Pericarditis/Tamponade
Pericarditis is an inflammation of the pericardium (heart sac) usually caused by a virus. Echocardiographic is often seen in the pericardium (pericardial effusion). A fatal complication of pericarditis is that an inflammation in the heart causes the pericardial fluid or blood to fill up when relaxed, this is called tamponade.
| Video |
| Tamponade picture with large amount of pericardial |
|---|
Inflow obstruction
At pericarditis or tamponade, there is an obstacle for intake from the atria to the ventricles. Due to the obstruction from outside, eg by pericardial fluid, so that the space in which the heart is restricted, filling of one ventricle will be detrimental to the area of the other ventricle. When inhaling the filling of the right ventricle does at the expense of the filling of the left ventricle. This is called interdependence. When tamponade is outside pressure causing this effect is much more to the ground compared with constrictive pericarditis with early diastolic filling is not obstructed. Throughout the diastolic filling This is also the reason why a tamponade almost always Pulsus paradoxus is found only rarely in a constrictive.
Inhalation decreases intrathoracic pressure, the pressure longveneuse this will also decrease, however intrapericardially located diastolic LV pressure is not falling. In other words, by inhalation reduced the pressure gradient between the pulmonary veins and left which will take off. Filling of the left ventricle.
|
|---|
| MV inflow variation >25% |
| Echocardiographic findings at a major inflow obstruction | |
|---|---|
| Doppler |
|
| 2 - D images |
|
| However, early after cardiac surgery, there may be geloketteerd pericardial. This may cause local compression to occur, and the evidence of inflow obstruction more difficult to interpret. | |
Doppler measurements Evidence of an inflow impediment to the LV and RV expressing itself in elevated filling pressures. The mitral and tricuspid inflow pattern will play an E / A ratio >1 exhibit generally. Also, the deceleration time will be of the mitral E- top shortened (<180 msec.) In the pulmonary vein flow, the S- wave will be smaller than the D- wave. In a constrictive the right and left ventricular filling influence each other. The following indications point to this: Respiratory variation in MV inflow (at start of inspiration decline MV inflow E -top >25%) and TV inflow (at start of inspiration increase of E -top >40%). Respiratory variation in pulmonary vein flow wherein at the beginning of expiration the diastolic forward flow >10% increase.
Also, atrial fibrillation, this respiratory variation can be observed. In severe obstructive pulmonary same pattern can be seen. Reinforced by the change in intrathoracic pressure However, this will also increase sharply to the right ventricle during inspiration caval flow. In a constrictive flow will hardly increase.
After a pericardectomie is often still an abnormal filling pattern was observed. On the one hand it is thought that this is due to incomplete pericardectomie. On the other hand this is possible because the myocardium is sometimes involved in the disease process. The measured with TDI early diastolic velocity of the mitral valve annulus septal (E ') often takes postoperatively decreases, which would fit in a relaxation disorder of the myocardium. When autopsies are also found increased myocardial fibrosis that may explain this. The disease process which gave constriction, can also cause myocardial fibrosis. (radiotherapy, auto- immune processes). The emergence of a more restrictive image after pericardectomie is associated with a worse prognosis.
constrictive pericarditis Constrictive pericarditis is a form of pericarditis in which the pericardverdikt and if it were a hard shell forms around the heart. This is also called " armored heart " called. Thus, the heart can not fill normally (diastolic dysfunction). Inhalation reduces the pressure in the chest. Due to the lower pressure more blood can flow to the right ventricle. This bends the ventricular septum to the LV far. The LV can therefore be less filled.
| Evidence of constrictive pericarditis
M -mode Rapid early diastolic and flat mid - diastolic LV motion back and aortic root Early diastolic notch in motion pattern interventricular septum At the end of diastolic notch, followed by forward movement of septum 2 - D images Pericardium thickened (often difficult to take MRI where much more reliable) Movement septum to LV during inspiration and expiration to RV at (AP4CH) Early opening of pulmonary valve Dilated inferior vena cava with little respiratory variation |
It is good to realize that none of the exceptions that can be seen specifically in a constrictive pericarditis for this syndrome. Also in other syndromes such deviations can be observed. It is the combination of abnormalities may be a strong indication of a constrictive pericarditis.
Vs. constrictive pericarditis. restrictive cardiomyopathy The image of a pericarditis resembles the image of a restrictive cardiomyopathy : good systolic LV function with diastolic dysfunction. However, there are differences that distinguish with echocardiography. In restrictive cardiomyopathy, there is a myocardial disease. Primarily, it is the function disorder of the myocardium. Therefore frequently hereby myocardial abnormalities seen bv speckled aspect, thickened valves, thickened atrial septal amyloidosis is also an impaired systolic function can often be observed. It can also often important klepdysfuncties observed while this is not part of constrictive pericarditis. At a restrictive cardiomyopathy The atria are often greatly enlarged with a restrictive cardiomyopathy. In a constrictive, there is also often some atria dilatation but this is not conspicuous. The mitral inflow patterns in a restrictive cardiomyopathy often show a more pronounced restrictive filling pattern emerges, E / A ratio of 2 or higher with deceleration times shorter than 140msec. In a restrictive cardiomyopathy, pulmonary hypertension can sometimes be a significant action (>50 mmHg). In a constrictive is rarely a pulmonary pressure above 50 mmHg found. More specific effects are shown in the table below :
| Constriction | Restriction | |
|---|---|---|
| Septal motion | Respiratory shift | Normal |
| Mitral E/A ratio | >1.5 | >1.5 |
| Mitral DecT (ms) | <160 | <160 |
| Mitral inflow respiratory variation | Usually present | Absent |
| Hepatic vein Doppler | Expiratory diastolic flow reversal | Inspiratory diastolic flow reversal |
| Mitral septal É (cm/s) | >7 | <7 |
| Mitral lateral É | < septal É | >É septal |
| Ventricular septal strain | Normal | Reduced |
| Video |
References
- Rajagopalan N, Garcia MJ, Rodriguez L, Murray RD, Apperson-Hansen C, Stugaard M, Thomas JD, and Klein AL. Comparison of new Doppler echocardiographic methods to differentiate constrictive pericardial heart disease and restrictive cardiomyopathy. Am J Cardiol. 2001 Jan 1;87(1):86-94. DOI:10.1016/s0002-9149(00)01278-9 |