© 2014, Wiley Periodicals, Inc. DOI: 10.1111/echo.12642
Echocardiography
CASE REPORTS Section Editor: Brian D. Hoit, M.D.
Isolated Left Ventricular Diastolic Collapse in Pericardial Tamponade: An Uncommon Echocardiographic Finding Vikas Singh, M.D., Sudhanshu K. Dwivedi, M.D., D.M., Sharad Chandra, M.D., D.M., Ritesh Sanguri, M.D., and Ram Kirti Saran, M.D., D.M. Department of Cardiology, King George’s Medical University, Lucknow, India
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. (Echocardiography 2014;31:E200–E203) Key words: left ventricular diastolic collapse, cardiac tamponade, pulmonary arterial hypertension
Case Report: A 36-year-old woman presented to the emergency department with complaints of generalized weakness and fatigue associated with gradual swelling of the body for last 6 months. She had a history of incompletely treated pulmonary tuberculosis 2 years back and admitted to a history of effort dyspnea NYHA-II since then. The patient was conscious and alert, but marked pallor and anasarca were present. Her BP was 100/60 mmHg and pulse rate was 100/min. Cardiovascular examination revealed raised jugular venous pulse with prominent A-wave. First heart sound was normal with loud pulmonary component of second heart sound. There was no rub or gallop; however, a pansystolic murmur (PSM) of grade III/VI was audible in left lower sternum, which increased with inspiration. Respiratory system examination revealed decreased air entry at both lung bases and scattered rales at right upper zone. ECG showed low-voltage complexes and sinus tachycardia two-dimensional echocardiography (2D-echo) revealed circumferential moderate pericardial effusion of approximately 12–15 mm, and left ventricular (LV) diastolic collapse (Fig. 1) (movie clips S1, S2). There was no collapse of right-sided chambers. Significant regurgitation across tricuspid valve was seen (Fig. 2) with moderately raised PASP (peak velocAddress for correspondence and reprint requests: Vikas Singh, RCA-30, Near-TV Tower, B H Colony, Kankarbagh, Patna800026 India. Fax: +91612-2351686; E-mail: [email protected]
E200
ity across tricuspid valve = 3.5 m/sec, peak gradient = 49 mmHg). Laboratory examination revealed serum protein of 6.1 g/dL and albumin of 2.8 g/dL, thereby a reversal of A:G ratio. Pericardial fluid examination showed cells of 275/mm3 with 60% lymphocytes, albumin 2 g%, and positive adenosine deaminase (64 U/mL). A diagnosis of tubercular pericardial effusion producing tamponade was made on the basis of history of untreated pulmonary tuberculosis, exudative nature of the effusion, and raised ADA. From the pericardial cavity, 350 mL of straw colored pericardial fluid was aspirated out. Repeat 2D-echo after the procedure showed disappearance of the LV collapse noted earlier (Fig. 3). The patient was started on 5 drug antitubercular therapy (ATT), vitamin, and oral iron supplementation. She was attached to the nearest Directly Observed Treatment, Short-Course (for tuberculosis) center to improve her compliance to therapy. At 1 month, she was followed in the outpatient department and was doing well. Discussion: Cardiac tamponade is characterized by cardiac compression caused by intrapericardial fluid and manifests as collapse of the right-sided and rarely left-sided cardiac chambers.1–4 Collapse of cardiac chambers in free pericardial effusion depends on chamber stiffness and transcavitary pressure relationship. Right-sided chambers are thinner and more compliant, and
Left Ventricular Collapse in Tamponade
Figure 1. M-mode at the mid-ventricular level showing LV posterior wall collapse. The 2 inward movements of posterior wall present a “M-shaped” appearance. Arrow represents the LV diastolic collapse. LV = left ventricular.
Figure 2. High-pressure tricuspid regurgitation reflecting raised pulmonary arterial pressure.
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Singh, et al.
Figure 3. Postpericardiocentesis image showing resolution of the LV collapse. LV = left ventricular.
