Inferior Vena Cava Plethora Research Articles

Demystifying Right Atrial Diastolic Collapse: A Sensitive and Specific Marker of Cardiac Tamponade

The echocardiographic markers that occur in sequence in cardiac tamponade are inferior vena cava plethora, right atrial diastolic collapse, exaggerated inspiratory variation in mitral and tricuspid velocities and finally right ventricular diastolic collapse. Contrary to popular belief, the degree of atrial inversion does not correlate with the presence or absence of tamponade physiology, however, the right atrial inversion time (exceeding one-third of the cardiac cycle) significantly improves the sensitivity of atrial collapse in predicting tamponade. We present here an important demonstration of fundamental physiology of respirophasic variation of right atrial collapse in cardiac tamponade.

Use of Direct-Acting Oral Anticoagulants in Patients With Atrial Fibrillation and Significant Tricuspid Regurgitation.

There are limited data on the efficacy and safety of direct oral anticoagulants (DOACs) in patients with atrial fibrillation with significant tricuspid regurgitation (TR), which can lead to hepatic dysfunction and intestinal malabsorption. We aimed to compare the efficacy and safety of DOACs and warfarin for patients with atrial fibrillation with significant (moderate to severe) TR. A total of 1215 patients with significant TR and atrial fibrillation who were treated with warfarin (N=491) or DOACs (N=724) were retrospectively analyzed. The primary outcomes were ischemic stroke, systemic embolic events, and hospitalization for major bleeding. The secondary outcomes were intracranial hemorrhage, hospitalization for gastrointestinal bleeding, all-cause mortality, and a composite outcome. The median follow-up duration was 2.4 years. In the inverse probability treatment weighting-adjusted cohort, DOACs and warfarin had a similar risk for ischemic stroke and systemic embolic events (adjusted hazard ratio [aHR], 0.95 [95% CI, 0.67-1.36]; P=0.79) and major bleeding (aHR, 0.78 [95% CI, 0.57-1.06]; P=0.11). For the secondary outcomes, relative to warfarin, DOACs had a lower risk of intracranial hemorrhage and the composite outcome, and a comparable risk for gastrointestinal bleeding and all-cause mortality. In the subgroup analysis, the effects of DOACs on ischemic stroke and systemic embolic events were comparable to the effects ofwarfarin, even in patients with inferior vena cava plethora (increased right atrial pressure) or severe TR. In this study, relative to warfarin, DOACs demonstrated comparable efficacy for ischemic stroke and systemic embolic events and major bleeding, with a lower intracranial hemorrhage risk in patients with significant TR and atrial fibrillation, indicating their effectiveness and safety.

