Pericardium

Etiology of Pericardial Disease

• Idiopathic • Associated with systemic disease
Acute idiopathic pericarditisa Uremia
Chronic idiopathic effusion
Hypothyroidism
Infectious
Viral Pregnancy
Bacterial Cirrhosis
Tuberculosis Malignancy
Spread from contiguous infection Direct tumor involvement
(e.g., pneumonia) Effusion due to lymphatic
Fungal obstruction
Inflammatory Miscellaneous
Associated with connective tissue Post trauma
disease
Post surgical
Rheumatoid arthritis
Systemic lupus erythematosis Congestive heart failure
Other Severe pulmonary hypertension,
Post myocardial infarction right heart failure
Acute after transmural infarct
Partial/complete free wall rupture
Delayed, “Dressler Syndrome”
M-mode echocardiograms recorded in patients with pericardial effusions. A:
Note the echo-free space (arrow) immediately behind the posterior wall of
the left ventricle consistent with a small pericardial effusion (PEF). Note also
that the space is larger in systole than in diastole. B: The patient has a larger
pericardial effusion with respiratory variation in right ventricular size and
septal position.
Parasternal long-axis
echocardiogram recorded in a
patient with a minimal
pericardial effusion. This amount
of pericardial fluid represents the
normal fluid seen in disease-free
individuals. A: Recorded at end-
diastole. B: Recorded at end-
systole. Note that at end-
diastole, there is no separation
between the epicardium and
pericardium. At end-systole, the
epicardium has lifted off the
pericardium revealing a very
small pericardial effusion,
maximal in the posterior
interventricular groove (arrows).
Parasternal long-axis
echocardiogram recorded in a
patient with a minimal
pericardial effusion. This amount
of pericardial fluid represents the
normal fluid seen in disease-free
individuals. A: Recorded at end-
diastole. B: Recorded at end-
systole. Note that at end-
diastole, there is no separation
between the epicardium and
pericardium. At end-systole, the
epicardium has lifted off the
pericardium revealing a very
small pericardial effusion,
maximal in the posterior
interventricular groove (arrows).
Parasternal long-axis echocardiogram recorded a patient with a
small pericardial effusion. Note the echo-free space, maximal in
the posterior interventricular groove (arrow) and a smaller
anterior echo-free space (downward-pointing arrow). In the
real-time image, this pericardial effusion can be seen to be
present both in diastole and systole.
Parasternal long-axis echocardiograms recorded in
patients with a small (A) and moderate to large (B)
pericardial effusion. A: There is an approximately 1-
cm space between the epicardium and pericardium
(arrow), consistent with a small pericardial effusion.
B: A larger pericardial effusion is present both
anteriorly and posteriorly (arrows).
Parasternal long-axis echocardiogram recorded a patient with a
large pericardial effusion, measuring 3 cm in its greatest
dimension posteriorly (arrow). In a real-time image, there is
evidence of a swinging heart within a large pericardial effusion.
Parasternal short-axis echocardiogram recorded a patient with a
small pericardial effusion. Note the echo-free space between
the epicardium and pericardium, which extends from the true
posterior wall of the left ventricle past the interventricular
groove (arrows). In this view, it is also seen behind the right
ventricle.
Parasternal short-axis view recorded a patient with a large
pericardial effusion (PEF). Note the large echo-free space
measuring more than 3 cm surrounding the left ventricle (LV) and
the free motion of the heart within the pericardial fluid.
Apical four-chamber view recorded in a patient with a moderate,
predominantly lateral pericardial effusion (PEF) (arrow). Note also
a smaller fluid collection behind the right atrium (RA).
Subcostal echocardiogram reveals a moderate to large pericardial
effusion. Note the effusion surrounding the entire heart, with its
greatest dimension lateral to the left ventricular free wall. Fluid is
clearly seen surrounding the right atrium (RA) and between the
pericardium and right ventricle (RV).
Apical four-chamber (A) and
parasternal short-axis (B)
views recorded in a patient
with a small, localized,
predominantly lateral
pericardial effusion (PEF). This
echocardiogram was recorded
approximately 2 weeks after
open-heart surgery.
Transesophageal echocardiogram recorded in a
patient with a moderate pericardial effusion and
evidence of fluid in the oblique sinus. A: Note the
echo-free space bounded by the left atrium (LA),
aorta (Ao), and pulmonary artery (PA). This
represents fluid accumulating in the pericardial
reflection around the great vessels. B: There is a
similar collection of fluid in the pericardial space
surrounding the left atrial appendage (LAA). In the
real-time image (B), note the excessive motion of
the wall of the left atrial appendage within the
pericardial fluid in the oblique sinus. On occasion,
the wall of the left atrial appendage can assume a
mass-like appearance and be confused with a
pathologic mass.
Distinguishing pericardial from pleural fluid
In the parasternal long axis view use the descending aorta as a
landmark.
The pericardial sac tucks in between the aorta and left atrium, so
pericardial fluid will extend up to the gap and lie in front of the
aorta.
Pleural fluid will track behind the aorta and over the left atrium.
If both pericardial and pleural fluid are suspected look for the
pericardium lying as a continuous dividing line within the fluid in
an apical
view.
Parasternal long axis view showing heart lying in global pericardiaI effusion.
Measure depth on 2D (double-ended arrow) or M-mode and report measurement
site.
 Pericardial effusion
Amount of pericardial fluid
• Measure fluid thickness-using 2D or M-mode in several places and
views.
• Report the depth of posterior echo free space and where the
measurement was made.

