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    Question 1

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    Question 1

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    ACCSAP: Pericardial Disease Practice Questions 2024

    Question 1 of 19

    A 53-year-old man with stable angina undergoes coronary angiography, which reveals a
    severe focal stenosis in the proximal right coronary artery. He receives successful
    percutaneous coronary intervention (PCI) with a single drug-eluting stent via a transradial
    approach.

    In the postprocedure recovery unit, he develops hypotension and tachycardia. On


    examination, his heart sounds are muffled and extremities are cool. His right radial access
    site does not have any signs of bleeding. Transthoracic echocardiography reveals a small
    pericardial effusion.
    Which one of the following is most likely present in this patient?

    A. Respiratory variation in tricuspid flow velocity of 30%. 5.12%

    B. Respiratory variation in mitral flow velocity of 20%. 3.39%

    C. Inferior vena cava collapse >50% with inspiration. 1.39%

    D. Diastolic collapse of the right ventricle. 89.5%


    E. Mitral early filling velocity >1.2 m/sec. 0.61%

    Commentary
    References
    Key Point

    The correct answer choice is diastolic collapse of the right ventricle (RV).

    This patient had suspected cardiac tamponade following PCI, which should be suspected in
    any patient with hypotension and a new and/or worsening pericardial effusion following a
    cardiac procedure. Small-sized and moderate-sized pericardial effusions can cause cardiac
    tamponade because the pericardium is stiff and less compliant in the setting of an acute
    pericardial effusion.

    Cardiac tamponade is a clinical diagnosis that relies heavily on echocardiography to


    establish the presence of a pericardial effusion and its hemodynamic significance. Chamber
    collapse is a common echocardiographic sign in cardiac tamponade and occurs when the
    intrapericardial pressure exceeds the intracardiac pressure. The right-sided chambers are
    more commonly affected because of their lower intracardiac pressure and increased
    compliance compared with the left-sided chambers. Diastolic collapse of the RV is a sign of
    elevated intrapericardial pressure and is highly suggestive of cardiac tamponade.

    Respiratory variation in right and left-sided volumes and filling velocities is also important
    when considering cardiac tamponade. During inspiration, systemic venous return increases,
    leading to higher right-sided heart volumes. In tamponade, the increase in right heart filling
    during inspiration can only be accommodated by bowing the interventricular septum toward
    the left ventricle (LV), leading to a lower LV end-diastolic volume, reduced stroke volume,
    and fall in systemic blood pressure (i.e., increased pulsus paradoxus). The exaggerated
    respiratory variation and ventricular interdependence result in significant variation in the
    mitral and tricuspid flow velocities in cardiac tamponade, and should generally exceed 30%
    and 60%, respectively. In normal circumstances, the inferior vena cava (IVC) will collapse
    >50% with inspiration because of increased systemic venous return. In cardiac tamponade,
    the IVC will often be dilated (>20 mm) and will not collapse >50%. An elevated mitral early
    filling velocity may be seen with significant mitral regurgitation.

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