Correlation of echocardiographic and clinical findings in patients with pericardial effusion

Echocardiographic Applications of M-Mode Ultrasonography in Anesthesiology and Critical Care

Proficiency in echocardiography and lung ultrasound has become essential for anesthesiologists and critical care physicians. Nonetheless, comprehensive echocardiography measurements often are time-consuming and technically challenging, and conventional 2-dimensional images do not permit evaluation of specific conditions (eg, systolic anterior motion of the mitral valve, pneumothorax), which have important clinical implications in the perioperative setting. M-mode (motion-based) ultrasonographic imaging, however, provides the most reliable temporal resolution in ultrasonography. Hence, M-mode can provide clinically relevant information in echocardiography and lung ultrasound-driven approaches for diagnosis, monitoring, and interventional procedures performed by anesthesiologists and intensivists. Although M-mode is feasible, this imaging modality progressively has been abandoned in echocardiography and is often underutilized in lung ultrasound. This article aims to comprehensively illustrate contemporary applications of M-mode ultrasonography in the anesthesia and critical care medicine practice. Information presented for each clinical application will include image acquisition and interpretation, evidence-based clinical implications in the critically ill and surgical patient, and limitations. The present article focuses on echocardiography and reviews left ventricular function (mitral annular plane systolic excursion, E-point septal separation, fractional shortening, and transmitral propagation velocity); right ventricular function (tricuspid annular plane systolic excursion, subcostal echocardiographic assessment of tricuspid annulus kick, outflow tract fractional shortening, ventricular septal motion, wall thickness, and outflow tract obstruction); volume status and responsiveness (inferior vena cava and superior vena cava diameter and respiratory variability [collapsibility and distensibility indexes]); cardiac tamponade; systolic anterior motion of the mitral valve; and aortic dissection.

"Porcelain heart" a case of acute heart failure with massive myocardial calcification complicated with primary hyperparathyroidism

A 47-year-old Japanese woman was transported to our hospital due to acute heart failure (AHF). She had been diagnosed with primary hyperparathyroidism (pHPT) and undergone parathyroidectomy 3 months previously. Chest X-ray showed marked cardiomegaly and severe pulmonary congestion, and transthoracic echocardiography indicated both left ventricular (LV) systolic and diastolic dysfunction, complicated with extensive massive myocardial calcification and no LV hypertrophy. Computed tomography also showed massive myocardial calcification in the posterior wall of the LV and the interventricular septum. After treatment with furosemide, olprinone, and carperitide under Swan-Ganz monitoring, LV ejection fraction was almost normalized. However, cardiac catheterization in the chronic phase indicated that LV diastolic dysfunction still existed, which might be affected by myocardial calcification. We followed this patient using spironolactone (25 mg/day), perindopril (8 mg/day), and bisoprolol (1.25 mg/day), with no further episode of heart failure for at least 6 months. Here, we report a rare case of AHF complicated with massive myocardial calcification possibly caused by primary hyperparathyroidism. <Learning objective: This is the first case report of acute heart failure due to left ventricular systolic and diastolic dysfunction, complicated with massive myocardial calcification, "porcelain heart", possibly caused by primary hyperparathyroidism.>.

Pericarditis

Pericarditis (inflammation of the pericardium) may be caused by infectious agents, autoimmune disorders, metabolic conditions, or malignancy, or it may be a complication of drug therapy, trauma, cardiac surgery, or smallpox vaccination. Diagnosis, based on clinical findings, electrocardiographic changes, chest radiograph, and ultrasound, may be confirmed as appropriate by pericardiocentesis. Although contemporary imaging technologies, such as computed tomography and magnetic resonance imaging, are useful, echocardiography remains the simplest and most expeditious noninvasive tool to assess inflammatory and infectious diseases of the pericardium. Although contemporary management of pericardial disease remains relatively unchanged, reports of innovative approaches to the management of pericardial effusion include the installation of intrapericardial thrombolytic agents to facilitate drainage of purulent effusions or balloon pericardiotomy for recurrent effusions. Both offer potential alternatives to the surgical pericardial window.

Transesophageal echocardiography in pericardial disease and tamponade

While most pericardial disorders can be imaged by transthoracic echocardiography, transesophageal echocardiography may be required in those cases where pericardial pathology is clinically suspected, but cannot be imaged adequately with transthoracic echocardiography. Transesophageal echocardiography is especially helpful in patients after heart or chest surgery, with cardiac compression by a loculated pericardial hematoma, in patients with dissection, endocarditis, or interatrial shunting associated with pericardial effusion, in patients with pericardial tumors, and in the differential diagnosis between constrictive pericarditis and restrictive cardiomyopathy.