28 CONSTRICTIVE PERICARDITIS: A ROOM FOR MULTI-MODALITY IMAGING

Abstract Introduction The diagnosis of constrictive pericarditis can be challenging through conventional imaging. Novel imaging techniques have been proposed to improve it. Clinical Case A 74-year-old man with a previous diagnosis of heart failure with preserved ejection fraction and permanent atrial fibrillation (AF) was admitted because of worsening dyspnea, peripheral edema, and ascites refractory to diuretics therapy. ECG revealed low QRS voltages and AF with normal heart rate and laboratory exams detected increased values of BNP and hepatic stasis indices; blood count and CRP were normal. Echocardiography revealed mildly reduced bi-ventricular pump function (left ventricular ejection fraction = 52%, right ventricular fractional area change = 25%) and slightly increased wall thickness. Atria were moderately dilated (left and right atrium 46 and 44 ml/mq, respectively) and mitral and tricuspid annuli were dilated too. There was inferior vena cava plethora, moderate atriogenic tricuspid regurgitation and mild-to-moderate atriogenic mitral regurgitation. A paradoxical interventricular septal motion and significant respiratory changes on trans-mitral (>25%) and trans-tricuspid (>30%) pulsed Doppler were noted; however, there was no "annulus reversus" (lateral and septal e’ 13 and 11 cm/sec, respectively) at TDI analysis. In contrast, 2D-speckle-tracking global longitudinal strain showed impaired deformation ​​of the lateral segments with relative sparing of the septal segments. The latter pattern has been recently described as "strain reversus" or "hot septum sign". The findings were suspected of constrictive pericarditis, but a chest Computed Tomography excluded pericardial calcifications. Cardiac magnetic resonance (CMR) was then performed revealing a "septal shift" at cine-real time sequences analysis. The pericardium was slightly thickened (4-5 mm) with widespread late gadolinium enhancement but without signs of acute inflammation at T2-weighted imaging. Tricuspid regurgitation was confirmed to be "moderate" after phase-contrast imaging. Cardiac catheterization finally revealed normal coronary arteries and confirmed the diagnosis of constrictive pericarditis (square root sign, equalization of bi-ventricular end-diastolic pressures). The patient underwent pericardiectomy and tricuspid and mitral valve repair and was asymptomatic at 6-months follow-up. Conclusions Constrictive pericarditis represents a potentially reversible cause of heart failure but can be easily missed through conventional imaging. In the present case, advanced echocardiography and CMR were essential to come up with an accurate diagnosis, guiding the patient's clinical management with excellent outcome.

CONTRIBUTION OF CARDIAC IMAGING (CT AND MRI) IN THEDIAGNOSIS OF CHRONIC CONSTRICTIVE PERICARDITIS: A SERIES OF 76 CASES

Background:Constrictive pericarditis (CP) is an uncommon disease that is usually difficult to diagnose. Transthoracic echocardiography can sometimes fail to establish its diagnosis. The aim of our study is to prove that both Computed tomography (CT) and magnetic resonance (MR) imaging offer distinct advantages to confirm the diagnosis of CP and make therapeutic decisions for patients with this condition. Methods:Data of 76 patients who underwent MRI for a suspicion of CP from January 2009 to October 2021 were reviewed retrospectively Results:MRI and CT scan confirmed the diagnosis showing pericardial thickening in all cases, measuring 7.6 ± 3.2 mm on average circumferential in 62,7 %, and localized in 37,3 %, pericardial calcification in 50 % of cases and inferior vena cava plethora in all cases. An abnormal septal motion was found in all patients. Imaging data namely pericardial thickening, calcifications, as well as their topography, were confirmed by surgical exploration, and the results were consistent in 100% of cases. Conclusion:Although cardiac CT and CMR are recommended as second-line tests in the diagnostic workup of constrictive pericarditis, they offer distinct advantages to not only confirm the diagnosis but also make therapeutic decisions for patients with this condition. Nowadays, many studies prove that a modern approach for the management of pericardial diseases should include the use of different imaging modalities.

