pericardial diseases · 2020. 7. 20. · 1. acute pericarditis • chronic pericarditis 2....

7/19/2020

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Pericardial Diseases

Mahi L. Ashwath MD, MBA, FACC, FASE, FSCMR President, Iowa ACC

Director, Cardiac MRI Associate Professor of Medicine and Radiology

University of Iowa Hospitals and Clinics

Outline

1. Anatomy of pericardium

2. Pericardial disease

• Pericarditis – Acute or recurrent

• Pericardial effusion

• Pericardial tamponade

• Constrictive pericarditis

• Pericardial Cysts, Malignancy, Congenital absence of pericardium

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Normal Pericardium

• Two layers: – Outer layer is parietal pericardium and consists of layers

of fibrous and serous tissue

– Inner layer is visceral pericardium and consists of serous tissue only

• Normal amount of pericardial fluid: 15-50 cc

Diseases of the Pericardium

1. Acute pericarditis

• Recurrent pericarditis

2. Pericardial effusion

• Pericardial Tamponade

3. Constrictive pericarditis

• Restrictive Cardiomyopathy

4. Pericardial Cysts

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Acute Pericarditis

• Defined as – Inflammation of the pericardial sac

• Myopericarditis, or perimyocarditis – acute pericarditis that also demonstrate myocardial

inflammation

• Myopericarditis – prevalent pericarditis and normal ventricular function

• Perimyocarditis – prevalent myocarditis and ventricular function is

reduced (new wall motion abnormalities or reduced ventricular function)

Etiology of Acute Pericarditis: Infection

• Viral: • Adeno • Entero • CMV • Influenza • Hepatitis B • Herpes Simplex • Echo virus • Mumps • COVID - 19

• Fungal • Parasitic

• Bacterial • Staphylococcus

• Streptococcus

• Pneumococcus

• Hemophilus

• Neisseria

• Chlamydia

• Legionella

• Tuberculosis

• Lyme Disease

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Etiology Continued

• Radiation

• Neoplasm – Metastatic

– Primary Cardiac

– Paraneoplastic

• Cardiac – Early infarction

– Dressler’s

• Myocarditis

• Aortic dissection

• Trauma – Blunt

– Iatrogenic (perforations, post surgical)

• Autoimmune – Rheumatic disease

– Non- rheumatic • Wegner's, sarcoid, IBD

Etiology Continued

• Drugs:

– Drug induced lupus • Hydralazine

• Isoniazid

• Procainamide

• Doxorubicin

• Phenytoin

• Metabolic

– Hypothyroid

– Uremia

– Ovarian Hyperstimulation

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Typical features of Acute Pericarditis

• Chest pain >85-90%

– sudden in onset

– anterior chest

– sharp and pleuritic in nature

– exacerbation by inspiration or coughing

– Decrease in intensity with sitting up and leaning forward

• Friction Rub <40%

– triphasic, with a superficial scratchy or squeaking quality

– intermittent

– three phases, - atrial systole, ventricular systole, and the rapid filling phase of early ventricular diastole

• Classic ECG 60%

• Effusion 60%

Acute Pericarditis

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Testing for Acute Pericarditis • ECG • Chest X Ray • Labs

– CBC – Troponin – ESR and CRP

• Optional – Blood culture/ Viral studies – Rheumatologic workup – Multimodality imaging – Pericardiocentesis – Pericardial Biopsy

Effusion: Echo Findings:

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Acute Pericarditis

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Normal Pericardium

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Predictors of poor prognosis:

• Fever >380 C

• Subacute onset

• Large pericardial effusion

• Cardiac tamponade

• No response to NSAIDs in first week

• Myopericarditis

• Immunosuppression

• Trauma

• Oral anticoagulant therapy

Need admission

Acute Pericarditis: Management

• Goal:

– Relief of pain

– Reduction of inflammation

– Prevention of recurrence/ complications

• Treatment:

– Activity restriction until resolution of symptoms

– NSAID agent for 1-2 weeks

• Aspirin 750 - 1000 mg q8

• Ibuprofen 800 mg q8

– Colchicine 0.6 mg bid X 3 months

• COPE and ICAP studies

– Avoid steroids – unless above agents are contraindicated

• (Eg: Pregnancy, Renal insufficiency)

