CHAPTER 6: ECHOCARDIOGRAPHIC ASSESSMENT OF PERICARDIAL DISEASE

INTRODUCTION

Echocardiography remains the principal imaging method to assess pericardial disease, especially in the acute setting, and it is the imaging method of choice to diagnose the presence of pericardial effusions. In fact, one of the initial descriptions of the use of echocardiography in the United States was a seminal paper by Dr. Harvey Feigenbaum in 1965 describing the use of cardiac ultrasound to detect pericardial fluid.¹

While other imaging techniques have provided improved assessment of pericardial anatomy, such as pericardial thickness, calcification, and congenital pericardial abnormalities, echocardiography is the modality of choice employed to evaluate the hemodynamic consequences of pericardial fluid (tamponade) and to assess (non-invasively) for pericardial constriction. The use of echocardiography is a Class 1 indication for the evaluation of many clinical scenarios in which pericardial involvement is suspected.² In the recently revised appropriate use criteria for echocardiography,³ echocardiography is deemed appropriate in a variety of clinical scenarios, including: possible pericardial effusion after severe trauma (indication 32); suspected pericardial conditions (indication 59); reevaluation of known effusions to guide therapy (indication 61); and guidance of percutaneous pericardiocentesis (indication 62).

Both cardiac CT and MRI do play a role in the evaluation of patients with pericardial disease. The recently published guidelines for multimodality imaging of patients with pericardial disease emphasize the primary role of echocardiography in this patient population, but also highlight the secondary roles of CT and MRI.⁴ This document provides a comprehensive review of imaging in these patients.

In this chapter, we will explore the use of echocardiography in a variety of clinical settings, including its role the evaluation of acute pericarditis, its role in the evaluation and management of idiopathic or chronic pericardial effusions, the assessment of cardiac tamponade and constriction, and its role in the acute setting of suspected cardiac perforation as a complication of invasive cardiac procedures.

SECTION 1: MALIGNANT PERICARDIAL EFFUSION

CLINICAL CASE PRESENTATION

The patient is a young man who was recently diagnosed with stage IV non-small cell lung carcinoma. He also has a history of COPD. He presented to the emergency room with worsening dyspnea for approximately 2 weeks. He had been treated with inhalers without improvement in his symptoms. He also noted increasing cervical adenopathy and generalized upper and lower extremity swelling. He had initially presented (3 months prior to this presentation) with dyspnea, and further workup demonstrated a left upper lobe mass as well as significant mediastinal adenopathy. He was treated with radiation therapy with plans for further chemotherapy, which had not been started.

On physical examination he was found to be tachycardic. He did not have significant neck vein distention. Cardiac exam revealed that he was tachycardiac with no murmurs, gallops, or rubs. He had trace lower extremity edema. Given his physical exam findings and hypoxia there was concern that he ...