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*F rom the Sec tion ofC ard io lo gy , A lbert E in ste in M edical C en te r,Philadelph ia .tA ssoc iate P ro fesso r o f M edic in e, T em ple U nivers ity S choo l o fM ed ic in e, P hilad elp hia .

tP ro fesso r o f M edicin e, T em ple U niversity Schoo l o f M edic ine ,Ph i lade lph ia .M anuscrip t r ece ived Septem b er 9 ; rev ision a ccep ted D ecem ber 2

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F I GURE 1 . M -m od e echocard iog ram show ing per ica r-d ia l (so lid arrow s) and ep ica rd ia l landm arks (openarrows) used in the m ea surem ent o f the ir respec tivem ino r axes .

C H E S T I 83 I 5 I M A Y , 19 83 76 7

E c h o c a rd io g ra p h ic Q ua n tita tio no f P e ric a rd ia l E ffu s io n *R . P aram esw aran , M . D . t a ndHarry G o ldb erg , M .D ., F C .C .P .1

Th is s tudy w as undertaken to tes t the va lid ity o f M -m odeech ocard iog raph ic qu ant ita tion o f p er ica rd ia l e ffu sio n . M -m ode estim ate of th e vo lum e o f p er ica rd ia l effus ion in 27pa tien ts w as com pared w ith th e a ctu al v o lum e o f per ica rd ia leffu sion rem oved during su rg ica l pe rica rd ia l d rain ag e. Th e16 tw o-d im ens iona l ech ocard iograph ic s tud ies in pa tien tswith sm all, m oderate , and la rge p ericard ia l e ffu sion s w ererev iew ed to ex am ine the d istr ibu tio n o f p ericard ia l flu id

E cho ca rd iog raph y has been sh ow n to be sen sitivean d re liab le in the d iagno sis o f pe rica rd ia l e ffu -1 A ltho ugh c rite r ia fo r the echoca rd iog raph ic

d iagno sis o f p e rica rd ia l effu sion have been w e ll e stab -lished , m e thod s fo r q uan tita ting th e vo lum e o f p ericar-d ia l e ffusio n have no t been w e ll s tud ied . F e igenbaumet a12 an d o th ers3 have su ggested tha t the v o lum e o fpe rica rd ial e ffusio n be expre ssed sim p ly as sm a ll,m od era te o r la rge . H orow itz and as soc ia tes4 d esc r ibeda sim p le M -m od e techn iq ue fo r q uan tita ting p e rica r-d ia l e ffu sion an d ind icated tha t echoca rd iog raphy m ayallow accurate p red ic tion of the v o lum e of pe rica rd ia lef fus ion . B ut a su bsequen t stud? in a sm a ll num ber o f

around th e h ear t. A lth ough th ere w as good correla tio nbe tw een th e echocard iog raph ic estim ate and the actua lvo lum e rem oved dur in g su rg ery (r 0 . 78) , sign ifican t o ver-es t imat ion and underestim a tion w ere no ted . O ur find in g ssuggest th a t th e erro rs in the es tim ate cou ld be a ttrib u ted inp ar t to d iff ic ult ie s in p rec ise m easu rem en t o f the ep icard ia land per icard ia l landm ark s and in pa rt to nonun ifo rmd istr ibu tio n o f pe rica rd ia l f lu id a ro und the h ea rt.

pa t ien ts qu estioned th e reliab ility o f th is techn iq ue .Perica rd iocen tesis w as used to quan tita te the vo lum eof f lu id in bo th th ese stud ie s . S ince lo cu latio n o f f lu idm ay o ccur in pe rica rd itis , the u se o f p ericard io cen te sism ay have led to inaccu rac ies in th e m easu rem en t o fpe rica rd ia l e ffusio n . F urthe r, p er icard ia l f ib rosis m ayhave m ade the echoca rd iog raph ic es tim a te o f pe rica r-d ia l effu sion inaccu ra te a s has been show n prev i-ou sly .67 W e, th e re fo re , und ertoo k the p re sen t stu dy inpa tien ts in w hom th e p ericard ium and th e p ericard ia lcav ity w ere exam in ed fo r th ick en ing and locu la tion offlu id during su rg ica l d ra inage of pe rica rd ia l e ffusio n .

