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Case report no. 3,
Department of Pathological Physiology
V. Danzig, MD, PhD,
2nd Dept. Internal Medicine
Cardiology and Angiology Division
1st Med.F CUNI
Patient history
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Female, 57 years old
Family history: father died aged 78, diabetes, prostate cancer
(Ab)usus: “reduced smoking” to 1 cigarette/ day half year ago, it
used to be 10 cigarettes daily before, alcohol drinking denies
Gynecological history: 2 childbirths, 4 months breastfeeding,
menopausis
4 years ago incidental mammographic finding of breast cancer in
upper left quadrant, treated by: excision, then repeated excision,
axillary exenteration, adjuvant chemo-therapy and radio-therapy,
histologically: invasive ductal carcinoma, highly malignant.
Patient history - questions
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Can you find some risk factors in the patient history at the onset of
carcinoma? (roll back one slide)
What are dangers of possible generalizations of early captured
breast cancer?
Can cancer therapy have adverse effects on heart?
Current disorder
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Two years ago during oncological checkup, a
generalization of cancer has been found, with
mediastinal lymphatic adenopathy, and affected liver.
One year ago, on PET/ CT scan, besides progression
of the lymphatic adenopathy, also found pericardial and
pleural effusion
Pericardial effusion classified as highly suspected as
malignant, chemotherapy adjusted/ changed
Both clinically and on ECG without signs of cardiac
tamponade
Current disorder - questions
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What are mechanisms of propagation of malignant tumor in organism?
What does the “PET/ CT scan” stand for? What physiological principle
this imaging method uses in detection of malignant and inflammatory
processes?
Under what circumstances can pericardial effusion cause tamponade
and what are conditions of its emergence?
What heart cavities are more prone to compression and why?
What physical phenomena (in palpation and listening) are found in
pericardial effusion?
Pericardial effusion notable especially at right atrium
(between nos. 6 and 9 on the yellow scale on left)
Pericardial effusion shown in M-mode
- before right ventricle and behind back wall of left ventricle,
larger in systole, +++ denoted by blue crosses +++
Next development of the disorder
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Last year in summer, clinical signs of cardiac tamponade showed
for the first time, confirmed by the echo-cardiography.
Patient indicated to pericardial puncture. In hemorrhagic effusion,
tumor elements have been found.
Due to recurrences of pericardial effusion with signs of tamponade,
punctures have been indicated repeatedly, one together with
cytostatic application into pericardium
Next development of the disorder - questions
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Under what conditions is cardiac tamponade manifested? What are
pressures and pressure relations in pericardium and in the right
heart cavities?
Why the compression of parts of left heart are much more rare
compared to the right heart?
What are clinical signs of cardiac tamponade? Into what two groups
can be these signs divided according to their origin?
What is “pulsus paradoxus”, can you explain its cause?
Pericardial tamponade
Vena cava inferior dilated,
with absent respiratory variability
Fluctuations of trans-mitral flow
Last developments – last hospital admission to date
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Patient admitted to hospital with developed edemas of
lower extremities (symmetrical on both legs under
knees), right side chest pain and with hepatomegalia
As highly suspect cause of right heart insufficiency was
given diagnosis of constrictive pericarditis.
Because of cancer with prognostic pessimism, a
conservative (= pharmacological) treatment was
recommended
Last developments - questions
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What are the causes of progression of constrictive pericarditis after
its several recurring attacks (and after attacks of pericardial
infiltration by cancer)? What can be other factors involved in this
patient?
What are other manifestations of right heart insufficiency besides
the leg edemas and hepatomegalia?
What other alternative to conservative treatment of recurring
idiopatic pericarditis can can be chosen in case of more optimistic
prognosis (=it is a surgical procedure…)?
Conclusions
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There are several conditions, which can cause pericardial effusion.
Amount of fluid in pericardium and the speed of the fluid production
(slower production enables adaptive mechanisms of parietal
pericardium) are factors important for the development of this
condition.
Cardiac tamponade occurs when the pressure in pericardial cavity
is higher than pressure in right heart and subsequently in other
heart partitions.
Signs of tamponade have clear patho-physiological cause and can
be divided into 2 groups : 1- due to low cardiac output,
2- due to congestion of blood before the right heart.
Conclusions II
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The threat of cardiac tamponade can be detected before its full
development by echo-cardiographic imaging.
Echo-cardiography is crucial in diagnosis of pericardial effusion and
the puncture is performed under ultrasonographic guidance.
Pericardial adhesions and their subsequent calcifications lead to a
fixed constrictive pericarditis picture.
A surgical treatment of choice is pericard-ectomia. This is however
a patient challenging cardiac surgery which is typicaly not possible
in cancer patients.