(Part 3) Pericardial Effusion & Tamponade

RV Diastolic collapse during Tamponade (Details)

-Early on, RV diastolic collapse is present during inspiration; this reflects a transient increased pericardial pressure that exceeds the RV pressure. - As the Tamponade increases in severity, the collapse remains throughout the respiratory cycle; the longer the collapse, the more severe the Tamponade.

Which view is ideal to differentiate Pericardial Effusion from Pleural Effusion?

-LAX is the ideal view.

Tamponade (Types)

Can be: - Acute, subacute, or chronic. - Mild to severe, and potentially life-threatening. -Low pressure tamponade is possible due to hypovolemia (a decreased volume of circulating blood in the body) or over-diuresis. - Regional tamponade affects selected chambers, usually the left heart due to a loculated effusion or precordial blood clot post cardiac surgery or MI.

Hepatomegaly (Define)

Enlarged liver due to increased venous pressure.

Dyspnea (Define)

May improve when the patient is upright.

What is Tamponade?

Potentially life-threatening pericardial effusion with significant hemodynamic compromise on cardiac filling & function.

What is Paradoxical Septal Motion?

The walls move parallel to one another rather than their normal contraction (toward) and relaxation (away).

Pericardial Effusion (Define)

Presence of an abnormal amount and/or type of fluid between the parietal and visceral layers of the pericardium.

Pericardial Effusion (Other Causes)

- Infectious. - Benign/Malignant Tumor. - Metastatic cancer to pericardium. - Radiation Therapy. - Chemotherapy. - Post MI (Dressler's Syndrome)/Cardiac Surgery. -Autoimmune, inflammatory, connective tissue disorders. - Drug induced. - Kidney Failure.

Tamponade Treatments

- O2, fluid, medical therapy, and remove the pericardial effusion. - Pericardiocentesis: The physician/surgeon taps the pericardial effusion via aspiration. - Pericardial window: Open pericardial drainage via a window made by the Surgeon. - Pericardiectomy: Removal of the pericardium by the Surgeon.

What is the best view to visualize Circumferential Pericardial Effusion?

- Parasternal, Subcostal, LAX % SAX are the best views.

Tamponade (2D Echo findings)

- Pericardial Effusion (possible swinging heart) - Decreased LV diastolic & systolic dimensions. - Walls appear hypertrophied. - Ventricular Respiratory Variation (LV diastolic dimension decreases with inspiration; RV diastolic dimension increases with respiration) - IVS Inspiratory bounce. - Paradoxical Septal Motion. - Dilated IVC & hepatic veins with lack of inspiratory. collapse; reflects elevated systemic venous pressure. - RV/RA diastolic collapse. - Compare the RV wall motion to the MV/TV motion.

How do you differentiate Pericardial and Pleural Effusion?

- Pericardial Effusion is anterior to DAO, and doesn't change with respiration. - A Pleural Effusion is positioned posterior to DAO, appears very large and may change with respiration.

Pericardial Effusion (2D Echo)

- Pericardial effusion is an echolucent space between heart & pericardium. - Effusion frequently originates near RA (lowest pressure), other chambers tend squeeze to area with least resistance. - Unusual for effusion to be solely anterior to the heart, unless loculated. - Locualted effusion is more common post-op cardiac surgery or metastatic disease. - Exudative pericardial effusion may contain fibrin strands, adhesions, or uneven distribution. - Fibrin strands frequently present with long standing pericardial effusion or metastatic disease.

How do you rule out RV diastolic collapse in M-Mode for Tamponade?

- Place the M-Mode cursor through pericardial effusion, RVFW, and MV. - Increase the sweep speed to 100 mm/s. - Compare the RVFW motion to the MV motion (normally open during diastole).

How do you rule out paradoxical wall motion in M-Mode for Tamponade?

- Place the M-Mode cursor through the ventricular walls. - Assess and compare the wall motion.

How do you rule out respiratory variation of the MV and TV using Doppler in Tamponade?

- Place the PWD gate at the tips of the MV and/or TV leaflets. - If the heart is swinging, watch a few cycles to make sure the Doppler waveform is stable. - Decrease the sweep speed at 25 mm/s to compress and capture more waveforms. - MV inflow decreases with inspiration (30% reduction is diagnostic) and increases with expiration. - TV inflow increases with inspiration and decreases with expiration.

An echo determines what of Tamponade?

- Size and location of pericardial effusion. - Presence and degree of hemodynamic compromise on the cardiac filling and function.

