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The Echo Manual

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CHAPTER 12 PERICARDIAL DISEASES

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FIGURE 12-18 A: Typical M-mode echocardiograms of constrictive pericarditis ( top ) and tamponade ( bottom ). Note the typical respiratory shift of the ventricular septal motion toward the left ventricle ( LV ) with inspiration ( upward arrow ) and toward the right ventricle ( RV ) with expiration ( downward arrow ) in both conditions (Video 12-6). This is a result of increased interventricular depen- dence. B: In constriction, the posterior wall is flattened soon after early dias- tole ( arrow at top ). In tamponade, the posterior wall does not have the early diastolic flattening ( arrow at bottom ).

and LV filling recovers with expiration. This characteristic hemodynamic pattern is best illustrated by simultaneous pressure recordings from the LV and pulmonary capil- lary wedge in combination with mitral inflow velocities (Fig. 12-19).

veins and LA decreases immediately after inspiration, reducing left heart filling. Consequently, mitral valve opening is delayed, which lengthens the isovolumic relaxation time (IVRT) and decreases the mitral inflow E velocity. Conversely, the pressure gradient driving LA

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FIGURE 12-19 A: Simultaneous pressure recordings from the left ventricle ( LV ) and pulmo- nary capillary wedge together with mitral inflow velocity on a Doppler echo- cardiogram. The onset of the respiratory phase is indicated at the bottom. EXP , expiration; INSP , inspiration. With the onset of expiration, pulmonary capillary wedge pressure ( PCW ) increases much more than LV diastolic pres- sure, creating a large driving pressure gradient ( large arrowhead ). With inspira- tion, however, PCW decreases much more than LV diastolic pressure, with a very small driving pressure gradient ( three small arrowheads ). These respira- tory changes in the LV filling gradient are well reflected by the changes in the mitral inflow velocities recorded on Doppler echocardiography. B: Diagram of a heart with a thickened pericardium to illustrate the respiratory variation in ventricular filling and the corresponding Doppler features of the mitral valve, tricuspid valve, pulmonary vein ( PV ), and hepatic vein ( HV ). These changes are related to discordant pressure changes in the vessels in the thorax, such as pulmonary capillary wedge pressure ( PCW ) and intrapericardial ( IP ) and intracardiac pressures. Hatched area under curve , reversal of flow; thicker arrows , greater filling; D , diastolic flow; LA , left atrium; LV , left ventricle; RA , right atrium; RV , right ventricle; S , systolic flow (Video 12-7).

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