PAT IE NT S AND M ETHODSPatien ts in wh om p ericard ial effu sio n w as de tec ted ech oca r-

d io graph ica lly and w ho subseq uen tly u nde rw ent surg ic al d rain ageof th e per icard ia l e ffus ion w e re ch osen for rev iew . The clin ic ald iagnose s inc lud ed a va rie ty o f con dit ion s inc lud ing chro n ic renalfa i lu re , v ira l per icard it is , a nd p eric ard ial e ffu sio n d ue to m alignan td is ease . E cho card io graph ic ex am ina tion w as p erfo rm ed w ith th e

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76 8 E c h o c ar d i o g r ap h i c Q u a n t i ta t i o n o ( P e r i c a r d i a lEffus ion (Parameswaran , Goldberg)

pa t ien ts in the sup in e or lef t la tera l decub itu s p osition us ing a 2 .25M Hz t ransducer . C onven tiona l tech n iques w ere used to de linea tethe ep ica rd ia l an d per ica rd ial landm arks u sed in the m easurem en t.

T he M -m ode records w ere ana ly zed u sing the m ethods s im ila r tothose used b y Ho row itz et a l.4 T he perica rd ia l m inor ax is w a smeasu red f rom th e last n onm oving chest wa l l echo to th e lead in ged g e of the po ste rio r pericard ia l e cho . T he card ia c m ino r ax is w asm easured from th ele ad ingedge ofthe an te rio rep icard ia l echo to thelead ingedge ofthe pos ter io r ep icard ial echo(F ig 1 ). T hese axes w erethen cub ed to ca lcu la te the pericard ial and card iac v o lum es. T hevolum e o fper ica rd ial f lu id w a s est im a ted by sub tra ctin g th e ca rd ia cvolume from the p er ica rd ia l vo lum e. A ll m easu rem en ts w ere m adei n e n d- d ia st ol e a t the level ofthe tip s o fthe m itral valv e le afle ts. Am inim um o f five cyc les w as exam ined and th e m easu rem en tsaveraged . In 23 pa tien ts, M -m ode record s w ere ana lyz ed an d thevolume ofper ica rd ia l e ffu sio n e stim ated by tw o independent ob se rv -ers . S ince M -m od e quan tita tion ofperica rd ia l e ffus io n is based onthe assum ption tha t the flu id is un ifo rm ly d is tribu ted around th ehear t , 16 tw o -d im ension al s tud ies from 15 pa tien ts w ith perica rd ia lef fus ion w ere rev iew ed to d ete rm ine w hether th is assum p tion isval id . These tw o -d im ension al s tu d ies inc luded th ree pa tien ts w hol at er u nd er we nt pe rica rd ial d ra inage.

SURG ICAL TECHN IQ UEPericard ial dra in age w as p erform ed u sin g th e fo llow -

in g techn iqu e . U nder local or g en era l an es th esia , w ithth e pa tien ts h ead elev ated to 1O to 15 #{176 }, sm allsu bx ip ho id in cisio n w as m ad e, and the pe rica rd iumexposed . A sm a ll q uan tity (1 0 to 20 m l) o f p e rica rd ia lf lu id w as asp ira ted fo r cy to lo gy an d o the r rou tin es tud ie s . Th e p ericard ia l cav ity w as then opened andth e con ten ts d ra in ed u sin g g enfle su ction . Fo llow ingd ra inage of th e f lu id , the pe rica rd ial cav ity w as ex -p lored w ith th e su rgeon s f in ger to de term in e w heth erad hesion s o r locu la tion s w ere p re sen t. A t the end ofth e pro cedu re, the vo lum e ofper icard ia l effu s ion , th eth ickness of th e p er ica rd ium , and th e p resen ce oflocu la tion of flu id , if any , w ere n o ted .

RESULTS

T echn ica lly ad equate echocard iogram s w ere ava ila -b le in 32 patien ts w ho underw en t p er icard ia l d ra in a ge .F ive o fth ese 32 pa tien ts w ere exc lud ed from th e studys ince the in te rva l be tw een echo card io g raph y an d su r-ge ry exceed ed five d ay s. Th e 2 7 s tu dy pa tien ts in -c lud ed 14 m en an d 13 w om en w ith ages rang ingbe tw een 24 and 79 yea rs. In 18 patien ts , p er icard ia ldrain ag e w as pe rfo rm ed les s th an 24 hours fo llow ingechocard iog raph ic ex am ination , in fou r w ith in 48hours, and in tw o w ith in 7 2 hours. In th e rem ain in gth ree, d ra in ag e w a s p er form ed betw een 72 and 96hours fo llow ing echo card iography .

