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.     

Prolapsed left atrium behind the left ventricular posterior wall: Two dimensional echocardiographic and angiographlc features

Left atrial enlargement can usually be detected accurately using M mode echocardiography. However, in the presence of heart disease, asymmetric enlargement may lead to inaccurate assessment of left atrial size and shape. Pericardial effusion can usually be diagnosed on the basis of characteristic M mode echocardiographic findings. However, false positive patterns sometimes occur with the use of this single dimensional technique. Three patients with a greatly enlarged left atrium are described whose M mode echocardiogram suggested significant posterior pericardial fluid accumulation. In each patient, two dimensional echocardiography detected portions of a huge left atrium that prolapsed behind the left ventricular posterior wall and mimicked an isolated posterior pericardial effusion. In one case a right anterior oblique left ventricular cineangiogram suggested the presence of a ventricular septal defect or a false aneurysm of the left ventricle due to the prolapsed left atrium. Because two dimensional echocardiography can provide accurate spatial orientation with visualization of intracardiac structures in relation to one another in real time, it can identify the presence of left atrial prolapse and play an important role in the differential diagnosis of isolated echo-free spaces behind the left ventricle detected with M mode echocardiography.     

Echocardiographic demonstration of right atrial rupture in a patient with right-sided cardiac tumor

Two-dimensional echocardiographic evaluation of a young man with recent drainage of a hemorrhagic pericardial effusion revealed persistent fluid and a massive tumor involving the right atrium, tricuspid valve, and right ventricle. Echocardiographic demonstration of right atrial wall rupture was confirmed at surgery; pathologic analysis showed a spindle cell sarcoma.     

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.     

Echocardiographic predictors of adverse outcomes in primary pulmonary hypertension

OBJECTIVES: The aim of this study was to evaluate the relationships between echocardiographic findings and clinical outcomes in patients with severe primary pulmonary hypertension (PPH).BACKGROUND: Primary pulmonary hypertension is associated with abnormalities of right heart structure and function that contribute to the poor prognosis of the disease. Echocardiographic abnormalities associated with PPH have been described, but the prognostic significance of these findings remains poorly characterized. METHODS: Echocardiographic studies, invasive hemodynamic measurements and 6-min walk tests were performed and outcomes prospectively followed in 81 patients with severe PPH. Subjects were participants in a 12-week randomized trial examining the effects of prostacyclin plus conventional therapy compared with conventional therapy alone. RESULTS: During the mean follow-up period of 36.9 +/- 15.4 months, 20 patients died and 21 patients underwent transplantation. Pericardial effusion (p = 0.003) and indexed right atrial area (p = 0.005) were predictors of mortality. Pericardial effusion (p = 0.017), indexed right atrial area (p = 0.012) and the degree of septal shift in diastole (p = 0.004) were predictors of a composite end point of death or transplantation. In multivariable analyses incorporating clinical, hemodynamic and echocardiographic variables, pericardial effusion and an enlarged right atrium remained predictors of adverse outcomes. Six-minute walk results, mixed venous oxygen saturation and initial treatment randomization were also independently associated with a poor prognosis. CONCLUSIONS: Pericardial effusion, right atrial enlargement and septal displacement are echocardiographic abnormalities that reflect the severity of right heart failure and predict adverse outcomes in patients with severe PPH. These characteristics may help identify patients appropriate for more intensive medical therapy or earlier transplantation.     

Echocardiography in pericardial effusion.

Echocardiography has become established as the procedure of choice for the detection, confirmation and serial follow-up of patients with pericardial effusion. In this article the technic and pitfalls of recording, and the criteria and their sensitivity for the diagnosis of pericardial effusion are reviewed. In addition, echographic findings in special instances, such as accumulation of pericardial effusion behind the left atrium, the swinging heart syndrome and cardiac tamponade, are discussed.     

