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After effusion is diagnosed, assess for presence of tamponade
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Cardiac Tamponde
• Sinus tachycardia
• Elevated Jugular Venous Pressure
• Pulsus Paradoxus
Effusion with tamponade
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M mode
Respiratory inflow variation
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• Drop in • Mitral flow by 30 percent - first
beat of inspiration , • Tricuspid valve flow by 60
percent – first beat of expiration
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IVC Plethora
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Pericardiocentesis
• Done for
– Tamponade
– Diagnosis – especially for malignancy history
• Don’t do
– Concern for aortic dissection
Summarize Pericardial Effusion:
• Wide spectrum in presentation and severity
• Recognize presentation and imaging features of tamponade
• Pericardiocentesis if needed
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Diseases of the Pericardium
1. Acute pericarditis
• Chronic pericarditis
2. Pericardial effusion
• Pericardial Tamponade
3. Constrictive pericarditis
• Restrictive Cardiomyopathy
4. Pericardial Cysts
Pericardial Constriction
• Recognize presentation
• Select appropriate testing
• Select appropriate management
• Differentiate between Constrictive Pericarditis and Restrictive Cardiomyopathy
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Pathophysiology
• Result of scarring and consequent loss of the normal elasticity of the pericardial sac
• Cardiac filling is impeded by an external force
– Virtually inelastic parietal and/or visceral pericardial tissue, which is thickened, fibrotic, and sometimes calcified
– Results in a markedly impaired ability to adapt to volume changes
– greatly enhanced ventricular interdependence, in which the hemodynamics of the left and right heart chambers are directly influenced by each other to a much greater degree than normal
Constrictive Pericarditis Presenting symptoms:
• CHF 67%
• Chest pain 8%
• GI Symptoms 6%
• Tamponade 5%
• Arrhythmia 4%
• Liver Disease 4%
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Constrictive Pericarditis Presenting signs:
• Elevated JVP 88%
• Peripheral edema 64%
• Hepatomegaly 53%
• Pericardial knock 47%
• Ascites 37%
• Kussmaul’s 21%
• Pulsus paradoxus 19%
JVP
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Constrictive Pericarditis: CXR and CT
Geske et al. JACC 68, 2016:2329-47
Constrictive Pericarditis
• Hallmark – Ventricular interdependance
• Dynamic hemodynamics during respiratory cycle
• Reflect increased ventricular interaction
• Dissociation between intrathoracic and intracardiac pressures
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Constrictive Pericarditis
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Constrictive Pericarditis - Treatment
• Exclude acute pericarditis
• Medical management
• Surgery – pericardial stripping
• Acute/ transient effusive constrictive pericarditis can be treated with aggressive anti-inflammatory therapy
Effusive-constrictive pericarditis
• Constrictive physiology with a coexisting pericardial effusion, often with cardiac tamponade
• Results in a mixed hemodynamic picture with features of both constrictive pericarditis and cardiac tamponade
• Mistakenly thought to have only cardiac tamponade
• Elevation of the right atrial and pulmonary wedge pressures after drainage of the pericardial fluid points to the underlying constrictive process
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Think Constriction
• Heart failure - Right heart failure – out of proportion to myocardial or valve findings
• History of radiation – Breast cancer
– Lymphoma
• History of prior cardiac surgery
• Constriction
– Disease of the pericardium
• Restriction
– Disease of the myocardium
Constriction versus Restriction
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Constriction versus Restriction: Hemodynamics
• Restriction – Ventricular concordance
– LV smaller, RV smaller, normal pericardium
– BNP usually elevated
– Left atrial enlargement
– Abnormal tissue doppler
– Elevated filling pressures
– RVSP, very high (>55 – 60 mm Hg)
• Constriction – Ventricular discordance
– LV smaller, RV larger
– BNP usually not much elevated
– Left atrium is normal in size
–Normal tissue doppler
– RVSP <35-45 mm Hg
Right atrial pressure tracings
Geske et al. JACC 68, 2016:2329-47
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Geske et al. JACC 68, 2016:2329-47
58 Geske et al. JACC 68, 2016:2329-47
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Constrictive Pericarditis
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• Constriction
– Disease of the pericardium
• Restriction
– Disease of the myocardium
Constriction versus Restriction
Summarize Pericardial Constriction:
• High index of suspicion
• Role of symptoms, EKGs, inflammatory markers
• Ventricular interdependence
• Exclude Pericardial inflammation
• Management – symptomatic - surgery
• Effusive Constrictive Pericarditis
• Disease of the pericardium – difference from restriction
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Diseases of the Pericardium
1. Acute pericarditis
• Chronic pericarditis
2. Pericardial effusion
• Pericardial Tamponade
3. Constrictive pericarditis
• Restrictive Cardiomyopathy
4. Pericardial Cysts etc
Pericardial Cysts
• Pericardial cysts
• Pericardial tumors
• Metastatic disease
• Congenital absence of pericardium
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Pericardial Cyst
• Usually diagnosed incidentally
• 1:100,000
• CT, MR are preferred
• Mostly asymptomatic
• Resect if symptomatic
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70
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Pericardial Malignancy
• Usually secondary
• Common primary – Lung
– Breast
– Esophagus
– Hematologic
– Melanoma
• If a patient with prior cancer history presents with large effusion, think recurrent/ metastatic
Pericardial Malignancy
• Treat symptomatically
– Tap for tamponade and for diagnosis
– Non-steroidal tx for pericardial pain
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Congenital Absence of Pericardium
Image from ScienceDirect.com
• Partial or complete
• Mostly asymptomatic
• Partial – herniation
• Complete – asymptomatic
• 50% associated with other Congenital cardiac defects
• Management – surgery if needed
Congenital Absence of Pericardium
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Outline
1. Anatomy of pericardium
2. Pericardial disease
• Pericarditis – Acute or recurrent
• Pericardial effusion
• Pericardial tamponade
• Constrictive pericarditis
• Pericardial Cysts, Malignancy, Congenital absence of pericardium