When pericardial fluid accumulates slowly, the pericardium can expand to accommodate as much as 2 liters of fluid. However, when acute, only a small volume can increase intrapericardial pressures, resulting in clinical symptoms. Pericardial effusions can be caused by multiple disease states, including any process that results in pericarditis or myocarditis.
The inflammatory reaction in these disease states can result in fluid accumulation in the pericardial space. Multiple infectious etiology of a pericardial effusion exist. The most common cause of a pericardial effusion, historically, has been tuberculosis; however, in the United States this is relatively rare. A pericardial effusion from tuberculosis can occur in isolation without any pulmonary manifestations. Viral pericarditis or myocarditis are associated with a pericardial effusion, most commonly the Coxsackie B virus.
Bacterial pericarditis resulting in a pericardial effusion is life-threatening and can be associated with bacterial endocarditis. A pericardial abscess requiring surgical drainage can occur in this setting. Fugal pericardial involvement is rare.
Iatrogenic pericardial effusions are common after cardiac surgery and frequently require drainage. Pericardial effusions caused by radiation therapy are less common due to the dose reduction possible today. Despite elevated filling pressures in both conditions, levels of BNP are significantly higher in restrictive cardiomyopathy. Pericardial calcifications Figure 10 , pleural effusions, and biatrial enlargement may be noted on the chest radiograph. Echocardiography is the best imaging modality for assessing hemodynamic parameters noninvasively.
M-mode echocardiography is useful for looking for rapid motion followed by abrupt flattening of the left ventricular free wall in early and mid diastole respectively. Two-dimensional echocardiography may demonstrate a thickened pericardium about one third of cases , myocardial tethering, abrupt cessation of left ventricular and right ventricular diastolic filling, biatrial enlargement, tubular deformity of the left ventricle, respirophasic septal shift, septal bounce and inferior vena cava plethora with absent inspiratory collapse.
Doppler echocardiographic findings have the highest sensitivity and specificity for detecting constrictive physiology. Excessive respiratory variations in transmitral, transtricuspid, pulmonary venous, and hepatic vein flow are characteristic. Low tissue velocity at both medial and lateral annuli suggests restriction. More recently developed echocardiographic modalities such as strain imaging have enhanced the ability to discriminate between restriction and constriction.
Direct pressure measurements are performed if there is doubt about the diagnosis. Characteristic features in the right atrium include: elevated right atrial pressures, prominent x and y decents and Kussmaul's sign. Square-root or dip-and-plateau right ventricular pressure waveforms reflect impaired ventricular filling. Because of the fixed and limited space within the stiff pericardium, end-diastolic pressure equalization typically within 5 mmHg occurs between these cardiac chambers.
Pulmonary artery systolic pressures are usually normal in pericardial constriction; higher pulmonary pressures suggest a restrictive cardiomyopathy. The ratio of the right ventricular to left ventricular systolic pressure-time area during inspiration compared to expiration is a highly sensitive and specific means of differentiating constriction from restriction Figure Computed tomography is the imaging modality of choice to evaluate the thickness of the pericardium and for pericardial calcification.
While echocardiography is the first choice imaging modality for assesssment of constriction, for many patients CMR is becoming increasingly utilized in the initial evaluation, particularly if any ambiguity remains regarding the diagnosis, if there is suggestion of active inflammation, or if the duration of symptoms has been brief. Cardiac magnetic resonance is very useful to differentiate a small pericardial effusion from pericardial thickening. The superior signal-to-noise and contrast-to-noise ratio of CMR allows precise evaluation of the morphological and hemodynamic changes seen in pericardial constriction.
Real-time cine sequences allow evaluation of the features described above in the 2D echocardiographic evaluation of pericardial constriction, which is useful if echocardiographic images are sub-optimal.
Phase encoding velocity imaging potentially provides similar data to Doppler echocardiography but is not yet generally employed in routine practice. The degree of constrictive physiology occurs along a spectrum of severity.
