Comparison of Doppler and Two-Dimensional Echocardiography for Assessment of Pericardial Effusion John J. Schutzman, MD, Timothy P. Obarski, DO, Gregory L. Pearce, MS, and Alan L. Klein, MD
Respiratory changes in left ventricular inflow velocities by Doppler echocardiography have been used to assess cardiac tamponade; however, Doppler echocardiography has not been compared to right atrial or right ventricular collapse. Pulsed Doppler echocardiography of left ventricular inflow velocities was performed with respiratory monitoring in 28 patients with small to large pericardial effusions. Ten of the 17 patients (59%) with large effusions had equalization of right-sided diastolic pressures before pericardial drainage. The measurements performed included percent change in left ventricular inflow peak early velocity, isovolumic relaxation time, change in inferior vena cava diameter from apnea to insplration, and the presence of right atrial and right ventricular collapse. Percent change in early left ventricular inflow velocities significantly correlated with pericardial effusion size (p = 0.001) and right ventricular collapse (p = 0.007), and showed a trend with right atrial collapse (p = 0.10). Pericardial effusions with a left ventricular inflow velocity change >22% were found to have right-sided equalization at a 95% confidence interval. Our data indicate that the respiratory changes in Doppler echocardiographic parameters are useful in the assessment of pericardial effusion and tamponade. This study concurs with the hypothesis that there is a continuum of hemodynamic compromise in pericardial effusion that is easily detected by Doppler echocardiography. (Am J Cardiol 1992;70:1353-1357)
From the Department of Cardiology, The Cleveland Clinic Foundation, Cleveland, Ohio. Manuscript received March 6, 1992; revised manuscript received and accepted May 29,1992. Address for reprints: Allan L. Klein, MD, Department of Cardiology, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, Ohio 44195-5064.
wo-dimensional echocardiography has been the “gold standard” in assessing pericardial effusion and cardiac tamponade. The traditional criteria for determining the presence of cardiac tamponade by 2-dimensional echocardiography include right atria1 and right ventricular collapse and inferior vena cava plethora.l,* Recently, Doppler echocardiographic assessment of flow velocities, including left ventricular and right ventricular inflow, hepatic vein, superior vena cava, and isovolumic relaxation time, has shown dramatic changes with the respiratory cycle in patients with cardiac tamponade.3-6 A comparison of 2-dimensional echocardiographic criteria with Doppler assessment of tamponade has not been described. The purpose of this study was to compare right atria1 and right ventricular collapse and inferior vena cava plethora with respiratory change in left ventricular inflow velocities and isovolumic relaxation time intervals. In addition, we aimed to study the influence of various sizes of pericardial effusion on the respiratory change in Doppler flows.
T
METHODS Patients: Twenty-eight patients (18 men and 10 women, mean age 52 f 19 years [range 28 to 791) referred to the Cleveland Clinic Foundation Echocardiography Laboratory and found to have pericardial effusions were entered into the study. Comprehensive Doppler recordings were obtained in 28 patients (73%) which comprised the patient population. The etiology of the pericardial effusions included postoperative cardiothoracic surgery in 4 patients, malignancy in 5, radiation in 1, Candida infection in 1, uremia in 1, hypothyroidism in 1 and idiopathic in 16 patients. Of the 17 patients with large effusions, 100% underwent therapeutic or diagnostic pericardiocentesis with right-sided cardiac catheterization. The 28 patients were subdivided into 3 groups (small, moderate and large) depending on the size of the effusion. The group with large effusion was further divided into groups with large effusions with and without equalization of diastolic pressure. The group with equalization consisted of patients who underwent right-sided cardiac catheterization, and pericardiocentesis, and who had right-sided equalization. Right-sided equalization was defined as a 12 mm Hg.* Only 1 of these patients had a surgical origin for their effusion, which was PERICARDIAL
EFFUSION
1353
also loculated. The group without equalization consisted of patients who underwent pericardiocentesis and rightsided cardiac catheterization but did not have equalization. Of these 7 patients, 3 had loculated effusions, of which 2 were surgical in origin. Echocardiographic examination: All patients underwent standard M-mode, 2-dimensional and Doppler echocardiography using commercially available equipment (Hewlett-Packard, Andover, Massachusetts) with respiratory monitoring using a respirometer (Interspec, Lewistown, Pennsylvania)? Echocardiographic assessment: The presence of right atria1 collapse, right ventricular collapse and pericardial effusion size was assessed by independent observers. Apical 4-chamber and subcostal short-axis views using 2-dimensional-directed M mode were used
FIGURE 1. Apical l&amber view slenwithrightatdalceuapse(arvewj.LA=leftatrium; LV = Ml ventricle; PE = pekardial hick!.
