myocarditis, pericarditis and effusion/tamponade. 6.22.22

Mostly we see circumferential effusions but some cases could see loculated pericardial effusions, know what this is associated with.

A loculated effusion is more common post cardiac surgery or metastatic disease. It is unusual for a pericardium to be positioned solely anterior unless it is loculated. Q- A loculated pericardial effusion is rare except for patient with - Post op cardiac surgery or metastatic disease.

Know what kind of symptoms or echo findings are associated with acute pericarditis

ACUTE ONSET occurs when 2+ of the 4 key findings are present. Pericardial friction rub, EKG changes such as diffuse concave ST segment elevation. Sharp, stabbing chest pain that radiates to the shoulder; often relieved by sitting up, leaning forward, avoiding deep breaths. New/worsening pericardial effusion, that is usually small and idiopathic or viral. Additional findings: fever, weakness, shortness of breath, palpitations, cough, labs show elevated inflammatory markers. NOTE: pericarditis is underdiagnosed in the ER.

Know the etiology (process) for acute pericarditis. Sequence of events (progression of disease)

Acute pericarditis (painful friction rub), obstruction of the hearts venous and lymphatic system = Pericardial effusion, Tamponade

Know everything you can know about epicardial fat on an echo? Where is it? What does it look like and how to differentiate it between pericardial effusion

Epicardial fat is a measure of visceral fat and has been linked to increased risk for coronary artery disease, metabolic syndrome and insulin resistance. By echo, epicardial fat is best visualized on the right ventricular free wall (RVFW), usually from the LAX or subcoastal views. Seen as an echo free space between the outer wall of the myocardium and the visceral layer of the pericardium. Appears brighter and more gelatinous than the myocardium and moves with the heart. Epicardial fat measurements have been acquired from 1 -23 mm. Sometimes pericardial effusion can be confused with pleural effusion or epicardial fat.

1. A patient has tamponade, what's the sequence of events that could lead to death.

Excessive pericardial fluid accumulates in a noncompliant pericardial space; the effusion compresses the heart and limits cardiac filling. Impaired diastolic filling progressively worsens. Elevation and equalization of diastolic and pericardial pressures. Then you have reduced cardiac output which creates an insufficient preload that cannot sustain cardiac filling results in a dramatic decrease in coronary and systemic perfusion, then cardiac arrest and death..

What is the difference you see would see if constrictive pericarditis vs a restrictive/infiltrative cardiomyopathy

Constrictive pericarditis - Surrounds the entire heart, impedes diastolic filling and the chamber pressure tend to equalize. The large E, small A with respiratory variation on MV inflow. Restrictive/infiltrative CMA - Involves the myocardium, impedes diastolic filling and result is biatrial enlargement. Large E, small A but without respiratory variation on MV inflow. This one is loculated in one spot.

Know why constrictive pericarditis is problematic for patients?

Creates an inelastic heart that restricts diastolic filling and decreases cardiac output.... Parietal and/or visceral pericardium, thicken (most cases), scar, and may calcify. The layers become dense and adhere to one other; this obliterates the pericardial space. Eventually the heart becomes a totally noncompliant, inelastic structure that restricts diastolic filling resulting in decreased cardiac output (similar to tamponade). A tense pericardial effusion develops that also impedes diastolic filling.

A patient has myocarditis, what do you expect to see on the echo (all of the above)

Dilated or hypertrophied ventricles, ventricular dysfunction, regional wall motion and evaluate valvular disease states and diastolic dysfunction.

Equalization of chamber pressure Is best detected with Doppler echo? T/F?

If all four chambers are involved equally, the RA, RV, PA, PCW and LV end diastolic pressure equalize and evaluate; this pressure equalization is best detected by cath. This answer will be false because its not detected by Doppler its detected by cath. Q- with constrictive pericarditis, if all 4 chambers are involved equally, the RA,RV,PA,PCW and LV equalize and elevate - end diastolic pressure.

What is the most common cause of myocarditis?

The most common cause is viral; and Coxsackievirus B is the most common culprit.

What are some things that can help you differentiate between a pleural and pericardial effusion? Will be an ALL of the above Q.

The pleural effusion is positioned posterior to the DAO, appears very large and may change with respiration. The pericardial effusion is positioned anterior to the descending aorta (DAO) and does not change with respirations. If both pleural and pericardial are present, visualize the pericardium between them.

