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Echocardiographic evaluation of the pericardium

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GRAPHICS

INTRODUCTION

Echocardiography is the method of choice for evaluating most pericardial diseases. When competently performed in patients with good acoustic windows, echocardiography accurately detects all pericardial effusions and provides clinically relevant information about their size and hemodynamic importance. The technique is less reliable than magnetic resonance imaging (MRI) and computed tomography (CT) in detecting pericardial thickening/constriction and calcification as well as small loculated effusions, but is still extremely useful in these conditions.

A 2003 task force of the American College of Cardiology (ACC), the American Heart Association (AHA), and the American Society of Echocardiography (ASE) gave class I recommendations for the following uses of echocardiography in known or suspected pericardial disease (table 1) [1].

  • Patients with suspected pericardial disease, including effusion, constriction, or effusive-constrictive process.
  • Patients with suspected bleeding in the pericardial space (eg, trauma, perforation).
  • Follow-up study to evaluate recurrence of effusion or to diagnose early constriction. Repeat studies may be goal directed to answer a specific clinical question.
  • Pericardial friction rub developing in acute myocardial infarction accompanied by symptoms such as persistent pain, hypotension, and nausea.

NORMAL PERICARDIUM

The pericardium consists of two layers, a thick fibrous parietal layer and a thin serosal visceral layer investing the epicardium. The parietal pericardium produces one of the most strongly reflective or echo-producing areas of the heart and it normally moves anteriorly with the epicardium; if the gain on the echo machine is lowered, only the signals from the strongest reflector in the tracing, the pericardium, remain.

M-mode echocardiogram — In the normal state, the layers of the pericardium appear to slide in parallel to one another and there is less than 20 mL of serous fluid in the pericardial sac formed by these layers [2]. The interposition of this fluid between the pericardial layers results in a very small separation of the layers and the space between them can barely be resolved by echocardiography. When this small, physiologic separation is appreciated on M-mode echocardiography, it is obvious only during systole (figure 1).
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References Top
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