A 66 year old woman presents with gradually increasing shortness of breath. She had a syncopal event whilst standing in church and remains grey and sweaty.
Describe and interpret these scans
Image 1: Subcostal View: A large pericardial effusion is seen with anechoic fluid surrounding the heart. This loop was taken during a single inspiration. Right atrial and ventricular collapse is evident in expiration, but on inspiration as the heart gets closer to the probe, negative intrathoracic pressures increase right sided venous return and the collapse is less pronounced.
Image 2: Apical 4 chamber view: Right atrial collapse is frequently seen with pericardial effusions. When it is present for more than a third of the cardiac cycle it is considered highly suggestive of tamponade. Right ventricular diastolic collapse occurs in early diastole – when the right ventricular pressures are lowest, and right atrial collpase is most pronounced late in diastole as it empties into the right ventricle. This explains the “see-saw” or “rocking” appearance of the free wall of the right sided chambers one sees as the right ventricle and atrium collapse at slightly different times during diastole.
Image 3: IVC view: The IVC is distended with absent respiratory variation.
Image 4 and 5: The parasternal views also demonstrate circumferential pericardial effusion.
Image 6: Left posterior chest wall view: This patient had a pleural effusion in addition to her pericardial effusion. In the plerual effusion is some atelectatic lung. Then the pericuarium is seen and pericardial effusion surrounding the heart. As the view is from the patient’s back the left ventricle is closer than the right.
Cardiac tamponade with small pleural effusion due to malignancy.
The old adage “tamponade is a clinical diagnosis“, is not completely without merit – when there is haemodynamic compromise the urgency for intervention is far greater.
There are many echocardiograpic signs of pericardial pressure effects that are evident before overt haemodynamic compromise.
For the Emergency Physician with basic echo competence the aim is to be able to detect and measure a pericardial effusion, to integrate findings with the clinical situation, and to ensure appropriate management.
More advanced echocardiographic evaluation involves two-dimensional, M-mode and Doppler assessment of the heart. Assess:
- the quantity and character of the pericardial fluid,
- collapse of the cardiac chambers
- respiratory variation of the ventricular diameters (ventricular interdependence)
- inferior vena caval size and respiratory variation,
- and flow patterns through the atrioventricular valves (respiratory variation).