Transcript Document - Cardiac Catheterization

Cath Conference
August 6, 2008
Priya Pillutla, M.D.
Kimble Poon, M.D.
History
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34 y/o M, no PMH
2 months prior to admission - URI
URI resolved but +SOB, LE edema
OVMC – Dx’d with pericarditis and R heart
failure
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NSAIDs: no improvement
Repeat TTE: thickened pericardium
Transferred here for further management
Priya Pillutla, M.D.
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Still complains of SOB and LE edema
No fevers or constitutional symptoms
Meds – Ibuprofen
NKDA
Social - +tobacco
Priya Pillutla, M.D.
Physical Exam
BP 130/84, HR 80, RR 14, sat 100% RA
Morbidly obese
JVP 15 cm
Normal carotid upstrokes
RRR nl s1/s2. +S3 +pericardial knock
Lungs clear
Lower extremity edema
Priya Pillutla, M.D.
Electrocardiogram
Priya Pillutla, M.D.
Transthoracic Echocardiography
Priya Pillutla, M.D.
Echocardiographic evidence for
pericardial constriction
Echocardiographic evidence for
pericardial constriction
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Thickened pericardium and tram-tracking
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Ventricular interdependence
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Septal bounce
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Respiratory variation of inflow velocities
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Normal or elevated mitral annulus motion
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Resolution after therapy
Thickened pericardium
and tram-tracking
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Pericardial thickness >3mm is abnormal but not
sensitive or specific for constriction
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Tram-tracking: during diastole, the parietal pericardium
and visceral pericardium are straight and fixed
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This is in contrast to normal pericardial movement and
cardiac tamponade
Tram-tracking in pericardial
constriction
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
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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
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2D manifestation of ventricular interdependence
Respiratory variation of inflow
velocities
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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
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Because the lateral motion of the ventricle is
constricted, motion along the basal to apical axis
is exaggerated
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E’ > 7 is consistent with constriction
E’ = 17
Resolution after therapy
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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 catheterization
Priya Pillutla, M.D.
Priya Pillutla, M.D.
Priya Pillutla, M.D.
Priya Pillutla, M.D.
Priya Pillutla, M.D.
Priya Pillutla, M.D.
Priya Pillutla, M.D.
Priya Pillutla, M.D.
Priya Pillutla, M.D.
Summary
Pericardial effusion
 Thickened pericardium
 Severely restricted cardiac motion
 Steep x and y descent on RA pressure waveform
 Near equalization of diastolic pressures in all
chambers
Findings consistent with effusive-constrictive
pericaditis
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Priya Pillutla, M.D.
Management
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Pericardiectomy was performed
Large effusion
 Pericardial thickening especially adjacent to right
ventricle
 Difficult dissection
 Visceral pericardium removed up to the phrenic
nerve laterally and the diaphragm inferiorly
 Intraoperative TEE showed improved diastolic
filling
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Priya Pillutla, M.D.
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At discharge:
Resolution of shortness of breath and edema
 Pericardial biopsy - nonspecific inflammation,
thickening of the pericardium
 Effusion – micro, chemistry negative
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Priya Pillutla, M.D.
Effusive-Constrictive Pericarditis
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First characterized by Hancock in 1971
Constriction caused by visceral pericardium in
presence of tense pericardial effusion
Usually diagnosed after pericardiocentesis for
tamponade
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Elevated RAP despite normal intrapericardial
pressure
In this case, mixed findings during RHC
suggested diagnosis
Priya Pillutla, M.D.
Priya Pillutla, M.D.
NEJM, 2004
Priya Pillutla, M.D.
NEJM, 2004
From Guide to Hemodynamic Data in the
Coronary Care Unit (Sharkey)
Tamponade
Constriction Eff-Const
Mean RAP
10-25 mmHg
10-25 mmHg 10-30 mmHg
RA
waveform
X>Y
RA/PCWP
Equal
X = Y or
X<Y
Equal
PASP
Normal/sl. ↑
30-45 mmHg 30-45 mmHg
Kussmaul
Absent
1/3 of cases Rare
Pulsus
Yes
1/3 of cases Pre-tap
Y may be 0
Priya Pillutla, M.D.
X = Y or
X<Y
Equal
N = 15 (largest series to date)
Priya Pillutla, M.D.
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Diagnostic criteria:
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Tamponade that evolved into constriction (failure of
RAP to fall by at least 50% or less than 10 mmHg)
after reduction of intrapericardial pressure to 0
Methods
Complete pressure measurements obtained prior to
and following pericardiocentesis (all chambers, IPP,
femoral pulsus)
 Pericardial fluid sent for chemistry, cyto, micro, AFB
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Priya Pillutla, M.D.
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Treatment varied
NSAIDs
 Avoided steroids
 Pericardiectomy for constriction and
severe/persistent heart failure
 If milder heart failure, medical therapy to allow
possible spontaneous resolution
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F/U – every 3 months for a year (if
pericardiectomy) then q3-5 years
Priya Pillutla, M.D.
Results
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15 patients met criteria (~1200 consecutive
patients with pericarditis; prevalence 1.3%)
All had signs of R heart failure
2/3 had pulsus paradoxus
Effusions predominantly serosanguinous
Priya Pillutla, M.D.
Management
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Inflammatory symptoms – NSAIDs
All patients – pericardiocentesis (13/15 had
improvement)
7/14 had pericardiectomy for persistent R heart
failure
4 idiopathic, 1 radiation, 1 TB, 1 postsurgical
 Nonspecific inflammation of the pericardium
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Priya Pillutla, M.D.
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No pericardiectomy (n=8)
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3 spontaneous resolution
4 neoplasm; 1 radiation pericarditis with LV dysfunction
After complete workup of all patients:
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Idiopathic (7)
Neoplasm (4)
Radiation pericarditis (2)
Postsurgical (1)
TB (1)
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Other case series – bacterial infections, fungal
Priya Pillutla, M.D.
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Importance of correct diagnosis:
Visceral pericardium needs to be removed
 Dissection can be difficult/hazardous
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Can resolve spontaneously ~ can watch and wait
if heart failure symptoms not severe
Priya Pillutla, M.D.
Video
Priya Pillutla, M.D.