D ur in g su rgery , th e p er ica rd ium wa s noted to b esligh tly or m arked ly th ick en ed in 20 pa tien ts . A l-th ough slig h t adh esion s w ere comm on , no patien t hadlocu la tion of p ericard ia l flu id . Th e vo lum e of pe rica r-d ia l f lu id ranged betw een 10 0 and 2 ,00 0 m l. In 1 7pa tien ts , th e vo lum e ofpe rica rd ia l f lu id exceed ed 500m l.

A num ber of p rob lem s w ere en coun tered in th e

I 1 I I I400 800 1200 1600 2000 2400

ECHO ESTIMATE#2 (m I )F I GURE 2 . R e la ti on s hi p b e tw een echocard iog raph ic es tim ates o f tw oin dependen t observ ers in 23 pa tien ts .

echoca rd iog raph ic e stim a tion of th e v o lum e of pe rica r-d ial e ffusio n . T hese in clu ded d ifficu lty in the p recis elocat ion ofth e ep ica rd ium and th e p er icard ium and th esp on taneou s va riab ility o f the an te r io r and posteriorecho free spaces . In sp ite o fth ese d ifficu ltie s , ind ep en -d en t echocard iog raph ic estim a tes show ed a rem ark -ab le d egree o f co rre la t ion (F ig 2 ) . D ifferen ces in th eest im ate b etw een th e tw o ob serv ers ranged betw een 1m land380m lw itham eanofl4 lm l. In ten o fthe23p atien ts , th e d ifference w as le ss than 10 0 m l, in f ive itw as le ss than 200 m l, and in seven it w as le ss than 3 00m l. T he re w as on e p atien t in w hom th e d iffe ren ce w as38 0 m l.

E cho ca rd io graphy ov erest im a ted th e vo lum e o fp ericard ia l e ffu sion in 20 patien ts and underest im atedits vo lum e in seven . The degree ofoveres tim ate rangedb etw een 92 and 818 m l and ex ceed ed 30 0 m l in IIp atien ts . U nd ere stim a te s ranged b e tw een 60 and 619

n27r .7# { 216 }a I. 6 3b0.596SE E 26 3

I I I I I I4 00 800 p200 1600 20 2400 2800

ECHO (m l)F IGUR E 3 . R e la tionsh ip b etw een the echocard iograp h ic es tim ate o fthe vo lum e of per icard ial effus ion and the m easured v o lum e o fp ericard ial ef ih isio n (w in dow ).

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_ _ _ _F IGURE 4 . R epre sen tative f ram es from tw o-d im ens ion al ech ocard iog ram s in a p atien t w ith a m od erateper icard ia l effusion . Panels A , B , and C w ere reco rded in end-d ia sto le . D istrib u tio n of pe ric ard ial flu idapp ears re la tively un ifo rm in th e lon g ax is v iew (PE , pan el A ) an d the shor t ax is v iew at lev el o f pap illarymu sc l e s ( a rrows , p ane l B ). H ow ev er, at a slig h tly m ore proxim a l le vel (pan el C ), the re is a m arked decrea se inthe po ster io r ech o-free spac e.

B

- F I GURE 5 . P an els A and B show rep resen tativ e f ram es from sho rt ax is v iew s in tw o p atie n ts w ith largep eric ard ial effu sio n . N o te th e n onuniform d istribu tio n ofp eric ard iai ef fusion ( P E ) poste rio rly (see tex t fo rd iscuss ion ) A o is ao rta , a nd PL .E . , p le ura l e ffu sio n.

CHEST/83/5 /MAY,1983 76 9

m l. T he re app ea red to be no co nsisten t re latio nsh ipbe tw een the d egree o f ove restim ate s and unde resti-m a te s and the ac tua l vo lum e o f p ericard ia l effu sion .A lthou gh the o ve ra ll co rre latio n be tw een the echoca r-d io g rap h ic e stim a te and the ac tua l vo lum e rem ov ed atsu rge ry w as good (r = 0 . 78 ), the re w as w id e sca tte r o fthe d ata and a ra the r la rge standa rd e rro r o f theestim a te (F ig 3 ) . T he corre la tion w as sim ila r in the 17p atien ts w ith e ffus ions g reate r than 50 0 m l (r = 0.7 5)b u t som ew hat p oore r (r = 0 . 6 6 ) in p atien ts w ith le ssthan 5 00 m l o f p ericard ia l e ffusio n .Tw o-D im ensio na l S tud ies

