Echocardiographic diagnosis of pericardial disease.

Echocardiograms were performed in 11 patients with constrictive pericarditis or effusive-constrictive pericarditis confirmed by cardiac catheterization and pericardiectomy. Three echocardiographic patterns of pericardial disease were noted and were related to three types of pericardial pathology. Parallel moving echoes separated by a clear space were reflected from chronically fibrosed and thickened pericardium without associated pericardial exudate. Effusive-constrictive pericarditis or subacute wet pericarditis was characterized on the echocardiogram by a posterior echo-free space representing the liquid pericardial effusion and multiple ultrasonic lines from the thickened visceral pericardium. Subacute dry pericarditis was associated with numerous ultrasonic signals filling the space between the visceral pericardium and the relatively flat parietal pericardium. These ultrasonic signals were reflected from coagulated pericardial exudate which was adherent both to the parietal pericardium and the visceral pericardium. Parallel moving echoes or dense bands of echoes were reflected from either or both thickened visceral and parietal pericardium.     

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.     

Unusual echocardiographic findings in pericardial tamponade.

M-mode echocardiographic scanning has been known to be a sensitive and reliable technique for the detection of pericardial effusion.^{1. 2} The diagnosis is established by the demonstration of an echo-free space between the left ventricle and the posterior pericardium. This space is said to disappear near the left atrioventricular junction on a continuous scan from the apex of the left ventricle to the aortic root. It is generally felt³ that fluid cannot accumulate behind the left atrium because of the nature of the reflection of the pericardium around the great vessels on the posterior surface of the heart. This report describes a case of pericardial tamponade in which M-mode echocardiography revealed definite fluid behind the left atrium. Other unusual echocardiographic features of this case were apparent prolapse of the mitral valve and markedly exaggerated motion of the heart as a whole. A normal EF slope was recorded despite the presence of pericardial tamponade.     

Recurrent cardiac tamponade and large pericardial effusions: management with an indwelling pericardial catheter

A new technique, using an atraumatic indwelling catheter, has been developed for short-term management of large or rapidly reaccumulating pericardial effusions. This technique (1) permits continuous pericardial fluid drainage, obviating repeated aspirations; (2) provides a convenient route for intrapericardial instillation of chemotherapeutic agents; and (3) enables one to await the results of diagnostic studies without subjecting a patient to thoracotomy. Experience in three patients suggests that in some cases the use of this catheter may eliminate the need for surgery; in others, it may serve as a valuable temporary measure to achieve stabilization of the patient's condition.     

Unusual echocardiographic manifestation of pericardial effusion.

Echocardiographic and sector scanning examinations were performed in a patient with pericardial effusion. In addition to the demonstration of fluid posterior to the left ventricle and anterior to the right ventricle, as in most significant pericardial effusions, there was an echo-free space representing fluid recorded posterior to the left atrium. Several possible explanations of this finding are offered.     

Percutaneous myocardial and pericardial biopsy with the Menghini needle

A simple, safe method of obtaining myocardial or pericardial tissue for analysis by light or electron microscopy or for culture has obvious application. The Menghini needle has been demonstrated to be a safe and effective instrument for the aspiration biopsy of liver and kidney. Therefore, application of aspiration biopsy with a 17 gauge Menghini needle to the heart by means of the left ventricular apical percutaneous approach has been evaluated in humans in 27 myocardial and 8 pericardial biopsies. Adequate tissue was obtained in all except one pericardial and two myocardial biopsy attempts. Of the eight pericardial biopsies, the diagnosis of tuberculous pericarditis was made in two cases and carcinomatous invasion of the pericardium was made in another two cases. Three cases showed nonspecific pericarditis. Of the 27 myocardial biopsies, 6 were examined by light microscopy and 21 were examined by electron microscopy. Light microscopy revealed no specific findings. However, electron microscopy showed moderate to severe intracellular abnormalities, the significance of which remains to be determined. Biopsy procedure takes 5 minutes or less under local anesthesia following mild premedication. Pneumothorax occurred in two patients and transient mild pleuritic chest pain occurred in four patients. Both complications were well tolerated. The technique seems effective and safe. Its utility and application remain to be determined.     

Delayed pericardial disease after radiotherapy

Delayed chronic constrictive pericarditis developed in seven patients 51 to 268 (mean 116) months after radiotherapy. Six of the seven complained of exertional dyspnea that was initially believed to be caused by mediastinal fibrosis. All patients had raised jugular venous pressure, although in two patients this finding was not appreciated by the primary physician. There were no consistent noninvasively identifiable features to allow prediction of constrictive pericarditis other than consideration of its existence and careful examination of the cardiovascular system. All patients had constrictive pericarditis proved at cardiac catheterization. Of the five patients who underwent pericardiectomy, two had an excellent functional result, one has residual pericardial constriction and two died of unrelated causes. Recommendations for the treatment of radiation-induced pericardial disease are given.     

