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CHAPTER 16: Pericardial Disease

GUIDELINES Source

  • Adler Y, Charron P, Imazio M, et al. The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology. Eur Heart J. 2015;36:2921–2964.

  • Extensive, easy-to-understand charts on the diagnosis and treatment of all pericardial disorders.

  • Includes cardio-oncology.

  • A web addendum complements the article.

Source

  • Klein AL, Abbara S, Agler DA, et al. American Society of Echocardiography clinical recommendations for multimodality cardiovascular imaging of patients with pericardial disease. J Am Soc Echocardiogr. 2013;26:965–1012.

  • This is an excellent, well-illustrated starting point for understanding the role of echo in all pericardial disorders.

ACUTE PERICARDITIS

  • A patient with acute pericarditis is diagnosed by the combination of pleuritic chest pain, a pericardial rub on auscultation, and a typical abnormal ECG.

  • A referral for an echocardiogram is expecting information about the presence and size of a pericardial effusion.

  • During the early stages of pericarditis, there may be little or no pericardial effusion.

Source

  • Markiewicz W, Brik A, Brook G, et al. Pericardial rub in pericardial effusion: lack of correlation with amount of fluid. Chest. 1980;77:643–646.

The presence or absence of a rub does not correlate with the amount of pericardial fluid.

A pericardial rub was noted in 4 of 13 patients with small pericardial effusion (<100 mL), in 23 of 40 patients with moderate effusion (100–500 mL), and in 10 of 23 patients with a large effusion.

No difference in the amount of fluid was demonstrated in the group of patients with a rub when compared to the group without one.

PERICARDIAL EFFUSION

  • A common question to the echocardiographer is about the size of a pericardial effusion.

  • In fact, the hemodynamic impact is more clinically important than the size.

  • An example of a popular arbitrary classification:

    • - Small: <0.5 cm posteriorly and minimal anteriorly.

    • - Moderate: >0.5 cm posteriorly with some extension anterior to the right ventricle.

    • - Large: circumferential with >2 cm anteriorly and posteriorly.

    • - Minimal: 2 mm in size posterior to the heart in PLAX. The anterior echolucent space is no bigger.

  • A large effusion raises the question of need for pericardiocentesis.

CARDIAC TAMPONADE

“Decreased blood pressure or decreased cardiac output due to cardiac compression by fluid in the pericardial space.”

  • Hemodynamic compromise is manifested as:

    • - Inversion of the right atrial or right ventricular free wall (Figs. 16-1 to 16-5).

    • - In patients with pulmonary hypertension there may be inversion of the left atrial free wall instead.

    • - Mitral inflow E velocities decrease by 25% or more on inspiration (Fig. 16-6).

    • - Tricuspid inflow E velocities decrease by 40% or more on expiration (Fig. 16-7).

FIGURE 16-1

Large pericardial effusion with partial right atrial collapse.

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