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Echocardiographic Identification of Intrapericardial Fibrous Strands in Acute Pericarditis with Pericardial Effusion
Echocardiographic Identification of lntrapericardial Fibrous Strands in Acute Pericarditis with Pericardial Effusion* Salvatore A. Chiaramida, M.D.; Mitchell A. Goldman, M.D.; Michael]. Zema, M.D.; Roy A. Pizzarello, M.D.; and Herbert M. Goldberg, M.D.
In three cases of acute pericarditis with pericardial etfu· sion, the presence of fibrous strands within the fluid· filled pericardia) cavity was demonstrated by M-mode
The diagnosis of pericardial effusion by M-mode and cross-sectional echocardiography is well established. 1•2 Although numerous observations have been made regarding methods for the determination of the extent and localization of pericardia) effusion, little attention has focused on the occurrence of echoes reflected from within the so-called echo-free space between the visceral and parietal pericardium in pericardial effusion. Three cases demonstrated unusual echocardiographic patterns in the pericardia) space which represented fibrous strands formed in acute effusive pericarditis. METHOD
and cross-sectional echocardiography. Pericardiocente· sis proved difticult in all three. No patient progressed to
constrictive pericarditis.
On transfer to our hospital, the blood pressure was 90/60 mm Hg without paradox; the pulse rate, 140 beats per minute; and respirations, 36 per minute. There was no neck vein distention. Breath sounds were diminished at the left base posteriorly. An apical three-component rub was present Chest x-ray film demonstrated an enlarged cardiac silhouette and a small left pleural effusion. The ST-T wave abnormalities consistent with pericarditis were present on ECG. M-mode and cross-sectional echocardiography demonstrated a large pericardial effusion extending anteriorly, laterally, posteromedially, and apically. Rapidly oscillating fibrous strands were demonstrated within the fluid-filled pericardia! cavity ( Fig I and 2). Pericardiocentesis was performed twice. Although the pericardial cavity was easily entered, it was possible to
M-mode echocardiographic examinations were performed using a standard M-mode ultrasonoscope (Picker Corporation) employing 3.5 mHz and 5.0 mHz medium internally focused transducers. M-mode echocardiograms were recorded on a Visicorder (Honeywell 1856A). Cross-sectional echocardiographic examinations were performed using a phased array system (Varian V3000) employing a 2.25 mHz transducer and imaging an 80° sector. Images were recorded on one-half inch video tape cassettes and individual frames were photographed on Polaroid film. All examinations were performed in both the supine and left lateral decubitus positions utilizing standard techniques. CASE REPORTS CASE
1
A four-year-old girl was admitted to another hospital after two days of fever, pharyngitis, and abdominal pain. Exploratory laparotomy performed to rule out appendicitis demonstrated mesenteric adenitis. Surgery was complicated by ventricular tachycardia. °From the Deparbnent of Medicine, Division of Cardiology, and the Department of Radiology, Division of Diagnostic Ultrasound~.North Shore University Hospital, Cornell University Meaical College, Manhasset, NY. Manuscript received May 7; revision accepted June 8. Reprint requests: Dr. Goldberg, Department of Radiology, North Shore Hospital, Manahaslet, New York 11030
CHEST, 77: l, JANUARY, 1980
F1cURE 1. Cross-sectional echocardiogram demonstrating fibrous strands ( FS) within pericardia) effusion ( PE ) between posterior left ventricular wall (PLVW) and adjacent lung. Fibrous strands oscillated rapidly throughout cardiac cycle in real-time. L V indicates left ventricle.
ECHOCARDIOGRAPHIC IDENTIFICATION OF INTRAPERICARDIAL FIBROUS STRANDS 85
FicUBE 2. M-mode echocardiogram demonstrating fibrous strands (arrows) within pericardial effusion anterior to right ventricle. These fine linear echoes demonstrated a rapid oscillating pattern.
aspirate only small amounts of the serosanguineous fluid. The patient improved clinically after a course of steroids and aspirin, and the effusion resolved. Acute and convalescent titers demonstrated a fourfold rise in coxsaclcievirus B1 titer. CASE
2
An 11-year-old girl on maintenance peritoneal dialysis was admitted to our hospital for fever, dyspnea, and chest pain. Initial blood pressure was 105/85 mm Hg without paradox; pulse rate, 120 beats per minute; and respirations, 26 per minute. There was no neck vein distention. Lung fields were clear. An apical pericardial rub was present.