thus are prone to collapse compared with the thick and stiff left ventricle that resists collapse in tamponade5; in addition, the normal diastolic pressures of the right atrium (RA) and right ventricle (RV) are lower than those of the LV. Left ventricular collapse is mostly reported to occur in situations that produce LV compression due to localized posterior pericardial effusion, postoperative hematomas,6 and tense left-sided pleural effusion.7 LV collapse with free pericardial effusion has rarely been reported8,9 and, in these situations, the hypertrophied RV in preexisting pulmonary hypertension causes the LV to collapse because the intrapericardial pressure exceeds the LV diastolic, but not the RV diastolic pressure. In this case, pulmonary hypertension developed in the course of patient’s initial pulmonary pathology prevented the collapse of right-sided cardiac chambers and presented in this unusual way on 2D-echo. Tuberculous pericarditis is an important complication of tuberculosis and occurs in approximately 1–2% of patients with pulmonary tuberculosis. The incidence in developed countries has declined, but it continues to be an E202
important presentation in developing countries. The growing incidence of HIV and the HIV-TB coinfection has only worsened the condition. A high index of suspicion is required as the tubercular collection in pericardial space is very slow and thus generally does not present acutely and with the classical signs of tamponade. References 1. Shiina A, Yaginuma T, Kondo K, et al: Echocardiographic evaluation of impending cardiac tamponade. J Cardiogr 1979;9:555–563. 2. Singh S, Wann LS, Schuchard GH, et al: Right ventricular and right atrial collapse in patients with cardiac tamponade: A combined echocardiogphic and hemodynamic study. Circulation 1984;70:966–971. 3. Rifkin RD, Pandian NG, Funai JT, et al: Sensitivity of right atrial collapse and right ventricular diastolic collapse in the diagnosis of graded cardiac tamponade. Am J Noninvasive Cardiol 1987;1:73–80. 4. D’Cruz I, Callaghan W, Arensman F, et al: Left atrial compression: A neglected sign of tamponade (abstract). J Am Coll Cardiol 1988;2:84A. 5. Fowler NO, Gabel M, Buncher CR: Cardiac tamponade: A comparison of right versus left heart compression. J Am Coll Cardiol 1987;12:187–193. 6. Jones MR, Vine DL, Attas M, et al: Late isolated left ventricular tamponade -Clinical, hemodynamic, and echocardiographic manifestations of a previously unreported
Left Ventricular Collapse in Tamponade
postoperative complication. J Thorac Cardiovasc Surg 1979;77:142–146. 7. Kisanuki A, Shono H, Kiyohnaga K, et al: Two-dimensional echocardiographic demonstration of left ventricular diastolic collapse due to compression by pleural effusion. Am Heart J 1991;4-I:1173–1175. 8. Sudhanshu KD, Ramkirti S, Varun SN: Left ventricular diastolic collapse in low pressure cardiac tamponade. Clin Cardiol 1998;21,224–226. 9. Aqel RA, Aljaroudi W, Hage FG, et al: Left ventricular collapse secondary to pericardial effusion treated with pericardicentesis and percutaneous pericardiotomy in severe pulmonary hypertension. Echocardiography 2008;25:658– 661.
Supporting Information Additional Supporting Information may be found in the online version of this article: Movie clips S1. for Figure 1. Parasternal long-axis (PLAX) view showing left ventricular diastolic collapse. Movie clips S2. for Figure 2. Apical fourchamber view showing circumferential pericardial effusion and left ventricular collapse.
E203
Echocardiography
CASE REPORTS Section Editor: Brian D. Hoit, M.D.
Isolated Left Ventricular Diastolic Collapse in Pericardial Tamponade: An Uncommon Echocardiographic Finding Vikas Singh, M.D., Sudhanshu K. Dwivedi, M.D., D.M., Sharad Chandra, M.D., D.M., Ritesh Sanguri, M.D., and Ram Kirti Saran, M.D., D.M. Department of Cardiology, King George’s Medical University, Lucknow, India
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. (Echocardiography 2014;31:E200–E203) Key words: left ventricular diastolic collapse, cardiac tamponade, pulmonary arterial hypertension
Case Report: A 36-year-old woman presented to the emergency department with complaints of generalized weakness and fatigue associated with gradual swelling of the body for last 6 months. She had a history of incompletely treated pulmonary tuberculosis 2 years back and admitted to a history of effort dyspnea NYHA-II since then. The patient was conscious and alert, but marked pallor and anasarca were present. Her BP was 100/60 mmHg and pulse rate was 100/min. Cardiovascular examination revealed raised jugular venous pulse with prominent A-wave. First heart sound was normal with loud pulmonary component of second heart sound. There was no rub or gallop; however, a pansystolic murmur (PSM) of grade III/VI was audible in left lower sternum, which increased with inspiration. Respiratory system examination revealed decreased air entry at both lung bases and scattered rales at right upper zone. ECG showed low-voltage complexes and sinus tachycardia two-dimensional echocardiography (2D-echo) revealed circumferential moderate pericardial effusion of approximately 12–15 mm, and left ventricular (LV) diastolic collapse (Fig. 1) (movie clips S1, S2). There was no collapse of right-sided chambers. Significant regurgitation across tricuspid valve was seen (Fig. 2) with moderately raised PASP (peak velocAddress for correspondence and reprint requests: Vikas Singh, RCA-30, Near-TV Tower, B H Colony, Kankarbagh, Patna800026 India. Fax: +91612-2351686; E-mail: [email protected]
E200
ity across tricuspid valve = 3.5 m/sec, peak gradient = 49 mmHg). Laboratory examination revealed serum protein of 6.1 g/dL and albumin of 2.8 g/dL, thereby a reversal of A:G ratio. Pericardial fluid examination showed cells of 275/mm3 with 60% lymphocytes, albumin 2 g%, and positive adenosine deaminase (64 U/mL). A diagnosis of tubercular pericardial effusion producing tamponade was made on the basis of history of untreated pulmonary tuberculosis, exudative nature of the effusion, and raised ADA. From the pericardial cavity, 350 mL of straw colored pericardial fluid was aspirated out. Repeat 2D-echo after the procedure showed disappearance of the LV collapse noted earlier (Fig. 3). The patient was started on 5 drug antitubercular therapy (ATT), vitamin, and oral iron supplementation. She was attached to the nearest Directly Observed Treatment, Short-Course (for tuberculosis) center to improve her compliance to therapy. At 1 month, she was followed in the outpatient department and was doing well. Discussion: Cardiac tamponade is characterized by cardiac compression caused by intrapericardial fluid and manifests as collapse of the right-sided and rarely left-sided cardiac chambers.1–4 Collapse of cardiac chambers in free pericardial effusion depends on chamber stiffness and transcavitary pressure relationship. Right-sided chambers are thinner and more compliant, and
Left Ventricular Collapse in Tamponade
Figure 1. M-mode at the mid-ventricular level showing LV posterior wall collapse. The 2 inward movements of posterior wall present a “M-shaped” appearance. Arrow represents the LV diastolic collapse. LV = left ventricular.
