Case reports Unusual echocardiographic pericardial tamponade
findings
M. P. Ravindra Nathan, M.D., M.R.C.P., Gregorio Lipat, M.D. Michael Sanders, M.D., F.A.C.C. Jersey
City,
in
F.R.C.P.(C)
N. J.
M-mode echocardiographic scanning has been known to be a sensitive and reliable technique for the detection of pericardial effusion.‘. ? 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 felt” 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. Method
M-mode echocardiographic examinations were performed before and during pericardial tamponade and after removal of pericardial fluid. All the studies were performed using an Irex echograph and a transducer with a focal length of 7.5 cm., a diameter of 0.5 inch, and frequency of 2.25 MHz. From the Departments of Cardiology and Nephrology, Jersey City Medical Center, Jersey City, N. d. Received for publication Mar. 27, 1978. Accepted for publication May 17, 1978. Reprint requests: Dr. M. P. Ravindra Nathan, Dept. of Medicine, Division of Cardiology, Jersey City Medical Center, Jersey City, N. d. 07304.
0002~8703/79/080225
+ 03$00.30/O
Q 1979 The
C. V. Mosby
Co.
Case report A 3%year-old white male with chronic renal failure being maintained on intermittent hemodialysis was admitted with retrosternal chest pain. Physical examination revealed a heart rate of 100 per minute and blood pressure of 100/80 mm. Hg. Cervical veins were not distended. Ausculation over the precordium revealed an S, gallop and a loud pericardial rub. The lungs were clear. An electrocardiogram revealed sinus tachycardia and repolariiation changes suggestive of pericarditis. Chest x-ray at the time of admission showed moderate cardiomegaly, clear lung fields, and no pleural effusions. An echocardiogram done one month prior to the present admission had shown no gross abnormalities except left ventricular hypertrophy. The study done at the time of admission showed a posterior pericardial effusion demonstrable both behind the left ventricle and left atrium (Fig. 1). Three days after admission, the patient suddenly became dyspneic, tachycardie, and hypotensive. The central venous pressure was vated to 17 cm. of water. An echocardiogram at this time sb wed a definite increase in the posterior pericardial effusion. In addition two new abnormalities were also recorded. These included (1) wide swinging movements of the entire heart, and (2) intermittent mitral valve prolapse (Fig. 2). The diastolic closure of mitral valve (EF slope) which previously had been normal, was unchanged. The patient then underwent an open pericardiotomy during which 680 C.C. of fluid were removed with rapid improvement in his clinical staus. An echocardiogram done 3 days afterward showed complete disappearance of the previously noted abnormalities.
Discussion Effusion behind the left atrium. Pericardial fluid is demonstrable echocardiographically as an echo-free space behind the left ventricle. As the transducer is angulated cephalad to the point where the left atrium becomes visible behind the posterior aortic wall, this echo-free space is no longer visualized. Recently however, Lemire and associates’ and Green and colleague.9 reported on pericardial effusion posterior to the left atrium. The latter group suggested the following explanation for effusion behind the atrium. The visceral
American
Heart
Journal
225
Nathan,
Lipat,
Fig.
and
1.
ventricle
Sandero-
M-mode
echocardiographic
scan
showing
pericardial
effusion-both
behind
the
left
atrium
and
left
(arrows).
this anatomic barrier may not be effective in preventing such an accumulation of fluid, especially if the fluid is under pressure. The fact that our patient developed pericardial tamponade soon after the demonstration of ffuid behind the atrium may suggest that the fluid was indeed under great pressure. If this is so, one might even be able to predict pericardial tamponade based on this finding. Mechanism and “swinging
Fig.
2.