Relationship between septal perfusion, viability, and motion before and after coronary artery bypass surgery

The etiology of abnormal interventricular septal motion occurring after open-heart surgery using cardiopulmonary bypass has not been clarified. Intraoperative ischemic septal injury has been proposed as one explanation for this finding. To examine this possibility, resting septal perfusion and viability were studied using rest and redistribution thallium-201 scintigraphy in 16 patients before and after coronary artery bypass surgery. The results were compared with septal motion on preoperative and postoperative resting gated blood pool scans. Preoperatively, septal thallium uptake was normal in 10 of 16 patients, and septal motion was normal in 14 of 16. Postoperatively, septal thallium uptake was normal in 11 of 16 patients, while septal motion was abnormal in all. Thus abnormal postoperative septal motion is usually associated with normal septal perfusion and viability on thallium scans and therefore is not the result of septal ischemic injury in a majority of patients.

Experimental cardiac tamponade: a hemodynamic and Doppler echocardiographic reexamination of the relation of right and left heart ejection dynamics to the phase of respiration

A hallmark of cardiac tamponade is pulsus paradoxus. However, the exact mechanism of pulsus paradoxus and the relation of left and right ventricular ejection dynamics remain controversial, with some studies suggesting an inverse relation in ventricular filling and ejection and others citing a more important role for the effects of right heart ejection dynamics delayed by transit through the pulmonary artery bed. To specifically reexamine this issue, six sedated but spontaneously breathing dogs were studied during experimental cardiac tamponade with use of extensive hemodynamic instrumentation and Doppler methods. During cardiac tamponade, left ventricular systolic pressure decreased from 125.8 +/- 12.1 to 81.7 +/- 26.7 mm Hg (p less than 0.01) and cardiac output from 5.86 +/- 1.48 to 2.34 +/- 0.98 liters/min (p less than 0.001); mean pericardial pressure increased from -1.2 +/- 0.8 to 10.5 +/- 3 mm Hg (p less than 0.001) and pulsus paradoxus from 4.3 +/- 1.6 to 10.7 +/- 1.2 mm Hg (p less than 0.001) compared with baseline values. An inverse relation in left and right ventricular ejection dynamics that was very close to 180 degrees out of phase was seen throughout the respiratory cycle in multiple hemodynamic and Doppler variables including peak systolic pressures, aortic and pulmonary flow velocities and ventricular ejection times. Simultaneous recording of the transmitral pressure gradient provided indirect evidence that the ventricular ejection dynamics were directly related to changes in ventricular filling. However, the magnitude of ventricular pressure or output flow velocity for each respiratory cycle was variable, depending on the exact timing of filling and ejection in relation to the phase of respiration. Variation in left ventricular output due to changes in right ventricular output delayed by transit through the pulmonary vasculature was not recognized in any animal. It is concluded that in spontaneously breathing dogs with acute cardiac tamponade, peak ventricular pressures, ventricular ejection times and pulmonary and aortic flow velocities have an inverse relation that is very close to 180 degrees out of phase.

Abnormal septal motion after aortic valve replacement for chronic aortic regurgitation: no evidence for myocardial ischaemia by exercise radionuclide angiography

To evaluate interventricular septal motion and left ventricular function after aortic valve replacement for chronic aortic regurgitation, we studied 12 patients at rest and during exercise by radionuclide angiography after a mean of 19 (range 12-36) months after operation (group I). Twenty patients with chronic aortic regurgitation without aortic valve replacement served as controls (group II). None of the patients had coronary artery disease as documented by arteriography. Abnormal interventricular septal motion at rest was seen in 11 patients of group I, of whom 8 showed hypokinesis and 3 akinesis. During exercise, the interventricular septal wall motion improved in 4 patients, worsened in 3 patients and did not change in 5 patients. All patients of group II had normal interventricular septal motion at rest. During exercise, 5 patients showed septal wall hypokinesia together with apical and posterolateral wall motion abnormalities. The left ventricular ejection fraction at rest was 62% +/- 20% in group I and 66% +/- 8% in group II (not significant). During exercise, the left ventricular ejection fraction was 59% +/- 24% in group I and 68% +/- 13% in group II (not significant). We conclude that abnormal interventricular septal motion at rest is commonly found in patients with aortic valve replacement for chronic aortic regurgitation. During exercise, septal wall motion in the patients with aortic valve replacement shows a variable response from complete normalization to akinesia. These findings are mostly associated with a normal global left ventricular function both at rest and during exercise, which precludes myocardial ischaemia as a primary cause for abnormal septal wall motion after aortic valve replacement.