Chest x-ray film demonstrated a globular heart. The ST-T wave abnormalities consistent with pericarditis were present on ECG. M-mode and cross-sectional echocardiography demonstrated a large pericardia! effusion distributed anteriorly, laterally, posteromedially, and apically. Thin intrapericardial fibrous strands were present ( Fig 3). Diagnostic pericardiocentesis was performed, but no fluid could be aspirated. The patient improved with intensive dialysis. Routine bacteriologic and serologic test findings were negative. CASE
3
A 10-year-old boy presented with fever, pharyngitis, and
FicUBE 3. Several fibrous strands ( FS) radiate from central coagulum in short axis view. Crosssectional echocardiogram through pericardial effusion (PE) distal to apex of left ventricle ( LV) . Line drawing indicates plane of view.
88 CHIWMIDA ET AL
CHEST, 77: 1, JANUARY, 1980
pleuritic chest pain. Initial blood pressure was 110/80 mm Hg; pulse rate 100 beats per minute, and respirations, 20 per minute. There was no neclc vein distention. Signs ·of . consolidation were present at the right base posteriorly. No pericardial rub was audible. Chest x-ray film demonstrated an enlarged cardiac siJhouette, right lower lobe consolidation, and a right pleural effusion. The ST-T wave abnormalities of pericarditis were present on ECG. M-mode and cross-sectional echocardiography demonstrated a large pericardial effusion. Rapidly oscillating fibrous strands were identified within the fluid collection (Fig 4). Subsequently, tamponade occurred. Pericardiocentesis was performed. Only 110 ml of straw-colored fluid could be aspirated. As the clinical response was inadequate, a pericardiotomy was done. On opening the pericardium, approximately 600 ml of similar fluid was forcefully expressed from the cavity. Extensive soft fibrous intrapericardial adhesions were easily dissected manually. No dense adhesions or loculations were present. The pathologic report of the surgical specimen revealed fibrinous pericarditis. The patient was hemodynamically stable after surgery, and the further clinical course was unremarkable. Routine bacteriologic and serologic test findings were negative. DISCUSSION
Echocardiography is a proven and sensitive technique in the diagnosis of pericardia! effusion. 3 The localization and quantification of pericardia! fluid and the detection of altered cardiac motion in its presence are well described.4 Little attention, however, has been given to echoes reflected from within the pericardia} fluid space itself. The standard technique for detection of pericardia} effusion on M-mode examination may be responsible for this in part. Sensitivity to low in-
tensity echoes anterior to the parietal pericardium is decreased, and attention is focused away from such echoes. 11 Dampening is less often required with cross-sectional echocardiography, and the opportunity to identify structure-related echoes in this region which was previously considered echo-free is enhanced. In the cases we present here, acute effusive pericarditis was associated with the presence of thin, rapidly oscillating fibrous strands between the pericardia! layers. It does not appear that this finding suggests any particular etiology, but rather that it might be present in any of the pericarditides in which fibrin is generated, including numerous infectious, neoplastic, and inflammatory causes. It was possible to aspirate only small amounts of pericardia! fluid in each case despite the presence of large effusions. Although it cannot be stated with certainty, the occurrence of fibrous strands within the pericardia! space may indicate that only limited amounts of fluid can be aspirated with standard techniques for pericardiocentesis. Loculation of fluid secondary to adhesions, obstruction of pericardiocentesis needles by fibrous materials or associated coagulum, and increased fluid viscosity are likely contributory factors. The occurrence of fibrous strands is consistent with resolution by organization of fibrin and progression to adhesive pericarditis, a condition which generally does not progress to constrictive pericarditis. The three cases presented here have been followed for a period of three months to one year, and there has been no evidence of pericardia} constriction. Altered pericardia} echoes and pericardia} thickening have been shown to occur in some cases of pericardia! disease.8 We did not find the pericardium itself to be thickened or altered in any of our cases. In summary, the finding of intrapericardial fibrous strands in patients with acute pericarditis with pericardia! effusion does not appear to suggest a specific etiology but is consistent with any of the effusive pericarditides in which fibrin is generated and may organize. It should be anticipated that aspiration of significant amounts of fluid may not be possible due to loculation or alteration of fluid viscosity. At this time, there is no evidence of an increased likelihood of progression to constrictive pericarditis related to this finding. REFERENCF.S
F1cURE 4. Fibrous strands ( FS) within pericardial effusion (PE) are present at apex of left ventricle ( LV) in long axis view. Presence of fibrous strands was easily detected with standard views in all cases.
