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Ng WWS, Tang KB, Man MY, Hui KY, Shum HP. An Unusual Case of Effusive-Constrictive Pericarditis in the Intensive Care Unit. CASE 2022; 6:269-274. [PMID: 36036044 PMCID: PMC9399560 DOI: 10.1016/j.case.2022.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Wincy Wing-Sze Ng
- Correspondence: Wincy Wing-Sze Ng, MBBS, MRCP (UK), PDipID (HK), FHKCP, FHKAM (Medicine), Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital, 3 Lok Man Road, Chai Wan, Hong Kong Special Administrative Region, China
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Dragoi L, Teijeiro-Paradis R, Douflé G. When is tamponade not an echocardiographic diagnosis… Or is it ever? Echocardiography 2022; 39:880-885. [PMID: 35734782 DOI: 10.1111/echo.15361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 04/13/2022] [Accepted: 04/23/2022] [Indexed: 11/30/2022] Open
Abstract
Although cardiac tamponade remains a clinical diagnosis, echocardiography is an essential tool to detect fluid in the pericardial space. Interpretation of echocardiographic findings and assessment of physiologic and hemodynamic consequences of a pericardial effusion require a thorough understanding of pathophysiologic processes. Certain echocardiographic signs point toward the presence of cardiac tamponade: a dilated inferior vena cava (IVC), collapse of the cardiac chambers, an inspiratory bulge of the interventricular septum into the left ventricle (LV) (the "septal bounce"), and characteristic respiratory variations of Doppler flow velocity recordings. However, in certain circumstances (e.g., mechanical ventilation, post-surgical patients, and pulmonary hypertension), these echocardiographic signs can be missing, despite the presence of clinical tamponade. Failure to recognize a potentially life-threatening clinical condition due to the absence of corresponding echocardiographic findings can delay both diagnosis and life-saving treatment. Thus, in the context of critical care, echocardiography should only be used to confirm the presence of pericardial fluid or localized hematoma, and the diagnosis of tamponade should rely on clinical criteria.
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Affiliation(s)
- Laura Dragoi
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ricardo Teijeiro-Paradis
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ghislaine Douflé
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesia and Perioperative Medicine, University Health Network, Toronto, Ontario, Canada
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Liu VC, Fritz AV, Burtoft MA, Martin AK, Greason KL, Ramakrishna H. Pericardiectomy for Constrictive Pericarditis: Analysis of Outcomes. J Cardiothorac Vasc Anesth 2021; 35:3797-3805. [PMID: 33722460 DOI: 10.1053/j.jvca.2021.02.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 02/05/2021] [Indexed: 01/17/2023]
Abstract
Constrictive pericarditis is caused by pericardial inflammation and fibrosis, leading to diastolic heart failure. The diagnosis requires a high index of suspicion because it often can mimic restrictive myocardial disease and cardiac tamponade and can be associated with severe tricuspid regurgitation and chronic liver disease. Patients who remain undiagnosed can experience a 90% mortality rate, and for those who undergo pericardiectomy, the survival rate varies significantly, depending on the underlying etiology and preoperative functional class of the patient. In this article, the authors review the pathophysiology, echocardiographic findings, management, and surgical outcomes of constrictive pericarditis to aid the cardiothoracic anesthesiologist in the perioperative management of this disorder.