Cardiac tumors: clinical and echocardiographic diagnosis of 65 cases

65 cases of cardiac tumors were diagnosed and studied by echocardiography. Among them 49 were primary tumors including 43 cases of myxoma, one case each of hamartoma, lipomatous infiltration, fibroma, hemangioma, rhabdomyosarcoma, pericardial mesothelioma, and 16 cases of secondary cardiac tumors. It was found that the nature of primary cardiac tumors could be speculated by two-dimensional echocardiography based on their pathological features. Most patients with large left atrial myxoma had obstructive symptoms of mitral valves, abnormal ECG and enlarged left atrium, whereas patients with small atrial myxoma, embolic phenomenon was liable to occur. Echocardiography of secondary cardiac tumors showed that the tumors usually invaded most frequently both the myocardium and pericardium as single or multiple nodular echoes in the myocardium under pericardium or within the pericardial cavity, with profuse pericardial effusion. Occasionally, the secondary tumor appeared as a large mobile intracavitary mass or an extracardiac one compressing the heart or large vessels. It was noticed that cardiac symptoms might be the clinical clue in certain patients with extracardiac primary malignancy.     

Regional cardiac tamponade resulting in hypoxia from acute right to left inter-atrial shunting

Loculated pericardial effusion, as a cause of acute hypoxia, is an unusual finding. Here, we describe the case of a patient who underwent percutaneous coronary intervention, complicated by a localized pericardial hematoma compressing the right atrium, resulting in right to left shunting of blood through a patent foramen ovale and subsequent hypoxia. Evacuation of the hematoma was eventually performed via a pericardial window with resolution of hypoxia.     

Left ventricular tamponade: echocardiographic and hemodynamic manifestations

A patient with progressive systemic sclerosis was evaluated for dyspnea. Echocardiography revealed enlarged right heart chambers, a moderate pericardial effusion, and diastolic collapse of the left ventricle. Hemodynamic studies before and after removal of pericardial fluid were consistent with compromise of left, but not right, heart filling by the pericardial fluid.     

Postoperative hemopericardium compressing the left atrium. Apropos of 8 cases

The authors report 8 cases of hemopericardium compressing the left atrium occurring at varying intervals after cardiac surgery. This is an unusual anatomical and classically rare site of pericardial effusion. This type of tamponnade has special clinical features, leading to a picture of subacute left ventricular failure, by interference with filling and typical echocardiographic appearances, with special features in two-dimensional mode and, in TM mode, an abnormal anterior movement of the posterior wall of the left atrium, which is studied. CT scan of the thorax, when performed, confirms this highly specific topographic situation. This type of effusion must be managed surgically as quickly as possible, with an anterior approach, either by left thoracotomy or by midline sternotomy.     

Collapse of three cardiac chambers due to a pericardial effusion

We report a case of pericardial effusion with collapse of three cardiac chambers including the left atrium, a very specific sign of tamponade always urging for quick pericardiocentesis.     

Isolated Left Ventricular Diastolic Collapse in Pericardial Tamponade: An Uncommon Echocardiographic Finding

A case of circumferential moderate pericardial effusion causing isolated collapse of left ventricular cavity on two‐dimensional echocardiography is reported. Pericardial effusion, mostly of infective etiology, is relatively common in this part of the world. When large enough to cause tamponade, collapse of right atrium, right ventricle, and uncommonly left atrium can be seen. Left ventricular collapse is rare, both due to the larger muscle mass and higher chamber pressure.     

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.     

Comparison of Afro-Caribbean patients presenting in heart failure with normal versus poor left ventricular systolic function

Data suggest that heart failure (HF) in Afro-Caribbean patients may be more often associated with preserved left ventricular (LV) systolic function, LV hypertrophy, and probable LV diastolic dysfunction than in other populations. Echocardiographic results on all patients referred for HF in a contemporary Afro-Caribbean population were reviewed, comparing findings in patients with and without preserved LV systolic function with. Echocardiographic findings included left atrial dimension, LV systolic and diastolic dimensions, ventricular septal and posterior wall thicknesses, right ventricular dimension, valve abnormality, or pericardial effusion. LV shortening fraction and ejection fraction were calculated. Age, gender, and presence of atrial fibrillation were recorded. Results from patients with preserved LV systolic function (LV shortening fraction >0.27) were compared with those with poor LV systolic function. There were 505 patients with HF with adequate studies; mean age +/- SD was 64 +/- 15 years, 46% were men, 17% had atrial fibrillation, and 285 of 505 (57%) had preserved LV systolic function. Those with preserved LV systolic function were no different in age (64 +/- 15 vs 64 +/- 14 years, p = 0.98) but were less likely to be men (40% vs 54%, p <0.01). They were less likely to have a dilated left atrium (61% vs 81%, p <0.001) or increased LV diastolic dimension (8% vs 63%, p <0.001). They were more likely to have increased ventricular septal or posterior wall hypertrophy (84% vs 66%, p <0.001) or other abnormal findings, including an abnormal valve, right ventricular enlargement, increased septal to posterior wall thickness ratio, or pericardial effusion (25% vs 6%, p <0.001). The presence of atrial fibrillation was no different (14% vs 20%, p = 0.10). In conclusion, most Afro-Caribbean patients with HF have preserved LV systolic function with high rates of LV hypertrophy, septal hypertrophy, and other echocardiographic abnormalities.     