• For global effusions, grade as mild. moderate, or large based on depth

(depth also approximates to volume of fluid).

• <0.5cm Minimal 50-100mL

• 0.5-1 cm Mild 100-250mL
• 1-2cm Moderate 250-500mL
• >2cm Large >500mL

• More accurate volume measures can be made with planimetry from

traced pericardiaI and heart borders in apical views. It is possible to
produce even more accurate measures with 3D echocardiography,
although there is not usually any clinical indication.
Apical four-chamber view recorded from a
patient with a large pericardial effusion and a
swinging heart. A pleural effusion is also
present, which allows direct visualization of
the pericardial thickness (arrows) (A). A, B:
Recorded from different cardiac cycles. Note
the marked change in position of the heart
within the pericardial space, which can be
appreciated as a swinging heart in the real-
time image. This variable position within the
thorax is the cause of electrical alternans seen
on surface electrocardiography.
Apical 4-chamber view with global pericardial effusion -and fibrin strands.
 Differentiation from restrictive cardiomyopathy
Clinical features of constrictive pericarditis and restrictive cardiomyopathy are similar.
Echocardiography is useful to differentiate.
Doppler findings suggestive of constriction
Assess mitral and tricuspid inflow during respiration just as for
tamponade. Constrictive pericarditis causes the same changes as
tamponade (>25% variation at tricuspid and >15% at mitral).

As the ventricles are supported by 'stiff pericardium no ventricular

collapse.
Look for features of diastolic dysfunction .

Exaggerated E/A ratio on mitral inflow and shortened deceleration time

(time from peak to end of E-wave; normal >160msec).

Use tissue Doppler (if available). In apical 4-chamber place cursor on

lateral mitral annulus. In constrictive pericarditis myocardial function is
normal and peak mitral annulus velocity is therefore normal
(>10mm/sec). If reduced, consider restrictive cardiomyopathy.
With CHF, consider constrictive pericarditis if E’ > 8 cm/sec
Diagram representing PW Doppler trace at tricuspid valve. There is significant
variation to tricuspid valve inflow (>25%) consistent with cardiac tamponade or
constrictive pericarditis. The same recording can be done at mitral valve but
maximum E-wave vetocity will be in expiration and normal variation is <15%.
Tissue Doppler imaging of lateral mitral annulus showing reduced movement in
restrictive cardiomyopathy (left) compared to normal myocardial function (right).
Normal motion is >10cm/sec.
Pericardiocentesis from subcostal position monitored by echocardiography from
apex. Agitated saline contrast has been injected down the pericardiocentesis
needle and is seen circulating in the pericardial space. This confirms the correct
location of the needle