544 Two cases of constrictive pericarditis temporally associated with mRNA-1273 COVID-19 vaccination

AimsThe SARS-CoV-2 pandemic has led to the development of the mRNA vaccines in humans which are well tolerated, safe, and highly efficacious; however, post-marketing surveillance is revealing potential rare cardiac adverse effects as acute pericarditis. We herein report two cases of symptomatic constrictive pericarditis following administration of the second dose of mRNA-1273 (Moderna) SARS-CoV-2 vaccine.Methods and resultsCase summary: A 75 years old male with history of hypertension and COPD presented to our Hospital approximately one month after the second dose of mRNA-1273 SARS-CoV-2 Vaccine with dyspnoea and leg oedema. Routine analysis resulted normal, no increasing of inflammatory markers or ECG abnormalities. Echocardiogram showed circumferential fibrinous pericardial effusion without tamponade and typical features of constrictive pericarditis: annulus reversus, ventricular interdependence, expiratory diastolic flow reversal in hepatic vein, inferior vena cava plethora. Pleural ultrasound showed bilateral pleural effusion that was sampled and showed a transudate fluid. Tumoral marker and a CT Scan, autoimmunity panel, blood tests for bacteraemia and Quantiferon were negative. Cardiac magnetic resonance imaging confirmed thickening of pericardium. A 68 years old male with history of ischaemic heart disease with previous CABG, hypertension, dyslipidaemia and chronic kidney disease presented with palpitations and mild legs swelling. Approximately, 2 months before he received the second dose of mRNA-1273 SARS-CoV-2 vaccine. Routine blood examinations resulted normal, ECG showed a right bundle branch block. Echocardiogram showed a mild enlargement of LV with normal systolic function, a moderate primary mitral regurgitation and a circumferential pericardial effusion, showing signs of constrictive syndrome. CT Scan demonstrated pericardium thickness. Constrictive pericarditis may represent a subacute complication of an asymptomatic exudative acute pericarditis. Although cases of acute pericarditis have been reported after SARS-CoV-2 vaccine, to our knowledge, the association with constrictive pericarditis has not been described. The temporal link between vaccination and symptoms development as the biological plausibility of autoimmune or cross-reaction response to vaccination in predisposed subjects could suggest a possible correlation as an adverse event, even if causality could not be established.ConclusionsWe present two cases of constrictive pericarditis occurring after mRNA-1273 SARS-CoV-2 vaccination, aiming further data to confirm a causal role.

Abstract 13025: The Inferior Vena Cava Plethora Is A Predictor Of Bleeding Events In Patients With Heart Failure With Reduced Ejection Fraction And Atrial Fibrillation

Introduction: In patients have heart failure with reduced ejection fraction (HFrEF) and atrial fibrillation (AF), anticoagulation therapy to prevent thromboembolic events was essential but occurs often bleeding complication. We explored echocardiographic markers to predict clinical outcome. Method: In-hospitalized 282 patients with HFrEF and AF between 2000 and 2021 were retrospectively analyzed. The presence of inferior vena cava plethora (IVCP) was confirmed by echocardiography at the time of admission. Eighty-five patients who had IVCP (IVCP group) was compared to 197 patients (70%) who did not have IVCP (control group) Result: IVCP group had more CKD (24% vs 13%, p=0.036), lower platelet (171k±63 vs 192k±64, p=0.007) and lower left ventricular ejection fraction (30±9 vs 34±11 p=0.001) than control group. Major bleeding event during 5 years follow up occurs significantly higher in IVCP group (Kaplan Meier Method, Log rank p=0.042) (figure). Gastrointestinal (GI) bleeding was 73% of major bleeding. In multivariable analysis, the IVCP was independent predictor of major bleeding (HR, 2.17; 95% CI 1.06-4.44). Conclusion: In patients with HFrEF and AF requiring antithrombotic treatment, IVCP was a predictor of major bleeding, especailly GI bleeding.

A study of etiology, clinical characteristics, electrocardiographic and echocardiographic findings in patients with cardiac tamponade in a tertiary care hospital in Western Odisha

