Integrative Clinical Hemodyamics

Transcription

1 Integrative Clinical Hemodyamics James A. Goldstein, MD Director, Research & Education Division of Cardiology William Beaumont Hospital

2 Disclosure Information Integrative Clinical Hemodyamics James A. Goldstein, MD Nothing to Disclose

3 Integrative Clinical Hemodynamics Think Image Invade

4 55 yo Male Chest pain and SOB increasing over 4 days Hx Chest Radiation for Hodgkins 9 months PTA BP=85/55 RR= 32 Pulsus Paradox=15 mmhg Chest: Clear CV: JVP= mmhg with W pattern Carotid upstrokes intact Precordium quiet Pericardial friction rub present

5 What s the DDX? Chest Pain: Pericardial/pleural Myocardial ischemia Aortic Dissection Pulmonary embolus Other: Gi, Musc-skeletal, etc SOB: Pericardial/pleural Myocardial ischemia +/- CHF Valvular Disease: Rad induced Pulmonary embolus Pneumonia

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7 Etiologies of Pericarditis INFECTIOUS: INFLAMMATORY: Viral, bacterial, TBC, fungal. Post-infarction (Dresslers Post-pericardiotomy. Vasculitis (SLE, RA, Drugs, etc). Polyserositis (FMF, etc). Uremia. Post-irradiation. NEOPLASTIC IDIOPATHIC

8 Radiation Effects on the Heart Pericardial: Pericarditis, effusion, constriction, effusive-cp Myocardial: Fibrosis with restriction Coronary Disease: Arteriopathy w Intimal hyperplasia, esp L Main Valves: Inflammation & Fibrosis w Regurgitation or stenosis Conduction System: RBBB

9 Radiation Induced Pericardial Disease Risk Factors & Clinical Onset Incidence: 6-30% Risk Factors: Dose of Radiation Degree of Shielding Multiple Treatments Clinical Onset: Short Term: Days-weeks Pericarditis +/- Effusion Longer Term: Highly Variable Pericarditis +/- effusion may be months or years later Constriction typically later

10 55 yo Male Chest pain and SOB increasing over 4 days Hx Chest Radiation for Hodgkins 9 months PTA BP=85/55 RR= 32 Pulsus Paradox=15 mmhg Chest: Clear CV: JVP= mmhg Carotid upstrokes intact Precordium quiet Pericardial friction rub present

11 Hypotension, Clear Lungs with Right Heart Failure Tamponade Pulsus Paradoxus, Effusion on echo RVI Acute chest pain, STEMI by ecg, large RV no fluid on echo Acute PE SOB/chest pain, RV strain by ecg, large RV no fluid on echo P. HTN w RV Failure Chronic RHF, large RV no fluid on echo Constriction / Restriction Chronic Bivent CHF, small RV/LV on echo Right Heart Mass Obstruction Chronic RHF, RA/RV mass on echo Goldstein. Prog CVD 1998;40:325

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14 Dell' Italia LJ. NEJM 1998;338:979

15 EXTRA-THORACIC INTRA-THORACIC ITP -5 TO 30 mmhg DIFFERENTIAL EFFECTS OF INTRATHORACIC PRESSURES LEFT V RIGHT HEART

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17 PATHOPHYSIOLOGY OF PERICARDIAL PRESSURE ELEVATION Spodick. NEJM 2003;349:684

18 CARDIAC TAMPONADE: CLINICAL PRESENTATIONS DYSPNEA PREDOMINANT RIGHT HEART FAILURE HYPOTENSION SINUS TACHYCARDIA UNEXPLAINED CARDIOMEGALY

19 PERICARDIAL EFFUSION HEMODYNAMIC CONSEQUENCES Dependent On: Volume Of Effusion Acuity Of Accumulation Pericardial Compliance Myocardial Compliance And Function

20 CARDIAC TAMPONADE Meltser Henry & Kalaria V. Catheter Cardiovasc Interv 2005;64:245

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22 PERICARDIAL DISEASE Little WC et al. Circ 2006;113:1622

23 ATYPICAL COMPRESSION SYNDROMES REGIONAL TAMPONADE LOCUALTED EFFUSION INTRAPERICARDIAL HEMATOMA EFFUSIVE-CONSTRICTIVE TRANSIENT CONSTRICTION

24 PERICARDIAL HEMATOMA Regional Compression Especially P-Valve surgery on Coumadin

25 CONSTRICTIVE PERICARDITIS HEART ENCASED IN THICK VIRTUALLY INELASTIC SHELL WHEN NOT FULLY FILLED (SYST, EARLY DIAST) NO RESIST RESIST TO FILLING THROUGHOUT GREATER PART OF DIASTOLE HEART INCAPABLE OF FURTHER DISTENSION WITH INSP