Arrow shows mitral
valve
prolapse.
pericardium on the posterior surface of the heart is reflected onto itself to form the parietal pericardium. The arrangement of the great vesselson the posterior aspect of the heart is such that the pericardium is pulled taut, but not attached between the points of its reflection onto these two vessels; this reflection divides off a part of the pericardial sac referred to as the oblique sinus, which is closed superiorly and to the right but is open inferiorly and to the left. While in most pericardial effusions this part is blocked by the tautness of the pericardium behind the atrium,
226
of pseudo mitral valve prolapse heart.” Since the advent of echo-
cardiography, the syndrome of mitral valve prolapse has been increasingly diagnosed and it is important to avoid misinterpretation. Mitral valve motion as observed echocardiographically is the result of intrinsic mitral leaflet movement and to a lesser extent, mitral ring and total heart motion.‘, 7Entire cardiac motion is exaggerated in the presence of a large pericardial effusion; this results in the appearance of an exaggerated posterior movement of mitral valve with leaflet prolapse. Observation of the motion of the entire heart will help to distinguish this pseudo prolapse from true prolapse. Systolic anterior movement of the mitral valve has also recently been observed in pericardial effusion,‘. R although the mechanism is not quite clear. According to Nanda and co-workers” the presence of significant fluid collections behind the left atria1 cavity associated with dynamic movements and systolic peak formation of the left atria1 wall compound the total swinging motion of the heart in the pericardial sac producing motion artefacts of cardiac valves. It is interesting that all their patients showing abnormalities of motion of cardiac valves had effusion behind the left atrium.
August,
1979, Vol. 98, No. 2
Rare ECHO
The diastolic closure slope of the mitral valve (EF slope) is related to the rate of left ventricular filling and a decreased EF slope is seen in those conditions where there is an increased resistance to left ventricular filling such as cardiac constriction.“’ It has been stated that a normal EF slope is evidence against the presence of pericardial tamponade.’ However, in the present patient the EF slope was found to be normal before, during, and after correction of pericardial tamponade. It is possible that in pericardial tamponade, the diminished posterior movement of the anterior mitral leaflet during closure could appear to be increased by the anterior movement of the entire heart during diastole. No decrease in EF slope in pericardial tamponade was observed by Zoneraich and colleagues” in their recent study. Thus the undue reliance on a decreased EF slope may limit the sensitivity of the echocardiogram in the diagnosis of pericardial tamponade. Mitral
EF slope.
1. 2.
3.
4.
5.
6.
7.
8.
American
Heart
Journal
in pericardial
tamponade
REFERENCES
Conclusion
As in the present case, serial echocardiographic studies may be necessary for the correct interpretation of some unusual features seen in pericardial tamponade. An important finding in patients with pericardial effusion may be fluid behind the left atrium, since it appears to presage cardiac tamponade although a normal EF slope may be preserved in such patients despite cardiac constriction.
findings
9.
10.
Feigenbaum, H.: Echocardiographic diagnosis of pericardial effusion, Am. J. Cardiol. 26:475, 1970. Horowitz, S. M., Schultz, C. S., Stinson, E. B., Harrison, D. C., and Popp, R. L.: Sensitivity and specificity of echocardiographic diagnosis of pericardial effusion, Circulation 50:239, 1974. Teichholz. L. E.: Echocardioeranhic evaluation in nericardial effusion, in Cardiac Ul&asound, Gramiak, R.,.and Wagg, R. C., eds., St. Louis, 1975, The C. V. Mosba Company. Lemire, F., Tajik, A. J., Giuliani, E. F., Gau, G. T., and Schattenberg, T. T.: Further echocardiographic observations in pericardial effusions, Mayo Clin. Proc. 51:13, 1976. Green, D. A., Kleid, J. J., and Naidu. S.: Unusual echocardiographic manifestations of pericardial effusions, Am. J. Cardiol. 39:112, 1977. Zaky, A., Nasser, W. K., and Feigenbaum, H.: Study of mitral valve action recorded by reflected ultrasound and its application in the diagnosis of mitral stenosis, Circulation 37:789, 1968. Vignola, 0. A., Pohost, G. M., Curfman, G. D., and Myers, G. S.: Correlation of echocardiographic and clinical findings in patients with pericardial effusion, Am. J. Cardiol. 37:701, 1976. Zoneraich, S., Zoneraich, O., and Rhee, J. J.: New, poorly recognized echocardiographic findings, J. A. M. A. 236:1954, 1976. Nanda, N. C., Gramiak, R., and Gross, C. M.: Echocardiography of cardiac.valves in pericardial effusion, Circulation 54:X10, 1976. Laniado, S., Yellin, E., Kotler, M., et al.: A study of the dynamic relations between the mitral valve echogram and phasic mitral flow, Circulation 51:104, 1975.