Background: Cardiac tamponade is a life-threatening condition characterized by elevated intracardiac pressure, limitation of diastolic filling, and reduction of cardiac output and mostly requires urgent therapeutic intervention. Pericardial disease in on the rise attributed to improved survival of malignancy, growing no of cardiac interventions, chronic kidney diseases with dialysis, advent of modern chemo-radiotherapy. Still, there are paucity of data on etiology, clinical characteristics, electrocardiogram (ECG) and echocardiographic features in patients with cardiac tamponade from Odisha. Aim of this study was to emphasize the etiology, clinical characteristics, electrocardiographic and echocardiographic features in patients with cardiac tamponade.Methods: A prospective observational study of 1-year duration was undertaken for patients with cardiac tamponade admitted at VIMSAR, a cardiology unit. Data on etiology, clinical characteristics, Echocardiography, ECG findings were documented. Echo guided pericardiocentesis followed culture, cytological and biochemical analysis done.Results: Most common symptom was dyspnoea (88%), clinical signs were tachypnoea (96%), raised jugular venous pulse (64%), tachycardia (84%), pulsus paradoxus (60%). Classical beck’s triad was seen in 42% cases. X-ray showed cardiomegaly (94%) & pleural effusion (64%). Common ECG findings were sinus tachycardia (84%), low voltage QRS (68%) and electrical alternans (44%). Echocardiography showed 80% and 68% of patients had right atrium collapse and right ventricle collapse respectively. Both inferior vena cava plethora and transmitral flow variation were seen in 88% of cases. 96% had normal left ventricle function. 80% had large effusion. Pericardiocentesis yield was mostly in between 500-1000ml (mean 908 ml) with 72% with haemorrhagic aspirate. All malignancy cases and 76% tubercular cases had haemorrhagic effusion. Most common etiology was tubercular (50%), followed by malignancy (28%). 6% remained idiopathic. chronic kidney disease, systemic lupus erythematosus, post MI intervention, hypothyroid were some of the other causes.Conclusions: Initial assessment with investigation and careful follow-up can yield a causal diagnosis in most cases. Early diagnosis and intervention by pericardiocentesis can be lifesaving.

Prognostic Implications of a Point-of-Care Ultrasound Examination on Hospital Ward Admission.

Few data exist regarding the use of ultrasound (US) to risk stratify ward admissions. Therefore, we evaluated associations between a cardiopulmonary limited ultrasound examination (CLUE) on admission and subsequent hospital outcomes. Over a 22-month period in a 300-bed hospital, CLUE data reviewed from a series of nonelective ward admissions were correlated with the composite outcome of a hospital stay of longer than 2 days, disposition to hospice, or death. The CLUE included 5 quick-look signs of left ventricular dysfunction, left atrial enlargement, lung B-lines, pleural effusions, and inferior vena cava plethora and had been performed as warranted by 1 of 31 US-trained admitting residents and then repeated by a cardiologist as the reference standard. The admitting condition, medical history, results of routine admission testing, and CLUE were assessed for an association with the outcome in univariate and multivariable models. Of 547 patients, the mean age ± SD was 62.9 ± 15.5 years; 59% were male; and the mean stay was 5.6 ± 8.1 days, with 355 (65%) lasting longer than 2 days and 21 (4%) having hospice disposition or death. An abnormal CLUE exam was found in 368 (67%) of patients, was related to the outcome (odds ratio [OR], 1.86; 95% confidence interval [CI], 1.23-2.68; P = .001) when obtained by a resident or cardiologist, and was included in a best-fit multivariable model with renal failure (OR, 2.44; 95% CI, 1.44-4.14; P < .001), infection/sepsis (OR, 2.25; 95% CI, 1.17-4.32; P = .02), and chest pain (OR, 0.36; 95% CI, 0.21-0.61; P < .001). An abnormal admission point of care ultrasound exam was related to complex hospitalization, specifically a longer length of stay.

Evidence Basis for a Point-of-Care Ultrasound Examination to Refine Referral for Outpatient Echocardiography

