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Kim JH et al. Circ 2025;151:e716-e761.

 

Pericardiocentesis - Using EKG via needle as guide

From Page 7.8 in Atlas of the Heart. Ed. J Willis Hurst, Robert H Anderson, Anton E Becker and Benson R Wilcox. Grower Medical Publishing, New York. 1988.

EKG: Postop. pericarditis

6 yr old boy, s/p Resection of subaortic membrane. Stable hemodynamics. ST segment elevation was noted on the monitor about 12 hrs after surgery. Therefore, the EKG in the upper panel was recorded. (Lower panel has the EKG recorded immediately upon arrival to ICU from the operating room ~10 hrs earlier).

ICU: Pericardial Tamponade

Beware of the importance of looking "all-around" when you are doing a "quick" echo when a baby is unstable, in the immediate postoperative period. (Poor image quality is part of the deal!)

The first two panels show no significant effusion. However, in the lower-most panel - angled more posteriorly - there is a localized collection of clot compressing right atrium and part of right ventricle. This was not recognized due to poor images. Chest was opened to cannulate for ECMO! Clot was noted in the pericardial space, compressing right atrium (Lower-most panel). Hemodynamic status improved when the clot was removed. ECMO was not necessary.

Newborn, s/p Arterial switch operation. 3 hrs postop.

Echo features of tamponade

14 yr old with history of intermittent facial swelling (SVC syndrome). Superior mediastinal widening and cardiomegaly on CXR.





Diastolic collapse of RV free wall.


Doppler equivalent of pulsus paradoxus (?!)

ICU: Pulsus Paradoxus

11 yr old female with respiratory distress.

Note the variation in arterial pressure and CVP.

Discuss the causes.

(Image courtesy: George Hartas)

How do you quantify pulsus paradoxus?

CXR: Pericardial effusion & ...after (partial) pericardiocentesis (Hydropneumopericardium)

"Money bag" appearance on CXR

Hydropneumopericardium

Cath Lab: Pressure Traces in Constrictive Pericarditis

From The Catheterization Handbook by Morton J. Kern
3rd ed. 1999. p. 201-202

Constrictive Pericarditis:
(From Boston Cath Manual)
1) Increase or equalization of pressures in RA, LA and EDPs (all within 5 mmHg from each other)...Isn't this normal?!
2) Kussmaul Sign: Loss of inspiratory decline in RA pressure (shown in trace above - lower panel)
3) Equalization of a and v waves, preserved x decent and prominent y decent. Thus creating "M" pattern. (shown in trace above)
4) Square root sign in ventricular pressure trace (both RV and LV). Shown in trace above. Also called "Dip and Plateau" sign.
Masked by tachycardia due to short diastole. So, inducing a PVC shows a long diastole - to visualize this pattern.
5) Record ventricular pressure during an induced ectopy for reason stated above.
6) Important: Most senstive and specific signs.
Ventricular discordance or Ventricular interdependence: Normally, RVSP and LVSP are supposed to raise and fall together with different phases of breathing. In Constrictive pericarditis, RVSP raises during inspiration while LVSP falls.
Also, Early transmitral gradient (LA - LVEDP or PAWp - LVEDP) decreases during inspiration. Normally, there is no such variation with respiration.

Echo: Abnormal Ventricular Diastolic Function

Extract from Snider's Echo book (Restrictive Cardiomyopathy):

Restrictive cardiomyopathy is characterized by

1) abrupt cessation of diastolic filling in the first 1/3rd of diastole

2) Associated with large atria, normal-sized ventricles and variable systolic function.

Normal LV dimensions, normal or low fractional shortening %.

M-mode:

Abrupt increase in LV dimension in early diastole (Abrupt posterior motion of LVPW and anterior motion of IVS) followed by no further increase in dimensions (i.e. flat LVPW & IVS throughout the rest of diastole)

2D:

Abrupt cessation of filling creates a jerky, spasmodic wall motion.

Doppler fl0w pattern:

MV Doppler:

Peak E and % of E area - Normal

Peak A & % of A area - Decreased

Therefore, E/A ratio is increased.

Mitral Deceleration Time:

Decreased less than 150 ms

LV. IVRT (Isovolumic relaxation time) - shorter

Mechnism of short deceleration time (MV): Rapid equalization of LVEDP and Atrial pressure(corresponds to "Rapid filling wave" in LV trace in cath lab).

Further shortening of TV deceleration occurs with inspiration (Increased filling -> septum bows to left -> Decreases LV diastolic function.

Mid-diastolic MR or TR (correspond to peak of rapid filling wave)

Systemic venous flow pattern:

1) Decreased forward flow during systole

2) Increased or prolong flow reversal during atrial contraction (worse during inspiration)...Reflects decreased RV compliance.

Diastolic forward flow in MPA (during inspiration)