Inferior vena cava plethora with blunted respiratory response: a sensitive echocardiographic sign of cardiac tamponade

To assess the diagnostic and prognostic value of the respiratory behavior of the inferior vena cava in pericardial effusions, clinical and two-dimensional echocardiographic data of 115 consecutive patients with a moderate or large effusion, including 33 who had cardiac tamponade, were reviewed. Echocardiograms were reviewed for effusion size, inferior vena cava diameter before and after deep inspiration and presence of right atrial and ventricular collapse. For the 83 patients (72%) with less than 50% decrease in inferior vena cava diameter after deep inspiration ("plethora"), inferior vena cava diameter decreased from 2.0 +/- 0.3 to 1.6 +/- 0.4 cm after inspiration (mean +/- SD) (mean decrease 18%). For the 32 patients (28%) without plethora, the diameter decreased from 1.6 +/- 0.5 to 0.6 +/- 0.3 cm (mean decrease 63%). Patients with plethora had significantly higher values for heart rate (111 +/- 21 versus 98 +/- 20 beats/min), pulsus paradoxus (24 +/- 15 versus 12 +/- 4 mm Hg), jugular venous distension (14 +/- 5 versus 8 +/- 3 cm H2O) and right atrial pressure (17 +/- 6 versus 12 +/- 6 mm Hg) and lower values for systolic blood pressure (109 +/- 22 versus 132 +/- 27 mm Hg) (all p less than 0.05) than did patients without plethora. Plethora was present in 58 (92%) of 63 patients who underwent a pericardial drainage procedure, 14 (88%) of 16 who developed constrictive physiology and 11 (92%) of 12 of those whose hospital death was related to pericardial effusion.(ABSTRACT TRUNCATED AT 250 WORDS)

Role of transient ischaemia and perioperative myocardial infarction in the genesis of new septal wall motion abnormalities after coronary bypass surgery

To evaluate the role of ischaemia in the genesis of new septal wall motion abnormalities after coronary artery bypass surgery 45 patients were studied by cross sectional echocardiography before and 8-10 days after operation. Regional left ventricular wall motion was classified as normal, hypokinetic, akinetic, or dyskinetic. Septal wall motion abnormalities were correlated with electrocardiographic Q wave changes and serial serum MB creatine kinase measured before and 4, 7, 21, 48, and 72 hours after operation. Of the 14 patients who developed new septal wall motion abnormalities after operation two developed septal akinesis (both had perioperative infarction) and one new dyskinesis in the previously akinetic septal segment. Of the 11 patients with new septal hypokinesis, eight had normal serial creatine kinase MB values, two had raised values peaking four and seven hours after operation, with a return to normal values at 21 hours indicating transient ischaemia, and one had enzymatic criteria for perioperative infarction. Most new echocardiographic septal wall motion abnormalities after coronary artery bypass grafting are not caused by transient ischaemia, perioperative infarction, or generalised cell necrosis.

Echocardiographic features of a mediastinal pancreatic pseudocyst

Cross sectional echocardiography detected a mediastinal pancreatic pseudocyst which caused extracardiac compression in a 49 year old man. Computed tomography confirmed the presence of a cystic lesion lying behind the heart and extending from the pancreas to above the carina. Surgical decompression resulted in resolution of the clinical and echocardiographic findings.

The relative merits of pulsus paradoxus and right ventricular diastolic collapse in the early detection of cardiac tamponade: an experimental echocardiographic study

An inspiratory decline in systolic arterial blood pressure exceeding 10 mm Hg has been used clinically to identify hemodynamically significant pericardial effusions. Recently, the echocardiographic sign of right ventricular diastolic collapse (RVDC) has been shown to occur early in the course of cardiac tamponade in association with a hemodynamically important decline in cardiac output. This study was undertaken to compare the relative merits of pulsus paradoxus and the onset of RVDC in the early detection of cardiac tamponade in an unanesthetized canine preparation. We studied six chronically instrumented, conscious dogs with two-dimensional echocardiography during cardiac tamponade induced by continuous infusion of saline into the pericardial space. We recorded intrapericardial pressure, cardiac output (electromagnetic flowmeter), aortic (catheter-tip transducer) and right atrial blood pressures, heart rate, and respiration. None of the dogs had RVDC when the pericardial space was empty, but all dogs showed RVDC during cardiac tamponade. We found that RVDC was strongly related to all of the cardiac parameters evaluated (intrapericardial pressure, cardiac output, aortic blood pressure, heart rate, and stroke volume) and provided information on each that was independent of that provided by pulsus paradoxus. Furthermore, RVDC appeared to be more strongly related to most cardiac parameters than was pulsus paradoxus and to be more sensitive and specific than pulsus paradoxus in detecting changes in intrapericardial pressure early in cardiac tamponade.

