Pericardial Disease Questions

Name: _Jennifer Pittman___________________

Date: __1/13/2014_______________

1. Name and describe the 2 main layers of the pericardium?

- Visceral (Continuous with epicardium)
- Parietal (thicker fibrous sac surrounding heart)
2. What is the normal amount of pericardial fluid?
- 5-10 mL
3. Describe the constraint of the pericardium and how alterations in the volume of
one chamber effects other chambers?
- The pericardium restrains the four chambers within a confined volume
and space, the total volume of the four chambers is limited and
alterations in the volume of one chamber must be reflected in an
opposite change in volume of another chamber.
4. How is a hemodynamic compromise related to pericardial fluid and why is this
relation important to understand as a sonographer?
- Accumulation of significant pericardial fluid reduces the total volume
that the 4 chambers can contain and may result in hemodynamic
deterioration related to under filling of the ventricles. Hemodynamic
compromise is related to elevated intrapericardial pressure, which is
related to the volume of pericardial fluid and the compliance or
distensibility of the pericardium.
5. List the 7 etiologies of pericardial disease given in your text book. Table 10.1 page
241
- Idiopathic, infectious, inflammatory, post-myocardial infarction,
systemic dz, malignancy, miscellaneous
6. What is demonstrated in Figure 10.2 image A and image B?
- PAX view demonstrating a minimal pericardial effusion
7. According to your book, what 2 echo techniques are used to help detect pericardial
effusion?
- 2D and M-mode
8. Describe how a pericardial effusion would appear on M-mode.
- An echo-free space both anterior and posterior to the heart
9. According to your book, how is pericardial effusions characterized and quantified?

Pericardial Disease Questions

Minimal, small, moderate, large. Characterized as free circumferential

or loculated as well as the presence or absence of hemodynamic
compromise.

10.

Where should you be able to measure a pericardial effusion to document its

maximal size?
- Posterior atrioventricular groove
11.

Which views should you document a pericardial effusion in to demonstrate

its extent?
- PLAX, PSAX, Apical, subcoastal
12.

What is the cause of electric alterans seen on the EKG in the presence of a

large effusion? Use Figure 10.7 and reading from page 242
- There is no constraint of an inflammatory component, allowing the
heart to move freely.
13.
-

How are small, moderate, and large effusions described?

Small: 1 cm of posterior echo-free space, with or without fluid
accumulation elsewhere.
Moderate: 1 2 cm of posterior echo-free space
Large: more than 2 cm of maximal separation and the heart may swing
within the pericardial space

14.

True / False: In disease-free states, the normal pericardium is rarely

visualized with TEE or TTE modalities? Page 246

- True
15.

When is it possible for a TTE to determine the thickness of the pericardium?

Page 246
- When both pericardial and pleural effusions are present
16.

What are the echo findings in Figure 10-14 and what is the significance of the

measurement?
- Pericardial effusion and pleural effusion, the pericardium is visualized
and the thickness can be measured.
17.

What does the detection of stranding imply in the case of pericardial

effusion? View Figure 10.16 and 10.17

Pericardial Disease Questions

Inflammatory or possible hemorrhage or malignant etiology of the

pericardial effusion

18.

How is a pleural effusion differentiated from pericardial effusion in the

Parasternal views? Page 248

- Pleural effusion is an echo-free space posterior to the heart in the
supine or LLD position, located exclusively behind the left atrium and
-

posterior to the thoracic aorta.

Pericardial fluid surround the pulmonary veins, located anterior to the
aorta

19.

What effect does the pericardium have on the combined volume of the 4

cardiac chambers and why do you need to understand this as a sonographer? Page
248
- Respiratory variations in intrapericardial pressure results in linked
variation in filling of the right and left ventricle. Important to know so
you can detect an abnormality.
20.

Describe the normal response to intrathroacic and intrapericardial pressures

to INSPIRATION
- The pressures decrease. The result is to augment flow into the right
heart and reduce flow out of the pulmonary veins.
21.

Describe the normal response to intrathroacic and intrapericardial pressures

to EXPIRATION
- Pressure increases. The result is a mild decrease in right ventricular
diastolic filling and a subsequent increase in left ventricular filling.
22.

What does any process that results in increasing pressure variation with the

respiratory cycle leads to? Page249

- Cardiac Tamponade

23.

Describe the mechanism of a pathologic pulsus paradoxus as seen in cardiac

tamponade. Page 249

- During expiration when the right ventricular filling is impeded to a
greater degree, and there is a marked exaggeration in the respiratorydependent phasic changes in right and left ventricular stroke volume.
There is also a greater decrease in systolic arterial blood pressure with
inspiration.

Pericardial Disease Questions

24.
-

True or False: Cardiac tamponade is a clinical diagnosis.

True

25.
-

What is one of the earlier signs of tamponade?

A swinging heart detected on M-Mode.

26.

What is the mechanism of electrical alternans seen in large pericardial

effusions?
- The varying cardiac positions within the pericardium from beat to
beat, related to the EKG leads.
27.
-

List the more specific sonographic features (2) of tamponade.

Diastolic right ventricular outflow collapse
Exaggerated right atrial collapse during atrial systole.

28.
-

Which views is the right ventricle collapse best appreciated?

PLAX, PSAX, and occasionally in the apical 4 chamber

29.
-

Which view is the RA collapse best appreciated?

Subcostal or apical 4 chamber

30.
-

What does the images in Figure 10.23 A and B demonstrate?

Diastolic right ventricular collapse in M-mode with a posterior motion
of the anterior right ventricular wall in diastole. This patient has
evidence of a hemodynamic compromise.

31.

How can Pulsed Doppler of TV and MV inflow be used to help evaluate for

tamponade? Page 251 and Figures10.28

- It can used to show the inspiratory and expiratory phases. In the TV
inflow, there is augmented flow during inspiration and diminished flow
during expiration. The MV inflow has the opposite effect.
32.
33.

What is the classic form of pericardial constriction? Page 254

Calcification constriction secondary to tuberculous pericarditis
What is the more common reason for constrictive pericarditis in todays

practice?
- The result of infectious or inflammatory processes such as connective
tissue disease or radiation therapy or develops several years after
cardiac surgery.

Pericardial Disease Questions

34.
-

Anatomically, when does constriction occur?

When there is stiffening of the pericardium.

35.
-

What are two Echo features seen with constrictive pericarditis?

The pericardium forms a rigid shell in which the cardiac chambers are

encased.
Persistence of pericardium thickening during gradual dampening on Mmode through the posterior ventricular wall