Cath Conference August 6, 2008

Cath ConferenceCath ConferenceAugust 6, 2008August 6, 2008

Priya Pillutla, M.D.Priya Pillutla, M.D.

Kimble Poon, M.D.Kimble Poon, M.D.

HistoryHistory

34 y/o M, no PMH 34 y/o M, no PMH 2 months prior to admission - URI2 months prior to admission - URI URI resolved but +SOB, LE edema URI resolved but +SOB, LE edema OVMC – Dx’d with pericarditis and R OVMC – Dx’d with pericarditis and R

heart failureheart failure NSAIDs: no improvementNSAIDs: no improvement

Repeat TTE: thickened pericardiumRepeat TTE: thickened pericardium Transferred here for further Transferred here for further

managementmanagementPriya Pillutla, M.D.

Still complains of SOB and LE Still complains of SOB and LE edemaedema

No fevers or constitutional No fevers or constitutional symptomssymptoms

Meds – IbuprofenMeds – Ibuprofen NKDANKDA Social - +tobaccoSocial - +tobacco

Priya Pillutla, M.D.

Physical ExamPhysical Exam

BP 130/84, HR 80, RR 14, sat 100% BP 130/84, HR 80, RR 14, sat 100% RARA

Morbidly obeseMorbidly obese

JVP 15 cmJVP 15 cm

Normal carotid upstrokesNormal carotid upstrokes

RRR nl s1/s2. +S3 +pericardial knockRRR nl s1/s2. +S3 +pericardial knock

Lungs clearLungs clear

Lower extremity edemaLower extremity edemaPriya Pillutla, M.D.

ElectrocardiogramElectrocardiogram


Transthoracic Transthoracic EchocardiographyEchocardiography


Echocardiographic evidence for pericardial constriction

Echocardiographic evidence for pericardial constriction

Thickened pericardium and tram-tracking

Ventricular interdependence

Septal bounce

Respiratory variation of inflow velocities

Normal or elevated mitral annulus motion

Resolution after therapy

Thickened pericardium and tram-tracking

Pericardial thickness >3mm is abnormal but not sensitive or specific for constriction

Tram-tracking: during diastole, the parietal pericardium and visceral pericardium are straight and fixed

This is in contrast to normal pericardial movement and cardiac tamponade

Tram-tracking in pericardial constriction

Absence of tram-tracking in a patient with cardiac

tamponade

During diastole, the visceral pericardium expands outward as the ventricle fills

Absence of tram-tracking in a patient with no

pericardial disease

Ventricular interdependence

During inspiration, the RV is preferentially filled at the expense of the LV

During expiration, the LV fills at the expense of the RV

Septal bounce

2D manifestation of ventricular inter-dependence

Respiratory variation of inflow velocities

MV variation >25% TV variation >40%

Peak 99 cm/s

Trough 57 cm/s

Difference 42 cm/s

% variation 42/57 = 74%

Peak 80 cm/s

Trough 38 cm/s

Difference 42 cm/s

% variation 42/38= 110%

Normal or elevated mitral

annulus motion Because the lateral motion of the

ventricle is constricted, motion along the basal to apical axis is exaggerated

E’ > 7 is consistent with constriction

E’ = 17

Resolution after therapy

Variation disappears after definitive therapy

Peak 110 cm/s

Trough 105 cm/s

Difference 5 cm/s

% variation 5/105 = 5%

Peak 60 cm/s

Trough 50 cm/s

Difference 10 cm/s

% variation 10/50 = 20%

Presence of effusion

Diagnosis

Effusive-pericardial constriction

Right heart Right heart catheterizationcatheterization


SummarySummary

Pericardial effusionPericardial effusion Thickened pericardium Thickened pericardium Severely restricted cardiac motionSeverely restricted cardiac motion Steep x and y descent on RA pressure Steep x and y descent on RA pressure

waveformwaveform Near equalization of diastolic pressures Near equalization of diastolic pressures

in all chambersin all chambers

Findings consistent with effusive-Findings consistent with effusive-constrictive pericaditisconstrictive pericaditis


ManagementManagement

Pericardiectomy was performedPericardiectomy was performed Large effusionLarge effusion Pericardial thickening especially adjacent Pericardial thickening especially adjacent

to right ventricleto right ventricle Difficult dissectionDifficult dissection Visceral pericardium removed up to the Visceral pericardium removed up to the

phrenic nerve laterally and the phrenic nerve laterally and the diaphragm inferiorlydiaphragm inferiorly

Intraoperative TEE showed improved Intraoperative TEE showed improved diastolic fillingdiastolic filling


At discharge:At discharge: Resolution of shortness of breath and Resolution of shortness of breath and

edemaedema Pericardial biopsy - nonspecific Pericardial biopsy - nonspecific

inflammation, thickening of the inflammation, thickening of the pericardiumpericardium