CHEST, 77: l, JANUARY, 1980
1 Feigenbaum H : Echocardiographic diagnosis of pericardial effusion. Am J Cardiol 26:475-479, 1970 2 Martin RP, Rakowski H, French J, et al : Localization of pericardial effusion with wide angle phased array echo-
ECHOCARDIOGRAPHIC IDENTIFICATION OF IRTRAPERICARDIAL FIBROUS STRANDS 87
cardiography. Am J Cardiol 42:904-912, 1978 3 Horowitz MS, Schultz CS, Stinson EB, et al: Sensitivity and specificity of echocardiographic diagnosis of pericardial effusion. Circulation 50:239-.246, 1974 4 Feigenbaum H, 7.alcy A, Grabhorn L: Cardiac motion in patients with pericardial effusion: A study using ultra-
•
CHIARAMIDA ET AL
sound cardiography. Circulation 34:611-619, 1966
5 Feigenbaum H: Echocardiography. Philadelphia, Lea &
Febiger, 1976, pp 419-446 6 Schnittger I, Bowden RE, Abrams A, et al: Echocardiography: Pericardial thickening and constrictive pericarditis. Am J Cardiol 42:388-395, 1978
CHEST, 77: 1, JANUARY, 1980
In three cases of acute pericarditis with pericardial etfu· sion, the presence of fibrous strands within the fluid· filled pericardia) cavity was demonstrated by M-mode
The diagnosis of pericardial effusion by M-mode and cross-sectional echocardiography is well established. 1•2 Although numerous observations have been made regarding methods for the determination of the extent and localization of pericardia) effusion, little attention has focused on the occurrence of echoes reflected from within the so-called echo-free space between the visceral and parietal pericardium in pericardial effusion. Three cases demonstrated unusual echocardiographic patterns in the pericardia) space which represented fibrous strands formed in acute effusive pericarditis. METHOD
and cross-sectional echocardiography. Pericardiocente· sis proved difticult in all three. No patient progressed to
constrictive pericarditis.
