Pericardial Diseases/Tamponade Illustrative Casesasecho.org/wordpress/wp-content/uploads/2017/01/Oh-Pericardial... · Pericardial Diseases/Tamponade Illustrative Cases Jae K. Oh,

1/18/2017

1

©2012 MFMER | 3200268v3(2010)-1

Pericardial Diseases/TamponadeIllustrative Cases

Jae K. Oh, MDEcho Hawaii 2017

©2016 MFMER | slide-2

47 year old man

• Chest pain

• Not exertional

• Normal Examination

Case #1

1/18/2017

2


47 year old man with chest painAbsent pericardium

• Usually left side

• Heart shifted to left

• Mostly asymptomatic

• Strangulation can happen


Congenital Absence of the Pericardium

Snoopy Sign

1/18/2017

3


Congenital Absence of the PericardiumDiagnostic Echo Study


Pericardial CystCase #2

1/18/2017

4


A large pericardial cyst

©2011

MFMER |

slide-7


Case #351 year old with SLE and BP 150/115

1/18/2017

5


57 year old male with STEMIThrombolysis and Stent

Hypotensive and tachycardic

1. Dopamine

2. IABP

3. Fluid

4. Surgery

Case # 4


57 year old man with STEMI

Hepatic vein diastolic

reversal with expiration

RV Diastolic Collapse

1/18/2017

6


74 year old man with chest pain for several days

• Normal LV

• Small pericardial effusion

• What to do?

Case # 5


Persistent pain and not feeling wellAtrial fibrillation and hypotension

1= Rate control 2= Steroid 3= Pericardiocentesis 4=More imaging

1/18/2017

7


What do you do now?

• 1.Steroid Therapy

• 2. TEE

• 3. CT

• 4. Surgery


Intraoperative TEE

1/18/2017

8


Tamponade Physiology

Pressure

Volume over time

Rapid effusion Slow effusion

Critical

tamponade

Limit of

pericardial

stretch

NEJM 349: 684, 2003

CP1299236-6


Cardiac Tamponade

RV collapse Mitral inflow variation HV expiratory reversal

1/18/2017

9


Case #677 yo man with severe aortic stenosisTAVR and PM implantation


77 yo man with severe aortic stenosisTAVR and PM implantation & RV Perforation

Pericardiocentesis yielded 125 cc of

bloody fluid

1/18/2017

10


77 yo man with severe aortic stenosisIncreasing dyspnea 2 months after pericardiocentesis


Effusive-Constrictive Pericarditis

Interventricular Dependence

Expiratory diastolic flow reversal

1/18/2017

11


©2011

MFMER |

slide-21

MRI DE in 2 patients with Constriction

Circulation Oct 3rd 2011

Baseline

Medical

RX

3 Months


©2011

MFMER |

slide-22

One week of Steroid RxTransient Constrictive Pericarditis

1/18/2017

12


©2011

MFMER |

slide-23

Transient ConstrictionReversible (N=14) Persistent (N=15)

Age 54 ± 17 59 ± 16

LVEF 57 ± 3 60 ± 3

E’ (cm/sec) 12 ± 1 11 ± 1

Steroid Rx 71 % 53 %

Pericardium 3.8 ± 0.6 mm 4.0 ± 0.6 mm

DE Pericardium 4.4 ± 0.4 mm 2.1 ± 0.4mm

Grade 3-4/4 DE 93 % 33 %

Sed rate 45 to 4 25 to 20

CRP 75 to 2 14 to 15


27 yo man with fatigue and dyspnea

• Sep. 2015…Flu-like symptoms, treated with inhaler

• Oct. 2015…Pre-syncopy and palpitation

• Pericardial rub

• Pericardial effusion on Echo

• Treated with Ibuprofen 2400 mg/d, Colchicine 0.6 mg BID

• Not feeling better and CRP 60

• Underwent pericardial window

Case # 7

1/18/2017

13


27 year old man underwent a windowReferred to Mayo

• Pericardial fluid …studies were negative

• Not feeling better

• RUQ abdominal pain and fatigue

• U/S…Enlarged gallbladder and liver


1/18/2017

14


27 yo man after pericardial window

1= CT 2= MRI 3= Cath 4= Pericardiectomy

Hepatic Vein

Expiratory Diastolic

Flow Reversal

Mitral Inflow

Mitral e’ = 15 cm/sec


Case #866 year old woman with dyspnea

• 2010 :Nissen fundoplication for Reflux

• 2012 : Gastric perforation, repaired

• June 2015 : Pneumothorax

• Oct 2015 : Dyspnea and chest pain

• Blood culture positive GP cocci

• Atrial fib with RVR

• Echocardiography obtained

1/18/2017

15


66 year old woman with dyspnea


66 year old woman with dyspneaGastro-pericardial fistula

Pneumo-pericardium

1/18/2017

16


©2012

MFMER |

3213949-31

Unusual caseWhat would you do for this patient?

• 45 y/o male with chest pain and dyspnea x 4 days

• Pain preceded by heavy lifting while camping. No relationship to exercise.

• MVA with pelvic and rib fractures. Chest tube and IVC filter placement 6 yrsago.

• Many risk factors

1=CT 2=Echo 3=Coronary angiogram 4=Stress test


©2012

MFME

R |

32139

49-32

Echocardiographic imagesWhat do you think?

1/18/2017

17


©2012

MFMER |

3213949-33

Chest and Cardiac CT


©2012

MFMER |

3213949-34

CT scans 2004 and 2012

1/18/2017

18


©2012

MFMER |

3213949-35

Embolic strut


©2012

MFMER |

3213949-36

1/18/2017

19


Most recent Interesting Case (being created)


Welles-04-07.mov

Echo guided Pericardiocentesis

18%3%

Chest wall

79%

SubcostalLocation

1/18/2017

20


Pericardial Diseases and TamponadeTake home message

• Always, identify underlying cause for pericarditis, pericardial effusion or tamponade

• Echo diagnosis of tamponade

• Plethoric IVC

• Diastolic collapse of RV, RA and LA

• Diastolic HV flow reversal with expiration

• Treat acute or effusive-constrictive pericarditis or pericardial inflammation with NSAID ( 1 month) and colchicine (0.6 mg BID for 3 months)


Thank You !

[email protected]

[email protected]

mailto:[email protected]

1/18/2017

21


50 yo man with Radiation Rx 32 years agoPresenting with HF 2 years after CABG


50 year old man with radiation Rx and CABG presenting with JVP elevation

Medial e’ 20 cm/sLateral e’ =12 cm/s

E= 90 cm/s Insp

E= 120 cm/s Exp

1/18/2017

22


Hepatic vein Doppler


50 yo man with CP

Documents

Pericardial Diseases/Tamponade Illustrative Casesasecho.org/wordpress/wp-content/uploads/2017/01/Oh-Pericardial... · Pericardial Diseases/Tamponade Illustrative Cases Jae K. Oh,