Home About us Current issue Back issues Submission Instructions Advertise Contact Login   

Search Article 
  
Advanced search 
 
Saudi Journal of Kidney Diseases and Transplantation
Users online: 1012 Home Bookmark this page Print this page Email this page Small font sizeDefault font size Increase font size 
 

Table of Contents   
BRIEF COMMUNICATION  
Year : 2011  |  Volume : 22  |  Issue : 5  |  Page : 994-997
The importance of echocardiographic evaluation of pericardial effusion associated with mitral valve pseudoprolapse in patients with chronic renal failure


1 Clinic of Internal Medicine, Service of Cardiology, University Clinical Center of Kosova, Prishtine, Kosova
2 Clinic of Internal Medicine, Service of Nephrology, University Clinical Center of Kosova, Prishtine, Kosova

Click here for correspondence address and email

Date of Web Publication6-Sep-2011
 

   Abstract 

To evaluate the clinical course of pericarditis in patients with chronic kidney disease (CKD), we studied echocardiography in 64 CKD patients and subdivided them into four groups according to their CKD condition and presence of effusion: 14 (22%) patients with pericardial effusion that formed during conservative treatment of CKD patients, 12 (19%) patients who developed the effusion while on regular hemodialysis, 31 (48%) CKD patients without pericardial effusion, and seven (11%) CKD patients with minimal effusion. In addition, the patients were then re- subdivided according to the amount of pericardial effusion into those with small amount, up to 1 cm echo- free space (EFS) (17 (27%) patients); with medium size pericardial effusion (9 (14%) patients); with large amount of pericardial effusion, above 2 cm (four (6%) patients); and with thickened pericardium (4 (6%) patients), three (5%) of whom were without pericardial effusion and one (2%) was with minimal effusion. Nine (15%) patients revealed signs of mitral valve prolapse. The presence of EFS between the posterior epicardium and pericardium during the entire cardiac cycle was found in 31 (48%) patients. We conclude that the presence of a positive EFS without other clinical symptoms does not confirm with certainty the presence of pericarditis in CKD patients.

How to cite this article:
Zahiti B, Bakalli A, Gorani D, Hasanxhekaj V. The importance of echocardiographic evaluation of pericardial effusion associated with mitral valve pseudoprolapse in patients with chronic renal failure. Saudi J Kidney Dis Transpl 2011;22:994-7

How to cite this URL:
Zahiti B, Bakalli A, Gorani D, Hasanxhekaj V. The importance of echocardiographic evaluation of pericardial effusion associated with mitral valve pseudoprolapse in patients with chronic renal failure. Saudi J Kidney Dis Transpl [serial online] 2011 [cited 2020 Dec 1];22:994-7. Available from: https://www.sjkdt.org/text.asp?2011/22/5/994/84519

   Introduction Top


Pericarditis is considered a high- risk complication in patients with chronic kidney disease (CKD), particularly in cases with uremic disorders. Pericardial tamponade, on the other hand, is a rare cause of death in CKD patients. [1]

Current guidelines suggest that CKD patients with pericardial effusion should undergo dialysis, although during hemodialysis these patients often experience accumulation of additional pericardial effusion or worsening of their overall condition. [1]

Symptoms and signs of pericarditis are dependent on the rate by which pericardial effusion forms as well as its amount. Pericarditis may present with chest pain or without it. There are plenty of studies regarding pericarditis in uremic patients associated with pericardial effusion that do not experience any symptoms for months. [2],[3],[4]

Echocardiography is the method of choice for diagnosing pericardial effusion and its use in detecting this condition represents the most important non- invasive method, which provides reliable information on the presence of pericardial effusion in small or large amounts. [5],[8]

The aim of the study was to evaluate the clinical course of pericardial effusion in CKD patients to assess the amount of pericardial effusion and to determine the prevalence of mitral valve prolapse in this patient group.


   Patients and Methods Top


We performed echocardiography in 64 CKD patients. Pericardial effusion was defined as echo- free space (EFS) between visceral and parietal pericardial layer. In cases where pericardial effusion was detected, its amount was determined by measuring the EFS distance. Particular attention was directed to the assessment of systolic motion of anterior and posterior mitral valve leaflets.


