Pericardial Diseases/Tamponade Illustrative Cases
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1 Pericardial Diseases/Tamponade Illustrative Cases Jae K. Oh, MD Echo Hawaii MFMER v3(2010)-1 Case #1 47 year old man Chest pain Not exertional Normal Examination 2016 MFMER slide-2 1
2 47 year old man with chest pain Absent pericardium Usually left side Heart shifted to left Mostly asymptomatic Strangulation can happen 2016 MFMER slide-3 Congenital Absence of the Pericardium Snoopy Sign 2016 MFMER slide-4 2
3 Congenital Absence of the Pericardium Diagnostic Echo Study 2016 MFMER slide-5 Case #2 Pericardial Cyst 2016 MFMER slide-6 3
4 A large pericardial cyst 2011 MFMER slide MFMER slide-7 Case #3 51 year old with SLE and BP 150/ MFMER slide-8 4
5 Case # 4 57 year old male with STEMI Thrombolysis and Stent Hypotensive and tachycardic 1. Dopamine 2. IABP 3. Fluid 4. Surgery 2016 MFMER slide-9 57 year old man with STEMI Hepatic vein diastolic reversal with expiration RV Diastolic Collapse 2016 MFMER slide-10 5
6 Case # 5 74 year old man with chest pain for several days Normal LV Small pericardial effusion What to do? 2016 MFMER slide-11 Persistent pain and not feeling well Atrial fibrillation and hypotension 1= Rate control 2= Steroid 3= Pericardiocentesis 4=More imaging 2016 MFMER slide-12 6
7 What do you do now? 1.Steroid Therapy 2. TEE 3. CT 4. Surgery 2016 MFMER slide-13 Intraoperative TEE 2016 MFMER slide-14 7
8 Tamponade Physiology Critical tamponade Pressure Limit of pericardial stretch Rapid effusion Slow effusion NEJM 349: 684, 2003 Volume over time CP MFMER slide-15 Cardiac Tamponade RV collapse Mitral inflow variation HV expiratory reversal 2016 MFMER slide-16 8
9 Case #6 77 yo man with severe aortic stenosis TAVR and PM implantation 2016 MFMER slide yo man with severe aortic stenosis TAVR and PM implantation & RV Perforation Pericardiocentesis yielded 125 cc of bloody fluid 2016 MFMER slide-18 9
10 77 yo man with severe aortic stenosis Increasing dyspnea 2 months after pericardiocentesis 2016 MFMER slide-19 Effusive-Constrictive Pericarditis Interventricular Dependence Expiratory diastolic flow reversal 2016 MFMER slide-20 10
11 MRI DE in 2 patients with Constriction Medical RX Baseline 3 Months 2011 MFMER Circulation Oct 3 rd slide MFMER slide-21 Transient Constrictive Pericarditis One week of Steroid Rx 2011 MFMER slide MFMER slide-22 11
12 Transient Constriction Reversible (N=14) Persistent (N=15) Age 54 ± ± 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 MFMER slide MFMER slide-23 Case # 7 27 yo man with fatigue and dyspnea Sep Flu-like symptoms, treated with inhaler Oct 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 2016 MFMER slide-24 12
13 27 year old man underwent a window Referred to Mayo Pericardial fluid studies were negative Not feeling better RUQ abdominal pain and fatigue U/S Enlarged gallbladder and liver 2016 MFMER slide MFMER slide-26 13
14 27 yo man after pericardial window Mitral Inflow Hepatic Vein Expiratory Diastolic Flow Reversal Mitral e = 15 cm/sec 1= CT 2= MRI 3= Cath 4= Pericardiectomy 2016 MFMER slide-27 Case #8 66 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 2016 MFMER slide-28 14
15 66 year old woman with dyspnea 2016 MFMER slide year old woman with dyspnea Gastro-pericardial fistula Pneumo-pericardium 2016 MFMER slide-30 15
16 Unusual case What 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 yrs ago. Many risk factors 1=CT 2=Echo 3=Coronary angiogram 4=Stress test 2012 MFMER MFMER slide-31 Echocardiographic images What do you think? MFMER slide-32 MFME 16
17 Chest and Cardiac CT 2012 MFMER MFMER slide-33 CT scans 2004 and MFMER MFMER slide-34 17
18 Embolic strut 2012 MFMER MFMER slide MFMER MFMER slide-36 18
19 Most recent Interesting Case (being created) 2016 MFMER slide-37 Echo guided Pericardiocentesis Welles mov Chest wall 79% 3% 18% Subcostal Location 2016 MFMER slide-38 19
20 Pericardial Diseases and Tamponade Take 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) 2016 MFMER slide-39 Thank You! Oh.jae@mayo.edu Jaekuen.oh@samsung.com 2016 MFMER slide-40 20
21 50 yo man with Radiation Rx 32 years ago Presenting with HF 2 years after CABG 2016 MFMER slide year old man with radiation Rx and CABG presenting with JVP elevation E= 90 cm/s Insp E= 120 cm/s Exp Lateral e =12 cm/s Medial e 20 cm/s 2016 MFMER slide-42 21
22 Hepatic vein Doppler 2016 MFMER slide yo man with CP 2016 MFMER slide-44 22
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