IMAGING IN CARDIOLOGY

Diagnosis

pericardial effusion: correlation between echocardiography and computed of

tomography M. Mirrasouli Ragland, Y. Ye, T. Tak

A 44-year-old male with a past medical history significant for end-stage renal disease and hypertension presented with chest pain, shortness of breath, and palpitations. On physical examination, he had a blood pressure of 97/80 mmHg with a pulse of 102 beats/min. Auscultation of the lungs and heart revealed bilateral rales at the lung bases and distant heart sounds. Arterial blood gas analysis showed metabolic acidosis consistent with his end-stage renal disease and an oxygen saturation of 95%. The electrocardiogram (ECG) demonstrated sinus tachycardia with a heart rate of 103 beats/min, intermediate electrical axis, voltage criteria positive for left ventricular hypertrophy, and nonspecific ST-T segment abnormalities. The chest X-ray showed cardiomegaly. A computed tomographic (CT) scan of the chest, carried out initially to rule out pulmonary embolism, demonstrated a massive circumferential pericardial effusion (figure 1), but no evidence ofpulnonary embolism. Transthoracic echocardiography (TT'E) confirmed the presence of a large circumferential pericardial effusion with 'diastolic collapse' of the right ventricle and right atrium, suggesting cardiac tamponade (figure 2). Urgent pericardiocentesis was performed with evacuation of approximately two litres of sero-sanguinous fluid. The patient's clinical condition improved and his blood pressure normalised soon after the removal of the pericardial fluid. t

Pericardial effusions may result from infections, inflammatory disorders, metastatic malignancies, renal failure, or congestive heart failure. The aetiology of M. Mirlsoull Ragland Y. Ye

T. Tak Departrnent of Medicine, University of North Texas Health Science Center, Fort Worth, Texas, USA Correspondence to: T. Tak Department of Medicine, Division of Cardiology, University of North Texas Health Science Center, 855 Montgomery Road, 4th Floor, Fort Worth, Texas 76107, United States of America E-mail: [email protected]

Netherlands Heart Journal, Volume 14, Number 6, June 2006

Figure 1. Computed tomography ofthe chestdemonstrating massive circumferential pericardial effusion (double arrows). RV=right ventrile, LV=left ventricle.

the pericardial effusion seen in this patient was end-stage renal disease. When patients present to the emergency department with chest pain and shortness of breath, it is usual for emergency physicians to rule out pulmonary embolism. In this patient, CT scanning ruled out pulmonary embolism; however, it demonstrated a large pericardial effusion. Hereafter, a complete echocardiogram/Doppler study was performed which confirmed a massive pericardial effusion and findings consistent with cardiac tamponade. Two-dimensional echocardiography is the gold standard for diagnosing pericardial effusion.' The echocardiographic diagnosis of pericardial effusion is usually based on visualisation of an echo-free space which is proportional to the amount of fluid in the pericardial sac.2'3 Computed tomography can also be used for evaluating pericardial disease including pericardial effusion. Although the role of CT in evaluating pericardial effusion is not well documented in the literature, there have been a few case reports indicating that CT may be useful in diagnosing pericardial effusion in selected patients, particularly when it is a

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Figure 2 Transthoraic echocardiography demonstratinga large pericardial effusion (PE) and the diastolic collapse of the tight ventricular free wall (see arrow). The extent of the effuesion is demonstrated in different views. A: Parasternal longm-axis view, B:- Parasternal short-axis view, C:- Apical four-chamber view, D: Subcostal view. LA=left atrium, RA=right atrium, LV=left ventricle, RV=right ventricle, PE=pericardial effusion. loculated effusion.4'5 Computed tomography is also very useful in the recognition ofunusual disorders such as pericardial cysts, tumours invading the pericardium, and congenital absence of pericardium.4'6'7 In fact, CT is considered superior to echocardiography in identifying pericardial thickness and is commonly indicated for establishing the diagnosis ofconstrictive pericarditis.4'7'5 In short, two-dimensional echocardiography remains the diagnostic test ofchoice in evaluating pericardial effusion and cardiac tamponade.46 Further research needs to be done to establish criteria for haemodynamic compromise and quantification of pericardial effusion seen by CT scanning. X References 1 2

3

Spieth M, Schmitz, Tak T. Incidental Massive Pericardial Effusion Diagnosed by Myocardial Perfusion Imaging. Clin Med Res2003; 1:141-4. D'Cruz IA, Constantine A. Problems and pitfalls in the echocardiographic assessment of pericardial effusion. Echocardiography 1993;10:151-66. Feigenbaum H, Armstrong W, Ryan T. Feigenbaum's Echocardiography. Philadelphia: Lippincott Williams & Wilkins, 2005: 247-69.

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Wang Z, Reddy G, Gotway M, Yeh B, Hetts S, Higgins C. CT and MRImaging ofPericardial Disease. Radiographics2003;23:S16780. Yousem D, Traill T, Wheeler P, Fishman E. Illustrative Cases in Pericardial Effusion Misdetection: Correlation ofEchocardiography and CT. Cardiovasc Intervent Radiol 1987;10:162-7. Karia D, Xing Y, Kuvin J, Nesser H, Pandian N. Recent Role of Imaging in the Diagnosis ofPericardial Disease. Curr Cardio Rep 2002;4:33-40. Breen JF. Imaging ofthe Pericardium.JThorac Imaging2001;16: 47-54. Dawson W, Mayo J, Muller N. Computed Tomography of Cardiac and Pericardial Tumors. Can Assoc RadiolJ 1990;41:270-5.

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Ncthcrlands Heart Journal, Volume 14, Number 6, June 2006

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Diagnosis of pericardial effusion: correlation between echocardiography and computed tomography.

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