concert with heart
• Pericardial effusion is usually echolucent and motionless

ASE

Pericardial Effusion

Indications for Echo

• Chest pain consistent with pericarditis or dissection
• Enlarged cardiac silhouette on chest x-ray
• Systemic disease associated with effusion
• Post-MI
• Hemodynamic instability after cardiac procedure

Sizing

• Measure between visceral and parietal pericardium at end diastole (multiple spots to increase accuracy to assess volume)
• Trivial (<10mm) <50mL
  • seen only in systole
• Small (<10mm) 50-100mL
• Moderate (10-20mm) 100-500mL
• Large (>20mm) >500mL

Examples

ASE

Pleural Effusion

• Assess on PLAX view
• Fluid between descending aorta and heart is pericardial
• Fluids below descending aorta is pleural

ASE

Stranding

UTD

• Pericardial stranding suggests fibrous material in the pericardial effusion
• Commonly seen post cardiac surgery, pericardial hemorrhage and in inflammatory process

Hematoma/Loculated Effusion

UTD

• Large pericardial clot causing obliteration of right atrium

Tamponade

Tamponade - Chamber Collapse

• RA and RV diastolic chamber collapse most commonly seen
• RA collapse sensitive not specific
  • If exceeds 1/3 cardiac cycle very sensitive and specific
• No chamber collapse has 90% negative predictive value

Tamponade - Resp Variation

• Resp Variation
  • Formula: (Exp-Insp)/Exp
    • Measure first beat after insp and exp
  • Mitral >30%
  • Tricuspid >60%
• Should not be used in isolated
• Differentiate from COPD:
  • Tamponade first insp beat largest vs COPD second beat

Acute Pericarditis

Acute Pericarditis

• All patients should undergo echocardiography
• Assess for:
  • Pericardial effusion
  • Exclude other etiologies of chest pain

Constriction

1. Ventricular septal motion abnormality (from ventricular interdependence)
2. Medial mitral annulus e' velocity ≥ 9 cm/sec
3. Hepatic vein expiratory diastolic reversal ratio ≥ 0.79 (Figure)
4. Restrictive mitral inflow velocity (E/A ratio > 0.8)
5. Plethoric inferior vena cava

1 + either 2 or 3 =  87% sensitive and 91% specific

Diagnosis