Few data exist on the potential utility of a cardiac point-of-care ultrasound (POCUS) examination in the outpatient setting to assist diagnosis of significant cardiac disease. Using a retrospective sequential cohort design, we sought to derive and then validate a POCUS examination for cardiac application and model its potential use for prognostication and cost-effective echo referral. For POCUS examination derivation, we reviewed 233 consecutive outpatient echo studies for 4 specific POCUS "signs" contained therein representing left ventricular systolic dysfunction, left atrial enlargement, inferior vena cava plethora, and lung apical B-lines. The corresponding formal echo reports were then queried for any significant abnormality. The optimal POCUS examination for identifying an abnormal echo was determined. We then reviewed 244 consecutive outpatient echo studies from another institution for associations between the optimal POCUS examination, clinical variables, and referral source with major adverse cardiac events and all-cause mortality in univariate and multivariate models. Assuming a referral model where the absence of POCUS signs or variables would negate initial echo referral, theoretical cost savings were expressed as a percentage in reduction of echo studies. In the derivation cohort, the combination of two signs, denoting left atrial enlargement and inferior vena cava plethora resulted in the highest accuracy of 72% [95% CI: 65%, 78%] in detecting an abnormal echocardiogram. In the validation cohort, mortality at 5.5 years was 14.6% overall, 23% in patients with the left atrial enlargement sign (OR 3.5 [1.6, 7.6]), 25% with inferior vena cava plethora sign (OR 2.2 [0.8, 6.0]), and 8.0% (OR 0.3 [0.2, 0.7]) in those lacking both signs. After adjusting for age, both diabetes (OR 4.8 [2.0, 11.6]), and the left atrial enlargement sign (OR 2.4 [1.1, 5.4]) remained independently associated with mortality (p<0.05). In the referral model, patients younger than 65 years of age without diabetes and without the left atrial enlargement sign would not have received echo referral, resulting in a 33% reduction in total echo cost and would have constituted a low-risk group with a 1.2% 5.5-year mortality. A quick-look sign for left atrial enlargement is associated with 5-year mortality and could function as an easily obtained outpatient POCUS examination to help in identifying patients in need of echo referral.

Ten questions about constrictive pericarditis

Constrictive pericarditis is one of the most feared complications of patients with pericarditis, especially if recurrent. The common perception is that the higher the number of recurrences, the higher the risk of constriction. However, the risk of constriction is related to the etiology and not to the number of recurrences. Constriction has never been reported as a complication of idiopathic recurrent pericarditis, while the risk is low (<1%) after a first attack of idiopathic or viral pericarditis, intermediate for immune-mediated etiologies (2-5%, e.g. systemic inflammatory diseases, post-pericardiotomy syndromes) and cancer, and high especially for bacterial etiologies (20.30%, e.g. tuberculosis, purulent pericarditis). Constriction may be reversible in the setting of pericarditis and about 7-10% of patients with acute pericarditis may have transient constriction during the acute phase of inflammation, due to increased pericardial stiffness. Empiric anti-inflammatory therapy may prevent pericardiectomy in one half of cases.The clinical diagnosis is not easy but feasible with prompt recognition of the clinical symptoms and signs that may mimic heart failure and chronic hepatic disease (e.g. jugular vein distention, peripheral edema, ascites), the echocardiographic signs (e.g. septal bounce, respiratory variations of transmitral and tricuspid flows, annulus reversus, inferior vena cava plethora), and other imaging features (e.g. pericardial thickening in about 80% of cases, pericardial calcifications).In this paper, we will try to give an answer to common clinical doubts for assessing the risk of constriction, making the diagnosis, and addressing the therapy of these patients also underlying the possible outcomes.

Arteriovenous Fistula Presented with Right Ventricular Failure

Arteriovenous fistula could be traumatic with one manifestation as high-output heart failure. We present a 29-year-old male, referred for unexplained right-sided enlargement and the symptoms of right ventricular failure for 8 months ago. Considering right-sided dilatation, marked inferior vena cava plethora, and increased pulmonary passage of flow in the absence of intracardiac shunts, arteriovenous shunt was suspected. He had a history of penetrating abdominal trauma which raised the suspicion for further evaluation. Abdominal sonography and contrast-enhanced computed tomography revealed a large arteriovenous fistula between the left common iliac artery and vein. The patient underwent successful percutaneous repair with a stent graft and dramatic improvement in symptoms and resolution of flushing and edema.

