Pericardial Disease

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Ashvin N. Pande, MD and Leonard S. Lilly, MD

Contents

Case Presentation Introduction Anatomy Physiology

Acquired Pericardial Disease Acute Pericarditis Chronic Constrictive Pericarditis Pericardial Effusions and Compressive Syndromes Conclusion of Case Presentation Suggested Reading case presentation

A 59-yr-old woman presents with a history of diabetes mellitus, hypertension, and end-stage renal disease. She presented with several weeks of fevers, sweats, fatigue, and progressive exertional dyspnea. On initial evaluation, she was mildly short of breath. Vital signs were: temperature, 100.2°F; pulse, 108; blood pressure, 98/60. Physical examination was notable for bibasilar rales, jugular venous pressure (JVP) of 10 cm H2O, and mild peripheral edema. Chest X-ray showed cardiomegaly, clear lung parenchyma, and small bilateral pleural effusions. She was admitted for further evaluation. The following morning, she underwent peritoneal dialysis, after which she developed worsening dyspnea and transient hypotension. Electrocardiogram (ECG) at that time revealed sinus tachycardia and electrical alternans. An urgent echocardiogram was performed (Fig. 1; please see companion DVD for corresponding video).

introduction

This chapter reviews key topics in pericardial disease and their characteristic echocardiographic features. Echocardiography serves a vital role in the diagnosis and evaluation of pericardial disease, which is often difficult to recognize by bedside examination alone.

anatomy

The pericardium consists of two layers that surround the heart and proximal portions of the great vessels. The inner layer, the visceral pericardium, is a thin serosal membrane formed by a single layer of mesothelial cells. This layer reflects back on itself to line the outer layer, the parietal pericardium—a thick, fibrous structure providing mechanical support to the heart by means of liga-mentous links to the sternum, diaphragm, and vertebrae. The parietal and visceral pericardium form a closed space circumscribing the heart, with finger-like projections leading to blind pockets around the great vessels. Reflections of the pericardium at the pulmonary veins and at the aorta and pulmonary trunk result in the oblique and transverse sinuses, respectively (Fig. 2A,B).

A few anatomical descriptions are notable regarding the complexity of pericardial anatomy. First, because of the nature of pericardial reflections around the systemic and pulmonary vessels, the pericardium blankets the anterior and medial aspects of the right atrium, whereas the pericardial space terminates around the vena cavae superiorly and posteriorly. The pericardial space reaches lateral to the left atrium and to the pericardial reflections around

From: Contemporary Cardiology: Essential Echocardiography: A Practical Handbook With DVD Edited by: S. D. Solomon © Humana Press, Totowa, NJ

Pericardial Disease

Fig. 1. Case vignette: 59-yr-old female with fever, fatigue, and progressive exertional dyspnea. (A) Subcostal and parasternal long-axis views showing right ventricular diastolic collapse (green arrow) in the midst of a relatively large pericardial effusion. Right ventricular diastolic collapse is a highly specific (90-100%) finding in cardiac tamponade. (B) M-Mode echocardiography (top left panel) of the same patient in A shows right atrial inversion or systolic collapse (arrows). Exaggerated respirophasic changes in right ventricular outflow pattern is shown on pulsed wave Doppler examination of the right ventricular outflow tract (top right panel). M-mode through right ventricle on subcostal views confirms right ventricular diastolic collapse (arrows, bottom left panel). Inferior vena cava plethora with loss of normal respirophasic movements—an indication of increased right atrial pressures—was present (bottom right panel). (Please see companion DVD for corresponding video.)

Fig. 1. Case vignette: 59-yr-old female with fever, fatigue, and progressive exertional dyspnea. (A) Subcostal and parasternal long-axis views showing right ventricular diastolic collapse (green arrow) in the midst of a relatively large pericardial effusion. Right ventricular diastolic collapse is a highly specific (90-100%) finding in cardiac tamponade. (B) M-Mode echocardiography (top left panel) of the same patient in A shows right atrial inversion or systolic collapse (arrows). Exaggerated respirophasic changes in right ventricular outflow pattern is shown on pulsed wave Doppler examination of the right ventricular outflow tract (top right panel). M-mode through right ventricle on subcostal views confirms right ventricular diastolic collapse (arrows, bottom left panel). Inferior vena cava plethora with loss of normal respirophasic movements—an indication of increased right atrial pressures—was present (bottom right panel). (Please see companion DVD for corresponding video.)

the tethering pulmonary veins. Therefore, the common locations where pericardial fluid can collect are medially, laterally, and apically, whereas superior and posterior extension is necessarily limited by pericardial reflections.

