cath conference august 6, 2008
DESCRIPTION
Cath Conference August 6, 2008. Priya Pillutla, M.D. Kimble Poon, M.D. History. 34 y/o M, no PMH 2 months prior to admission - URI URI resolved but +SOB, LE edema OVMC – Dx’d with pericarditis and R heart failure NSAIDs: no improvement Repeat TTE: thickened pericardium - PowerPoint PPT PresentationTRANSCRIPT
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Cath ConferenceCath ConferenceAugust 6, 2008August 6, 2008
Priya Pillutla, M.D.Priya Pillutla, M.D.
Kimble Poon, M.D.Kimble Poon, M.D.
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HistoryHistory
34 y/o M, no PMH 34 y/o M, no PMH 2 months prior to admission - URI2 months prior to admission - URI URI resolved but +SOB, LE edema URI resolved but +SOB, LE edema OVMC – Dx’d with pericarditis and R OVMC – Dx’d with pericarditis and R
heart failureheart failure NSAIDs: no improvementNSAIDs: no improvement
Repeat TTE: thickened pericardiumRepeat TTE: thickened pericardium Transferred here for further Transferred here for further
managementmanagementPriya Pillutla, M.D.
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Still complains of SOB and LE Still complains of SOB and LE edemaedema
No fevers or constitutional No fevers or constitutional symptomssymptoms
Meds – IbuprofenMeds – Ibuprofen NKDANKDA Social - +tobaccoSocial - +tobacco
Priya Pillutla, M.D.
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Physical ExamPhysical Exam
BP 130/84, HR 80, RR 14, sat 100% BP 130/84, HR 80, RR 14, sat 100% RARA
Morbidly obeseMorbidly obese
JVP 15 cmJVP 15 cm
Normal carotid upstrokesNormal carotid upstrokes
RRR nl s1/s2. +S3 +pericardial knockRRR nl s1/s2. +S3 +pericardial knock
Lungs clearLungs clear
Lower extremity edemaLower extremity edemaPriya Pillutla, M.D.
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ElectrocardiogramElectrocardiogram
Priya Pillutla, M.D.
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Transthoracic Transthoracic EchocardiographyEchocardiography
Priya Pillutla, M.D.
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Echocardiographic evidence for pericardial constriction
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Echocardiographic evidence for pericardial constriction
Thickened pericardium and tram-tracking
Ventricular interdependence
Septal bounce
Respiratory variation of inflow velocities
Normal or elevated mitral annulus motion
Resolution after therapy
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Thickened pericardium and tram-tracking
Pericardial thickness >3mm is abnormal but not sensitive or specific for constriction
Tram-tracking: during diastole, the parietal pericardium and visceral pericardium are straight and fixed
This is in contrast to normal pericardial movement and cardiac tamponade
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Tram-tracking in pericardial constriction
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Tram-tracking in pericardial constriction
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Absence of tram-tracking in a patient with cardiac
tamponade
During diastole, the visceral pericardium expands outward as the ventricle fills
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Absence of tram-tracking in a patient with no
pericardial disease
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Ventricular interdependence
During inspiration, the RV is preferentially filled at the expense of the LV
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During expiration, the LV fills at the expense of the RV
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Septal bounce
2D manifestation of ventricular inter-dependence
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Respiratory variation of inflow velocities
MV variation >25% TV variation >40%
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Peak 99 cm/s
Trough 57 cm/s
Difference 42 cm/s
% variation 42/57 = 74%
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Peak 80 cm/s
Trough 38 cm/s
Difference 42 cm/s
% variation 42/38= 110%
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Normal or elevated mitral
annulus motion Because the lateral motion of the
ventricle is constricted, motion along the basal to apical axis is exaggerated
E’ > 7 is consistent with constriction
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E’ = 17
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Resolution after therapy
Variation disappears after definitive therapy
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Peak 110 cm/s
Trough 105 cm/s
Difference 5 cm/s
% variation 5/105 = 5%
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Peak 60 cm/s
Trough 50 cm/s
Difference 10 cm/s
% variation 10/50 = 20%
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Presence of effusion
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Diagnosis
Effusive-pericardial constriction
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Right heart Right heart catheterizationcatheterization
Priya Pillutla, M.D.
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Priya Pillutla, M.D.
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Priya Pillutla, M.D.
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Priya Pillutla, M.D.
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Priya Pillutla, M.D.
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Priya Pillutla, M.D.
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Priya Pillutla, M.D.
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Priya Pillutla, M.D.
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Priya Pillutla, M.D.
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SummarySummary
Pericardial effusionPericardial effusion Thickened pericardium Thickened pericardium Severely restricted cardiac motionSeverely restricted cardiac motion Steep x and y descent on RA pressure Steep x and y descent on RA pressure
waveformwaveform Near equalization of diastolic pressures Near equalization of diastolic pressures
in all chambersin all chambers
Findings consistent with effusive-Findings consistent with effusive-constrictive pericaditisconstrictive pericaditis
Priya Pillutla, M.D.
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ManagementManagement
Pericardiectomy was performedPericardiectomy was performed Large effusionLarge effusion Pericardial thickening especially adjacent Pericardial thickening especially adjacent
to right ventricleto right ventricle Difficult dissectionDifficult dissection Visceral pericardium removed up to the Visceral pericardium removed up to the
phrenic nerve laterally and the phrenic nerve laterally and the diaphragm inferiorlydiaphragm inferiorly
Intraoperative TEE showed improved Intraoperative TEE showed improved diastolic fillingdiastolic filling
Priya Pillutla, M.D.