Low-Pressure Pericardial Tamponade: Case Report and Review of the Literature

BackgroundFocused cardiac ultrasound (FoCUS) is accurate for determining the presence of a pericardial effusion. Using FoCUS to evaluate for pericardial tamponade, however, is more involved. Many experts teach that tamponade is unlikely if the inferior vena cava (IVC) shows respiratory variation and is not distended. Case ReportA 53-year-old woman presented to the emergency department (ED) with severe orthostatic hypotension, exertional dyspnea, and hypoxia. The evaluation did not reveal an acute cardiopulmonary etiology, but FoCUS demonstrated a pericardial effusion, with several signs consistent with tamponade. The IVC, however, was not distended. She was believed to be hypovolemic, but fluid therapy provided minimal benefit. The patient's condition improved only after aspiration of the effusion. The patient's presentation was likely a “low-pressure” pericardial tamponade. Patients with this subset of tamponade often do not have significant venous congestion, but urgent pericardial aspiration is still indicated. Why Should an Emergency Physician Be Aware of This?Pericardial tamponade may not manifest with IVC plethora on ultrasound. Patients with low-pressure tamponade do not present with the most florid signs of tamponade, but they nonetheless fulfill diagnostic criteria for tamponade. If a non-plethoric IVC is used to rule out tamponade, the clinician risks delaying comprehensive echocardiography or other tests. Furthermore, the potential for deterioration to frank shock could be discounted, with inappropriate disposition and monitoring.

Echocardiographic investigation of the mechanism underlying abnormal interventricular septal motion after open heart surgery.

BackgroundAbnormal interventricular septal motion (ASM) is frequently observed after open heart surgery (OHS). The aim of this study was to investigate the incidence and temporal change of ASM, and its underlying mechanism in patients who underwent OHS using transthoracic echocardiography (TTE).MethodsIn total, 165 patients [60 ± 13 years, 92 (56%) men] who underwent coronary bypass surgery or heart valve surgery were consecutively enrolled in a prospective manner. TTE was performed preoperatively, at 3--6-month postoperatively, and at the 1-year follow-up visit. Routine TTE images and strain analysis were performed using velocity vector imaging.ResultsASM was documented in 121 of 165 patients (73%) immediately after surgery: 26 patients (17%) presented concomitant expiratory diastolic flow reversal of the hepatic vein, 11 (7%) had inferior vena cava plethora, and 11 (7%) had both. Only 2 patients (1%) showed clinically discernible constriction. ASM persisted 3--6 months after surgery in 38 patients (25%), but only in 23 (15%) after 1 year. There was no difference in preoperative and postoperative peak systolic strain of all segments of the left ventricle (LV) between groups with or without ASM. However, systolic radial velocity (VRad) of the mid anterior-septum and anterior wall of the LV significantly decreased in patients with ASM.ConclusionAlthough ASM was common (74%) immediately after OHS, it disappeared over time without causing clinically detectable constriction. Furthermore, we consider that ASM might not be caused by myocardial ischemia, but by the decreased systolic VRad of the interventricular septum after pericardium incision.

Cardiopulmonary Limited Ultrasound Examination for “Quick-Look” Bedside Application

Although taking a "quick look" at the heart using a small ultrasound device is now feasible, a formal ultrasound imaging protocol to augment the bedside physical examination has not been developed. Therefore, we sought to evaluate the diagnostic accuracy and prognostic value of a cardiopulmonary limited ultrasound examination (CLUE) using 4 simplified diagnostic criteria that would screen for left ventricular dysfunction (LV), left atrial (LA) enlargement, inferior vena cava plethora (IVC+), and ultrasound lung comet-tail artifacts (ULC+) in patients referred for echocardiography. The CLUE was tested by interpretation of only the parasternal LV long-axis, subcostal IVC, and 2 lung apical views in each of 1,016 consecutive echocardiograms performed with apical lung imaging. For inpatients, univariate and multivariate logistic regression analyses were performed to assess the relations between mortality, CLUE findings, age, and gender. In this echocardiographic referral series, 78% (n = 792) were inpatient and 22% (n = 224) were outpatient. The CLUE criteria demonstrated a sensitivity, specificity, and accuracy for a LV ejection fraction of ≤40% of 69%, 91%, and 89% and for LA enlargement of 75%, 72%, and 73%, respectively. CLUE findings of LV dysfunction, LA enlargement, IVC+, and ULC+ were seen in 16%, 53%, 34%, and 28% of inpatients. The best multivariate logistic model contained 3 predictors of in-hospital mortality: ULC+, IVC+ and male gender, with adjusted odds ratios (95% confidence intervals) of 3.5 (1.4 to 8.8), 5.8 (2.1 to 16.4), and 2.3 (0.9 to 5.8), respectively. In conclusion, a CLUE consisting of 4 quick-look "signs" has reasonable diagnostic accuracy for bedside use and contains prognostic information.