Isolated right atrial tear following blunt chest trauma: report of three cases

Blunt chest trauma causing isolated right atrial tear and cardiac tamponade in three patients is reported. All three patients presented with hypotension, elevated central venous pressure and altered consciousness. Echocardiographic examination demonstrated pericardial effusion in all three cases. All three patients underwent operation with a median sternotomy approach without using cardiopulmonary bypass. At operation, two patients had one tear in the right atrium, the other had two tears in the right atrium. All three patients recovered uneventfully. Early use of echocardiography to detect the presence of hemopericardium and cardiac tamponade in patients with suspected atrial rupture following blunt chest trauma is advocated.     

Pulmonary arterial hypertension: evaluation of the newly diagnosed patient

With a quickly growing range of therapeutic options precise prognostic stratification became particularly important for clinical decision making in patients with pulmonary arterial hypertension (PAH). Assessment of disease-specific functional class remains the simplest method and is a fairly reliable way of assessing severity of PAH, and current guidelines recommend a therapeutic algorithm based on functional class evaluation. Six-minute walk is the most widely used test assessing exercise tolerance both in clinical practice and in clinical trials testing new therapies in PAH. Right heart catheterization with a vasoreactivity test is mandatory to identify a subgroup that has good long-term prognosis when treated with calcium channel blockers alone. Echocardiographic variables of documented prognostic value in PAH are not those directly correlated with pulmonary arterial pressure (PAP). Instead, the presence of pericardial effusion, enlarged right atrium, and elevated Doppler index of right ventricular performance have been the most consistently reported signs of poor prognosis. Low or decreasing brain natriuretic peptide (BNP) suggests a good outcome whereas troponin T leak persisting despite therapy is a poor prognostic sign. Biomarkers seem particularly useful for noninvasive follow-up of patients with PAH, and due to simplicity and low costs may successfully compete with echocardiography.     

Malignant schwannoma of the heart

Primary cardiac tumor is an extremely rare disease entity. Only three cases of primary malignant cardiac schwannoma, the subject of this report, have been recorded in Japan. Recently, we encountered a case of malignant schwannoma in which retention of pericardial effusion was the first clinical finding. This case was a 30-year-old female, who had dyspnea at work, general fatigue, and fever. Striking cardiac expansion was seen, with a cardiothoracic ratio (CTR) of 69% on chest x-ray. Two-dimensional echocardiograms showed a large volume of pericardial effusion between the side wall of the left ventricle and the epicardium, and the presence of a parenchymatous tumor. An increase in tumor size was detected on chest computer tomography (CT) scan. Using a pump oxygenator, median sternotomy was performed to reach the epicardium. A pale yellow, soft tumor was seen in the left atrium near the left ventricle. Histologically, the patient was diagnosed as having a malignant schwannoma. We have reported a case of primary malignant schwannoma which was surmised to have arisen from the boundary between the atrium and the ventricle.     

Cardiac angiosarcoma with ruptured right atrium diagnosed by echocardiography

A 41-year-old man was admitted to our hospital complaining of right-sided chest pain. Two-dimensional echocardiographic examination revealed a ruptured right atrium and a localized pericardial effusion. Color Doppler echocardiography and contrast echocardiography showed blood flow from the right atrium into pericardial effusion, which was confirmed at emergency surgery. The pathologic specimen from the right atrium showed a spindle cell angiosarcoma.