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Affiliation(s)
- Victor C Liu
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Ashley V Fritz
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Melissa A Burtoft
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Archer K Martin
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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Nicoara A, Skubas N, Ad N, Finley A, Hahn RT, Mahmood F, Mankad S, Nyman CB, Pagani F, Porter TR, Rehfeldt K, Stone M, Taylor B, Vegas A, Zimmerman KG, Zoghbi WA, Swaminathan M. Guidelines for the Use of Transesophageal Echocardiography to Assist with Surgical Decision-Making in the Operating Room: A Surgery-Based Approach: From the American Society of Echocardiography in Collaboration with the Society of Cardiovascular Anesthesiologists and the Society of Thoracic Surgeons. J Am Soc Echocardiogr 2020; 33:692-734. [PMID: 32503709 DOI: 10.1016/j.echo.2020.03.002] [Citation(s) in RCA: 96] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Intraoperative transesophageal echocardiography is a standard diagnostic and monitoring tool employed in the management of patients undergoing an entire spectrum of cardiac surgical procedures, ranging from "routine" surgical coronary revascularization to complex valve repair, combined procedures, and organ transplantation. Utilizing a protocol as a starting point for imaging in all procedures and all patients enables standardization of image acquisition, reduction in variability in quality of imaging and reporting, and ultimately better patient care. Clear communication of the echocardiographic findings to the surgical team, as well as understanding the impact of new findings on the surgical plan, are paramount. Equally important is the need for complete understanding of the technical steps of the surgical procedures being performed and the complications that may occur, in order to direct the postprocedure evaluation toward aspects directly related to the surgical procedure and to provide pertinent echocardiographic information. The rationale for this document is to outline a systematic approach describing how to apply the existing guidelines to questions on cardiac structure and function specific to the intraoperative environment in open, minimally invasive, or hybrid cardiac surgery procedures.
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Affiliation(s)
| | | | - Niv Ad
- White Oak Medical Center and University of Maryland, Silver Spring, Maryland
| | - Alan Finley
- Medical University of South Carolina, Charleston, South Carolina
| | | | - Feroze Mahmood
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | | | | | | | | | | | | | - Bradley Taylor
- University of Maryland Medical Center, Baltimore, Maryland
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Helwani MA, Alber S, DeWet CJ, Zoller JK. Intraoperative Assessment of Hepatic Vein Tracings in Constrictive Pericarditis During Surgical Pericardiectomy. J Cardiothorac Vasc Anesth 2020; 34:1099-1102. [DOI: 10.1053/j.jvca.2019.11.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 11/04/2019] [Accepted: 11/09/2019] [Indexed: 11/11/2022]
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Ardhanari S, Yarlagadda B, Parikh V, Dellsperger KC, Chockalingam A, Balla S, Kumar S. Systematic review of non-invasive cardiovascular imaging in the diagnosis of constrictive pericarditis. Indian Heart J 2016; 69:57-67. [PMID: 28228308 PMCID: PMC5318986 DOI: 10.1016/j.ihj.2016.06.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2016] [Revised: 05/26/2016] [Accepted: 06/08/2016] [Indexed: 11/10/2022] Open
Abstract
Background Diagnosis of constrictive pericarditis (CP) can be challenging. It can be nearly impossible to distinguish CP from other causes of right heart failure. Although various imaging modalities help in the diagnosis, no test is definitive. Several reviews have addressed the role of various imaging techniques in the diagnosis of CP but a systematic review has not yet been published. Objective Our intention was to study the ability of various non-invasive imaging modalities to diagnose CP in patients with surgically confirmed disease and to apply our findings to develop a clinically useful diagnostic algorithm. Methods A PubMed (NLM) search was performed with MeSH term “constrictive pericarditis”. Original articles that investigated the ability of various cardiovascular imaging modalities to noninvasively diagnose surgically confirmed CP were included in our review. Investigations that included any cases without surgical confirmation were excluded. Results The PubMed search yielded 3001 results with MeSH term “constrictive pericarditis” (January 8, 2016). We identified (40) studies on CP that matched our inclusion criteria. We summarized our results sorted by individual non-invasive CV imaging modalities – echocardiography, cardiac computed tomography (CT), and magnetic resonance imaging (MRI). Under each imaging modality, we grouped our discussion based on different parameters useful in CP diagnosis. Conclusions In conclusion, contemporary diagnosis of CP is based on clinical features and echocardiography. Cardiac MRI is recommended in patients where echocardiography is not diagnostic. Both cardiac MRI and CT can guide surgical planning but we prefer MRI as it provides both structural and functional information.