Rapid Progression of Pericardial Calcification Containing a “Calcium Paste” in a Patient With End-Stage Renal Disease

A 52-year-old man with end-stage renal disease (ESRD) secondary to chronic glomerulonephritis was admitted to our hospital with aggravated exertional dyspnea. He had been maintained on hemodialysis for the past 16 years. One year previously, he had been hospitalized for complicated pleural effusion, which was confirmed as Gram-positive cocci infection, and was treated through percutaneous drainage and antibiotics. Chest computed tomography (CT) taken at the time of initial hospitalization showed bilateral complicated pleural effusion and diffuse pericardial thickening without calcification (Figure 1). During that period, parathyroid hormone markedly increased to 1113 pg/mL (normal range, 10 to 65 pg/mL); hyperphosphatemia was also noted. His hyperparathyroidism was thought to be secondary to ESRD; thus, he underwent subtotal parathyroidectomy 6 months later. Serial plain chest radiographs at the time of pleural infection and at the time of parathyroidectomy showed rapid progression of the smooth and diffuse pericardial calcific opacities within only a 6-month period, and these findings were maintained until this admission (Figure 2). Transthoracic echocardiography revealed diffuse pericardial thickening with septal bouncing and inferior vena cava plethora, suggestive …

Echocardiography of the coronary sinus in adults.

The coronary sinus (CS) is a small tubular structure just above the posterior left atrioventricular junction. The CS can be imaged in several different echocardiographic views. Using zoom M-mode recordings of the CS in apical two-chamber view, CS caliber can be sharply imaged and easily measured during different phases of the cardiac cycle. We have recently shown that the CS narrows during atrial contraction in persons with sinus rhythm, but does not narrow at all if atrial fibrillation is present. Attenuation of CS narrowing occurs in patients with congestive heart failure and inferior vena cava plethora. Maximal CS caliber occurs during ventricular systole. Patients with poor left ventricular systolic function show mild CS dilatation. Greater CS dilatation is present in patients with persistent left superior vena cava, and huge dilatation when this anomaly is accompanied by absence of a right superior vena cava. Injection of sonicated saline into a left and then a right arm vein is diagnostically useful in confirming these two venous anomalies. Pulsed-wave Doppler of the CS can be recorded in the parasternal right heart inflow view. From this and from the CS cross-section area it may be possible to estimate coronary blood flow.

Pulmonary Hypertension Decreases the Predictive Accuracy of Echocardiographic Clues for Cardiac Tamponade

A number of echocardiographic clues of pericardial tamponade have been described, but their accuracy in patients with pulmonary hypertension has not been well elucidated. Four echocardiographic clues of pericardial tamponade, namely, right atrial collapse (RAC), right ventricular diastolic collapse (RVDC), marked (> 40%) respiratory variation in transmitral Doppler flow velocity ("flow velocity paradoxus [FVP]"), and inferior vena cava plethora (IVCP) were prospectively evaluated in 32 patients with large pericardial effusions. Of 12 patients with pulmonary hypertension, 6 had invasively determined evidence of tamponade and 6 did not; of 20 patients without pulmonary hypertension, 11 had tamponade and 9 did not. These echocardiographic clues were evaluated in a blinded fashion. Predictive accuracies for RAC, RVDC, FVP, and IVCP were 75%, 80%, 90%, and 95%, respectively, for the patients without pulmonary hypertension and 67%, 58%, 58%, and 83%, respectively, for the patients with pulmonary hypertension. Although all predictive accuracies were lower in patients with pulmonary hypertension, statistically significant decreased predictive accuracy was found only with FVP (p < 0.05). Interestingly, IVCP had the best predictive accuracy among patients with pulmonary hypertension. Our findings suggest that despite somewhat decreased accuracy in patients with pulmonary hypertension, traditional echocardiographic clues for pericardial tamponade may be useful.

