Download Hemodynamic Conference

Hemodynamic Conference
Eckhard Alt, M.D.
Holger Salazar, M.D.
Robert Smith, M.D., M.Sc.
Tulane University School of Medicine
Cardiac Cath Conference
December 23, 2003
Outline
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Right Heart Catheterization Overview
Review of Waveform Analysis
Practice Case
Case Presentation with RHC Results
Discussion of Differential Diagnosis
Review of Echocardiographic Findings and
Follow up
• Discussion
Right Heart Catheterization
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Measures Central Venous Pressure/Right Atrial Pressure
Measures RV Pressures and PA Pressures
Gives Indirect Measure of Left Atrial Pressure (PCWP)
Avoids Septal Puncture
Estimates Cardiac Output
Quantifies Oxygen Utilization
Useful in Diagnosis of Shock Etiology
Useful for Peri-Operative Volume Management
Pressure Waveforms
Practice Case
RA
RV
PA
PCW
Diagnosis?
M5
M12
Diagnosis
Non-Ischemic Cardiomyopathy
Case Presentation
CC is a 19 yo AAM with no significant PMHx
who presented with a 2 year history of progressive
abdominal distention. Pt. reported that the
abdominal distention had particularly worsened
during the six months prior to presentation and he
presented to the medicine clinic at the insistence
of his family. He reported that he was active in
sports and denied LE edema, SOB, PND, and
orthopnea. In fact, he reported that, aside from his
worsening abdominal distention, he generally felt
well. He was admitted from the clinic for workup
of his abdominal distention.
PMHx: None
Medications: None
Family History: No family h/o heart disease
Social History: Denies EtOH, Tobacco, Drugs.
One lifetime sexual partner
Physical Exam
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123/72 62 16 97.2
Comfortable, NAD
JVD present at 9 cm, + hepatojugular reflux
nlS1S2, 2/6 HSM  apex
Decreased breath sounds at bilateral bases
Abd distended with + fluid wave. Liver was
palpable 3 cm below the costal margin and the
spleen tip was palpable
• No LE edema
Labs
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Na 134
K+ 3.9
Cl- 100
HCO3- 27
BUN 13
Cr 0.9
Glucose 89
Ca 8.9
LDH 118
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AST 37
ALT 11
AP 75
TP 7.9
Alb 3.0
TB 1.8
CK 21
CKMB 0.4
Troponin <0.05
TSH 3.17
Labs (cont)
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WBC 12.2
Hgb 12.2
Hct 36.6
Plt 190
MCV 90
Neutrophils 70%
Lymphocytes 22%
Basophils 0%
Eosinophils 1%
Monocytes 7%
• INR 1.4
• PTT 35.6
• Blood Cultures Drawn
Ascites Fluid
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Clear and Yellow
WBC’s 21
RBC’s 453
Albumin 2.6
TP 4.8
LDH 74
Glucose 104
Cholesterol 20
Gram Stain and cultures sent
Cytology sent
ECG
CC
CC
CC
CC
CC
During this admission, a TTE was performed and
showed a large pericardial effusion without evidence
of tamponade (the study has been lost). Blood
cultures were negative for bacterial infection and
fluid cultures were smear negative and culture
negative for AFB, fungus and bacteria Clinically, he
looked well and was discharged by the primary
service for outpatient workup. He failed to keep his
appointments and presented to the ER with SOB
approx. 1 month after discharge. During this second
admission, workup included echocardiography, left
and right heart cath. The echocardiographic
findings will be discussed at the end of the case.
C5
C8
C2
RA
RV
PA
PCW
RV/LV
Differential Diagnosis
• Constrictive Pericarditis
• Restrictive Cardiomyopathy
Etiologies of Constrictive Pericarditis
Common Causes
-Idiopathic
-Infection
Bacterial: TB
Fungal: Histoplasmosis,
Coccidiomycosis
Viral: Coxsackie
Parasitic: Amebiasis, Echinococcus
Uncommon causes
-Sarcoidosis
-Post MI
-Asbestosis
-Amyloidosis
-Drug Induced Lupus
-Acute Rheumatic Fever
-Drugs
-Neoplastic
Lymphoma, Melanoma, Primary
Mesothelioma, Breast & Lung cancer
-Following Cardiac Surgery
-Connective Tissue Disease
RA, SLE, Scleroderma,
Dermatomyositis
-Trauma
-Renal Failure
-Radiation
-AICD/Pacer placement
Rare Causes
-Actinomycosis
-Asbestosis
-Whipples Disease
-Lassa Fever
-Sclerotherapy of Esophageal
Varices
Restrictive Cardiomyopathy
Primary RCM
-Loeffler’s cardiomyopathy
-Idiopathic RCM
-Endomyocardial Fibrosis
Secondary RCM
Infiltrative
-Sarcoidosis
-Amyloidosis
-Post Radiation
Therapy
-Gaucher’s Disease
-Hurler’s Disease
Noninfiltrative
-Fabry’s Disease
-Hemochromatosis
-Glycogen Storage
Disease
-Scleroderma
-Pseudoxanthoma
Elasticum
-Storage Disease
Echocardiographic Presentation
Holger Salazar, M.D.
Chene3-23
Chene3-8
Chene3-9
Chene3-3
Chene3-13
Chene3-12
Chene3-preop,continuing 14
Chene3-14
Chene3-preop, continuing 5
Chene3-preop, continuing 9
Chene3-11
Chene3-5
Chene3-20
Chene3-preop, continuing 1
Chene3-preop, continuing 4
Diagnosis
Constrictive Pericarditis
Follow Up
• Pericardial biopsy (done during pericardectomy) showed
dense fibrous tissue with focal dystrophic calcification and
mesothelial hyperplasia
• The pericardium was densely calcified and adherent
• Epicardial biopsy showed dense fibrous tissue without
evidence of active inflammation or malignancy
• Pericardial fluid was bloody and contained atypical
mesothelial cells
• Pericardial fluid was smear and culture negative for AFB
• Pericardial fluid was smear and culture negative for
bacteria and fungi
• Serum ANA was negative
• PPD was negative
• HIV was negative
Follow Up (cont)
• The underlying etiology remains unclear
• The patient has developed refractory atrial
fibrillation with RVR
• Anticoagulation has been complicated by a
lower GI bleed
• He failed to improve after pericardectomy,
and has recently been referred to transplant
clinic