* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Constrictive Pericarditis - STA HealthCare Communications
Survey
Document related concepts
Management of acute coronary syndrome wikipedia , lookup
Coronary artery disease wikipedia , lookup
Heart failure wikipedia , lookup
Cardiac contractility modulation wikipedia , lookup
Hypertrophic cardiomyopathy wikipedia , lookup
Cardiothoracic surgery wikipedia , lookup
Myocardial infarction wikipedia , lookup
Jatene procedure wikipedia , lookup
Electrocardiography wikipedia , lookup
Echocardiography wikipedia , lookup
Ventricular fibrillation wikipedia , lookup
Arrhythmogenic right ventricular dysplasia wikipedia , lookup
Transcript
Constrictive Pericarditis: Risk for Cardiac Morbidity N. Ghorpade, MBBS, MS, MCh; and A. Koshal, MBBS, MS, FRCSC CardioCase presentation Charles’ constrictive pericarditis For one year, Charles remained active, but Charles, 42, presents to the ED with returned to the hospital as he slowly progressive shortness of breath and leg developed: swelling. He had suffered a viral infection while he was on vacation, one month prior • shortness of breath, to this presentation. At that time, he • severe lower © swelling of his legs and experienced: • an increase in the size of his belly. d, • fever, nloa w o d • decreased urine output and On examination, he had jugular can raised use and ersmarked l • swollen feet. venous pressure, ascites s a u n ed erso A clinical diagnosis An echocardiography was done and severe r pedema. horisperipheral o t f u y A op pericarditis was made. d. of constrictive revealed a pericardial effusion. Thereiwas biteno gle c h n i o s r evidence of tamponade. Heswas e p treated nast a ed u and asteroids. d pri s n i an outpatient with diuretics Charles’ investigations included: r o th iew • ECG, Unau isplay, v d was admitted to hospital A week later, he • Echocardiography with low BP. Another echocardiography • Chest X-ray demonstrated pericardial tamponade. The • CT/MRI scan pericardial effusion was drained and an • Cardiac catherterization analysis of this pericardial fluid was consistent with viral pericarditis. Bacterial culture and culture for TB were negative. Charles recovered and was discharged. See page 20 to find out Charles’ results. n o i t u t h trib g i s i r y D rcial Cop r eo l a S or Not f e m m Co CardioCase discussion Pathophysiology of constrictive pericarditis The pericardium is composed of two layers, the visceral layer and the parietal layer. The visceral pericardium is a serous membrane and has a single layer of mesothelial cells.The parietal pericardium is fibrous and thick and surrounds the heart, forming a sac. The pericardial space normally contains 50 ml of serous fluid. Acute pericarditis results from acute inflammation due to wide a variety of diseases. Constrictive pericarditis represents the endstage of an inflammation involving the pericardium (Table 1). It can take months to years to develop constrictive pericarditis, which then results in Perspectives in Cardiology / October 2006 19 dense fibrosis, calcification and adhesions between the parietal and visceral pericardium. This scarring process is mostly symmetrical and obstructs the normal filling of all the heart chambers. As a result, the atrial filling pressures are raised and equalised; hence there is rapid abnormal filling of ventricles in early diastole which abruptly halts in mid-diastole. Complete filling of the ventricles is limited by non-compliance of the ventricles, which are restricted due to constricting pericardium. This chronic high pressure leads to systemic venous congestion, resulting in hepatomegaly, ascites, peripheral edema and right ventricular failure. Table 1 Etiology of constrictive pericarditis • • • • • • • • • Idiopathic, almost 50% Post-TB, 15% Post-surgical Chest radiation therapy Chronic renal failure patient on dialysis Connective tissue disorders Post-bacterial/viral/fungal infection pericarditis Spread of malignancy from pleura Post-MI pericarditis Patients may present with these clinical signs and symptoms at various stages. Investigating Charles ECG Cardiac catheterization Charles’ ECG was unremarkable. In some patients an ECG may show low QRS voltage or atrial fibrillation. Charles’ cardiac pressure studies were diagnostic of constrictive pericarditis. The diagnostic criteria for this include: • elevation and equalization of diastolic pressures in each of the cardiac chambers, • ventricular tracing showing square root sign, an early diastolic dip and plateau of the ventricular pressure and • prominent ‘y’ descent in the right atrial pressure tracing. An endomyocardial biopsy is sometimes necessary to differentiate between restrictive cardiomyopathy and constrictive pericarditis. Left ventricular angiogram shows calcified pericardium outline and constricted left ventricule (Figure 2). Once a diagnosis of constrictive pericarditis is confirmed, the best treatment option is surgical removal of the pericardium, known as pericardiectomy. This option may not be suitable for some patients who present in very advanced stages of the disease. Echocardiography Charles’ echocardiography confirmed the clinical diagnosis of constrictive pericarditis by demonstrating a thickened pericardium and the abrupt termination of ventricular diastolic filling. Abnormal septal movement (also known as septal bounce) was noted. Chest X-ray Charles’ chest X-ray showed a calcified pericardium. Almost 50% of patients with constrictive pericarditis have calcified pericardium (Figure 1). CT chest scan His CT scan and MRI confirmed constrictive pericarditis. 20 Perspectives in Cardiology / October 2006 Surgical management Charles underwent pericardiectomy which was performed with a heart-lung machine on standby. His sternum was opened in midline and carefully, the pericardium, which is very adherent to heart surface, was separated from: • all the chambers of the heart, • the pulmonary veins, • the superior and inferior vena cavae and • was excised from the level of right phrenic nerve to left phrenic nerve. Removing the pericardium freed up the heart from constriction, which improved the filling function of the heart as well as cardiac output. Operative mortality Figure 1. Charles’ chest X-rays show a calcified pericardium. The operative mortality for this surgery is reported to be between 5% and 20%. The most common postsurgery complication is low output failure, which occurs in almost 30% of patients and requires temporary inotropic support. Though it is a high-risk surgery, when successful, the five-year survival rate is between 75% and 85%. PCard Resources 1. LeWinter M, Kabbani S: Pericardial Diseases. In: Braunwald’s Heart Disease. Seventh Edition. Saunders, 2005, p.1757-80. 2. Tirilomis T, Unverdorben S, Von Der Emde J: Pericardiectomy for Chronic Constrictive Pericarditis: Risks and outcome. Eur J Cardiothorac Surg 1994; 8(9):487. About the authors... Figure 2. Charles’ left ventricular angiogram reveals calcified pericardium outline and constricted left ventricle. Dr. N. Ghorpade is a Senior Clinical Fellow in the Division of Cardiac Surgery at the University of Alberta Hospital, Edmonton, Alberta. Dr. A. Koshal is a Director of the Division of Cardiac Surgery at the University of Alberta Hospital, Edmonton, Alberta. Perspectives in Cardiology / October 2006 21