Right ventricular and right atrial collapse in patients with cardiac tamponade--a combined echocardiographic and hemodynamic study

To determine the hemodynamic derangement associated with right ventricular diastolic collapse and to assess the value of right ventricular and right atrial collapse in identifying cardiac tamponade, two-dimensional echocardiograms were recorded simultaneously with measurement of right atrial, pulmonary capillary wedge, intrapericardial, and systemic arterial pressures and cardiac output in 16 patients as they underwent pericardiocentesis. Twelve patients (group I) had evidence of right ventricular or right atrial collapse or both on their echocardiograms and hemodynamic evidence of cardiac tamponade before pericardiocentesis. All hemodynamic parameters improved after pericardiocentesis (p less than or equal to .05). Continuous monitoring during pericardiocentesis in three of these patients showed significant improvement in all parameters except heart rate (p less than or equal to .02) at the point of disappearance of right ventricular diastolic collapse, with further improvement in cardiac output as pericardiocentesis continued (p less than .01). Right atrial collapse persisted after right ventricular collapse disappeared but was no longer present when pericardiocentesis was completed. Three patients (group II) had no right ventricular or right atrial collapse, no hemodynamic evidence of cardiac tamponade, and no improvement in hemodynamic parameters after pericardiocentesis. A single patient (group III) was found to have elevated right heart pressures and right ventricular hypertrophy before pericardiocentesis. Although there was hemodynamic evidence of cardiac tamponade in this patient, there was no evidence of right ventricular or right atrial collapse. In this study, the sensitivity of right ventricular collapse as a marker for cardiac tamponade was 92%, its specificity 100%, its accuracy 94%, and its predictive value 100%.(ABSTRACT TRUNCATED AT 250 WORDS)

Preservation of interventricular septal function in patients having coronary artery bypass grafts without cardiopulmonary bypass

Abnormal interventricular septal motion develops in the majority of patients after cardiac surgery and has been attributed to a variety of causes. This study assesses the role of cardiopulmonary (CP) bypass in the genesis of abnormal septal motion. Twenty-two patients having single coronary artery bypass grafts had septal motion and ejection fraction evaluated preoperatively and postoperatively. The results for 11 patients who had coronary artery bypass grafting (CABG) with CP were compared to those for 11 patients who had grafting without CP bypass. Postoperatively, all 11 patients having bypass grafting with CP bypass had diminution in septal function while 10 of 11 patients having bypass grafting performed without CP bypass had no change or improvement in septal motion (p less than 0.0005). Changes in ejection fraction were not statistically significantly different. This study suggests that abnormal septal motion in patients having CABG is related to CP bypass and/or myocardial preservation techniques.

Sequential study of echocardiographic changes in purulent pericarditis

Serial echocardiographic studies were performed in a child with purulent pericarditis. Besides demonstrating the pericardial effusion, echocardiography was used to assess cardiac function. Computer analysis of changes in left ventricular dimension showed impaired diastolic filling, persisting after pericardiocentesis but normalizing after pericardiectomy.

Clinical and hemodynamic correlation in patients with pericardial effusion and swinging heart by echocardiography

The clinical and hemodynamic findings in 13 consecutive patients with "swinging heart" on M-mode echocardiography were analyzed. In these patients the anterior right ventricular and posterior left ventricular walls and interventricular septum moved almost parallel to each other throughout the cardiac cycle, often with exaggerated excursion. In 10 of 13 patients right heart catheterization revealed the hemodynamic profile of cardiac tamponade, while one additional patient was found to have evidence of cardiac compression at the time of surgery. In the remaining two patients no acute invasive diagnostic procedures were performed. During the same observation period cardiac tamponade was observed in five patients without echocardiographic evidence of a swinging heart, and four of these had large clots in the pericardial space. Thus, the swinging heart pattern appears to be a reliable marker of cardiac tamponade, except in those patients with intrapericardial lesions which mechanically limit cardiac motion.