What is the most important component in the development of tamponade

The rate of accumulation, not the size. Tamponade is very large or rapidly accumulating pericardial effusion...

Can myocarditis and pericarditis happen at the same time? T/F

True, they can happen at the same time. Myocarditis of the outer myocardium is frequently accompanied by pericarditis.

What clinical finding do you expect to see in a patient with myocarditis? (all of the above)

Associated with viral infection, they mimic MI and they resemble heart failure. Symptoms associated with viral infection (fever, body aches, sore throat, malaise and fatigue). · Myocarditis that mimics MI presents with chest pain due to coronary artery inflammation or coronary spasm (from the inflammatory cells). However, the coronary arteries usually appear normal, no blockages as seen with MI.

When a patient has cardiac tamponade, what do we except the insta cardiac pressure to be?

COME BACK.

1. What is the definition of pericardial effusion?

Pericardial effusion is the presence of an abnormal amount and or type of fluid between the parietal and visceral layers of the pericardium. Q- A pericardial effusion is described as - abnormal amount or type of fluid, circumferential or loculated and fluid within the pericardial space.

What's a quick and easy method that allows for the sonographer to check right ventricular diastolic collapse?

M-MODE Rule out right ventricular (RV) diastolic collapse - THE RV free wall (RVFW) collapses into the RV during diastole, while the MV is open. The LAX or SAX or Subcostal views are best

What is the most common cause of pericarditis?

More common in men 20-50 years of age or those with previous acute pericarditis. Various causes of pericarditis (acute injury, acute/post MI, autoimmune/collagen vascular disease, cancer, cardiac surgery, congenital anomaly, HIV/AIDS, idiopathic, infectious, kidney failure, radiation therapy, reaction to medicine, TB).. Friction between the layers causes irritation and inflammation

1. What is the difference in a pericardial effusion and a pleural effusion relative to the descending aorta?

Pericardial effusion is anterior (above) of the DOA, does not change with respiration. Pleural effusion is posterior (below) to the DOA, may change with respirations.

What should always be evaluated on echo when looking for signs of tamponade?

Respiratory variation of the mitral/tricuspid valve inflow with accompanying changes in the isovolumic relaxation time. Mitral valve inflow decreases with inspiration and increases with expiration. Tricuspid valve inflow increases with inspiration and decreases with expiration

It is important to remember that tamponade is a clinical diagnosis, if its clinical why do we do echo? (All of the above)

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

The difference between a pleural and pericardial effusion is relative depending on the aorta, which window would you use to make that determination?

The LAX is the ideal view. LAX or parasternal long axis view is best to visualize the effusions.

You go into a room to-do an echo, a patient is flat on their back and having trouble breathing and is short of breath, what's the first thing you're going to do?

With acute onset pericarditis, with sharp, stabbing chest pain that radiates to the shoulder; often relieved by sitting up, leaning forward and avoiding deep breaths. Sit them up...

1. Pericardial effusion measurements/sizes/etiology.

· Small pericardial effusion is < 10 mm by echo (50-100 ml). This is acute pericarditis, idiopathic and infectious, usually viral. · Moderate pericardial effusion is 10-20 mm by echo (100-500 ml). This can occur because of various causes. · Large pericardial effusion is >20 mm, and very large is > 25 mm by echo > 500ml. Hyperthyroidism, neoplasia - abnormal growth atypical proliferation of tissue, tuberculosis. Rapid accumulation - acute myocardial infarction with cardiac rupture, ascending aortic dissection, blunt trauma and cardiac perforation (Cath procedure or other). Q- by echo, a moderate pericardial effusion is defined as (10-20) mm, 50- 100 ml. Q- by echo, a large pericardial effusion is defined as (> 20 mm),(> 500 ml).

What are the management techniques for myocarditis?

· The management of myocarditis depends on the underlying cause. Antibiotics are administered for bacterial infections. Corticosteroids or other medications that suppress the immune system are administered for viral infections. · Other medical therapy (antiarrhythmic, diuretic). · More aggressive treatment modalities can be utilized if indicated, such an intra-aortic balloon pump (IABP), left ventricular assist device (LVAD) and heart transplant.