– Duration determined by symptoms and CRP

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• Prolonged NSAIDs and Colchicine – guided by symptoms and inflammatory markers

• Triple therapy

– Add steroid to above agents

• Moderate doses with very slow taper

• Gradual taper with improvement in symptoms and inflammatory markers

– Taper Steroids

– Followed by NSAIDs

– Followed by Colchicine

Recurrent Pericarditis

Colchicine – Adverse effects

• Blood dyscrasias:

– Myelosuppression

– Thrombocytopenia, leukopenia, granulocytopenia, pancytopenia and aplastic anemia

• Gastrointestinal symptoms:

– anorexia, diarrhea, nausea, vomiting

• Neuromuscular toxicity:

– Myotoxicity (including rhabdomyolysis)

– Renal dysfunction and elderly patients - increased risk

– Concomitant use of cyclosporine, diltiazem, verapamil, fibrates, and statins

– Symptoms typically resolve within 1 week to several months of colchicine discontinuation

• Hepatic impairment: Clearance is decreased in hepatic impairment

• Renal impairment: Clearance is decreased in renal impairment

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Myopericarditis

• If troponin is elevated

• MRI to confirm no extensive myocarditis

• Consider coronary angiogram to exclude Coronary

artery disease

• Hospitalization

• Return to competition (6 months after onset)

Summarize Acute Pericarditis:

• Inflammation of the pericardium usually due to a viral infection

• Diagnosed by history, pericardial rub, elevated CRP, Abnormal ECG

• Troponin helpful in knowing if any component of myocarditis is also present

• Management: NSAIDs and Colchicine

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• Chronic pericarditis






Pericardial effusion and tamponade

• Recognize presentation

• Appropriate testing

• Management strategies

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• Usually discovered incidentally

• Pericarditis

• Hemodynamically significant effusion

– signs and symptoms of impaired cardiac function

– dyspnea, elevated JVP, hypotension and impaired perfusion

Presentation

Etiology • Infection

– Viral, Bacterial

• Malignancy

• Post Cardiac Injury

– Post MI syndrome

– Post Pericardiotomy syndrome

– Post traumatic

• Radiation

• Drugs

• Systemic Disorders

– Collagen Vascular Disease

– Uremia and dialysis

– Hypothyroidism

• Idiopathic

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Etiology of symptomatic effusions (173 patients)

• Malignancy – 33%

• Chronic-idiopathic – 14 %

• Acute pericarditis – 12%

• Trauma – 12 %

• Uremia – 6 %

• Post-pericardiotomy – 5 %

• Indeterminate – 8 %

• Other causes (including infection, collagen vascular disease, radiation, heart failure, etc) – 10 %

Medicine (Baltimore) . 2006; 85:49

Chest X Ray

• Requires about 200 cc of fluid

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Pericardial effusion

• Low voltage and electrical alternans

Effusion: Echo Findings:

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After effusion is diagnosed, assess for presence of tamponade

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Cardiac Tamponde

• Sinus tachycardia

• Elevated Jugular Venous Pressure

• Pulsus Paradoxus

Effusion with tamponade

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M mode

Respiratory inflow variation

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• Drop in • Mitral flow by 30 percent - first

beat of inspiration , • Tricuspid valve flow by 60

percent – first beat of expiration

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IVC Plethora

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Pericardiocentesis

• Done for

– Tamponade

– Diagnosis – especially for malignancy history

• Don’t do

– Concern for aortic dissection

Summarize Pericardial Effusion:

• Wide spectrum in presentation and severity

• Recognize presentation and imaging features of tamponade

• Pericardiocentesis if needed

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Pericardial Constriction

• Recognize presentation

• Select appropriate testing

• Select appropriate management

• Differentiate between Constrictive Pericarditis and Restrictive Cardiomyopathy

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Pathophysiology

• Result of scarring and consequent loss of the normal elasticity of the pericardial sac

• Cardiac filling is impeded by an external force

– Virtually inelastic parietal and/or visceral pericardial tissue, which is thickened, fibrotic, and sometimes calcified

– Results in a markedly impaired ability to adapt to volume changes

– greatly enhanced ventricular interdependence, in which the hemodynamics of the left and right heart chambers are directly influenced by each other to a much greater degree than normal