On transfer to our hospital, the blood pressure was 90/60 mm Hg without paradox; the pulse rate, 140 beats per minute; and respirations, 36 per minute. There was no neck vein distention. Breath sounds were diminished at the left base posteriorly. An apical three-component rub was present Chest x-ray film demonstrated an enlarged cardiac silhouette and a small left pleural effusion. The ST-T wave abnormalities consistent with pericarditis were present on ECG. M-mode and cross-sectional echocardiography demonstrated a large pericardial effusion extending anteriorly, laterally, posteromedially, and apically. Rapidly oscillating fibrous strands were demonstrated within the fluid-filled pericardia! cavity ( Fig I and 2). Pericardiocentesis was performed twice. Although the pericardial cavity was easily entered, it was possible to
M-mode echocardiographic examinations were performed using a standard M-mode ultrasonoscope (Picker Corporation) employing 3.5 mHz and 5.0 mHz medium internally focused transducers. M-mode echocardiograms were recorded on a Visicorder (Honeywell 1856A). Cross-sectional echocardiographic examinations were performed using a phased array system (Varian V3000) employing a 2.25 mHz transducer and imaging an 80° sector. Images were recorded on one-half inch video tape cassettes and individual frames were photographed on Polaroid film. All examinations were performed in both the supine and left lateral decubitus positions utilizing standard techniques. CASE REPORTS CASE
1
A four-year-old girl was admitted to another hospital after two days of fever, pharyngitis, and abdominal pain. Exploratory laparotomy performed to rule out appendicitis demonstrated mesenteric adenitis. Surgery was complicated by ventricular tachycardia. °From the Deparbnent of Medicine, Division of Cardiology, and the Department of Radiology, Division of Diagnostic Ultrasound~.North Shore University Hospital, Cornell University Meaical College, Manhasset, NY. Manuscript received May 7; revision accepted June 8. Reprint requests: Dr. Goldberg, Department of Radiology, North Shore Hospital, Manahaslet, New York 11030
CHEST, 77: l, JANUARY, 1980
F1cURE 1. Cross-sectional echocardiogram demonstrating fibrous strands ( FS) within pericardia) effusion ( PE ) between posterior left ventricular wall (PLVW) and adjacent lung. Fibrous strands oscillated rapidly throughout cardiac cycle in real-time. L V indicates left ventricle.
ECHOCARDIOGRAPHIC IDENTIFICATION OF INTRAPERICARDIAL FIBROUS STRANDS 85
FicUBE 2. M-mode echocardiogram demonstrating fibrous strands (arrows) within pericardial effusion anterior to right ventricle. These fine linear echoes demonstrated a rapid oscillating pattern.
aspirate only small amounts of the serosanguineous fluid. The patient improved clinically after a course of steroids and aspirin, and the effusion resolved. Acute and convalescent titers demonstrated a fourfold rise in coxsaclcievirus B1 titer. CASE
2
An 11-year-old girl on maintenance peritoneal dialysis was admitted to our hospital for fever, dyspnea, and chest pain. Initial blood pressure was 105/85 mm Hg without paradox; pulse rate, 120 beats per minute; and respirations, 26 per minute. There was no neck vein distention. Lung fields were clear. An apical pericardial rub was present.
Chest x-ray film demonstrated a globular heart. The ST-T wave abnormalities consistent with pericarditis were present on ECG. M-mode and cross-sectional echocardiography demonstrated a large pericardia! effusion distributed anteriorly, laterally, posteromedially, and apically. Thin intrapericardial fibrous strands were present ( Fig 3). Diagnostic pericardiocentesis was performed, but no fluid could be aspirated. The patient improved with intensive dialysis. Routine bacteriologic and serologic test findings were negative. CASE
3
A 10-year-old boy presented with fever, pharyngitis, and
FicUBE 3. Several fibrous strands ( FS) radiate from central coagulum in short axis view. Crosssectional echocardiogram through pericardial effusion (PE) distal to apex of left ventricle ( LV) . Line drawing indicates plane of view.
