Pericarditis echocardiography and ultrasound

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S. Homa Najafi, M.D.[2]

Overview

The role of echocardiography in the evaluation of the patient with pericarditis is to chracterize the presence, size, location, and hemodynamic impact of a pericardial effusion. Echocardiography is not needed to diagnose pericarditis. Echocardiography should be performed if there is a suspicion of tamponade (e.g. distended neck veins, pulsus paradoxus).

Echocardiography/Ultrasound

Echocardiography

• The American College of Cardiology (ACC), the American Heart Association (AHA), and the American Society of Echocardiography in its recommendations on echocardiography gave strong recommendations for echocardiography in pericardial disease.
• Two dimensional and doppler echocardiography should be done in all suspected cases of cardiac tamponade and pericardial effusion.
• Follow up/sequential echocardiography for assessment of impending cardiac tamponade should be considered.
• Helps in diagnosing pericardial disease, hemodynamic parameters (pressure in different cardiac chambers).
• Pericardial effusion secondary to pericarditis is seen on echocardiogram as a large hypoechoic region surrounding the heart.
• The best view to visualize a pericardial effusion is the subcostal view.
• The location of the fluid and the presence of loculations can be determined so that the feasibility and safety of pericardiocentesis can be assessed. Usually pericardiocentesis can be performed if there is over 0.5 cm of anterior fluid.

Echocardiographic Findings in Cardiac Tamponade

• Presence of moderate and large pericardial effusion.
• Swinging of the heart within the effusion. It is this swinging motion that gives rise to electrical alternans.
• Reversal of right atrial and right ventricular diastolic transmural pressures.
• Cardiac chamber indentation or collapse is a common finding in cardiac tamponade.
• Right atrium and right ventricle are the commonest to collapse when intrapericardial pressure exceeds intracardiac pressure within any particular chamber.
• Right atrial collapse:
  • Right atrial pressure is minimal during diastole. However, pericardial pressure is maximal in diastole. Due to this the first signs of collapse could be seen during right atrial diastole.
  • Right atrial collapse if persists for > 1/3rd of cardiac cycle is a good indicator of impending tamponade.
  • Transient right atrial collapse can occur normally also.
• Diastolic collapse of right ventricle is very specific for cardiac tamponade.
• Diastolic left atrial collapse are very specific for cardiac tamponade.
• Left ventricle collapse is uncommon due to high thickness of ventricular wall.
• The respiratory variation of mitral valve and tricuspid valve is increased.

Pericardial Effusion and Cardiac Tamponade

In pericardial effusion, large hypoechoic regions are seen surrounding the heart with presence of oscillatory motion of the heart.
The echocardiogram below demonstrates swinging motion of the heart in cardiac tamponade. {{#ev:youtube|U4xQ3-VRiNg}}

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Echocardiography of heart with loculated pericardial effusion compressing the left ventricle {{#ev:youtube|unnmmlCyyZM}}

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Cardiac tamponade {{#ev:youtube|YWVI6rRTIzU}}

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Cardiac tamponade {{#ev:youtube|_az8_V6bHE8}}

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Left ventricular free wall rupture in patient with cardiac tamponade {{#ev:youtube|g9TdKcFRiLo}}

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Collapse of right ventricle in patient with cardiac tamponade {{#ev:youtube|dwJkJr00v5c}}

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A very large pericardial effusion due to malignancy as seen on cardiac ultrasound. Closed arrow: the heart, open arrow: the effusion

2015 ESC Guidelines on the Diagnosis and Treatment of Pericarditis (DO NOT EDIT)

Recommendations for the general diagnostic work-up of pericardial diseases

Class I

1. In all cases of suspected pericardial disease a first diagnostic evaluation is recommended with: – auscultation – ECG – transthoracic echocardiography – chest X-ray – routine blood tests, including markers of inflammation (i.e., CRP and/or ESR), white blood cell count with differential count, renal function and liver tests and myocardial lesion tests (CK, troponins). 2. CT and/or CMR are recommended as second-level testing for diagnostic workup in pericarditis. 3. Pericardiocentesis or surgical drainage are indicated for cardiac tamponade or suspected bacterial and neoplastic pericarditis. 4. Further testing is indicated in high-risk patients (defined as above) according to the clinical conditions. (Level of Evidence: C)

Recommendations for diagnosis of acute pericarditis

Class I

1. ECG is recommended in all patients with suspected acute pericarditis. 2. Transthoracic echocardiography is recommended in all patients with suspected acute pericarditis. 3. Chest X-ray is recommended in all patients with suspected acute pericarditis. 4. Assessment of markers of inflammation (i.e. CRP) and myocardial injury (i.e. CK, troponin) is recommended in patients with suspected acute pericarditis. (Level of Evidence: C)

Recommendations for the diagnosis of constrictive pericarditis

Class I

1. Transthoracic echocardiography is recommended in all patients with suspected constrictive pericarditis. 2. Chest X-ray (frontal and lateral views)with adequate technical characteristics is recommended in all patients with suspected constrictive pericarditis. 3. CT and/or CMR are indicated as second-level imaging techniques to assess calcifications (CT), pericardial thickness, degree and extension of pericardial involvement. 4. Cardiac catheterization is indicated when non-invasive diagnostic methods do not provide a definite diagnosis of constriction. (Level of Evidence: C)