CARDIOLOGY - Pericardial Diseases

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2011 David Stultz

PericardialPericardial

DiseasesDiseases

David Stultz, MD, FACCDavid Stultz, MD, FACC

July 19, 2011July 19, 2011

www.drstultz.com

2011 David Stultz


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Goals of ConferenceGoals of Conference

Identify signs and symptoms ofIdentify signs and symptoms of

pericardial diseasespericardial diseasesDiscuss workup and treatmentDiscuss workup and treatment

strategies for pericarditisstrategies for pericarditis List common causes of pericarditisList common causes of pericarditis

and pericardial effusionand pericardial effusion


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The PericardiumThe Pericardium

Outer fibrous layerOuter fibrous layer

Inner lining (serous)Inner lining (serous) Visceral pericardiumVisceral pericardium(epicardium)(epicardium)

Parietal pericardiumParietal pericardium

lines outer fibrouslines outer fibrouslayerlayer

Pericardial space isPericardial space isin between visceralin between visceraland parietaland parietalpericardiumpericardium Normally 15Normally 15--50mL of50mL of

fluidfluid


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Case #1Case #1

32 year old Male32 year old Male

1 week ago started with sore throat,1 week ago started with sore throat,myalgiasmyalgias

Developed chest pain (pressure)Developed chest pain (pressure) Left substernalLeft substernal

Radiating to neckRadiating to neck

Improves when sitting upImproves when sitting up

No significant medical, family, socialNo significant medical, family, social

historyhistory No medicationsNo medications

Physical Exam unremarkablePhysical Exam unremarkable


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Case #1 EKGCase #1 EKG


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Laboratory DataLaboratory Data

WBC 12.8WBC 12.8

Renal panel normalRenal panel normal

LDL 113LDL 113

Troponin I 4.0Troponin I 4.0CPK 240, CKCPK 240, CK--MB 21.8 (index 9.1%)MB 21.8 (index 9.1%)

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What is the most likely diagnosis?What is the most likely diagnosis?

1.1. Acute myocardial infarctionAcute myocardial infarction

2.2. Acute pericarditisAcute pericarditis3.3. Acute myopericarditisAcute myopericarditis

4.4. Constrictive pericarditisConstrictive pericarditis5.5. Pericardial tamponadePericardial tamponade

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What would you do next?What would you do next?

1.1. Cardiac CatheterizationCardiac Catheterization

2.2. EchocardiographyEchocardiographyOr go straight to treatment withoutOr go straight to treatment without

imaging:imaging:3.3. High dose NSAIDSHigh dose NSAIDS

4.4. High dose NSAIDS + ColchicineHigh dose NSAIDS + Colchicine5.5. PrednisonePrednisone

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Now What Would You Do ForNow What Would You Do For

Treatment?Treatment?1.1. Indomethacin 25mg po q6Indomethacin 25mg po q6--8h8h

2.2. Ibuprofen 800mg po q6hIbuprofen 800mg po q6h3.3. Aspirin 650Aspirin 650--800mg po q6800mg po q6--8h8h

4.4. Indomethacin + colchicine 0.6mg dailyIndomethacin + colchicine 0.6mg daily

5.5. Ibuprofen + colchicine 0.6mg dailyIbuprofen + colchicine 0.6mg daily

6.6. Aspirin + colchicine 0.6mg dailyAspirin + colchicine 0.6mg daily

7.7. Prednisone 60mg po daily with taperPrednisone 60mg po daily with taper

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What is the Most Common CauseWhat is the Most Common Cause

of Acute Pericarditis?of Acute Pericarditis?1.1. Idiopathic/ViralIdiopathic/Viral

2.2. BacterialBacterial3.3. MalignancyMalignancy

4.4. UremiaUremia5.5. Acute Myocardial InfarctionAcute Myocardial Infarction

6.6. Autoimmune diseaseAutoimmune disease

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Acute PericarditisAcute Pericarditis

Inflammation of PericardiumInflammation of Pericardium

Symptoms include sharp chest painSymptoms include sharp chest painOften improved with uprightOften improved with upright

positionposition

Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK. Pericardial disease: diagnosis and

management. Mayo Clin Proc. 2010 Jun;85(6):572-93.

