Pericardial Disease

Notes

Cards

• basicV.A-001
  State the two named sinuses of the pericardium and their locations.
  → Transverse sinus: behind the aorta and pulmonary artery. Oblique sinus: behind the left atrium.
• basicV.A-002
  Normal volume of pericardial fluid?
  → ~15–35 mL.
• basicV.A-003
  State the 2-D echo definitions of small, moderate, and large pericardial effusion.
  → Small: < 0.5 cm at end-diastole. Moderate: 0.5–2 cm. Large: > 2 cm.
• basicV.A-004
  What is the MOST SPECIFIC echo sign of cardiac tamponade?
  → Right ventricular diastolic collapse. (Most sensitive: RA inversion > 1/3 of the cardiac cycle.)
• basicV.A-005
  What respiratory changes in transvalvular flow suggest tamponade?
  → Exaggerated respirophasic variation: > 25% increase in tricuspid inflow with inspiration AND > 25% decrease in mitral inflow with inspiration (opposite pattern from normal).
• basicV.A-006
  Why does inspiration paradoxically decrease LV filling in constrictive pericarditis?
  → The rigid pericardium prevents the drop in intrathoracic pressure from being transmitted to the LA. So the gradient between pulmonary veins (falling with inspiration) and LA is reduced → less LV filling. Simultaneously RV filling is unchanged/enhanced → septal shift toward LV.
• basicV.A-007
  State the four 2013 ASE Nagueh criteria for constrictive pericarditis.
  → 1) Respiration-related ventricular septal shift. 2) Preserved or increased medial mitral annular e′ ≥ 9 cm/s. 3) Prominent hepatic vein expiratory diastolic flow reversal (ratio ≥ 0.79). 4) IVC plethora (max diameter ≥ 21 mm and < 50% inspiratory collapse).
• basicV.A-008
  How is 'annulus reversus' defined and what does it suggest?
  → Medial e′ velocity > lateral e′ velocity (E′_lateral / E′_medial < 1). Suggests constrictive pericarditis — lateral annular motion is restricted by pericardial adhesion/calcification.
• basicV.A-009
  How is 'annulus paradoxus' defined and what does it suggest?
  → Inverse (rather than positive) correlation between E/e′ and wedge pressure. In CP the medial e′ is paradoxically preserved or exaggerated despite elevated LAP, so E/e′ underestimates filling pressure. Sign of constriction.
• basicV.A-010
  What e′ velocity cutoff has 95% sensitivity and 96% specificity for constrictive pericarditis?
  → Medial mitral annular e′ > 8 cm/s (using ≥ 9 cm/s in the 2013 ASE criteria).
• basicV.A-011
  How do you distinguish constrictive pericarditis from restrictive cardiomyopathy on TDI?
  → Constriction preserves relaxation → normal or elevated medial e′ (≥ 9 cm/s). Restriction impairs both relaxation and stiffness → reduced e′ (< 8 cm/s).
• basicV.A-012
  How does COPD mimic constrictive pericarditis on Doppler and how do you distinguish them?
  → Both can show > 25% respiratory variation in mitral E. In COPD: mitral inflow is NOT restrictive AND there is marked inspiratory INCREASE in SVC forward flow. In CP: SVC forward flow is minimally variable with respiration and mitral inflow is restrictive.
• basicV.A-013
  Describe cath findings characteristic of constrictive pericarditis.
  → Elevated and equalized RVEDP, LVEDP, and mean RAP (within ~5 mmHg). Rapid y descent. 'Dip-and-plateau' (square-root) sign. PASP < 50 mmHg. DISCORDANT respiratory changes in LV vs RV pressure (opposite direction).
• basicV.A-014
  How do LV and RV systolic pressures change with respiration in constriction vs restriction?
  → Constriction: DISCORDANT changes (LV and RV pressures move in opposite directions with respiration — ventricular interdependence). Restriction: CONCORDANT changes.
• basicV.A-015
  State the pericardial thickness threshold and modality for the diagnosis of CP.
  → Pericardial thickness ≥ 3 mm by TEE has 95% sensitivity, 86% specificity. CT and cMRI are also useful. Thickening is not required for the diagnosis — physiology alone can support CP.
• basicV.A-016
  On M-mode, what is a 'septal bounce' or 'septal shudder' and what does it suggest?
  → Abrupt displacement of the IVS in early diastole caused by RV filling pressure transiently exceeding LV filling pressure. Highly suggestive of constrictive pericarditis. Also seen in massive RV volume overload.
