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

• 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

• 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

• 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• Na 134

• K+ 3.9

• Cl- 100

• HCO3- 27

• BUN 13

• Cr 0.9

• Glucose 89

• Ca 8.9

• LDH 118

• 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)

• 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• 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

CCCC

CCCC

CCCC

CCCC

CCCC

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 PericarditisCommon Causes

-Idiopathic

-Infection Bacterial: TB

Fungal: Histoplasmosis, Coccidiomycosis

Viral: CoxsackieParasitic: Amebiasis, Echinococcus

-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

Uncommon causes

-Sarcoidosis-Post MI-Asbestosis-Amyloidosis-Drug Induced Lupus-Acute Rheumatic Fever

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 Noninfiltrative

-Sarcoidosis -Fabry’s Disease

-Amyloidosis -Hemochromatosis

-Post Radiation -Glycogen Storage

Therapy Disease

-Gaucher’s Disease -Scleroderma

-Hurler’s Disease -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