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Common Causes of AcuteCommon Causes of Acute

PericarditisPericarditis Idiopathic (85Idiopathic (85--90%)90%)

InfectiousInfectious

Viral (1Viral (1--2%)2%) Bacterial (1Bacterial (1--2%)2%)

Tuberculous (4%)Tuberculous (4%)

Neoplastic disease (7%)Neoplastic disease (7%)

UremiaUremia Before dialysis (5%)Before dialysis (5%)

After initiation of dialysis (13%)After initiation of dialysis (13%)

Systemic autoimmune disease (3Systemic autoimmune disease (3--5%)5%)

As a complication ofAs a complication of Acute myocardial infarction (5Acute myocardial infarction (5--20%)20%)

Myocarditis (30%)Myocarditis (30%)

Adapted from Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK. Pericardial disease: diagnosis

and management. Mayo Clin Proc. 2010 Jun;85(6):572-93.

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Rare Causes of Acute PericarditisRare Causes of Acute Pericarditis

After cardiotomy or thoracic surgeryAfter cardiotomy or thoracic surgery

Aortic dissectionAortic dissectionChest wall traumaChest wall trauma

Chest wall irradiationChest wall irradiationAdverse drug reactionAdverse drug reaction

Rare Infectious causesRare Infectious causes FungalFungal

ParasitesParasites

Adapted from Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK. Pericardial disease: diagnosis

and management. Mayo Clin Proc. 2010 Jun;85(6):572-93.


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Pericarditis Chest PainPericarditis Chest Pain

Sudden onsetSudden onset

RetrosternalRetrosternal Pleuritic/SharpPleuritic/Sharp

Worse with inspirationWorse with inspiration Improved when sitting up or leaningImproved when sitting up or leaning

forwardforwardChest pain can radiateChest pain can radiate



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Pericarditis Friction RubPericarditis Friction Rub

Caused by rubbing of inflamed visceral andCaused by rubbing of inflamed visceral andparietal pericardiumparietal pericardium

Variable over timeVariable over time

Present in 85% of patients with pericarditis atPresent in 85% of patients with pericarditis atsome pointsome point

High pitched scratch or squeak at left lowerHigh pitched scratch or squeak at left lowersternal bordersternal border

Classically 3 phasesClassically 3 phases

Atrial systole,Atrial systole, Ventricular systoleVentricular systole

Rapid ventricular filling during early diastoleRapid ventricular filling during early diastole

May be only biphasic or monophasicMay be only biphasic or monophasicKhandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK. Pericardial disease: diagnosis and


http://depts.washington.edu/physdx/heart/tech5.html

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Pericarditis EKG ChangesPericarditis EKG Changes

Diffuse ST segment elevation and PR segmentDiffuse ST segment elevation and PR segmentdepressiondepression

Stage 1Stage 1 Hours to daysHours to days

ST elevation and PR depressionST elevation and PR depression

Possible PR segment elevation in aVRPossible PR segment elevation in aVR

Stage 2Stage 2 Normalization of ST and PR segmentsNormalization of ST and PR segments

Stage 3Stage 3

Diffuse T wave inversionsDiffuse T wave inversions

Stage 4Stage 4 EKG normalizes (or T wave inversions persist)EKG normalizes (or T wave inversions persist)



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Laboratory Studies in PericarditisLaboratory Studies in Pericarditis

Nonspecific elevation of inflammatory markersNonspecific elevation of inflammatory markers Erythrocyte sedimentation rateErythrocyte sedimentation rate

CC--reactive proteinreactive protein White blood cell countWhite blood cell count

Viral titers and cultures not usefulViral titers and cultures not useful

ANA, Rheumatoid factor useful only if otherANA, Rheumatoid factor useful only if otherautoimmune findings are presentautoimmune findings are present

Elevated troponinElevated troponin

Mild increase when presentMild increase when present Usually patent coronary arteries at catheterizationUsually patent coronary arteries at catheterization

Usually resolve in 1Usually resolve in 1--2 weeks2 weeks

Prognosis is goodPrognosis is good



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MyopericarditisMyopericarditis

Predominantly pericardial involvementPredominantly pericardial involvementwith associated myocardialwith associated myocardialinflammation.inflammation.