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Affiliation(s)
- Sivakumar Ardhanari
- Department of Medicine, Division of Cardiology, University of Missouri School of Medicine, Columbia, MO, United States
| | - Bharath Yarlagadda
- Department of Medicine, Division of Cardiology, University of Missouri School of Medicine, Columbia, MO, United States
| | - Vishal Parikh
- Department of Cardiology, University of South Florida, Tampa, FL, United States
| | - Kevin C Dellsperger
- Department of Medicine, Augusta University Health, Augusta, GA, United States
| | - Anand Chockalingam
- Department of Medicine, Division of Cardiology, University of Missouri School of Medicine, Columbia, MO, United States
| | - Sudarshan Balla
- Department of Medicine, Division of Cardiology, University of Missouri School of Medicine, Columbia, MO, United States
| | - Senthil Kumar
- Department of Medicine, Division of Cardiology, University of Missouri School of Medicine, Columbia, MO, United States.
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Cartwright BL, Jackson A, Cooper J. Intraoperative Pulmonary Vein Examination by Transesophageal Echocardiography: An Anatomic Update and Review of Utility. J Cardiothorac Vasc Anesth 2013; 27:111-20. [DOI: 10.1053/j.jvca.2012.06.019] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2011] [Indexed: 11/11/2022]
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Abstract
Pericardial disease leading to pericardial effusion (PEF) is a common condition encountered by the clinician in day-to-day practice. If the PEF becomes large enough, it can cause hemodynamic compromise, resulting in a cardiogenic shock state known as cardiac tamponade. There are many clinical and echocardiographic signs that a clinician can use to assess whether a large PEF is hemodynamically significant. However, these signs can be either conflicting or even absent. The purpose of this review is to first, describe the physiology of the pericardium in health and how it changes with disease; second, outline the pathophysiology of pericardial tamponade and discuss how it is responsible for the physical and echocardiographic findings of cardiac tamponade; and third, suggest an approach to applying these findings in a systematic order to ensure a correct diagnosis.
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Faehnrich JA, Noone RB, White WD, Leone BJ, Hilton AK, Sreeram GM, Mark JB. Effects of positive-pressure ventilation, pericardial effusion, and cardiac tamponade on respiratory variation in transmitral flow velocities. J Cardiothorac Vasc Anesth 2003; 17:45-50. [PMID: 12635060 DOI: 10.1053/jcan.2003.9] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To determine the effects of positive-pressure ventilation and experimentally induced pericardial effusion and tamponade on transmitral flow velocities in dogs. DESIGN Descriptive. SETTING University laboratory. PARTICIPANTS Eleven tracheally intubated and mechanically ventilated dogs. INTERVENTIONS Experimental pericardial effusion and cardiac tamponade were created by pericardial injection of warm saline. MEASUREMENTS AND MAIN RESULTS Hemodynamic parameters and pericardial pressures were monitored in the 11 dogs. Pulsed-wave Doppler tracings of mitral valve flow were obtained at the leaflet tips along with hemodynamic measurements at 4 stages: control, effusion (no decrease in mean arterial pressure), tamponade (>or=40% decrease in mean arterial pressure), and tamponade relief (after evacuation of pericardial fluid). Maximal variation (36%) in transmitral flow velocity over the respiratory cycle during positive-pressure ventilation was seen in the control stage. In the effusion and tamponade stages, variation in transmitral flow velocity decreased progressively to 29% (p = 0.1804, not significant) and 16% (p < 0.0001), respectively. CONCLUSION Intrathoracic pressure and lung volume changes caused by positive-pressure ventilation influence transmitral flow velocity patterns. Respiratory variation in transvalvular flow is pronounced during standard positive-pressure mechanical ventilation, decreases in the presence of pericardial effusion, and becomes almost nonexistent when cardiac tamponade is present. These findings show that the echocardiographic criteria used to diagnose cardiac tamponade based on mitral valve inflow patterns are different during positive-pressure ventilation from spontaneously breathing subjects.
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Affiliation(s)
- Jana A Faehnrich
- Department of Anesthesiology, Duke University Medical Center, and Anesthesiology Service, Veterans Affairs Medical Center, Durham, NC 27705, USA
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