Epicardial fat is a common anatomic and echocardio-graphic finding, often present on the anterior aspect of the cardiac surface. It is more common in older patients with obesity or diabetes. It is occasionally detected posteriorly where it can be particularly difficult to distinguish from pericardial effusion as discussed next (Fig. 3; please see companion DVD for corresponding video).

A small amount (15-35 mL) of pericardial fluid separates the two layers and serves a physiological lubricating function. The fluid consists of a plasma ultrafiltrate generated by the mesothelial lining of the pericardium and is drained by the thoracic lymphatic system. This small amount of pericardial fluid may be visualized by echocardiography under normal conditions,

Layers The Pericardium Heart

Fig. 2. Pericardium: anatomical relationships. The pericardium completely invests the heart and proximal portions of the great vessels and consists of two separate layers—the thin visceral pericardium (epicardium) and a thicker fibrous parietal pericardium. (A) Posterior view. The inferior parietal pericardium is adherent to the central tendon of the diaphragm. Most of the lateral and posterior parietal pericardium is in contact, but not adherent to the parietal pleura. A portion of the anterior parietal pericardium lies immediately posterior to the sternum and related fascia. (B) Lateral view. The transverse pericardial sinus lies between the arterial and venous poles of the heart. The oblique pericardial sinus is a blind recess running between the pulmonary veins and the inferior vena cava.

Fig. 2. Pericardium: anatomical relationships. The pericardium completely invests the heart and proximal portions of the great vessels and consists of two separate layers—the thin visceral pericardium (epicardium) and a thicker fibrous parietal pericardium. (A) Posterior view. The inferior parietal pericardium is adherent to the central tendon of the diaphragm. Most of the lateral and posterior parietal pericardium is in contact, but not adherent to the parietal pleura. A portion of the anterior parietal pericardium lies immediately posterior to the sternum and related fascia. (B) Lateral view. The transverse pericardial sinus lies between the arterial and venous poles of the heart. The oblique pericardial sinus is a blind recess running between the pulmonary veins and the inferior vena cava.

Prominent Epicardial Fat Pad
Fig. 3. Pericardial fat pad. Subcostal views show a prominent pericardial fat pad (becoming more prominent during systole). It is more common in obese and older adults. (Please see companion DVD for corresponding video.)

usually posterior to the left ventricle (LV) near the atrioventricular groove.

Echocardiographically, the pericardium is visualized as a thin, echo-dense structure surrounding the heart, most evident at the posterior cardiac interface (Fig. 4). The pericardium can usually be visualized in all standard echocardiographic windows such that diffuse pericardial pathology can be observed in most views. Localized peri-cardial disease, such as loculated fluid collections or hematomas, may require more focused examinations. In patients with pericardial fluid or infiltration, the pericardium appears more prominent and distinction between the parietal and visceral layers is often more evident. In general, the evaluation of pericardial thickness by transthoracic echocardiography is less accurate than by other imaging modalities, such as computerized tomography or magnetic resonance imaging.

physiology

The normal physiological functions of the pericardium are of some debate, given the relatively benign consequences of its absence, either surgically or congen-itally. Nevertheless, one obvious mechanical function is to allow the heart to beat in a minimal friction environment. Another function may be one of passive restraint of the structures contained by the pericardium. Specifically, the fibrous parietal pericardium likely

Fig. 4. Normal pericardium. The normal pericardium appears as a hyperechoic linear structure surrounding the heart. Increased echo-reflectivity occurs at the interface between cardiac tissue and the air-filled lungs (see arrows). Normal pericardial thickness is less than 3 mm (best assessed by transesophageal echocardiography), but its appearance on transthoracic echocardiography is influenced by image quality and instrument settings.

Parasternal

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