Early forms may be difficult to diagnose without a high degree of clinical suspicion. It is increasingly recognized that some of these patients may respond to medical therapy, without surgical intervention; this is referred to as transient constrictive pericarditis.
Medical treatment is limited in chronic constrictive pericarditis in the absence of active inflammation. Diuretics and a low-sodium diet may be tried for patients with mild to moderate New York Heart Association Class I or II heart failure symptoms or contraindications to surgery.
For effusive-constrictive pericarditis therapy includes pericardiocentesis initially, followed by treatment with anti-inflammatory agents. Frequently, pericardiectomy is necessary for long-term management. Recurrence following surgery is caused mainly by incomplete resection of the pericardium. Without surgical treatment, biventricular failure develops.
Long-term survival after pericardiectomy is worse than matched controls but this is mainly related to the underlying etiology. Grimm, DO Published: July Summary Suggested Readings References. Figure 1: Click to Enlarge. Figure 2: Click to Enlarge. Figure 3: Click to Enlarge. Figure 4: Click to Enlarge. Figure 5: Click to Enlarge. R and V 1 leads and PR depression elsewhere.
Figure 7A: Click to Enlarge. Figure 7B: Click to Enlarge. Figure 8A: Click to Enlarge. Figure 8B: Click to Enlarge. Figure 9: Click to Enlarge. Figure Click to Enlarge.
American Society of Echocardiography clinical recommendations for multimodality cardiovascular imaging of patients with pericardial disease: endorsed by the Society for Cardiovascular Magnetic Resonance and Society of Cardiovascular Computed Tomography.
J Am Soc Echocardiogr ; — LeWinter MM. Pericardial diseases. Philadelphia, PA: Saunders; — The usefulness of diagnostic tests on pericardial fluid. Chest ; — Fowler NO, Tuberculous pericarditis. JAMA ; — Pericarditis in end-stage renal disease. Cardiol Clin ; — Pericarditis associated with renal failure: evolution and management. Semin Dial ; p. Factors associated with pericardial effusion in acute Q wave myocardial infarction.
Circulation ; — Electrocardiographic diagnosis of postinfarction regional pericarditis. Ancillary observations regarding the effect of reperfusion on the rapidity and amplitude of T wave inversion after acute myocardial infarction. Subscriber sign in You could not be signed in, please check and try again. Username Please enter your Username. Password Please enter your Password. Forgot password? Don't have an account? Sign in via your Institution. You could not be signed in, please check and try again.
Sign in with your library card Please enter your library card number. Contents Front Matter Section Editors Foreword Foreword Preface Symbols and abbreviations Key to recommendation tables and levels of evidence Contributors 3D interactives and videos Amendments and Updates Part 1 Introduction to the cardiovascular system Section 1 Cardiovascular history and physical examination Chapter 1.
Section 34 Tumours of the heart Chapter Chapter Disclaimer Oxford University Press makes no representation, express or implied, that the drug dosages in this book are correct.
Show Summary Details Section 16 Genetics of cardiovascular diseases Section 17 Congenital heart disease in children and adults Section 18 Prevention in cardiovascular disease and rehabilitation Section 19 Diabetes mellitus and metabolic syndrome Section 20 Heart and the brain Section 21 Cardiovascular problems in chronic kidney disease Section 22 Erectile dysfunction Section 23 Lung disease Section 24 Gastrointestinal disease Section 25 Rheumatoid arthritis and the heart Section 26 Rheumatic heart disease Section 27 Cardio-oncology Section 28 HIV Section 29 Acute coronary syndromes Section 30 Takotsubo syndrome Section 31 Chronic ischaemic heart disease Section 32 Myocardial disease Section 33 Pericardial disease Chapter If left untreated, pericardial effusion can lead to heart failure or even death.
Fluid on the heart can build up slowly without any signs, so you may not even know you have the condition. Certain symptoms can signal pericardial effusion is severely affecting your heart.
This a medical emergency. Call if you or someone you know is experiencing:. Sometimes the pericardium becomes inflamed for no known reason.
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