halevy mr 21814
TRANSCRIPT
MR Cardiology 2/18/14 Jon Halevy
Causes of Pericardial disease • Idiopathic • Infec.ous (viral, bacterial, fungal, parasiAc, IE with abscess) • Radia.on • Neoplas.c / paraneoplasAc • Cardiac – early/late post-‐MI. MyocardiAs, dissecAon, post-‐
cardiac surgery • Trauma • Autoimmune – rheumaAc, IBD, sarcoid, vasculiAs,
whipples, behcet’s • Drugs – drug-‐induced lupus, others (incl penicillins • Metabolic – hypothyroid, uremia, ovarian oversAm)
Sagrista, 2000 (N=322)
• Mod-‐large pericardial effusion (>10 mm) • 37% with tamponade • Idiopathic – 29%; Iatrogenic – 16%; Malignancy 13%; uremia – 6%; post acute MI 8%; infecAon 6%; Collagen Vascular 5%; Hypothyroid 2%, other 15%
h\p://www.cardiothoracicsurgery.org/content/2/1/30/figure/F2?highres=y
• Large/acute Pericardial effusion • CompeAAon with heart and pericardial volume for space à constrained cardiac filling
• Normally venous return bimodal peaking in ventricular systole and early diastole, heart volume minimal during systole/ejecAon. Lose early diastole filling peak. Relying on systole to fill.
• Tamponade when this impairs filling of ventricles à can cause shock
• Volume DepleAon = BAD (avoid diuresis!)
Pericardial FricAon Rub h\p://www.youtube.com/watch?v=fI4XXFRotNE -‐ Actual sounds are only last 20 seconds
Pulsus alternans (q2 beats, LV systolic
faiure) versus Pulsus
paradoxus (lower during inspiraAon)
Electrical alternans
Respiratory VariaAon • Normally about 10 pt drop in SBP during inspira.on • Inspiratory decline in thoracic pressure is transmi\ed through the
pericardium to the right side of the heart and the pulmonary vasculature. As a result, systemic venous return to the right heart increases with inspiraAon, and pulmonary venous return to the lej heart decreases with inspiraAon.
• In cardiac tamponade, the rigid pericardium prevents the free wall from expanding. The ensuing distension of the right ventricle is limited to the interventricular septum, which along with relaAve underfilling of the lej ventricle causes the septum to bulge to the lej, reducing lej ventricular compliance and contribuAng to further decreased filling of the lej ventricle during inspiraAon. This concept is referred to as "ventricular interacAon" or "ventricular interdependence".
• RA Pressure = RVEDP and LVEDP = PA Diastolic Pressure
Acuity Ma\ers • Hyperacute Coronary laceraAon (acute -‐ red) versus presumed viral pericardiAs (chronic – blue) Data from pericardiocentesis