The 16 tw o-d im ens iona l s tud ie s rev iew ed inc lud edfiv e w ith sm all e ffus ions, fiv e w ith m ode rate e ffus ions,and six w ith large e ffusio ns. Sm a ll effu sion s w erep red om in an tly o r ex clu sive ly po ster io r in d istr ibu tio n ,the m ax im a l echo -free space be ing n o ted po ster io r ly ato r ju st be low the lev el o f th e m itra l lea f lets . A ltho ughm od era te e ffusio ns tend ed to b e m o re un ifo rm in the ird is tribu tion , th ere w as con side rab le va riab ility in thesize o f th e echo-free spaces a roun d the h ea rt. In lo ngax is v iews , the pos ter io r ech o-free space w as fre -qu en tly la rge r a t the lev el o f th e m itra l v alv e lea fle ts ,tap erin g p rox im ally and d ista lly . In short ax is v iew s,

su ch a d istr ibu tio n re su lted in sig n if ican t va riab ility o fthe po ster io r space depend ing on the leve l o f the shortax is p lan e (F ig 4 ) . In seve ral in stances , sho rt ax is v iew srevea led m ore flu id in the pos terom ed ial pe rica rd ialrecess than d irec tly poste r io r ly , o r po ste ro la te ra lly . Inla rge e ffusio ns, the la rg est am oun ts o fflu id w ere no teda ro und th e ap ica l reg ion . S h ort ax is v iew s in th esestud ies rev ealed m ore flu id in th e po ste rom ed ia l andpo ste ro late ral recesse s than d irectly poste r io r ly (F ig5 ).

DISCUSSIONThe resu lts o f th is stu dy a re in g ene ra l ag reem en t

w ith th ose o f H orow itz an d assoc ia te s4 and sh ow acorre la tion b etw een the size o fthe echo -free spaces onthe M -m ode ech oca rd io g ram and th e actu a l vo lum e ofpe rica rd ia l e ffus io n . H ow ev e r, the re is sig n if ican t sca t-ter of the d ata m ak ing accu ra te p red ictio n of th evo lum e o f flu id d ifficu lt (F ig 3 ) . T he e rro rs in theestim a te o f p ericard ia l effu sion cou ld h av e re su ltedfrom a num ber of facto rs . A s d iscu ssed ea rlie r , m ea -su remen t o f th e pe rica rd ial and ca rd iac d im ensio nsw as often d iff icu lt, requ iring c lose exam in atio n of anum ber of card iac cyc les . A lth ough su ch d iff icu ltyco u ld h av e led to in consis ten cie s in the m easu rem en t

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77 0 Echocard iog rap h lc O uan tita tlon of P ec ard E ffus ion (Parameswaran , Goldberg)

of pericard ial and ca rd ia c vo lum es, th e ex cellen t cor -rela tio n b etw een th e est im ates by th e tw o ob serverssug gests tha t e rro rs in m easu rem en t co u ld n o t h av ebeen th e so le cau se o f th e w id e sca tter o f th e data .

A s no ted ea rlie r , e choca rd iog raphy ov ere stim a tedth e vo lum e of p erica rd ia l flu id in th e m a jo rity o fpatien ts . A s id e from a system a tic e rro r in the id en tifi-cat ion of th e p er ica rd ia l o r th e ep icard ia l in terfaces,such ov ere stim a tes cou ld re su lt from locu la tion o f thef lu id a long th e path o f th e u ltrason ic b eam , o r frompe rica rd ia l th ick en ing and fib ro sis w h ich a re kn ow n tom im ic flu id . N one ofth e pa tien ts in c lud ed in th e studyshow ed lo cu la tion offlu id . A lth ough per ica rd ia l th ick-en in g w as pre sen t in 20 o f th e 2 7 pa tien ts rep orted inth is study , th ere w as no con sisten t re la t ion sh ip b e -tw een a th ick en ed pe rica rd ium and ove res tim a tion o fth e v o lum e of flu id . F u rth er, in fiv e pa tien ts withp ericard ia l th icken ing , echoca rd iog raphy und ere sti-m ated th e vo lum e offlu id . T hu s , n e ith er lo cu la tion norpericard ial th ick en in g appeared to accoun t for th efrequ en t ov ere stim a te o f the vo lum e of pe rica rd ialf lu id .