Effusion – micro, chemistry negativeEffusion – micro, chemistry negative


Effusive-Constrictive Effusive-Constrictive PericarditisPericarditis

First characterized by Hancock in 1971First characterized by Hancock in 1971 Constriction caused by visceral Constriction caused by visceral

pericardium in presence of tense pericardium in presence of tense pericardial effusionpericardial effusion

Usually diagnosed after Usually diagnosed after pericardiocentesis for tamponadepericardiocentesis for tamponade Elevated RAP despite normal Elevated RAP despite normal

intrapericardial pressureintrapericardial pressure In this case, mixed findings during In this case, mixed findings during

RHC suggested diagnosisRHC suggested diagnosis


Priya Pillutla, M.D. NEJM, 2004

From Guide to Hemodynamic Data in the Coronary Care Unit (Sharkey)

TamponadTamponadee

ConstrictiConstrictionon

Eff-ConstEff-Const

Mean Mean RAPRAP

10-25 10-25 mmHgmmHg



RA RA waveformwaveform

X>YX>YY may be 0Y may be 0

X = Y X = Y oror

X < Y X < Y X = Y X = Y oror

X < YX < Y

RA/PCWPRA/PCWP EqualEqual EqualEqual EqualEqual

PASPPASP Normal/sl. Normal/sl. ↑ ↑



KussmaulKussmaul AbsentAbsent 1/3 of 1/3 of casescases

Rare Rare

PulsusPulsus YesYes 1/3 of 1/3 of casescases

Pre-tap Pre-tap


N = 15 (largest series to date) Priya Pillutla, M.D.

Diagnostic criteria:Diagnostic criteria: Tamponade that evolved into constriction Tamponade that evolved into constriction

(failure of RAP to fall by at least 50% or less (failure of RAP to fall by at least 50% or less than 10 mmHg) after reduction of than 10 mmHg) after reduction of intrapericardial pressure to 0intrapericardial pressure to 0

MethodsMethods Complete pressure measurements obtained Complete pressure measurements obtained

prior to and following pericardiocentesis (all prior to and following pericardiocentesis (all chambers, IPP, femoral pulsus)chambers, IPP, femoral pulsus)

Pericardial fluid sent for chemistry, cyto, Pericardial fluid sent for chemistry, cyto, micro, AFBmicro, AFB


Treatment variedTreatment varied NSAIDs NSAIDs Avoided steroidsAvoided steroids Pericardiectomy for constriction and Pericardiectomy for constriction and

severe/persistent heart failuresevere/persistent heart failure If milder heart failure, medical therapy If milder heart failure, medical therapy

to allow possible spontaneous to allow possible spontaneous resolutionresolution

F/U – every 3 months for a year (if F/U – every 3 months for a year (if pericardiectomy) then q3-5 yearspericardiectomy) then q3-5 years


ResultsResults

15 patients met criteria (~1200 15 patients met criteria (~1200 consecutive patients with consecutive patients with pericarditis; prevalence 1.3%)pericarditis; prevalence 1.3%)

All had signs of R heart failure All had signs of R heart failure 2/3 had pulsus paradoxus2/3 had pulsus paradoxus Effusions predominantly Effusions predominantly

serosanguinousserosanguinous


Management

Inflammatory symptoms – NSAIDsInflammatory symptoms – NSAIDs All patients – pericardiocentesis All patients – pericardiocentesis

(13/15 had improvement)(13/15 had improvement) 7/14 had pericardiectomy for 7/14 had pericardiectomy for

persistent R heart failurepersistent R heart failure 4 idiopathic, 1 radiation, 1 TB, 1 4 idiopathic, 1 radiation, 1 TB, 1

postsurgicalpostsurgical Nonspecific inflammation of the Nonspecific inflammation of the

pericardiumpericardium


No pericardiectomy (n=8)No pericardiectomy (n=8) 3 spontaneous resolution3 spontaneous resolution 4 neoplasm; 1 radiation pericarditis with LV 4 neoplasm; 1 radiation pericarditis with LV

dysfunctiondysfunction After complete workup of all patients:After complete workup of all patients:

Idiopathic (7)Idiopathic (7) Neoplasm (4)Neoplasm (4) Radiation pericarditis (2)Radiation pericarditis (2) Postsurgical (1)Postsurgical (1) TB (1) TB (1)

Other case series – bacterial infections, Other case series – bacterial infections, fungal fungal


Importance of correct diagnosis:Importance of correct diagnosis: Visceral pericardium needs to be Visceral pericardium needs to be

removedremoved Dissection can be difficult/hazardousDissection can be difficult/hazardous

Can resolve spontaneously ~ can Can resolve spontaneously ~ can watch and wait if heart failure watch and wait if heart failure symptoms not severesymptoms not severe



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