227
findings
M. P. Ravindra Nathan, M.D., M.R.C.P., Gregorio Lipat, M.D. Michael Sanders, M.D., F.A.C.C. Jersey
City,
in
F.R.C.P.(C)
N. J.
M-mode echocardiographic scanning has been known to be a sensitive and reliable technique for the detection of pericardial effusion.‘. ? 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 felt” 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. Method
M-mode echocardiographic examinations were performed before and during pericardial tamponade and after removal of pericardial fluid. All the studies were performed using an Irex echograph and a transducer with a focal length of 7.5 cm., a diameter of 0.5 inch, and frequency of 2.25 MHz. From the Departments of Cardiology and Nephrology, Jersey City Medical Center, Jersey City, N. d. Received for publication Mar. 27, 1978. Accepted for publication May 17, 1978. Reprint requests: Dr. M. P. Ravindra Nathan, Dept. of Medicine, Division of Cardiology, Jersey City Medical Center, Jersey City, N. d. 07304.
0002~8703/79/080225
+ 03$00.30/O
Q 1979 The
C. V. Mosby
Co.
Case report A 3%year-old white male with chronic renal failure being maintained on intermittent hemodialysis was admitted with retrosternal chest pain. Physical examination revealed a heart rate of 100 per minute and blood pressure of 100/80 mm. Hg. Cervical veins were not distended. Ausculation over the precordium revealed an S, gallop and a loud pericardial rub. The lungs were clear. An electrocardiogram revealed sinus tachycardia and repolariiation changes suggestive of pericarditis. Chest x-ray at the time of admission showed moderate cardiomegaly, clear lung fields, and no pleural effusions. An echocardiogram done one month prior to the present admission had shown no gross abnormalities except left ventricular hypertrophy. The study done at the time of admission showed a posterior pericardial effusion demonstrable both behind the left ventricle and left atrium (Fig. 1). Three days after admission, the patient suddenly became dyspneic, tachycardie, and hypotensive. The central venous pressure was vated to 17 cm. of water. An echocardiogram at this time sb wed a definite increase in the posterior pericardial effusion. In addition two new abnormalities were also recorded. These included (1) wide swinging movements of the entire heart, and (2) intermittent mitral valve prolapse (Fig. 2). The diastolic closure of mitral valve (EF slope) which previously had been normal, was unchanged. The patient then underwent an open pericardiotomy during which 680 C.C. of fluid were removed with rapid improvement in his clinical staus. An echocardiogram done 3 days afterward showed complete disappearance of the previously noted abnormalities.
Discussion Effusion behind the left atrium. Pericardial fluid is demonstrable echocardiographically as an echo-free space behind the left ventricle. As the transducer is angulated cephalad to the point where the left atrium becomes visible behind the posterior aortic wall, this echo-free space is no longer visualized. Recently however, Lemire and associates’ and Green and colleague.9 reported on pericardial effusion posterior to the left atrium. The latter group suggested the following explanation for effusion behind the atrium. The visceral
American
Heart
Journal
225
Nathan,
Lipat,
Fig.
and
1.
ventricle
Sandero-
M-mode
echocardiographic
scan
showing
pericardial
effusion-both
behind
the
left
atrium
and
left
(arrows).
this anatomic barrier may not be effective in preventing such an accumulation of fluid, especially if the fluid is under pressure. The fact that our patient developed pericardial tamponade soon after the demonstration of ffuid behind the atrium may suggest that the fluid was indeed under great pressure. If this is so, one might even be able to predict pericardial tamponade based on this finding. Mechanism and “swinging
Fig.
2.