26 Lorell and Grossman. Cardiac Cath and Angio 1998

27 EXTRA-THORACIC INTRA-THORACIC x x ITP -5 TO 30 mmhg X X X CONSTRICTIVE PERICARDITIS

28 CP: KUSSMAUL S Lorell and Grossman. Cardiac Cath and Angio 1998

29 CONSTRICTION: VENTRICULAR DISCORDANCE Higano et al. Cath and Cardiovasc. 1999;46:473

30 Normal Pericardium Constrictive Pericarditis

31 Radiation Induced Acute Fibrinous Pericarditis

32 FIBRINOUS PERICARDITIS Weyman Principles of Echocardiography

33 EFFUSIVE - CONSTRICTIVE Craig AS et al. NEJM 2004;350:476

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35 EFFUSIVE - CONSTRICTIVE Sagristà-Sauleda J et al. NEJM 2004;350:469

36 Radiation Induced Constriction

37 Radiation Induced Constriction: Poor Surgical Outcome Ling LH et al. Circ 1999;100:1380

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39 Does Dx Require Invasive Hemodynamics? NO Assuming pericardiocentesis results in complete resolution AND.Even Pts with Effusive-constrictive Dz typically resolve with drainage + Med Rx BUT Many pts with Radiation-induced pericarditis evolve into CP and may have RCM as well due to myocardial fibrosis Such pts may ultimately need R Ht Cath as prelude to surgery

40 Radiation Induced Effusive Disease What are the Optimal Rx Steps? Pericardiocentesis: Therapeutic & Diagnostic Indwelling Catheter Drainage? Anti-Inflammatory Agents? Indomethacin 50 mg TID, High Dose ASA 3-4 qd Corticosteroids Colchicine: 0.5 mg b.i.d.) with Prednisone; Then 1 mg qd with steroid taper over 1 month. Surgical Pericardiectomy? Even After Successful Drainage?

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43 Percent (%) Idiopathic Cardiac surgery Pericarditis Radiation Infection Arthritides Others to 1982 (n=231) 1985 to 1995 (n=135) 5/26/2010 Ling LH et al. Circ 1999;100:1380

44 Etiologies of Pericarditis INFECTIOUS: INFLAMMATORY: Viral, bacterial, TBC, fungal. Post-infarction (Dresslers Post-pericardiotomy. Vasculitis (SLE, RA, Drugs, etc). Polyserositis (FMF, etc). Uremia. Post-irradiation. NEOPLASTIC IDIOPATHIC

45 Acute Pericarditis: Complications Cardiac tamponade. Arrhythmias. Recurrent pericarditis. Pericardial constriction.

46 Management of Idiopathic Pericarditis INITIAL ATTACK: ASA (650 mg qd) + Indomethacin (25-50 mg q 8 h) If no improvement in 2 days: Methylpred. 500 mg qd FIRST x 2-5. RECURRENCE: Same as initial attack, but earlier steroids. SUBSEQUENT RECURRENCES: Steroids: Prednisone (10-60 mg qd). IV if prominent flare. CHRONIC Colchicine MAINTENANCE: (1 mg qd) followed Options by steroid taper over 1 month. Aspirin ( mg qd) Colchicine (1 mg qd) Prednisone (10-60 mg qd) Ibuprofen (? high dose) INTRACTABLE RECURRENT PERICARDITIS: Surgical Pericardectomy

47 Mayo Clinic Cardiology Review - 2nd Editio

48 CONSTRICTION Vaitkus et al. Circ 1996;93:834

49 CALCIFIC CONSTRICTIVE PERICARDITIS Cavendish J et al. Circ 2005;112:e137

50 NEJM 2000;343:106

51 Pericardial Thickening / Adhesions

52 TRANSIENT CP Haley JH et al. JACC 2004;43:271

53 Haley JH et al. JACC 2004;43:271

54 Frequency (%) Transient Nontransient CV Surgery Idiopathic Pericarditis CVD Infection Radiation 0 Other Haley JH et al. JACC 2004;43:271

55 Pericardial Tamponade with Right-Sided Collapse J am Coll Cardiol Intv 2009;2:

56 Repeat TTE

57 Repeat TTE Tricuspid Inflow Mitral Inflow

58 Admission CXR

59 A X Y RAP 18 mmhg Sinus Tachycardia Y>X Descent DFP Equalization Insp augment Blunted

60 EFFUSIVE-CONSTRICTIVE POST PERICARDIOCENTESIS Y RAP 8 mmhg HR slower Y Descent Enhanced Insp return augmented