Constrictive Pericarditis Presenting symptoms:

• CHF 67%

• Chest pain 8%

• GI Symptoms 6%

• Tamponade 5%

• Arrhythmia 4%

• Liver Disease 4%

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Constrictive Pericarditis Presenting signs:

• Elevated JVP 88%

• Peripheral edema 64%

• Hepatomegaly 53%

• Pericardial knock 47%

• Ascites 37%

• Kussmaul’s 21%

• Pulsus paradoxus 19%

JVP

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Constrictive Pericarditis: CXR and CT

Geske et al. JACC 68, 2016:2329-47

Constrictive Pericarditis

• Hallmark – Ventricular interdependance

• Dynamic hemodynamics during respiratory cycle

• Reflect increased ventricular interaction

• Dissociation between intrathoracic and intracardiac pressures

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48

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50

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Constrictive Pericarditis - Treatment

• Exclude acute pericarditis

• Medical management

• Surgery – pericardial stripping

• Acute/ transient effusive constrictive pericarditis can be treated with aggressive anti-inflammatory therapy

Effusive-constrictive pericarditis

• Constrictive physiology with a coexisting pericardial effusion, often with cardiac tamponade

• Results in a mixed hemodynamic picture with features of both constrictive pericarditis and cardiac tamponade

• Mistakenly thought to have only cardiac tamponade

• Elevation of the right atrial and pulmonary wedge pressures after drainage of the pericardial fluid points to the underlying constrictive process

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Think Constriction

• Heart failure - Right heart failure – out of proportion to myocardial or valve findings

• History of radiation – Breast cancer

– Lymphoma

• History of prior cardiac surgery

• Constriction

– Disease of the pericardium

• Restriction

– Disease of the myocardium

Constriction versus Restriction

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Constriction versus Restriction: Hemodynamics

• Restriction – Ventricular concordance

– LV smaller, RV smaller, normal pericardium

– BNP usually elevated

– Left atrial enlargement

– Abnormal tissue doppler

– Elevated filling pressures

– RVSP, very high (>55 – 60 mm Hg)

• Constriction – Ventricular discordance

– LV smaller, RV larger

– BNP usually not much elevated

– Left atrium is normal in size

–Normal tissue doppler

– RVSP <35-45 mm Hg

Right atrial pressure tracings

Geske et al. JACC 68, 2016:2329-47

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Geske et al. JACC 68, 2016:2329-47

58 Geske et al. JACC 68, 2016:2329-47

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59


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• Constriction

– Disease of the pericardium

• Restriction

– Disease of the myocardium

Constriction versus Restriction

Summarize Pericardial Constriction:

• High index of suspicion

• Role of symptoms, EKGs, inflammatory markers

• Ventricular interdependence

• Exclude Pericardial inflammation

• Management – symptomatic - surgery

• Effusive Constrictive Pericarditis

• Disease of the pericardium – difference from restriction

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4. Pericardial Cysts etc

Pericardial Cysts

• Pericardial cysts

• Pericardial tumors

• Metastatic disease

• Congenital absence of pericardium

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Pericardial Cyst

• Usually diagnosed incidentally

• 1:100,000

• CT, MR are preferred

• Mostly asymptomatic

• Resect if symptomatic

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Pericardial Malignancy

• Usually secondary

• Common primary – Lung

– Breast

– Esophagus

– Hematologic

– Melanoma

• If a patient with prior cancer history presents with large effusion, think recurrent/ metastatic

Pericardial Malignancy

• Treat symptomatically

– Tap for tamponade and for diagnosis

– Non-steroidal tx for pericardial pain

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Congenital Absence of Pericardium

Image from ScienceDirect.com

• Partial or complete

• Mostly asymptomatic

• Partial – herniation

• Complete – asymptomatic

• 50% associated with other Congenital cardiac defects

• Management – surgery if needed

Congenital Absence of Pericardium

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Outline

1. Anatomy of pericardium

2. Pericardial disease

• Pericarditis – Acute or recurrent

• Pericardial effusion

• Pericardial tamponade

• Constrictive pericarditis

• Pericardial Cysts, Malignancy, Congenital absence of pericardium

Thank you!!

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pericardial diseases · 2020. 7. 20. · 1. acute pericarditis • chronic pericarditis 2....

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