Figure 2. High-pressure tricuspid regurgitation reflecting raised pulmonary arterial pressure.
E201
Singh, et al.
Figure 3. Postpericardiocentesis image showing resolution of the LV collapse. LV = left ventricular.
thus are prone to collapse compared with the thick and stiff left ventricle that resists collapse in tamponade5; in addition, the normal diastolic pressures of the right atrium (RA) and right ventricle (RV) are lower than those of the LV. Left ventricular collapse is mostly reported to occur in situations that produce LV compression due to localized posterior pericardial effusion, postoperative hematomas,6 and tense left-sided pleural effusion.7 LV collapse with free pericardial effusion has rarely been reported8,9 and, in these situations, the hypertrophied RV in preexisting pulmonary hypertension causes the LV to collapse because the intrapericardial pressure exceeds the LV diastolic, but not the RV diastolic pressure. In this case, pulmonary hypertension developed in the course of patient’s initial pulmonary pathology prevented the collapse of right-sided cardiac chambers and presented in this unusual way on 2D-echo. Tuberculous pericarditis is an important complication of tuberculosis and occurs in approximately 1–2% of patients with pulmonary tuberculosis. The incidence in developed countries has declined, but it continues to be an E202
important presentation in developing countries. The growing incidence of HIV and the HIV-TB coinfection has only worsened the condition. A high index of suspicion is required as the tubercular collection in pericardial space is very slow and thus generally does not present acutely and with the classical signs of tamponade. References 1. Shiina A, Yaginuma T, Kondo K, et al: Echocardiographic evaluation of impending cardiac tamponade. J Cardiogr 1979;9:555–563. 2. Singh S, Wann LS, Schuchard GH, et al: Right ventricular and right atrial collapse in patients with cardiac tamponade: A combined echocardiogphic and hemodynamic study. Circulation 1984;70:966–971. 3. Rifkin RD, Pandian NG, Funai JT, et al: Sensitivity of right atrial collapse and right ventricular diastolic collapse in the diagnosis of graded cardiac tamponade. Am J Noninvasive Cardiol 1987;1:73–80. 4. D’Cruz I, Callaghan W, Arensman F, et al: Left atrial compression: A neglected sign of tamponade (abstract). J Am Coll Cardiol 1988;2:84A. 5. Fowler NO, Gabel M, Buncher CR: Cardiac tamponade: A comparison of right versus left heart compression. J Am Coll Cardiol 1987;12:187–193. 6. Jones MR, Vine DL, Attas M, et al: Late isolated left ventricular tamponade -Clinical, hemodynamic, and echocardiographic manifestations of a previously unreported
Left Ventricular Collapse in Tamponade
postoperative complication. J Thorac Cardiovasc Surg 1979;77:142–146. 7. Kisanuki A, Shono H, Kiyohnaga K, et al: Two-dimensional echocardiographic demonstration of left ventricular diastolic collapse due to compression by pleural effusion. Am Heart J 1991;4-I:1173–1175. 8. Sudhanshu KD, Ramkirti S, Varun SN: Left ventricular diastolic collapse in low pressure cardiac tamponade. Clin Cardiol 1998;21,224–226. 9. Aqel RA, Aljaroudi W, Hage FG, et al: Left ventricular collapse secondary to pericardial effusion treated with pericardicentesis and percutaneous pericardiotomy in severe pulmonary hypertension. Echocardiography 2008;25:658– 661.
Supporting Information Additional Supporting Information may be found in the online version of this article: Movie clips S1. for Figure 1. Parasternal long-axis (PLAX) view showing left ventricular diastolic collapse. Movie clips S2. for Figure 2. Apical fourchamber view showing circumferential pericardial effusion and left ventricular collapse.
E203