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At discharge:At discharge: Resolution of shortness of breath and Resolution of shortness of breath and
edemaedema Pericardial biopsy - nonspecific Pericardial biopsy - nonspecific
inflammation, thickening of the inflammation, thickening of the pericardiumpericardium
Effusion – micro, chemistry negativeEffusion – micro, chemistry negative
Priya Pillutla, M.D.
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Effusive-Constrictive Effusive-Constrictive PericarditisPericarditis
First characterized by Hancock in 1971First characterized by Hancock in 1971 Constriction caused by visceral Constriction caused by visceral
pericardium in presence of tense pericardium in presence of tense pericardial effusionpericardial effusion
Usually diagnosed after Usually diagnosed after pericardiocentesis for tamponadepericardiocentesis for tamponade Elevated RAP despite normal Elevated RAP despite normal
intrapericardial pressureintrapericardial pressure In this case, mixed findings during In this case, mixed findings during
RHC suggested diagnosisRHC suggested diagnosis
Priya Pillutla, M.D.
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Priya Pillutla, M.D. NEJM, 2004
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Priya Pillutla, M.D. NEJM, 2004
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From Guide to Hemodynamic Data in the Coronary Care Unit (Sharkey)
TamponadTamponadee
ConstrictiConstrictionon
Eff-ConstEff-Const
Mean Mean RAPRAP
10-25 10-25 mmHgmmHg
10-25 10-25 mmHgmmHg
10-30 10-30 mmHgmmHg
RA RA waveformwaveform
X>YX>YY may be 0Y may be 0
X = Y X = Y oror
X < Y X < Y X = Y X = Y oror
X < YX < Y
RA/PCWPRA/PCWP EqualEqual EqualEqual EqualEqual
PASPPASP Normal/sl. Normal/sl. ↑ ↑
30-45 30-45 mmHgmmHg
30-45 30-45 mmHgmmHg
KussmaulKussmaul AbsentAbsent 1/3 of 1/3 of casescases
Rare Rare
PulsusPulsus YesYes 1/3 of 1/3 of casescases
Pre-tap Pre-tap
Priya Pillutla, M.D.
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N = 15 (largest series to date) Priya Pillutla, M.D.
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Diagnostic criteria:Diagnostic criteria: Tamponade that evolved into constriction Tamponade that evolved into constriction
(failure of RAP to fall by at least 50% or less (failure of RAP to fall by at least 50% or less than 10 mmHg) after reduction of than 10 mmHg) after reduction of intrapericardial pressure to 0intrapericardial pressure to 0
MethodsMethods Complete pressure measurements obtained Complete pressure measurements obtained
prior to and following pericardiocentesis (all prior to and following pericardiocentesis (all chambers, IPP, femoral pulsus)chambers, IPP, femoral pulsus)
Pericardial fluid sent for chemistry, cyto, Pericardial fluid sent for chemistry, cyto, micro, AFBmicro, AFB
Priya Pillutla, M.D.
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Treatment variedTreatment varied NSAIDs NSAIDs Avoided steroidsAvoided steroids Pericardiectomy for constriction and Pericardiectomy for constriction and
severe/persistent heart failuresevere/persistent heart failure If milder heart failure, medical therapy If milder heart failure, medical therapy
to allow possible spontaneous to allow possible spontaneous resolutionresolution
F/U – every 3 months for a year (if F/U – every 3 months for a year (if pericardiectomy) then q3-5 yearspericardiectomy) then q3-5 years
Priya Pillutla, M.D.
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ResultsResults
15 patients met criteria (~1200 15 patients met criteria (~1200 consecutive patients with consecutive patients with pericarditis; prevalence 1.3%)pericarditis; prevalence 1.3%)
All had signs of R heart failure All had signs of R heart failure 2/3 had pulsus paradoxus2/3 had pulsus paradoxus Effusions predominantly Effusions predominantly
serosanguinousserosanguinous
Priya Pillutla, M.D.
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Management
Inflammatory symptoms – NSAIDsInflammatory symptoms – NSAIDs All patients – pericardiocentesis All patients – pericardiocentesis
(13/15 had improvement)(13/15 had improvement) 7/14 had pericardiectomy for 7/14 had pericardiectomy for
persistent R heart failurepersistent R heart failure 4 idiopathic, 1 radiation, 1 TB, 1 4 idiopathic, 1 radiation, 1 TB, 1
postsurgicalpostsurgical Nonspecific inflammation of the Nonspecific inflammation of the
pericardiumpericardium
Priya Pillutla, M.D.
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No pericardiectomy (n=8)No pericardiectomy (n=8) 3 spontaneous resolution3 spontaneous resolution 4 neoplasm; 1 radiation pericarditis with LV 4 neoplasm; 1 radiation pericarditis with LV
dysfunctiondysfunction After complete workup of all patients:After complete workup of all patients:
Idiopathic (7)Idiopathic (7) Neoplasm (4)Neoplasm (4) Radiation pericarditis (2)Radiation pericarditis (2) Postsurgical (1)Postsurgical (1) TB (1) TB (1)
Other case series – bacterial infections, Other case series – bacterial infections, fungal fungal
Priya Pillutla, M.D.
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Importance of correct diagnosis:Importance of correct diagnosis: Visceral pericardium needs to be Visceral pericardium needs to be
removedremoved Dissection can be difficult/hazardousDissection can be difficult/hazardous
Can resolve spontaneously ~ can Can resolve spontaneously ~ can watch and wait if heart failure watch and wait if heart failure symptoms not severesymptoms not severe
Priya Pillutla, M.D.
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Priya Pillutla, M.D.
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