Ocular and pericardial involvement in Legionnaires' disease

Legionnaires' disease can exhibit protean extrapulmonary manifestations. Pericardial involvement is rare and has been described in three case reports. A patient is described with Legionnaires' disease and pericardial and ocular involvement, an entity that has not been reported previously. This patient was successfully treated with intravenous erythromycin with resolution of his pericardial effusion and ophthalmologic findings.     

Echocardiographic mimicry of pericardial effusion

Echocardiography is a sensitive technique for the detection of pericardial effusion, but the abnormal echocardiographic patterns seen with effusions are not, however, entirely specific for that diagnosis. This study describes four patients in whom anatomic structures, a coronary artery to coronary sinus fistula (one case) and tumors metastatic to pericardium (three cases), produced posterior and, in two cases, anterior spaces compatible with pericardial fluid. Echocardiographic patterns mimicking pericardial effusion have previously been reported in patients with anatomic abnormalities such as mitral anular calcification, pleural effusions, left atrial enlargement, anterior mediastinal or pericardial tumors, foramen of Morgagni hernia and pseudoaneurysm of the left ventricle. It appears that structures of fluid or tissue density, interposed between the heart and the airfilled lung, can produce echocardiographic patterns simulating pericardial effusion.     

Congenital right-sided pericardial defect with herniation of part of the lung into the pericardial cavity

This study describes an infant with congenital right-sided pericardial defect and herniation of part of the lung into the pericardial cavity. The patient presented with severe heart failure caused by a ventricular septal defect, a patent ductus arteriosus and mitral stenosis. During periods of deterioriation severe signs of superior vena caval obstruction were present, thought to be due to pressure of the herniated part of the lung on this vein. Chest roentgenograms showed a clearly demarcated radiolucent shadow in the superior mediastinum. The infant died at age 8 weeks because of intractable congestive heart failure. Necropsy revealed, in addition to the cardiovascular malformations, aplasia of the vermis cerebelli. The embryologie aspects of congenital pericardial defects are discussed.     

Technetium-99m stannous pyrophosphate myocardial scintigrams in pericardial disease

Technetium-99m stannous pyrophosphate (^99mTc-PYP) myocardial scintigrams were obtained in 35 acute pericarditis and in three chronic constrictive pericarditis patients. Thirteen of 35 acute pericarditis patients (37%) and one of three chronic constrictive pericarditis patients (33%) had abnormal scintigrams (a diffuse pattern in eight patients and a regional pattern in six patients). Of the 17 acute pericarditis patients with classic ST-segment changes of acute pericarditis, 10 (56%) had abnormal scintigrams compared to three of 17 patients (18%) without these ECG change (P < 0.02). These data indicate that pericardial disease may cause an abnormal scintigram. Therefore, one must rule out pericardial disease before concluding that a positive scintigram is due to acute myocardial infarction.     

Clinical utility of pericardial fluid pH determination

The pH of pericardial fluid has not been well characterized. Therefore, it was analyzed in 13 consecutive patients who had pericardial disease of varying causes and were undergoing pericardiocentesis. Values ranged from 6.82 to 7.59. In seven patients with bloody pericardial effusions, the pH was significantly lower than the simultaneously determined arterial pH (7.31 +/- 0.07 versus 7.45 +/- 0.04, p less than 0.01). Pericardial fluid pH discriminated between inflammatory (pH 7.06 +/- 0.07) and noninflammatory (pH 7.42 +/- 0.06) causes (p less than 0.001). Thus, pericardial fluid pH determination is a quick and accurate method to exclude inadvertent ventricular punctures in bloody pericardiocentesis and to distinguish between inflammatory and noninflammatory causes of pericardial fluid accumulation.     

Massive haemorrhagic pericardial effusion in beta-thalassaemia major

The case of a child with beta-thalassaemia major who developeda massive haemorrhagic pericardial effusion is reported andin whom the clinical picture completely resolved after pericardiocentesis.Possible causes are discussed and the role of echocardiographyin the follow-up of thalassaemic patients is emphasized.     

Echocardiographic manifestations of tense pericardial effusion

Echocardiography has emerged as a sensitive study in the evaluation of pericardial effusion. The specificity of echocardiographic signs in cardiac tamponade remains undefined, however. Two such signs, early diastolic collapse of the right ventricular free wall and late diastolic collapse of the right atrial wall, were observed in two patients without clinical evidence of cardiac tamponade. Increased intrapericardial pressure was documented in each patient. Accumulation of pericardial fluid under high pressure results in a reversal of the instantaneous transmural pressure gradients in early and late diastole, causing collapse of the right ventricular and the right atrial wall, respectively; however, such a tense pericardial effusion may not cause hemodynamic embarrassment severe enough to yield clinical signs of cardiac tamponade.     

Gamma globulin complexes in rheumatoid pericardial fluid.

Cardiac tamponade due to pericarditis occurred in a patient with rheumatoid arthritis. Aspiration afforded us an opportunity to expand the characterization of pericardial fluid. Elevated acid phosphatase levels, decreased whole hemolytic complement and gamma globulin complexes similar to those found in rheumatoid synovial fluid were noted, supporting the concept of a unitary nature of inflammation in rheumatoid disease.