T he p rin c ip a l as sum p tion under ly in g th e techn iqu edescribed by H orow itz and assoc iate s4 is tha t thepencard ial flu id is un iform ly d istr ibu ted around th eheart. P rev io us stu d ie s by Sou len an d assoc ia te s8sugge sted tha t th is assum ption m ay b e inco rrect.H ow ev er , in th e th ree pa tien ts d escr ib ed in Sou len sstudy , th e v o lum e o f p ericard ia l e ffus ion w as no tde te rm in ed , and it is unc lear w he the r th e sam efind in gs cou ld app ly to e ffu sion s o f var iou s size s. Arecen t stud y by M artin an d asso cia te s9 u tiliz ing tw o-d im ens ion echo ca rd iog raph y add s im portan t in fo rm a-tio n in th is rega rd . In th is study , it w as no ted tha t insma l l an d large effu s ion s, th e d istribu tion o f f lu idaround th e h ear t w as no t un iform . In m odera te e ffu -sions, o n th e o the r hand , the d istr ibu tio n o f flu id w asno ted to b e un iform , lead in g to th e au thors su gg estio nthat M -m ode quan tita tio n of p er icard ia l e ffu sion m aybe m ost accu ra te in the p re sen ce of m ode rate pe rica r-d ia l effu s ion . O ur ow n f ind in gs on tw o-d im en sion al

echocard iog raphy in patien ts w ith per icard ia l effu s iona re in gene ral ag reem en t w ith the observa tion s o fMar t i n et a l. H ow ever , w e have found tha t even inpatients w ith m oderate p er icard ia l effu sion s, th e d is-tnbu tion o f f lu id m ay not b e su ffic ien fly un iform toa llow accurate pred ic tio n of th e vo lum e o f f lu id . It isappa ren t from our ob serva tion s th at , d ep end ing on th epath of th e u ltrason ic b eam , th e size o f th e echo-freespaces reco rd ed by the M -m ode tech n iqu e m ay va rysign ifican tly (F ig 4 ). T h ese find in g s sub stan tia te th ere se rva tions ex pressed by p rev io us ob serve rs 3 w ithreg ard to th e M -m ode quan tita t ion o f p en card ia le ffusio n . I t w ou ld app ea r th a t tw o -d im ension a l stu d ie sa lon e , or M -m ode echocard iog ram s der ived from tw o-d im ension al stud ie s , w ou ld m in im ize the e rro rs in thequ an tita tion o fpe rica rd ia l e ffu s io n .AC KN OW LED G M EN T : The au thors g ra te fu lly acknow led ge thetechn ica l a ssistan ce o f C aro l R ab in and Bonn ie Swink prov idedt ec hn ic al a ss is ta nc e.

REFERENCES1 F eigenb aum H , Z aky A , W aldhausen JA . U se ofu ltraso und in the

d ia gno sis of p ericard ia l e ffu sion . Ann In tern M ed 1962 ;65 :443-522 F eig en baum H . E ch oca rd iography. Ph ila de lph ia: L ea &

F eb iger, 1 976 ; 4 30-323 Te ich holz L E . E cho card io graph ic eva lua tion of perica rd ia l d is-

eases. P rog C ard iovasc D is 1 978 ; 133-404 H orow itz M S, Schu lz C S , S tinson EB , H arrison D C , P opp RL .

S ensitiv ity an d specific ity o f ech ocard iograph ic d iagnos is o fper ica rd ia l e ffusio n. C ircu la tion 1974 ; 50:239-47

5 P rakash R , M oorthy K , D elV icario L , A ronow W S . R eliab ility o fecho card iography in quan tita tin g perica rd ia l e ffusion : A p ro-spec tive study . J C lin U ltrasou nd 1977 ; 5 :398402

6 M illm an A , M elle rJ , M otro M , M illm an A , M elle rJ , M otro M , e tal. Per icard ial tum oror fib ro sis m im ick ingp erica rd ia le ffus ion byecho card iography . A nn In te rn M ed 1 97 7; 8 6; 43 4- 36

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9 M ar tin RP , R akow sk i H , French J, Popp R L . L oca lization o fper icard ial ef fusion w ith w ide angle p ha se d a rra y e ch oc ard io gr a-phy . Am J Card io l 1 97 8; 4 2: 90 4-1 2

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