• basicV.A-017
  What echo findings suggest congenital absence of the left hemipericardium?
  → Enlargement of RV and leftward shift of the heart on standard views; excessive posterior LV wall motion; paradoxical septal motion mimicking RV volume overload (similar appearance to a large ASD).
• basicV.A-018
  Where do most pericardial cysts occur, and what is their appearance?
  → ~70% at the right cardiophrenic angle. Well-defined, thin-walled, echo-lucent structure without internal echoes. Usually asymptomatic — conservative management.
• basicV.A-019
  State four common causes of a large pericardial effusion.
  → Malignancy (lung, breast, lymphoma, melanoma), uremia, tuberculosis, autoimmune disease (SLE, RA), post-cardiac surgery (Dressler-like syndrome), aortic dissection (hemopericardium), viral pericarditis.
• basicV.A-020
  When should conservative therapy be tried before pericardiectomy in new constrictive pericarditis?
  → When there is evidence of ongoing inflammation (elevated CRP/ESR or imaging inflammation), the patient is hemodynamically stable, and there are no chronic signs (cachexia, AF, hepatic dysfunction, pericardial calcification). A 3–6 month anti-inflammatory trial is recommended.
• basicV.A-021
  Give three ECG features of acute pericarditis.
  → 1) Diffuse concave ('scooped') ST elevation across multiple leads. 2) PR depression (especially in lead II). 3) Reciprocal changes only in aVR. Evolves over four stages: ST elevation → normalization → T inversion → resolution.
• basicV.A-022
  What is 'electrical alternans' on ECG and what does it suggest?
  → Beat-to-beat variation in QRS amplitude, from the heart 'swinging' within a large pericardial effusion. Suggests significant effusion — highly specific for cardiac tamponade in the right clinical context.
• basicV.A-023
  What is pulsus paradoxus and what is the clinical threshold suggesting tamponade?
  → A > 10 mmHg drop in systolic BP with inspiration (exaggeration of normal < 10 mmHg physiologic drop). Highly suggestive of tamponade but not specific — also seen in severe asthma, COPD, and constriction.
• basicV.A-024
  How does 'annulus reversus' distinguish constriction from restriction?
  → Constriction: E′_lateral / E′_medial < 1 (medial e′ > lateral e′) because pericardial adhesion restricts lateral wall motion. Normal or restriction: E′_lateral > E′_medial.
• basicV.A-025
  State the ASE 2013 Nagueh criterion for 'significant respiratory variation' in mitral E in constriction.
  → Respiratory variation in mitral E velocity ≥ 25% (largest inspiratory E − smallest expiratory E) / expiratory E × 100. Note: > 25% variation also occurs in COPD but with different SVC and mitral inflow patterns.
• basicV.A-026
  When is pericardiocentesis the initial management for a pericardial effusion?
  → 1) Clinical tamponade with hemodynamic compromise. 2) Effusion suspicious for infection (empyema of the pericardium). 3) Diagnostic sampling for suspected malignancy or unknown etiology.
• basicV.A-027
  What complication of purulent bacterial pericarditis carries a very high mortality?
  → Purulent pericarditis has 100% mortality untreated and 40% mortality even with treatment. Requires urgent drainage plus IV antibiotics; often needs surgical pericardial window.
• basicV.A-028
  What is 'effusive-constrictive pericarditis'?
  → Combined pericardial effusion AND constriction. RA pressure fails to normalize after pericardiocentesis due to underlying constrictive physiology of the visceral pericardium. Often requires pericardiectomy.
• basicV.A-029
  What imaging modality best measures pericardial thickness?
  → Cardiac MRI is the gold standard for pericardial thickness measurement. TEE is next best (95% sensitivity, 86% specificity for ≥ 3 mm). Note: constriction can occur even without pericardial thickening ('non-thickened constrictive pericarditis').
• basicV.A-030
  State the standard medical therapy for uncomplicated acute pericarditis.
  → NSAID (ibuprofen 600 mg TID or aspirin 750–1000 mg TID) for 1–2 weeks with taper, PLUS colchicine (0.5 mg BID for 3 months). Colchicine reduces recurrence by ~50%.