DC Fellows ForumDC Fellows Forum

Raj Khandwalla M.D.Raj Khandwalla M.D.

Georgetown/Washington Hospital CenterGeorgetown/Washington Hospital Center

History of Present IllnessHistory of Present Illness

• 65 yo M with PMH of MV replacement in 1975 s/p 65 yo M with PMH of MV replacement in 1975 s/p Bjork Shiley mitral valve who presents to the cath Bjork Shiley mitral valve who presents to the cath lab with a two month history of decreased exercise lab with a two month history of decreased exercise tolerance. tolerance.

• Patient has a history of paroxysmal AF for the past Patient has a history of paroxysmal AF for the past ten years with multiple cardioversions. ten years with multiple cardioversions.

• Last cardioversion was in May, but his AF recurred Last cardioversion was in May, but his AF recurred and has persisted for the past two months. and has persisted for the past two months. Previously, the patient was able to run 2.5 miles, but Previously, the patient was able to run 2.5 miles, but now he cannot run. now he cannot run.

• Patient underwent an exercise stress test in which he Patient underwent an exercise stress test in which he was only able complete stage II Bruce Protocol and was only able complete stage II Bruce Protocol and had an echo which showed a normal EF, but the had an echo which showed a normal EF, but the mitral valve was not able to be evaluated.mitral valve was not able to be evaluated.

History of Present IllnessHistory of Present Illness

As such, the patient was referred for cardiac As such, the patient was referred for cardiac cath in order to assess his coronary arteries cath in order to assess his coronary arteries and measure the gradient across the mitral and measure the gradient across the mitral valve. valve.

History of Present IllnessHistory of Present Illness

• PMHX:PMHX: as above, GERD as above, GERD

• MEDS:MEDS: Propafenone, Warfarin Propafenone, Warfarin

• ALL:ALL: NKDA NKDA

• SOCHX:SOCHX: social drinker, quit smoking 40 social drinker, quit smoking 40 years agoyears ago

• FH:FH: denies denies

Physical ExamPhysical Exam

• Gen: no apparent distress, appears younger than Gen: no apparent distress, appears younger than stated agestated age

• VS: T 98.0 BP129/77 HR 60 RR 16 98% VS: T 98.0 BP129/77 HR 60 RR 16 98% RARA

• Neck: JVD elevated to angle of jawNeck: JVD elevated to angle of jaw• Chest: Well healed sternotomy scarChest: Well healed sternotomy scar• Heart: irreg, irreg, +valve clicks appreciatedHeart: irreg, irreg, +valve clicks appreciated• Lungs: clear to auscultationLungs: clear to auscultation• Abdomen: soft, NT, ND, + hepatojugular reflexAbdomen: soft, NT, ND, + hepatojugular reflex• Ext: 2+ pitting edema to the shinsExt: 2+ pitting edema to the shins

Laboratory Assessment:Laboratory Assessment:

1.611.3 – 13.3INR

33.622.1 – 35.1Partial-thromboplastin time (sec)

118150,000 – 300,000Platelet Count (per mm3)

4.50 – 8 Eosinophils

17.64 – 11 Monocytes

37.522 – 44 Lymphocytes

4040 – 70 Neutrophils

Differential Count (%)

4.04,500 – 11,000White-cell count (per mm3)

36.241.0 – 53.0

Hematocrit (%)

12.313.5 – 17.5Hemoglobin (g/dl)

HEMATOLOGY

ON ADMISSIONREFERENCE RANGETEST

Laboratory Assessment:Laboratory Assessment:

2180.0-99Brain Naturitic Peptide (pg/ml)

1.30.6 – 1.5Creatinine (mg/dl)

228 – 25Urea nitrogen (mg/dl)

2423.0 – 31.9Carbon dioxide (mmol/liter)

107100 – 108Chloride (mmol/liter)

4.33.4 – 4.8Potassium (mmol/liter)

140135 – 145Sodium (mmol/liter)

CHEMISTRY

ON ADMISSIONREFERENCE RANGETEST

Tracings

Tracings

Tracings

Tracings

Tracings

Tracings

What is the differential diagnosis for these tracings?

How do we make the diagnosis?

TracingsTracings

TracingsTracings

Ventricular InterdependenceVentricular Interdependence

Restrictive Constrictive

• Normal pericardial thickness

• Multiple adhesions between the pericardium and the heart

• RV directly below the sternum

Constrictive PericarditisConstrictive Pericarditis• Represents the end stage of an inflammatory process Represents the end stage of an inflammatory process

• Can occur in months, but usually takes years to developCan occur in months, but usually takes years to develop• EtiologiesEtiologies

• IdiopathicIdiopathic• IrradiationIrradiation• PostsurgicalPostsurgical• InfectiousInfectious• NeoplasticNeoplastic• Autoimmune disorderAutoimmune disorder• UremiaUremia• PosttraumaticPosttraumatic• SarcoidSarcoid• Methysergide therapyMethysergide therapy• Implantable defibrillator patchesImplantable defibrillator patches

PathophysiologyPathophysiology• Pericardial scarring restricts filling of all Pericardial scarring restricts filling of all

chambers which symmetrically results in the chambers which symmetrically results in the elevation of filling chamberselevation of filling chambers

• Early diastoleEarly diastole• Rapid filling of the ventricles due to high atrial Rapid filling of the ventricles due to high atrial

pressures and increased diastolic suction (due to pressures and increased diastolic suction (due to small end-systolic volumes)small end-systolic volumes)

• Mid diastoleMid diastole• Ventricular filling is abruptly stopped when the Ventricular filling is abruptly stopped when the

intracardiac volume can no longer expand due to intracardiac volume can no longer expand due to the noncompliant pericardiumthe noncompliant pericardium

HemodynamicsHemodynamics

Constrictive pericarditis

RV infarct Tamponade

Restrictive cardiac disease

Pulses

paradoxus

< 1/3 Occasional Frequent Rare

RA waveforms

Prominent

y descent

Prominent y descent

Prominent

x descent

Insp. ↓

Variable

y descent

Equalization of diastolic pressures

Frequent Frequent Frequent Rare

“Square root” sign

Frequent Frequent Absent Variable