of a large
psricardial
effusion;
RV = right
effuven-
FIGURE 3. Proximal inferior vena cava (IVC) with lapse to deep inspiration (hp.). Exp. = expiration.
FlGURE 2. Parastemal long-axis vkw eflash with tight VW collapse um;l.V=leftventriek;PE=pericaMalefhrsion;RV=right
of a large pericardial (arrewj. LA = left at&
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FlGURE 4. lnfehr vena cava (IVC) plethora with a 60% decrease in proximal inferior vena cava dlameter from desp inspiration (hp.) to apnea. Exp. = expiration.
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to detect right atria1 and right ventricular collapse (Fig- tween aortic valve closure and mitral valve opening. This time interval was determined by measuring the disures 1 and 2). Bight atria1 collapse was defined as significant inver- tance between the aortic and mitral valve clicks recordsion of the right atria1 free wall X55 the cardiac cycle. ed by placing the continuous-wave Doppler beam in beBight ventricular collapse was defined as persistent dia- tween the left ventricular inflow and outflow tracts stolic inversion of the right ventricular free wall noted (Figure 5). after opening the mitral valve.’ IVC plethora was deDoppier measurerments: Peak early (E) and late (A) fined by a lO mm Hg decrease in flGURE5.DiagmmshowingthedeavmehMtvedhdar systolic blood pressure with inspiration.g (Lv)MlewvebcityandEncnarcinisevehanicrelaxationtime (IVRT) with hphtim (hp.). A = eariy dlastoh Row; Statistical analysis: Analysis of variance techniques E=latediastokilow;ECG= -am; Exp. = explwere used to compare the 4 pericardial effusion size ration. groups with respect to percent change in peak E-wave
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FIGURE 6. Pubd-wave Doppktr iracing ol normal kfl vent&dar(LV)Mew,shewin6nosi6nbadchanghwRh6w respimt~cyde.otherabbre~asinFigvc3.
flGURE 7. Puked Doppler tracing of kli llowefalargepeticardideHusienwRhrig$tt-sidedequalhatimshowingamarked&creasehleftvenbidarin(lowvebcity frem expira6en (Exp.) te inspiratim ImddonsasinFi~S.
PERICARDIAL
(I-V) in-
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(hp.).
other
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TABLE I Summary of Hemodynamic Large Pericardial Effusions
Data in Patients
TABLE
with
With (n = 10)
Without (n = 7)
p Value
114 2 12 18 Z!Z7
90 zi 18 7?6
0.008 0.004
22 + 6 26 f 6
14 i: 3 23 + 4
0.01 0.22
25 ” 6
20 f 5
0.05
130~28 14 + 13
118211 9+4
Echocardiographic
Pericardial Effusion Size
Equalization
Heart rate (beatsimin) Pulsus paradoxus (mm Hg) Right atrial pressure (mm Hg) Pulmonary arterial diastolic pressure (mm Hg) Pulmonary arterial wedge pressure (mm Hg) Systolic blood pressure (mm Hg) Pericardial pressure (mm Hg)
II Doppler
No. of Pts.
6 5
Small Moderate Large Without equalization With equalization
7 10
Criteria % Change in LV inflow Peak Early Velocity
% lsovolumic Relaxation Time
0.3 + 10 -15 + 12
13 r 10
-13 -23
17 2 4 22 + 6
f 11 e lO*t
19 f 15
*p