Pericardial effusion: 2 cases. Christina Attenhofer Jost SGK 2016
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1 Pericardial effusion: 2 cases Christina Attenhofer Jost SGK 2016
2 Case yo F with chest pain Chest pain since 1.5 yr, left side, not related to exercise, oppression, DOE No cardiovascular risk factors Physical exam unremarkable apart from pectus excavatum, exquisite pain of the chest wall on compression, no edema, normal jugular venous pressure, no pericardial rub BP 110/80, HR 80bpm ECG normal
3 Case yo F with chest pain Evaluation with echo, ECG, computed tomography of the chest and cardiac CMR: pericardial effusion Referred to exclude pericarditis/constrictive pericarditis
4 5 Mayo Clinic criteria for constrictive pericarditis Dissociation of intrathoracic and intracardiac pressures along with interventricular coupling or dependence within a fixed space: Respiration-related ventricular septal shift Variation in mitral inflow E velocity 14.6% (not valid in afib/flutter) Medial mitral annular e' velocity 9cm/sec Ratio of medial mitral annular e' to lateral e 0.91 Hepatic vein expiratory diastolic reversal ratio 0.79 Welsh. Circ Cardiovasc Imaging Independent predictors
5 5 Mayo Clinic criteria for constrictive pericarditis Any respiration-related ventricular septal shift (parasternal long axis) Variation in mitral inflow E velocity by 14.6% Welsh. Circ Cardiovasc Imaging. 2014
6 Mayo Clinic criteria for constrictive pericarditis Medial mitral annular e' velocity of 9cm/sec Ratio of medial mitral annular e' to lateral e 0.91 Anulus reversus or anulus paradoxus Welsh. Circ Cardiovasc Imaging. 2014
7 Mayo Clinic criteria for constrictive pericarditis Hepatic vein expiratory diastolic reversal ratio 0.79 Welsh. Circ Cardiovasc Imaging. 2014
8 5 Mayo Clinic criteria for constrictive pericarditis The presence of ventricular septal shift in combination with either medial e' 9 cm/s or hepatic vein expiratory diastolic reversal ratio 0.79 corresponded to a desirable combination of sensitivity (87%) and specificity (91%) for constrictive pericarditis. Welsh. Circ Cardiovasc Imaging. 2014
9 Case yo F with chest pain -18.3%
10 Case yo F with chest pain
11 Case yo F with chest pain LV inflow Lateral E 12cm/sec Medial E 10cm/sec
12 Case yo F with chest pain no ventricular septal shift
13 Case yo F with chest pain CMR Normal sized left ventricle, EF 47 %, LVEDV 60ml No signs of ischemia Pericardial effusion up to 6mm No thickening of pericardium
14 Diagnosis? No echo or CMR signs of constriction or pericardial inflammation/thickening, only pericardial effusion TSH normal No signs of collagen vascular disease No prior malignancy, radiation therapy, infection etc. Simple pericardial effusion in pectus excavatum and chest wall pain
15 Echo 18 pts CMR 18 pts P value LVEF 62±7 59± RVOT enlargement 28% 6% 0.13 Localized RV wall anomalies 28% 33% 1.0 RV enlargement 0 28% 0.06 Pericardial effusion 33% 56% 0.13 Diminished RV systolic function Prominent moderator band 11% RV FAC<33% 44% (RVEF<52%) % 22% 1.0 Any signs of ARVC 39% 56% 0.45
16
17 Steady-state free precession axial image by CMR showing microaneurysms of the RV anterior wall a bright layer of fluid (arrows) around the posterior wall of LV representing the pericardial effusion.
18 70year old woman with pectus excavatum: ARVC?!?
19 Pectus excavatum Cardiopulmonary morbidity Psychosocial impact 1:400 males>>>females CTD, neuromuscular disease, Noonan, Turner, MEN type 2b Exercise intolerance 82%; chest pain 68%; Shortness of breath 42% From wikipedia.de
20 Pectus excavatum in CTD Marfan syndrome 1:5000-1: FBN 1 mutation Noonan syndrome 1:1000-1:2500; PTPN11 mutation Turner syndrome 45X, 1:2500 Cobben Eur J Med Gen 2014
21 Echo in Pectus Excavatum RV changes reversed curvature RV free wall, RV and RVOT enlargement, rounding of RV apex, sacculation of RV free wall (microaneurysms), regional or global RV dysfunction, prominent RV sacculations, moderator band hypertrophy, prominent crista terminalis, regional RV wall thinning Mitral or tricuspid valve prolapse Pericardial effusion Aortic root enlargement Silbiger 2016
22 ASD>VSD, PAVSD, aortic root enlargement CTD ARVC like Mitral- and tricuspid valve prolapse Pericardial effusion
23 Case y male with dyspnea and edema 1942 diphtheria 1965 tuberculosis neck, tuberculostatic RX 1993 brucellosis with epididymitis 2009 chronic hepatitis C, genotype IB (liver biopsy) - treatment with faldaprevir and deleobuvir, relapse! - then successful standard treatment with Peg-INF and Ribavirin 2011
24 Case y male with dyspnea and edema Current problem: Since one year, dyspnea, loss of appetite, increase in BW by 4-5kg, edema, abdominal bloating, palpitations, some memory loss
25 Case y male with dyspnea and edema 68kg, 182cm BP 141/74, HR 75/min, O2 Sat 93%. Elevated JVP. Heart examination unremarkable. Hyperpigmentation lower extremities. Liver at rib cage, indurated. Spleen not palpable.