Prognostic value of echocardiography in hospitalized patients with pericardial effusion.

It is often difficult to predict outcome in hospitalized patients with pericardial effusion. To address this issue, the prognostic value of echocardiography was studied in 187 hospitalized patients diagnosed with pericardial effusions over a 1-year period. The index echocardiogram showed that 11 effusions were large (6%), 39 were moderate (21%), and 137 were small (73%). Right ventricular collapse was present in 7% of cases (13 of 178), right atrial collapse in 12% (21 of 168), and inferior vena cava (IVC) plethora with blunted response to respiration in 35% (46 of 132). During the course of hospitalization, 9 patients (5%) had cardiac tamponade and 16 (9%) had cardiac tamponade, pericardiocentesis and/or surgical drainage (combined end point). By univariate analysis, each echocardiographic sign was associated with both cardiac tamponade and the combined end point (p less than or equal to 0.01 for comparisons with size and right-sided chamber collapse; p less than or equal to 0.07 for comparisons with IVC plethora). When the data were analyzed with logistic regression modeling, effusion size was the most powerful predictor of outcome (cardiac tamponade: odds ratio 51, 95% confidence interval 3.5-729, p = 0.004; combined end point: odds ratio 78, 95% confidence interval 14-421, p = 0.0001), and neither right-sided chamber collapse nor IVC plethora with blunted response to respiration retained significant associations. It is concluded that echocardiographically determined effusion size is a powerful predictor of outcome in hospitalized patients with pericardial effusion, and that right-sided chamber collapse and IVC plethora with blunted response to respiration add little if any additional prognostic information.

Inferior vena cava plethora with blunted respiratory response: A sensitive echocardiography sign of cardiac tamponade

To assess the diagnostic and prognostic value of the respiratory behavior of the inferior vena cava in pericardial effusions, clinical and two-dimensional echocardiographic data of 115 consecutive patients with a moderate or large effusion, including 33 who had cardiac tamponade, were reviewed. Echocardiograms were reviewed for effusion size, inferior vena cava diameter before and after deep inspiration and presence of right atrial and ventricular collapse. For the 83 patients (72%) with less than 50% decrease in inferior vena cava diameter after deep inspiration ("plethora"), inferior vena cava diameter decreased from 2.0 +/- 0.3 to 1.6 +/- 0.4 cm after inspiration (mean +/- SD) (mean decrease 18%). For the 32 patients (28%) without plethora, the diameter decreased from 1.6 +/- 0.5 to 0.6 +/- 0.3 cm (mean decrease 63%). Patients with plethora had significantly higher values for heart rate (111 +/- 21 versus 98 +/- 20 beats/min), pulsus paradoxus (24 +/- 15 versus 12 +/- 4 mm Hg), jugular venous distension (14 +/- 5 versus 8 +/- 3 cm H2O) and right atrial pressure (17 +/- 6 versus 12 +/- 6 mm Hg) and lower values for systolic blood pressure (109 +/- 22 versus 132 +/- 27 mm Hg) (all p less than 0.05) than did patients without plethora. Plethora was present in 58 (92%) of 63 patients who underwent a pericardial drainage procedure, 14 (88%) of 16 who developed constrictive physiology and 11 (92%) of 12 of those whose hospital death was related to pericardial effusion.(ABSTRACT TRUNCATED AT 250 WORDS)