Pericardial Effusion (Complications, Signs & Symptoms)

- Small pericardial effusion usually asymptomatic. - Symptoms may be due to compression of structures. - Chest Pain, pressure or discomfort. - Palpitations. - SoB/Dyspnea. - Cough/Hoarseness. - Difficulty Swallowing. - Feeling of fullness in abdomen/nausea. - Lightheaded, confusion. - Anxiety. - Syncope.

What happens to preload during Tamponade?

- There's insufficient preload that can't sustain cardiac filling, leads to dramatic decrease in coronary and systemic perfusion.

Pericardial Effusion (Types)

1. Acute (sudden) versus chronic (>3 months) 2. Local versus systemic disorder. 3. Circumferential (around the heart) or loculated (localized) 4. Transudative: Extravascular fluid, low in protein, non-inflammatory. 5. Hemorrhagic/hemopericardium: Blood in the pericardial sac, most due to trauma or aortic dissection. 6. Malignancy: Secretes fluid into the pericardial space.

Epicardial Fat (Define)

A measure of visceral fat and has been linked to increased risk for coronary artery disease, metabolic syndrome, and insulin resistance.

Tamponade (Doppler Findings/Uses)

- Rule out MV/TV inflow respiratory variation. - MV decreases with inspiration & increases with expiration. - TV increases with inspiration & decreases with expiration.

Pulsus Paradoxus (Define)

An exaggerated decrease in systolic BP with inspiration.

Pericardial Effusion (Rapid Accumulation Details)

Causes: - Blunt trauma. - Ascending AO dissection. - Acute MI with rupture. - Perforation.

Trivial Pericardial Effusion

Only visible during systole.

What is Right Ventricular Diastolic Collapse?

The RV free wall (RVFW) collapses into the RV during diastole, while the MV is open.

Clinical Presentation of Tamponade

- Beck's Triad. - Pulsus Paradoxus. - Pericardial Friction Rub. - Tachycardia. - Dyspnea. - Hepatomegaly.

Epicardial Fat (Detail)

- Best visualized on RVFW, usually from LAX and Sub-costal views. - Seen as echo free space between the outer wall of myocardium and the visceral layer of the pericardium. - Appears brighter than Myocardium and moves with heart. - Measures between 1 - 23 mm.

Tamponade (Complications, Signs & Symptoms)

- Depend on etiology & rate of accumulation. - These patients usually feel horrible and need to sit up. - Cardiogenic shock. - Blue appearance of lips & skin. - Cold extremities/peripheral cyanosis. - Hypotension. - Tachycardia. - Fatigue/weakness. - Lightheaded, dizziness, syncope. - Altered mental status, anxiety. - Dyspnea that improves when the patient sits up. - SoB. - Cough. - Dysphasia (Difficulty swallowing). - Symptoms related to underlying cause. - Death.

Tamponade process.

- Excessive pericardial fluid accumulates in a noncompliants pericardial space; compresses the heart and limits filling. - Impaired diastolic filling worsens. - Elevation and equalization of diastolic and pericardial pressures. - Reduced CO. - Insufficient preload that can't sustain cardiac filling, leads to dramatic decrease in coronary and systemic perfusion. - Cardiac arrest and death.

What are the three components of Beck's Triad?

- Hypotension and weak pulse due to low CO. - Muffled Heart Sounds due to fluid around the heart. - Elevated Venous Pressure and extended neck veins because it's difficult for blood to return to the heart.

Moderate Pericardial Effusion (Details)

- 10 - 20 mm by echo (100 - 500 ml) - Various causes.

Small Pericardial Effusion (Details)

- < 10 mm by echo (50 - 100 ml) Causes: - Acute Pericarditis. - Idiopathic. - Infectious, usually viral.

Large Pericardial Effusion (Details)

- > 20 mm and very large is > 25 mm by echo (>500 ml) -Causes: Hypothyroidism Neoplasia: Abnormal growth/atypical proliferation of tissue. Tuberculosis

Tamponade (Causes)

- Ascending aortic dissection. - Autoimmune, connective tissue, inflammatory disease. - Cardiac Surgery. - Cardiac perforation. - Cardiomyopathy. - Chest trauma. - Hypothyroidism. - Infectious. - Kidney failure/uremia. - Large pleural effusion. - Malignant disease. - MI. - Pericarditis. - Radiation therapy, chemotherapy.

What views are ideal to rule out RV diastolic collapse for Tamponade in M-Mode?

The parasternal/subcostal LAX and SAX views are ideal.