26 Case y male with dyspnea and edema Holter ECG 48 hours: 433 VPCs; no VT, 247 APCs
27 Case y male with dyspnea and edema
28 Case y male with dyspnea and edema
29 Case y male with dyspnea and edema Septal 12cm/s Lateral 10cm/s 32%
30 DD constrictive pericarditis (Up-to-date) Idiopathic or viral % Post-cardiac surgery % Post-radiation therapy 2-31 % primarily after Hodgkin s disease or breast cancer Connective tissue disorder 3-7 % Postinfectious (Tbc or purulent pericarditis) 3-15 % Miscellaneous causes (malignancy, trauma, druginduced, asbestosis, sarcoidosis, uremic pericarditis) 1-10 %
31 CXR: no pericardial calcification. Effusion both sides. Consolidation right base DD dystelectasis
32 Lab tests June 2015 Hb 13.5, WBC 3.1, platelets 113, lymphocytopenia 0.44x10E9/l INR 1.09, D-Dimers 0.34, ygt 198, alkphosph 205, normal GOT, GPT, Calcium Hb A1c 5.8%, BNP 47, NT-proBNP 482, Cholesterol 3.4, LDL 1.8, TSH 2.6, ft4 16, CRP weeks later: WBC 3.18, platelets 127 ACE 50 (20-70), normal protein electrophoresis
33 CT chest and abdomen lymphadenopathy with calcified, increased and enlarged lymph nodes in the chest and abdomen; bronchiectases with peribronchial infiltrates in the middle lobe of unknown etiology
34 Case 2. CMR Aug 24, 2015 Pleural effusion both sides Thickened pericardium Septal shudder No significant calcifications Tiny late-enhancement (midline) inferior and inferolateral basal segment Increased signal apex RV, inferolateral CONSTRICTIVE PERICARDITIS, Tbc?
35 Case y male with dyspnea and edema Pulmonary function testing normal incl. diffusion capacity Bronchoscopy: chronic deforming bronchitis, hemorrhagic pleural effusion, multiple small nodular pleural lesions on both sides Puncture pleural effusion: no malignant cells, bacterial cultures negative, culture and PCR negative for Tbc
36 Case 2. Thoracoscopy Aug 2015: pleura without adhesions, granulomatous inflammation Pericardial thickening, adherent to the heart, inflammatory reaction Right side: ML segment resection, pericardial biopsy and pleural abrasion, talk pleurodesis Biopsy: Sarcoidosis (Interferon-induced) with constriction and signs of biventricular failure 2009 chronic hepatitis C, genotype IB (liver biopsy) - treatment with faldaprevir and deleobuvir, relapse! - successful standard treatment with Peg-Interferon and Ribavirin 2011
37 Interferon-induced sarcoidosis Hep C, 43yo male: peginterferon and ribavirin After 5 months red changes and hyperpigmentation scars, noncaseating granulomas IF induced sarcoidosis: 70% lung/lymphnodes, skin in 60% IF stop, systemic steroids as needed, frequently benign with clinical remission Cardoso. BMJ Case Reports 2011
38 Case 2. Interferon induced sarcoidosis Sarcoidosis: Lung, heart (right, left, pericardium), brain? Medication Prednisone 25mg (for a total of 6 months) Torasemide 10mg ½-0-0 PET-CT: calcified lymph nodes, some activity heart, FDG uptake right lung Cardiac CMR, echo: improvement
39 Definite cardiac sarcoidosis 9 patients Possible cardiac sarcoidosis 23 patients Mean age, years (+/ ) (+/ ) Gender Female Male Sinus rhythm Atrial fibrillation QRS duration (mean) PR interval (mean) AV block - first degree - second degree - total AV block 9 5 (55.55%) 4 (44.44%) 9/9 (100%) 0/9 (0%) (+/ ) (+/ ) 5/9 (55.55%) 1/9 (11.11%) 1/9 (11.11%) 3/9 (33.33%) (52.17%) 11 (47.82%) 22/23 (95%) 1/23 parox (5%) (+/ ) (+/ ) 6/23 (26.08%) 3/23 (13.04%) 0/23 (0%) 3/23 (13.04%) Pacemaker 4/9 (44.44%) 3/23 (13.04%) Complete right bundle branch block 2/9 (22.22%) 5/23 (21.73%) Complete left bundle branch block 1/9 (11.11%) 1/23 (4.34%) Pericardial effusion/thickening 0/9 (0%) 3/23 (13.04%) Ventricular tachycardia 2/9 (22.22%) 6/23 (26.1%) Scar by echo 4/9 (44.44%) 4/23 (17.39%) Scar by CMR 5/9 (55.55%) 6/23 (26.08%) Myocardial biopsy 5/9 (55.55%) 4/23 (17.39%) Immunosuppressant therapy 6/9 (66.66%) 4/23 (17.39%) Poster SGK 2016: Attenhofer Jost, Dominik Maurer et al.
40 Sometimes you may be wrong and sarcoidosis can be the culprit
41 end
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