Diagnosed after pericarditis diagnosedDiagnosed after pericarditis diagnosed

and evidence of myocardial involvementand evidence of myocardial involvement Abnormal cardiac enzymesAbnormal cardiac enzymes

New onset of global or regional leftNew onset of global or regional leftventricular dysfunctionventricular dysfunction

Endomyocardial biopsy not neededEndomyocardial biopsy not needed

Approximately 17% of patientsApproximately 17% of patients

ultimately diagnosed with pericarditisultimately diagnosed with pericarditisundergo heart catheterizationundergo heart catheterizationSalisbury AC, Olalla-Gomez C, Rihal CS, et al. Frequency and predictors of urgent coronary angiography in patients with acute

pericarditis. Mayo Clin Proc. 2009;84(1):11-15.

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Imaging StudiesImaging Studies

Chest XChest X--rayray Usually not helpful unlessUsually not helpful unless

there is a significant pericardial effusionthere is a significant pericardial effusion EchocardiographyEchocardiography Indicated forIndicated for

hemodynamic compromisehemodynamic compromise

Computed TomographyComputed Tomography useful touseful tomeasure pericardial thickness (usually 1measure pericardial thickness (usually 1--

2mm) and pericardial effusion2mm) and pericardial effusion

Cardiac MRICardiac MRI Delayed gadoliniumDelayed gadolinium

enhancement shows inflammation ofenhancement shows inflammation of

pericarditispericarditisKhandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK. Pericardial disease: diagnosis and


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Cardiac MRI of PericarditisCardiac MRI of Pericarditis

Delayed Gadolinium EnhancementDelayed Gadolinium Enhancement



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Initial EvaluationInitial Evaluation

HistoryHistory

Any suggestion of malignancy orAny suggestion of malignancy orautoimmune diseaseautoimmune disease

Physical ExaminationPhysical Examination

Friction rubFriction rub

Signs of TamponadeSigns of Tamponade

Pulsus ParadoxusPulsus ParadoxusKussmaulKussmauls signs sign

BeckBecks Triads Triad




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Selected EvaluationsSelected Evaluations

Echocardiogram for hemodynamicEchocardiogram for hemodynamiccompromisecompromise

Suspected autoimmune diseaseSuspected autoimmune disease Antinuclear Antibody titersAntinuclear Antibody titers

Rheumatoid FactorRheumatoid Factor Suspected infectious diseaseSuspected infectious disease

Tuberculin skin testingTuberculin skin testing

Human Immunodeficiency VirusHuman Immunodeficiency Virus Blood CulturesBlood Cultures

Malignancy workupMalignancy workup



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HospitalizationHospitalization

Any high risk featuresAny high risk features FeverFever

LeukocytosisLeukocytosis

Large pericardial effusion (>20 mm)Large pericardial effusion (>20 mm)

Cardiac tamponadeCardiac tamponade

Acute traumaAcute trauma

Immunosuppressed stateImmunosuppressed state

Anticoagulated patientAnticoagulated patient

Failure of NSAID treatmentFailure of NSAID treatment

Abnormal troponinAbnormal troponin

Recurrent pericarditis.Recurrent pericarditis.