88 CHIWMIDA ET AL
CHEST, 77: 1, JANUARY, 1980
pleuritic chest pain. Initial blood pressure was 110/80 mm Hg; pulse rate 100 beats per minute, and respirations, 20 per minute. There was no neclc vein distention. Signs ·of . consolidation were present at the right base posteriorly. No pericardial rub was audible. Chest x-ray film demonstrated an enlarged cardiac siJhouette, right lower lobe consolidation, and a right pleural effusion. The ST-T wave abnormalities of pericarditis were present on ECG. M-mode and cross-sectional echocardiography demonstrated a large pericardial effusion. Rapidly oscillating fibrous strands were identified within the fluid collection (Fig 4). Subsequently, tamponade occurred. Pericardiocentesis was performed. Only 110 ml of straw-colored fluid could be aspirated. As the clinical response was inadequate, a pericardiotomy was done. On opening the pericardium, approximately 600 ml of similar fluid was forcefully expressed from the cavity. Extensive soft fibrous intrapericardial adhesions were easily dissected manually. No dense adhesions or loculations were present. The pathologic report of the surgical specimen revealed fibrinous pericarditis. The patient was hemodynamically stable after surgery, and the further clinical course was unremarkable. Routine bacteriologic and serologic test findings were negative. DISCUSSION
Echocardiography is a proven and sensitive technique in the diagnosis of pericardia! effusion. 3 The localization and quantification of pericardia! fluid and the detection of altered cardiac motion in its presence are well described.4 Little attention, however, has been given to echoes reflected from within the pericardia} fluid space itself. The standard technique for detection of pericardia} effusion on M-mode examination may be responsible for this in part. Sensitivity to low in-
tensity echoes anterior to the parietal pericardium is decreased, and attention is focused away from such echoes. 11 Dampening is less often required with cross-sectional echocardiography, and the opportunity to identify structure-related echoes in this region which was previously considered echo-free is enhanced. In the cases we present here, acute effusive pericarditis was associated with the presence of thin, rapidly oscillating fibrous strands between the pericardia! layers. It does not appear that this finding suggests any particular etiology, but rather that it might be present in any of the pericarditides in which fibrin is generated, including numerous infectious, neoplastic, and inflammatory causes. It was possible to aspirate only small amounts of pericardia! fluid in each case despite the presence of large effusions. Although it cannot be stated with certainty, the occurrence of fibrous strands within the pericardia! space may indicate that only limited amounts of fluid can be aspirated with standard techniques for pericardiocentesis. Loculation of fluid secondary to adhesions, obstruction of pericardiocentesis needles by fibrous materials or associated coagulum, and increased fluid viscosity are likely contributory factors. The occurrence of fibrous strands is consistent with resolution by organization of fibrin and progression to adhesive pericarditis, a condition which generally does not progress to constrictive pericarditis. The three cases presented here have been followed for a period of three months to one year, and there has been no evidence of pericardia} constriction. Altered pericardia} echoes and pericardia} thickening have been shown to occur in some cases of pericardia! disease.8 We did not find the pericardium itself to be thickened or altered in any of our cases. In summary, the finding of intrapericardial fibrous strands in patients with acute pericarditis with pericardia! effusion does not appear to suggest a specific etiology but is consistent with any of the effusive pericarditides in which fibrin is generated and may organize. It should be anticipated that aspiration of significant amounts of fluid may not be possible due to loculation or alteration of fluid viscosity. At this time, there is no evidence of an increased likelihood of progression to constrictive pericarditis related to this finding. REFERENCF.S
F1cURE 4. Fibrous strands ( FS) within pericardial effusion (PE) are present at apex of left ventricle ( LV) in long axis view. Presence of fibrous strands was easily detected with standard views in all cases.
CHEST, 77: l, JANUARY, 1980
1 Feigenbaum H : Echocardiographic diagnosis of pericardial effusion. Am J Cardiol 26:475-479, 1970 2 Martin RP, Rakowski H, French J, et al : Localization of pericardial effusion with wide angle phased array echo-
ECHOCARDIOGRAPHIC IDENTIFICATION OF IRTRAPERICARDIAL FIBROUS STRANDS 87
cardiography. Am J Cardiol 42:904-912, 1978 3 Horowitz MS, Schultz CS, Stinson EB, et al: Sensitivity and specificity of echocardiographic diagnosis of pericardial effusion. Circulation 50:239-.246, 1974 4 Feigenbaum H, 7.alcy A, Grabhorn L: Cardiac motion in patients with pericardial effusion: A study using ultra-
•
CHIARAMIDA ET AL
sound cardiography. Circulation 34:611-619, 1966
5 Feigenbaum H: Echocardiography. Philadelphia, Lea &
Febiger, 1976, pp 419-446 6 Schnittger I, Bowden RE, Abrams A, et al: Echocardiography: Pericardial thickening and constrictive pericarditis. Am J Cardiol 42:388-395, 1978
CHEST, 77: 1, JANUARY, 1980