The hemodynamic derangement associated with right ventricular diastolic collapse in cardiac tamponade: an experimental echocardiographic study

Clinical reports indicate that right ventricular diastolic collapse (RVDC) is associated with cardiac tamponade. To assess the hemodynamic abnormalities associated with RVDC, we studied six chronically instrumented conscious dogs (group A) with two-dimensional echocardiography during cardiac tamponade induced by continuous saline infusion into the pericardial space. We recorded cardiac output (electromagnetic flowmeter), heart rate, respiration, and aortic, intrapericardial, and right atrial pressures. In four additional animals (group B), we recorded right ventricular pressure and placed a hydraulic occluder around the pulmonary artery so that short-term reversible obstruction to right ventricular outflow could be produced. None of the dogs had RVDC when the pericardial space was empty, but all dogs showed RVDC during cardiac tamponade. The appearance of RVDC in group A was associated with a 21% reduction in cardiac output (p less than .01) and no change in mean aortic pressure. Short-term partial pulmonary artery obstruction led to increased right ventricular pressures and a striking reduction in RVDC in early tamponade, suggesting that RVDC is caused by pericardial pressure exceeding right ventricular pressure in early diastole. An additional animal had right ventricular hypertrophy caused by a severe "heart worm" infestation and did not show RVDC during cardiac tamponade. These observations suggest that in the absence of increased resistance to right ventricular outflow or right ventricular hypertrophy, RVDC occurs early in the course of cardiac tamponade and is associated with a hemodynamically important decrease in cardiac output.

Hydrodynamic compression of the right atrium: a new echocardiographic sign of cardiac tamponade

The relationship of right atrial inversion, a previously undescribed cross-sectional echocardiographic sign, to the presence of cardiac tamponade was examined. We studied 127 patients with moderate or large pericardial effusions. Cardiac tamponade was present in 19 and absent in 104. Four patients with equivocal tamponade were excluded from analysis. Right atrial inversion was present in 19 of 19 patients with cardiac tamponade and 19 of 104 without cardiac tamponade (sensitivity, 100%; specificity, 82%; predictive value, 50%). The degree of inversion as quantitated by the area-corrected curvature did not improve the ability to discriminate between patients with and without cardiac tamponade. However, consideration of the duration of inversion by the right atrial inversion time index (duration of inversion/cardiac cycle length) and an empirically derived cut-off of 0.34 did improve the specificity and predictive value (100% and 100%, respectively) without a significant loss of sensitivity (94%). We conclude that right atrial inversion, particularly if prolonged, is a useful echocardiographic marker of cardiac tamponade that may be of particular diagnostic value when the clinical picture is unclear.

Effect of cardiac surgery on ventricular septal motion: assessment by intraoperative echocardiography and cross-sectional two-dimensional echocardiography

Echocardiographic evidence of paradoxical septal motion frequently occurs after cardiac surgery. To assess possible etiologic factors 17 patients were studied preoperatively, intraoperatively, and 7 days after surgery. Preoperative septal motion was normal in 14 and paradoxical in three (two with previous cardiac surgery, one with atrial septal defect [ASD]). Intraoperative septal motion prior to surgical procedure was normal in 16 and paradoxical in one (ASD). Septal motion (excursion and thickening fraction) was normal in all patients prior to chest closure. Echocardiograms of adequate quality were obtained at 7 days post surgery in 15 patients; septal motion was paradoxical in nine (group A) and normal in six (group B). No significant differences were seen between the two groups in ischemic time or in the preoperative to postoperative change in left ventricular (LV) and right ventricular diastolic dimension, shortening fraction, or septal and posterior wall thickening fraction. A significant postoperative decrease in septal excursion was seen in group A but not in group B; significant postoperative increases in posterior wall excursion were seen in both groups. Cross-sectional two-dimensional echocardiograms performed in 20 patients (8 normal, 12 postoperative paradoxical septal motion) were analyzed. In normal controls no significant change was detected in the LV centroid position during systole. In contrast, the 12 postoperative patients showed significant anterior displacement of the LV centroid and right septum during systole. Thus, paradoxical septal motion after cardiac surgery appears to relate to excessive anterior cardiac mobility due to pericardiotomy rather than to myocardial ischemia resulting from cardiopulmonary bypass.

Primary versus secondary mitral valve prolapse: clinical features and implications

This study considers the implications that two types of mitral valve prolapse exist. One is primary, and consists of a basic abnormality of the mitral apparatus. While the etiology of this lesion may not always be the same, the major gross abnormalities are usually constant. Secondary mitral valve prolapse generally exists merely as a consequence of reduced or abnormal ventricular dimensions, and usually appears to be a benign phenomenon.