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OutpatientOutpatient Day HospitalDay Hospital ManagementManagement

No high risk featuresNo high risk features

254 out of 300 cases low risk254 out of 300 cases low risk Treated with Aspirin 800mg q6Treated with Aspirin 800mg q6--8h x 28h x 2--3 weeks with3 weeks with

taperingtapering

Baseline echocardiogramBaseline echocardiogram

Clinical and echo followClinical and echo follow--up periodically over 1 yearup periodically over 1 year

Mean followMean follow--up of 38 monthsup of 38 months 43 (16.9%) cases of relapses43 (16.9%) cases of relapses

4 (1.6%) cases of constrictive pericarditis4 (1.6%) cases of constrictive pericarditis

No cases of cardiac tamponadeNo cases of cardiac tamponade

Failure to respond to Aspirin after 7Failure to respond to Aspirin after 7--10 days10 dayspredicted higher rates of complicationpredicted higher rates of complication

Imazio M, Demichelis B, Parrini I, et al. Day-hospital treatment of acute pericarditis: a management program for outpatient therapy. J

Am Coll Cardiol. 2004;43(6):1042-1046.

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Treatment of PericarditisTreatment of Pericarditis NSAIDSNSAIDS

High dose Aspirin or ibuprofenHigh dose Aspirin or ibuprofen Aspirin 800mg q6Aspirin 800mg q6--8h x 78h x 7--10 days then taper off over 210 days then taper off over 2--3 weeks3 weeks

GI prophylaxis recommendedGI prophylaxis recommended

Indomethacin not recommended in patients with coronaryIndomethacin not recommended in patients with coronarydiseasedisease

ColchicineColchicine Use in conjunction with aspirin for 4Use in conjunction with aspirin for 4--6 weeks6 weeks

Caution with severe renal insufficiency, hepatobiliaryCaution with severe renal insufficiency, hepatobiliarydysfunction, gastrointestinal motility disordersdysfunction, gastrointestinal motility disorders

CorticosteroidsCorticosteroids Reserved for patients failing initial therapy withReserved for patients failing initial therapy with

NSAID+colchicineNSAID+colchicine

Increased risk of relapsing pericarditisIncreased risk of relapsing pericarditis Consider using inConsider using in Autoimmune diseaseAutoimmune disease

Connective tissue disorderConnective tissue disorder

Uremic pericarditisUremic pericarditis

Prednisone 1mg/kg/day, taper after 2Prednisone 1mg/kg/day, taper after 2--4 weeks of therapy4 weeks of therapy



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COPE TrialCOPE Trial

120 Patients with first episode120 Patients with first episodepericarditispericarditis

ConventionalConventional ASA 800mg q6ASA 800mg q6--8h for 78h for 7--10 days with tapering10 days with tapering

over 3over 3--4 weeks4 weeks

ExperimentalExperimental ASA + Colchicine 1ASA + Colchicine 1--2mg day 1 then 0.52mg day 1 then 0.5--1mg1mg

daily for 3 monthsdaily for 3 months

Addition of Colchicine beneficialAddition of Colchicine beneficial Lower rate of recurrence at 18 months (11%Lower rate of recurrence at 18 months (11%vs. 33%)vs. 33%)

Better 72 hour symptom resolution (12% vs.Better 72 hour symptom resolution (12% vs.

37%)37%)Imazio M, Bobbio M, Cecchi E, Demarie D, Demichelis B, Pomari F, Moratti M, Gaschino G, Giammaria M, Ghisio A, Belli R, TrincheroR. Colchicine in addition to conventional therapy for acute pericarditis: results of the COlchicine for acute PEricarditis (COPE) trial.Circulation. 2005 Sep 27;112(13):2012-6.


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Relapsing pericarditisRelapsing pericarditis

Usual first recurrence within 18 monthsUsual first recurrence within 18 months

IncessantIncessant Pericarditis returns within 6 weeks of treatmentPericarditis returns within 6 weeks of treatment

discontinuationdiscontinuation

IntermittentIntermittent

Usually responds to steroidsUsually responds to steroids Usual causesUsual causes

AutoimmuneAutoimmune

Viral or other infectionViral or other infection

PostPost--pericardial/Postpericardial/Post--myocardial injury syndromesmyocardial injury syndromes

Consider pericardiectomy in extreme casesConsider pericardiectomy in extreme cases