   Results Top


[Figure 1], [Figure 2]shows the pericardial effusion determined by measuring the EFS between posterior portion of epicardium and pericardium, which persisted throughout the cardiac cycle.
Figure 1: Eco-free space (EFS) up to 1 cm between epicardium and pericardium in the M mode echo.

Click here to view
Figure 2: Echo-free space (EFS) >2 cm in the 2D echocardiogram.

Click here to view


The study patients were subdivided into four groups according to their CKD condition and presence of effusion: 14 (22%) patients with pericardial effusion that formed during conservative treatment of CKD patients; 12 (19%) patients who developed the effusion while on regular hemodialysis; 31 (48%) CKD patients without pericardial effusion; and seven (11%) CKD patients with minimal effusion, five (8%) had minimal pericardial effusion while the other two (3%) did not have signs of pericardial liquid accumulation.

The patients with pericardial effusion in relation to the size of EFS were re- subdivided into four groups: 17 (27%) patients with small amount of pericardial effusion, up to 1 cm, in the posterior wall of the left ventricle; Nine (14%) patients with medium size effusion in the free space of the posterior wall of the left ventricle, above 1 cm of EFS distance in the posterior portion, but without EFS on the anterior wall; Four (6%) patients with pericardial effusion above 2 cm, which was present throughout the cardiac cycle in both walls (anterior and posterior); and four (6%) patients with thickened pericardium and ≥0.5 cm width, three (5%) patients did not have pericardial effusion, while one (2%) patient revealed minimal pericardial effusion.

We detected mitral valve prolapse in only nine (15%) of the study patients.


   Discussion Top


In our study of the CKD patients, 48% had pericardial effusion. Prevalence of pericarditis and pericardial effusion in CKD patients varies from 18 to 50%. [6],[7]

Pericarditis in CKD patients has remained "as general tendency of involvement", which mainly presents "as inflammatory aseptic process" with small or large amount of pericardial effusion. [3],[9],[10] Many other infectious conditions as well as other disorders contribute in inadequate hypercatabolic processes during dialysis, which can often be a response to activation of different inflammatory mediators in pericardium. Some authors accused heparin as a cause for occurrence of hemorrhagic pericardial effusion, although there are data that suggest improvement of pericardial effusion during dialysis. [11],[12]

Diagnosis of pericarditis and pericardial effusion is mainly based on clinical picture, however, clinical symptoms are not reliable indicators of this condition. [13]

Echocardiography is more sensitive and specific in the evaluation of pericardial effusions. EFS was present between epicardium and pericardium in the posterior wall in 31 (48%) patients during the entire cardiac cycle. The percentages of detected pericardial effusion in our CKD patients coincide with the results of other authors. [7],[8],[9] However, Wray et al in a prospective routine echocardiography on CKD patients found signs of pericardial effusion in only14% of the cases. [10]

In our study population, the patients with small amount of pericardial effusion (<1 cm) were asymptomatic, while those with moderate amount (<2 cm) to large size pericardial effusion (>2 cm) presented with clinical symptoms of pericarditis.

On the other hand, there are some precautions that should be taken during the echocardiographic examination. The mere presence of anterior EFS in the absence of posterior EFS does not pose clinical meaning. [7] In addition, the heart is smaller during end- systole, and the mobile and free pericardial effusion gravitates mostly toward the posterior part of the pericardium, while the heart is maximally dilated during the end- diastole and the pericardial effusion distributes evenly around the heart; therefore, measurement of EFS during this phase best determines the amount of pericardial effusion. The presence of EFS only during systole, which disappears during diastole, may be a negative sign for the existence of pericardial effusion, while a small EFS that persists during diastole is considered positive for the presence of pericardial effusion. Accordingly, wide and large EFS, which persists during the complete cardiac cycle, is clear that it presents pericardial effusion. [10] When a large pericardial effusion occurs, excursions of the anterior wall of the heart appear in most cases.

