Hemodynamic ConferenceEckhard Alt, M.D.Holger Salazar, M.D.Robert Smith, M.D., M.Sc.Tulane University School of MedicineCardiac Cath ConferenceDecember 23, 2003
OutlineRight Heart Catheterization OverviewReview of Waveform AnalysisPractice CaseCase Presentation with RHC ResultsDiscussion of Differential DiagnosisReview of Echocardiographic Findings and Follow upDiscussion
Right Heart CatheterizationMeasures Central Venous Pressure/Right Atrial PressureMeasures RV Pressures and PA PressuresGives Indirect Measure of Left Atrial Pressure (PCWP)Avoids Septal PunctureEstimates Cardiac OutputQuantifies Oxygen UtilizationUseful in Diagnosis of Shock EtiologyUseful for Peri-Operative Volume Management
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.
Family History: No family h/o heart disease
Social History: Denies EtOH, Tobacco, Drugs. One lifetime sexual partner
Physical Exam 123/72 62 16 97.2Comfortable, NADJVD present at 9 cm, + hepatojugular refluxnlS1S2, 2/6 HSM apexDecreased breath sounds at bilateral basesAbd distended with + fluid wave. Liver was palpable 3 cm below the costal margin and the spleen tip was palpableNo LE edema
LabsNa 134K+ 3.9Cl- 100HCO3- 27BUN 13Cr 0.9Glucose 89Ca 8.9LDH 118
AST 37ALT 11AP 75TP 7.9Alb 3.0TB 1.8CK 21CKMB 0.4Troponin
Labs (cont)WBC 12.2Hgb 12.2Hct 36.6Plt 190MCV 90Neutrophils 70%Lymphocytes 22%Basophils 0%Eosinophils 1%Monocytes 7%INR 1.4PTT 35.6Blood Cultures Drawn
Ascites FluidClear and YellowWBCs 21RBCs 453Albumin 2.6TP 4.8LDH 74Glucose 104Cholesterol 20Gram Stain and cultures sentCytology sent
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.
Differential DiagnosisConstrictive PericarditisRestrictive Cardiomyopathy
Etiologies of Constrictive PericarditisCommon Causes-Idiopathic-Infection Bacterial: TBFungal: Histoplasmosis, CoccidiomycosisViral: CoxsackieParasitic: Amebiasis, Echinococcus-Drugs-NeoplasticLymphoma, Melanoma, Primary Mesothelioma, Breast & Lung cancer-Following Cardiac Surgery-Connective Tissue Disease RA, SLE, Scleroderma, Dermatomyositis-Trauma-Renal Failure-Radiation-AICD/Pacer placementUncommon 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 CardiomyopathyPrimary RCM-Loefflers cardiomyopathy-Idiopathic RCM-Endomyocardial Fibrosis Secondary RCM
Infiltrative Noninfiltrative -Sarcoidosis -Fabrys Disease -Amyloidosis -Hemochromatosis -Post Radiation -Glycogen Storage Therapy Disease -Gauchers Disease -Scleroderma -Hurlers Disease -Pseudoxanthoma Elasticum -Storage Disease
Echocardiographic PresentationHolger Salazar, M.D.
Chene3-preop, continuing 5
Chene3-preop, continuing 9
Chene3-preop, continuing 1
Chene3-preop, continuing 4
Follow UpPericardial biopsy (done during pericardectomy) showed dense fibrous tissue with focal dystrophic calcification and mesothelial hyperplasiaThe pericardium was densely calcified and adherentEpicardial biopsy showed dense fibrous tissue without evidence of active inflammation or malignancyPericardial fluid was bloody and contained atypical mesothelial cellsPericardial fluid was smear and culture negative for AFBPericardial fluid was smear and culture negative for bacteria and fungiSerum ANA was negativePPD was negativeHIV was negative
Follow Up (cont)The underlying etiology remains unclearThe patient has developed refractory atrial fibrillation with RVRAnticoagulation has been complicated by a lower GI bleed He failed to improve after pericardectomy, and has recently been referred to transplant clinic