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Case #1Case #1

Diagnosis: MyopericarditisDiagnosis: Myopericarditis

Treated with ibuprofen 800mg poTreated with ibuprofen 800mg poq8h x 5 days then 400mg po q12h xq8h x 5 days then 400mg po q12h x5 days5 days

Started on carvedilol 3.125mg poStarted on carvedilol 3.125mg poq12hq12h

Discharged after overnightDischarged after overnighthospitalizationhospitalization

Doing well at 3 month followDoing well at 3 month follow--upup

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Case #2Case #2

53 year old male53 year old male

Increasing chest pressure and neck painIncreasing chest pressure and neck pain Almost constantAlmost constant

Worse with activity or deep breathWorse with activity or deep breath

Better when sitting upBetter when sitting up

Fevers, chills, nausea, and vomiting 3 monthsFevers, chills, nausea, and vomiting 3 monthsagoago

Past medical historyPast medical history HypertensionHypertension

HyperlipidemiaHyperlipidemia

No pertinent medications, family or socialNo pertinent medications, family or socialhistoryhistory

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Case #2 EKGCase #2 EKG

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CAT Scan of the ChestCAT Scan of the Chest

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EchocardiogramEchocardiogram

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Cardiac TamponadeCardiac Tamponade

Increased fluid in pericardial spaceIncreased fluid in pericardial space

Increases intracardiac pressuresIncreases intracardiac pressures Impairs normal cardiac fillingImpairs normal cardiac filling

Exaggerated by respirationsExaggerated by respirations

Inspiration decreases right ventricularInspiration decreases right ventricular

pressure but increases left ventricularpressure but increases left ventricular

pressurepressure

May be acute, subacute, or chronicMay be acute, subacute, or chronic

Cardiac procedures are the most commonCardiac procedures are the most common

acute cause!acute cause!



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DiagnosisDiagnosis

Symptoms may include chestSymptoms may include chest

discomfort, shortness of breathdiscomfort, shortness of breath Pulsus paradoxusPulsus paradoxus

Decrease in systolic blood pressure ofDecrease in systolic blood pressure of

>10mmHg with inspiration>10mmHg with inspiration

Jugular venous distensionJugular venous distension

Normal x descent (atrial diastole) withNormal x descent (atrial diastole) withblunted y descent (atrial systole)blunted y descent (atrial systole)



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Echocardiography in TamponadeEchocardiography in Tamponade

Right atrial collapse (late diastole)Right atrial collapse (late diastole)

Right ventricular collapse (earlyRight ventricular collapse (earlydiastole)diastole)

Respiratory variation ofRespiratory variation oftransvalvular inflow (i.e. the echotransvalvular inflow (i.e. the echo

pulsus paradoxus)pulsus paradoxus)

Tricuspid >40%Tricuspid >40%

Mitral >25%Mitral >25%

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Ri h A i l C llRi h A i l C ll


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Right Atrial CollapseRight Atrial Collapse

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Tricuspid Valve Inflow withTricuspid Valve Inflow with


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Tricuspid Valve Inflow withTricuspid Valve Inflow with

Respiratory VariationRespiratory Variation

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Mitral Valve Inflow withMitral Valve Inflow with


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Mitral Valve Inflow withMitral Valve Inflow with

Respiratory VariationRespiratory Variation


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Pericardial effusion withoutPericardial effusion without


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Pericardial effusion without

tamponadetamponade 1/3 of patients with large (>20mm)1/3 of patients with large (>20mm)

pericardial effusion develop tamponadepericardial effusion develop tamponade

Consider pericardiocentesis if effusion persistsConsider pericardiocentesis if effusion persists

more than 1 monthmore than 1 month

Regular clinical and echocardiographicRegular clinical and echocardiographicfollowfollow--up recommendedup recommended

Consider thoracic duct obstruction withConsider thoracic duct obstruction with

chylopericardium if persistentchylopericardium if persistent Consider hypothyroidismConsider hypothyroidism



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P i di l H tPericardial Hematoma


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Pericardial HematomaPericardial Hematoma