Left ventricular outflow obstruction induced by tamponade in hypertrophic cardiomyopathy

Echocardiographic abnormalities of valvular movement described in patients with pericardial effusions have included systolic anterior motion (SAM) of the mitral valve. Published illustrations have shown, however, "pseudo-SAM" rather than true SAM. We report a patient with asymmetric septal hypertrophy whose echocardiogram during tamponade showed true SAM, which was no longer apparent and could not be provoked following resolution of tamponade. Two prior cardiac catheterizations revealed no intraventricular pressure gradients in either normal or postextrasystolic beats. Tamponade was the only stimulus that provoked signs of obstruction in this patient with asymmetric septal hypertrophy.

Diagnosis and management of postoperative pericardial effusions and late cardiac tamponade following open-heart surgery

The clinical and laboratory findings of 28 patients identified as having late pericardial effusions were examined. Eleven of these patients were asymptomatic; 9 patients had moderate symptoms including fatigue, malaise, weight gain, and dyspnea on exertion, and 8 patients with similar symptoms had evidence of cardiac tamponade. Ten patients underwent right heart catheterization in the intensive care unit; normal hemodynamics were confirmed in 4 and cardiac tamponade in 6 patients. Pericardiocentesis was effective in decompressing cardiac tamponade in 7 of 8 patients. One patient required operative subxiphoid drainage after unsuccessful pericardiocentesis. In addition, 5 patients with moderate clinical symptoms and pericardial effusions, who did not have cardiac tamponade, underwent pericardiocentesis because of a need for chronic anticoagulant therapy. The remaining patients were managed successfully by observation, discontinuation of warfarin when possible, fluid restriction, and diuretic therapy. All but 1 patient was symptomatically improved. A diagnostic and therapeutic schema is presented as an aid to early recognition of this troublesome and potentially lethal complication.

Influence of positive end-expiratory pressure on left ventricular performance

Although left ventricular dysfunction is common during ventilatory support with positive end-expiratory pressure (PEEP), the mechanism of this disorder remains unclear. In 10 patients with the adult respiratory-distress syndrome we studied the effects of a stepwise increase in PEEP from 0.to 30 cm H2O on left ventricular output, intracardiac transmural pressures, and two-dimensional echocardiographic measurements of left ventricular cross-sectional area at end-systole and at end-diastole. Increasing PEEP was associated with progressive declines in cardiac output, mean blood pressure, and left ventricular dimensions and with equalization of right and left ventricular filling pressures. The radius of septal curvature decreased at both end-diastole and end-systole, implying a leftward shift of the interventricular septum. At the highest PEEP, blood-volume expansion did not restore cardiac output, although left ventricular transmural filling pressures had returned to base-line values. We conclude that decreased cardiac output during PEEP is mediated by a leftward displacement of the interventricular septum, which restricts left ventricular filling.

Detection of pericardial metastases by cross-section echocardiography

Cross-sectional echocardiography was performed on 69 patients with pericardial effusion. The etiology of the pericardial effusion was malignant infiltration of the pericardium in nine patients; chronic renal failure in 10; postcardiac surgery in 31; viral pericarditis in three; tuberculous pericarditis in two; and undetermined in 14. Seven of the nine patients with pericardial metastases were noted to have irregular cauliflower-like masses protruding from the pericardium and the epicardium into the echo-free space of the pericardial effusion. These masses demonstrated a to-and-fro motion within the pericardial space during ventricular systole. The presence of pericardial metastases was confirmed at operation in four cases and the three others had intrathoracic or colonic malignancy with widespread metastases. None of the patients without pericardial metastasis showed the characteristic abnormality seen in patients with pericardial metastases. Six patients had dense linear echoes connecting the pericardium and epicardium that probably represented adhesions (confirmation at surgery in one, and confirmation at autopsy in another), with an appearance that was different from that seen in pericardial metastases. We conclude that cross-sectional echocardiography may be useful for detecting pericardial metastases.

Two dimensional echocardiography in mitral, aortic and tricuspid valve prolapse. The clinical problem, cardiac nuclear imaging considerations and a proposed standard for diagnosis

The mitral valve prolapse syndrome may present with a variety of clinical manifestations and has proved to be a common cause of nonspecific cardiac symptoms in clinical practice. Primary and secondary forms must be distinguished. Myxomatous degeneration appears to be the common denominator of the primary form. The diagnostic standard of this form has not previously been defined because the detection of mitral leaflet tissue in the left atrium (prolapse) on physical examination or angiography is nonspecific. M mode echocardiography has greatly enhanced the recognition of this syndrome but has not proved to be the best diagnostic standard because of its limited view of mitral valve motion. The advent of two dimensional echocardiography has provided the potential means for specific identification of the mitral leaflet motion in systole and can be considered the diagnostic standard for this syndrome. Primary myxomatous degeneration with leaflet prolapse is not localized to the mitral valve. Two dimensional echocardiography has detected in preliminary studies tricuspid valve prolapse in up to 50 percent and aortic valve prolapse in about 20 percent of patients with idiopathic mitral valve prolapse.