In our study, we found mitral valve prolapse (pseudoprolapse) in a small percentage of CKD patients. This condition was found in patients with large amount of pericardial effusion, in whom heart excursions had increased and mitral valve echocardiography revealed posterior mitral leaflet movement in a non uniform fashion, thus giving the impression of presence of mitral valve prolapse. Therefore, this "pseudoprolapse" was created as a consequence of heart excursion enhancement. [2]

We conclude that echocardiography evaluation is one of the most valuable tests for assessment and follow- up of pericardial effusion in CKD patients.

 
   References Top

1.Christensen EE, Bonte FJ. The relative accuracy of echocardiography in detecting pericardial effusion in dogs. Radiology 1968:91;256- 70.  Back to cited text no. 1
    
2.DeMaria AN, Kind JF, Bogren HG, Lies JE, Mason DT. The variable spectrum of echocardiographic manifestations of the mitral valve prolapse syndrome. Circulation 1974;50:33- 41.  Back to cited text no. 2
    
3.Buselmeier TJ, Simmons RL Najarian JS, Mauer SM, Matas AJ, Kjellstrand CM. Uremic pericardial effusion. Nephron 1976;16:371- 80.  Back to cited text no. 3
    
4.Naggar CZ, Dillon WD, Bitterly JR, Malacoff RF. Echocardiographic manifestations of tense pericardial effusion. J Am Coll Cardiol 1985;6 (2):467- 70.  Back to cited text no. 4
    
5.Feingenbaum H. Echocardiographic diagnosis of pericardial effusion. Am J Cardiol 1970;26:475- 9.  Back to cited text no. 5
    
6.Hindermann- Fischer E, Amann FW, Jenzer HR, Blumberg A. Uremic pericarditis: clinical aspects, echocardiography, therapy Schweiz Med Wochenschr 1978:108:1625- 32.  Back to cited text no. 6
    
7.Horowiz MS, Schultz CS, Stinson EB, Harrison DC, Popp RL. Sensitivity and specificity of echocardiographic diagnosis of pericardial effusion. Circulation 1974;50:239- 47.  Back to cited text no. 7
    
8.London E, et al. Echocardiographic essement of pericardial effusion in patients with chronic renal failure. Circulation 1976;54:21.  Back to cited text no. 8
    
9.Reyman TA. Subacute constrictive uremic pericarditis. Am J Med 1969;46(6):972- 5.  Back to cited text no. 9
    
10.Wray TM, Stone WJ. Uemic pericarditis: A prospective echocardiographic and clinical study. Clin Nephrol 1976;6:295- 302.  Back to cited text no. 10
[PUBMED]    
11.Adiari V, Thahur A. Echocardiographic detection of cardiac involvement in chronic renal failure. J Assoc Physicians India 1989;37(7):434- 6.  Back to cited text no. 11
    
12.Masbernard A, Guibaud J, Guidicelli C, Utzinger B, Vallet M. Uremic chronic constrictive pericarditis established during periodic hemodialysis. Ann Med Intern (Paris)1972;123:525- 31.  Back to cited text no. 12
    
13.Klein JJ, Segal BL. Pericardial effusion diagnosed by reflected ultrasound. Am J Cardiol 1968;22:57- 64.  Back to cited text no. 13
[PUBMED]    

Top
Correspondence Address:
Bedri Zahiti
Clinic of Internal Medicine, Service of Cardiology, University Clinical Center of Kosova, Prishtine
Kosova
Login to access the Email id


PMID: 21912031

Rights and Permissions


    Figures

  [Figure 1], [Figure 2]



 

Top
   
 
 
    Similar in PUBMED
    Search Pubmed for
    Search in Google Scholar for
    Email Alert *
    Add to My List *
* Registration required (free)  
 


 
    Abstract
   Introduction
   Patients and Methods
   Results
   Discussion
    References
    Article Figures
 

 Article Access Statistics
    Viewed3124    
    Printed76    
    Emailed0    
    PDF Downloaded380    
    Comments [Add]    

Recommend this journal