Arrow shows mitral
valve
prolapse.
pericardium on the posterior surface of the heart is reflected onto itself to form the parietal pericardium. The arrangement of the great vesselson the posterior aspect of the heart is such that the pericardium is pulled taut, but not attached between the points of its reflection onto these two vessels; this reflection divides off a part of the pericardial sac referred to as the oblique sinus, which is closed superiorly and to the right but is open inferiorly and to the left. While in most pericardial effusions this part is blocked by the tautness of the pericardium behind the atrium,
226
of pseudo mitral valve prolapse heart.” Since the advent of echo-
cardiography, the syndrome of mitral valve prolapse has been increasingly diagnosed and it is important to avoid misinterpretation. Mitral valve motion as observed echocardiographically is the result of intrinsic mitral leaflet movement and to a lesser extent, mitral ring and total heart motion.‘, 7Entire cardiac motion is exaggerated in the presence of a large pericardial effusion; this results in the appearance of an exaggerated posterior movement of mitral valve with leaflet prolapse. Observation of the motion of the entire heart will help to distinguish this pseudo prolapse from true prolapse. Systolic anterior movement of the mitral valve has also recently been observed in pericardial effusion,‘. R although the mechanism is not quite clear. According to Nanda and co-workers” the presence of significant fluid collections behind the left atria1 cavity associated with dynamic movements and systolic peak formation of the left atria1 wall compound the total swinging motion of the heart in the pericardial sac producing motion artefacts of cardiac valves. It is interesting that all their patients showing abnormalities of motion of cardiac valves had effusion behind the left atrium.
August,
1979, Vol. 98, No. 2
Rare ECHO
The diastolic closure slope of the mitral valve (EF slope) is related to the rate of left ventricular filling and a decreased EF slope is seen in those conditions where there is an increased resistance to left ventricular filling such as cardiac constriction.“’ It has been stated that a normal EF slope is evidence against the presence of pericardial tamponade.’ However, in the present patient the EF slope was found to be normal before, during, and after correction of pericardial tamponade. It is possible that in pericardial tamponade, the diminished posterior movement of the anterior mitral leaflet during closure could appear to be increased by the anterior movement of the entire heart during diastole. No decrease in EF slope in pericardial tamponade was observed by Zoneraich and colleagues” in their recent study. Thus the undue reliance on a decreased EF slope may limit the sensitivity of the echocardiogram in the diagnosis of pericardial tamponade. Mitral
EF slope.
1. 2.
3.
4.
5.
6.
7.
8.
American
Heart
Journal
in pericardial
tamponade
REFERENCES
Conclusion
As in the present case, serial echocardiographic studies may be necessary for the correct interpretation of some unusual features seen in pericardial tamponade. An important finding in patients with pericardial effusion may be fluid behind the left atrium, since it appears to presage cardiac tamponade although a normal EF slope may be preserved in such patients despite cardiac constriction.
findings
9.
10.
Feigenbaum, H.: Echocardiographic diagnosis of pericardial effusion, Am. J. Cardiol. 26:475, 1970. Horowitz, S. M., Schultz, C. S., Stinson, E. B., Harrison, D. C., and Popp, R. L.: Sensitivity and specificity of echocardiographic diagnosis of pericardial effusion, Circulation 50:239, 1974. Teichholz. L. E.: Echocardioeranhic evaluation in nericardial effusion, in Cardiac Ul&asound, Gramiak, R.,.and Wagg, R. C., eds., St. Louis, 1975, The C. V. Mosba Company. Lemire, F., Tajik, A. J., Giuliani, E. F., Gau, G. T., and Schattenberg, T. T.: Further echocardiographic observations in pericardial effusions, Mayo Clin. Proc. 51:13, 1976. Green, D. A., Kleid, J. J., and Naidu. S.: Unusual echocardiographic manifestations of pericardial effusions, Am. J. Cardiol. 39:112, 1977. Zaky, A., Nasser, W. K., and Feigenbaum, H.: Study of mitral valve action recorded by reflected ultrasound and its application in the diagnosis of mitral stenosis, Circulation 37:789, 1968. Vignola, 0. A., Pohost, G. M., Curfman, G. D., and Myers, G. S.: Correlation of echocardiographic and clinical findings in patients with pericardial effusion, Am. J. Cardiol. 37:701, 1976. Zoneraich, S., Zoneraich, O., and Rhee, J. J.: New, poorly recognized echocardiographic findings, J. A. M. A. 236:1954, 1976. Nanda, N. C., Gramiak, R., and Gross, C. M.: Echocardiography of cardiac.valves in pericardial effusion, Circulation 54:X10, 1976. Laniado, S., Yellin, E., Kotler, M., et al.: A study of the dynamic relations between the mitral valve echogram and phasic mitral flow, Circulation 51:104, 1975.
227
