Download Constrictive Pericarditis

Pericardial Disease
Simulation
training
Curriculum
Constrictive Pericarditis
Etiology
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Idiopathic
Irradiation
Post-surgical
Infectious
Neoplastic
Connective tissue
disorder
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Uremia
Trauma
Sarcoid
Methysergide therapy
Epicardial implantable
defibrillator patches
CATHSAP6: Coronary Angiography and Intervention
CATHSAP6: Coronary Angiography and Intervention
CATHSAP6: Coronary Angiography and Intervention
CATHSAP6: Coronary Angiography and Intervention
CATHSAP6: Coronary Angiography and Intervention
Kussmaul’s Sign
CATHSAP6: Coronary Angiography and Intervention
CATHSAP6: Coronary Angiography and Intervention
CATHSAP6: Coronary Angiography and Intervention
Cardiac
Tamponade
40
20
0
CATHSAP6: Coronary Angiography and Intervention
Balloon Pericardiotomy
Case 1: Constrictive Pericarditis
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64 year old female
1 Year s/p 3-vessel CABG
Presents with 6 months of progressive dyspnea
and atypical chest pain
At angiography, all grafts are patent
Hemodynamics
40
Right atrium
20
0
40
20
0
LV vs. RV
40
20
0
LV vs. RV with Valsalva
Constrictive Pericarditis
Right Atrial Tracing
X-descent
y-descent
Constrictive Pericarditis – LV vs. RV.
Tachycardia Obscures Evaluation
PVB
Kussmaul sign
CATHSAP6: Coronary Angiography and Intervention
CATHSAP6: Coronary Angiography and Intervention
CATHSAP6: Coronary Angiography and Intervention
Restrictive Cardiomyopathy
Ventricular Interdependence During Respirations
Differentiates Constrictive Pericarditis from
Restrictive Cardiomyopathy
Constrictive
Pericarditis
(LV and RV discordant)
Hurrell et al, Circulation 1996; 93:2007
Restrictive
Cardiomyopathy
(LV and RV concordant)
Sensitivities, Specificities, Positive Predictive
Values, and Negative Predictive Values as a
[Return to Article]
Function of Criteria
Table 3. Sensitivities, Specificities, Positive Predictive Values, and Negative Predictive Values as a Function
Criteria
Conventional
LVEDP–RVEDP mm Hg
RVEDP/RVSP >1/3
PASP <55 mm Hg
LV RFW mm Hg
Respiratory change in RAP <3 mm Hg
Dynamic respiratory
PCWP/LV respiratory gradient mm Hg
LV/RV interdependence
5
7
5
Sensitivity,
%
Specificity,
%
PPV,
%
NPV,
%
60
93
93
93
93
38
38
24
57
48
4
52
47
61
58
57
89
25
92
92
93
100
81
95
78
94
94
100
PPV indicates positive predictive value; NPV, negative predictive value; and RAP, right atrial pressure.
[Return
Article]
Hurrellto et
al, Circulation
1996; 93:2007
Constrictive Pericarditis vs. Restrictive
Cardiomyopathy
• Greater ventricular interdependence in constrictive
pericarditis
• Greater separation of diastolic pressure in restrictive
cardiomyopathy
• LV and RV diastolic filling more rapid in constrictive
pericarditis
• Pulmonary pressures higher in restrictive
cardiomyopathy
• Adjunctive tests: evidence of pericardial thickening
(normal 1-2 mm; thickening ≥ 3 mm); pericardial
calcification, RV biopsy, exploratory thoracotomy
Case 3: Pericardial Tamponade
• 37 year old female
• 2 day history of dyspnea, fatigue and
dizziness
• Mastectomy for breast cancer 3 years ago
• Echocardiogram suggests pericardial
tamponade
• Hemodynamics
Cardiac Tamponade
Pulsus Paradoxus
200 Femoral artery
inspiration
100
0
expiration
40
Right atrium
20
0
40
20
0
Right ventricle
40
20
0
Pulmonary artery
40
20
0
Pulmonary capillary wedge
40
Before Pericardiocentesis;
Pericardium vs. RA
20
0
After Pericardiocentesis
40
20
Right atrium
Pericardium
0
After Pericardiocentesis
40
20
0
Right ventricle
After Pericardiocentesis
40
Pulmonary capillary wedge
20
0
Long-Term Effectiveness of
Pericardiocentesis
• 2/3 of patients with malignant pericardial effusions
redevelop tamponade after a median of 7 days
• More than 80% of patients with non-malignant
pericardial effusion require no further intervention
Laham et al, Heart 1996; 75:67
Variants on Constrictive-Restrictive
Physiology
• Acute enlargement of the heart with constriction
by normal pericardium
– right ventricular infarct, tricuspid regurgitation,
mitral regurgitation
• Low pressure tamponade
• Effusive-constrictive pericarditis
• Single chamber tamponade
• Localized constriction
• Occult constrictive pericarditis
Severe, Acute
Tricuspid
Regurgitation
Associated With
ConstrictiveRestrictive
Physiology
Severe, Acute Mitral Regurgitation Associated
With Constrictive-Restrictive Physiology
Variants on Constrictive-Restrictive
Physiology
• Acute enlargement of the heart with constriction
by normal pericardium
– right ventricular infarct, tricuspid regurgitation,
mitral regurgitation
• Low pressure tamponade
• Effusive-constrictive pericarditis
• Single chamber tamponade
• Localized constriction
• Occult constrictive pericarditis