Blood clot in pericardial spaceBlood clot in pericardial space

Causes tamponade physiologyCauses tamponade physiologyDiagnosed by transthoracic orDiagnosed by transthoracic or

transesophageal echocardiogramtransesophageal echocardiogram

EtiologyEtiology IatrogenicIatrogenic

post cardiac surgery or other procedurepost cardiac surgery or other procedure Aortic dissectionAortic dissection

TraumaTrauma

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What is the Most Common Cause ofWhat is the Most Common Cause of


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nonnon--Iatrogenic Cardiac Tamponade?Iatrogenic Cardiac Tamponade?1.1. Idiopathic/ViralIdiopathic/Viral

2.2. MalignancyMalignancy3.3. UremiaUremia

4.4. Acute Myocardial InfarctionAcute Myocardial Infarction5.5. Autoimmune diseaseAutoimmune disease

6.6. TraumaTrauma7.7. HypothyroidismHypothyroidism

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Case #3Case #3


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Case #3Case #3 50 year old female50 year old female Increasing dyspnea and orthopnea over several daysIncreasing dyspnea and orthopnea over several days

Bilateral lower extremity edema and night sweats for two daysBilateral lower extremity edema and night sweats for two days

Dry cough and lowDry cough and low--grade fever (101grade fever (101F) 10 days agoF) 10 days ago

Recent chest painsRecent chest pains Thoracentesis for bilateral pleural effusionsThoracentesis for bilateral pleural effusions

Recently diagnosed atrial fibrillation & atrial flutter on admisRecently diagnosed atrial fibrillation & atrial flutter on admissionsion

Past Medical HistoryPast Medical History HypothyroidismHypothyroidism

Hodgkin lymphoma (radiation & chemotherapy)Hodgkin lymphoma (radiation & chemotherapy) Basal cell carcinomaBasal cell carcinoma

MedicationsMedications Levothyroxine 112 mcg/day, diltiazem 30 mg q12h, propafanoneLevothyroxine 112 mcg/day, diltiazem 30 mg q12h, propafanone

150mg q12h, warfarin150mg q12h, warfarin

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Case #3Case #3


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Case #3Case #3

WBC 13.6, Hgb 12.3, Platelets 384WBC 13.6, Hgb 12.3, Platelets 384

Na 131, K+ 3.9, creatinine 1.0Na 131, K+ 3.9, creatinine 1.0 TSH 25.4, free T4 1.0TSH 25.4, free T4 1.0

Cholesterol 131, trigs 54, LDL 89, HDLCholesterol 131, trigs 54, LDL 89, HDL

3131

BNP 833BNP 833

Erythrocyte sedimentation rate 120Erythrocyte sedimentation rate 120 C Reactive protein 115C Reactive protein 115

INR 4INR 4


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What is the Most LikelyWhat is the Most Likely


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Diagnosis?Diagnosis?1.1. HypothyroidismHypothyroidism

2.2. Acute pericarditisAcute pericarditis3.3. Pericardial tamponadePericardial tamponade

4.4. Restrictive cardiomyopathyRestrictive cardiomyopathy5.5. Constrictive pericarditisConstrictive pericarditis

6.6. Ischemic cardiomyopathyIschemic cardiomyopathy

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Constrictive PericarditisConstrictive Pericarditis


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Constrictive PericarditisConstrictive Pericarditis

Symptoms of heart failure withSymptoms of heart failure withpreserved ejection fractionpreserved ejection fraction

Due to thickening of pericardiumDue to thickening of pericardium Impairs diastolic fillingImpairs diastolic filling

Etiology in developed countriesEtiology in developed countries

IdiopathicIdiopathic Cardiac surgeryCardiac surgery

PericarditisPericarditis

Mediastinal radiation therapyMediastinal radiation therapy Tuberculosis is major cause inTuberculosis is major cause in

developing countriesdeveloping countries



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Constrictive Pericarditis vs.Constrictive Pericarditis vs.