Echocardiographic study of the paradoxical arterial pulse in chronic obstructive lung disease

In nine subjects with chronic obstructive pulmonary disease (COPD) and pulsus paradoxus, M-mode echocardiograms showed inspiratory augmentation of right ventricular dimensions and inspiratory decrease of left ventricular diastolic dimensions. In five subjects in whom the echocardiographic transistor was in the subxiphoid position, mean right ventricular dimensions increased during inspiration from 1.4 +/- 0.20 to 2.96 +/- 0.38 cm (p < 0.01). With inspiration, mean left ventricular diastolic dimensions decreased from 4.8 +/- 0.61 to 3.7 +/- 0.63 cm (p < 0.01) in these five subjects. Two-dimensional echocardiograms, performed in three subjects, confirmed inspiratory augmentation of right ventricular cross-sectional area. Similar changes were produced in two normal volunteers by artificial obstruction to breathing. Left ventricular ejection time measurements demonstrated an inspiratory decline in left ventricular stroke volume. Inspiratory filling of the right ventricle is not hampered, but rather is exaggerated in patients with COPD and pulsus paradoxus, and left ventricular stroke volume is reduced during inspiration. Exaggerated variations in intrathoracic pressure alone did not explain pulsus paradoxus. Increased right ventricular filling and stroke volume during inspiration probably play a part.

Early detection of doxorubicin cardiotoxicity by M-mode echocardiography

The influence of increasing doses of doxorubicin on the heart was examined in 30 patients with solid tumors, M-mode echocardiography being used to evaluate left ventricular contractility. The function of the left ventricle remained normal in 26 subjects, whereas four patients had evidence of cardiotoxicity after cumulative doses of 220, 380, 420, and 450 mg/m2. Transient overt heart failure was noted in one subject only. Doxorubicin cardiotoxicity can be detected by M-mode echocardiography, a simple and non-invasive technique, prior to the appearance of overt congestive heart failure. Patients demonstrating left ventricular dysfunction are probably not candidates for receiving further therapy with anthracycline antibiotics. Limitation of M-mode echocardiography include a 28% incidence of inadequate studies in this group of patients, and a relative inaccuracy of the technique in evaluating patients with prior myocardial infarction.

Echocardiographic observations regarding pericardial effusions associated with cardiac disease

Cardiac disease associated with congestive heart failure was found to be the most common cause (22 of 76) of pericardial effusion in patients referred for echocardiography. Parameters of left heart function were markedly abnormal in these patients with congestive heart failure and pericardial effusion, but were not significantly different from a group of patients with congestive heart failure without pericardial effusion. Clinical findings consistent with cardiac decompensation also failed to discern between these two groups. Nonetheless, patients with congestive heart failure with pericardial effusion had significantly larger right ventricular internal dimensions than those without effusion. Patients with pericardial effusion related to congestive heart failure (P < .01), heart disease without congestive heart failure (P < 0.001) and those patients post recent myocardial infarction (P < 0.05) had significantly larger right ventricular internal dimensions in diastole than normal subjects. Patients with pericardial effusions related to recent open heart surgery, idiopathic pericarditis or of miscellaneous causes had normal right ventricular internal dimensions. It is likely that right ventricular dilation indicates abnormal volume/pressure relationships of the right heart and that this abnormality, through alterations in venous and lymphatic drainage, underlies the accumulation of pericardial effusion in these patients with heart disease with or without congestive heart failure.

Echocardiographic observations of paradoxic pulse without pericardial disease

Echocardiograms were obtained in 10 normal patients and in 11 patients with respiratory insufficiency due to chronic obstructive lung disease (8) and to thoracic poliomyelitis (3). Only the eight patients with obstructive lung disease had paradoxic pulse. No patient had pericardial disease. The left ventricular internal dimension, stroke volume, and the mitral valve E-F slope and D-E excursion were measured. The inspiratory to expiratory ratio of each measurement was significantly lower in patients with obstructive lung disease than in normal subjects. The patients with thoracic poliomyelitis demonstrated almost no respiratory change in these measurements. The magnitude of the change in the measured factors probably relates to the degree of negativity of intrathoracic pressure during respiration. The inspiratory reduction of mitral valve motion and left ventricular internal dimension is not specific to tamponade but may be seen in patients who exhibit paradoxic pulse due to other conditions.