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Restrictive CardiomyopathyRestrictive CardiomyopathyRestrictive Cardiomyopathy is RARERestrictive Cardiomyopathy is RARE

AmyloidosisAmyloidosis SarcoidosisSarcoidosis

Hypereosinophilic syndromesHypereosinophilic syndromes

Endomyocardial fibrosisEndomyocardial fibrosis

Chemotherapy or RadiationChemotherapy or Radiation



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Gross SpecimensGross Specimens


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Constrictive pericarditis vs.Constrictive pericarditis vs.Restrictive CardiomyopathyRestrictive Cardiomyopathy



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Diagnosis of ConstrictiveDiagnosis of Constrictive


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PericarditisPericarditisHistoryHistory

Physical examinationPhysical examination Jugular venous distentionJugular venous distention

KussmaulKussmauls sign (rise in JVD withs sign (rise in JVD with

inspiration)inspiration)

Pericardial knockPericardial knock

EKGEKG NonspecificNonspecific



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Chest XChest X--ray in Constrictive Pericarditisray in Constrictive Pericarditis


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Hemodynamics in a NutshellHemodynamics in a Nutshell


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Constrictive pericarditis vs. Restrictive CardiomyopathyConstrictive pericarditis vs. Restrictive Cardiomyopathy

In Constrictive Pericarditis there isIn Constrictive Pericarditis there is

ventricular interdependence accentuatedventricular interdependence accentuated

by respirationby respiration

As inspiration occurs, RV filling improves atAs inspiration occurs, RV filling improves at

the expense of LV fillingthe expense of LV filling

RV pressure increases as LV pressureRV pressure increases as LV pressure

decreasesdecreases

Echocardiographic criteria based on thisEchocardiographic criteria based on thisphenomenaphenomena

Can be measured invasivelyCan be measured invasively



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Hemodynamics in a NutshellHemodynamics in a Nutshell


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Constrictive pericarditis vs. Restrictive CardiomyopathyConstrictive pericarditis vs. Restrictive Cardiomyopathy



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Treatment of ConstrictiveTreatment of Constrictive


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PericarditisPericarditis If transient due to acuteIf transient due to acute

inflammation, medical therapyinflammation, medical therapy If chronic, pericardiectomy isIf chronic, pericardiectomy is

consideredconsidered

Surgical mortality approaches 6%Surgical mortality approaches 6%

Must be a complete pericardiectomyMust be a complete pericardiectomy



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Case #3 TreatmentCase #3 Treatment


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Case #3 TreatmentCase #3 eat e t

Started on furosemideStarted on furosemide

Levothyroxine dose increasedLevothyroxine dose increasedReferred to tertiary care center forReferred to tertiary care center for

pericardiectomypericardiectomy


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Congenital Absence ofCongenital Absence of


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PericardiumPericardium Usually partial absence of leftUsually partial absence of left

pericardiumpericardium

Male predominanceMale predominance

Associated withAssociated with

Atrial septal defectAtrial septal defect Bicuspid aortic valveBicuspid aortic valve

Bronchogenic cystsBronchogenic cysts

Usually asymptomaticUsually asymptomatic

May require surgical closure of partialMay require surgical closure of partial

defect if symptomaticdefect if symptomaticKhandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK. Pericardial disease: diagnosis and



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http://radiopaedia.org/encyclopaedia/quizzes/all/11753

http://www.ctsnet.org/sections/clinicalresources/clinicalcases/article-16.html

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ConclusionsConclusions


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Acute pericarditisAcute pericarditis

Most often viralMost often viral

Treat with high dose NSAIDS + colchicineTreat with high dose NSAIDS + colchicine

Pericardial tamponadePericardial tamponade

Often caused by malignancyOften caused by malignancy Volume support until pericardiocentesisVolume support until pericardiocentesis

Constrictive pericarditisConstrictive pericarditis

Suspect with diastolic heart failure symptoms,Suspect with diastolic heart failure symptoms,thickened pericardium, and history ofthickened pericardium, and history of

pericarditis or radiation exposurepericarditis or radiation exposure

Documents

CARDIOLOGY - Pericardial Diseases