Left ventricular function in presence of small pericardial effusion. Echocardiography study

Using echocardiography, various indices of left ventricular function were studied in a group of 11 patients with small posterior pericardial effusion. The only index of left ventricular function that was abnormal in this group was maximum diastolic endocardial velocity (DEVM), a measure of left ventricular relaxation. When evaluated as a group, DEVM was significantly decreased in the presence of effusion as compared with the control group. This change in DEVM in the presence of small effusion, without any other associated changes in left ventricular function, suggests that the mechanism of impaired left ventricular relaxation is a change in compliance of the pericardium. In large effusions, left ventricular relaxation abnormalities are associated with changes in left ventricular dimensions, and impaired relaxation may also be the result of shift in intracardiac structures.

Echocardiographic features of cardiac compression by mediastinal pancreatic pseudocyst

Echocardiogram of a patient who had retrocardiac compression by pancreatic pseudocyst is described both before and after drainage. Mass of echoes behind the anterior leaflet of the mitral valve and its disappearance after drainage of a pseudocyst have not been described in available literature. These findings mimic left atrial myxoma, and we discuss their differentiation in this case report.

Can cardiac tamponade be diagnosed by echocardiography? Experimental studies

The purpose of this study was to determine if respiratory variation and/or absolute size of echocardiographically measured right or left ventricular internal dimension at end-diastole (RVIDd or LIVIDd) are accurate indicators of the presence or severity of cardiac tamponade. We measured RVIDd or LVIDd by echocardiography in nine closed-chest, spontaneously breathing dogs in control and during hypotensive tamponade. With tamponade, the end-expiratory RVIDd and LVIDd were significantly smaller than control. Inspiratory increases in RVIDd and decreases in LVIDd were exaggerated during tamponade. Because of the wide range and overlap of RVIDd and LVIDd, no single expiratory value or amount of respiratory change indicated the presence or severity of tamponade. We conclude that if serial echocardiograms show a pericardial effusion, a decreasing end-expiratory RVIDd and LVIDd and an increasing percentage change in ventricular diameter with inspiration, a progressive degree of tamponade should be suspected However, a single echocardiogram cannot accurately predict the presence or severity of tamponade.

Echocardiography in the diagnosis of idiopathic hypertrophic subaortic stenosis coexisting with pericardial effusion

Of 89 patients with idiopathic hypertrophic subaortic stenosis who had M-mode echocardiagrams recorded, seven patients with coexisting moderate to large pericardial effusions were identified. The clinical profile, M-mode echocardiograms, and cardiac catheterization and angiocardiographic studies in two of the seven patients were analyzed. That the two entities were not associated was suggested by the identification of an etiology for the pericardial effusion in four of the patients. Although the "swinging heart" phenomenon was exhibited in the echocardiograms of each patient, the presence of a significant pericardial effusion did not preclude the ability to establish a diagnosis of idiopathic hypertrophic subaortic stenosis by M-mode echocardiography.

Echocardiographic evaluation of pericardial diseases

This review has attempted to summarize the usefulness of echocardiography in pericardial effusion and other pericardial diseases. As stated before, it is an extremely useful technique for the detection and following of patients with pericardial effusion. The usefulness in other forms of pericardial disease is less well-established.

Pericardial effusion and electrical alternans: echocardiographic assessment

Clinical diagnosis of pericardial effusion is often difficult, and assessment of the effects of effusion on cardiac hemodynamics is often imprecise. Electrical alternans is a reasonably specific ECG indicator of the presence of a large effusion and imminent or actual cardiac tamponade. If echocardiography verifies the presennce of pericardial fluid and shows abnormal cardiac motion, a diagnosis of cardiac tamponade can be made without further, more invasive, studies.

Echocardiographic study of cardiac tamponade

We studied 14 patients with cardiac tamponade and pulsus paradoxus; 11 were studied after relief of tamponade by pericardiocentesis. Right ventricle diastolic diameter increased during inspiration in each of 12 patients; left ventricle diastolic diameter decreased during inspiration in each of 13. Mitral valve DE amplitude decreased with inspiration in 13 of 14 patients. Mitral valve E-F slope could be measured in eight patients, and was rounded and not measurable in six. Six of the eight showed inspiratory decrease in mitral E-F slope. Similar changes were observed in two other patients with pulsus paradoxus who had chronic obstructive airway disease. Twenty patients with large pericardial effusions and no tamponade did not show these changes. These results suggest inspiratory augmentation of right ventricular filling and inspiratory diminution of left ventricular filling, not only in cardiac tamponade, but in obstructive airway disease associated with pulsus paradoxus.