Pericardial disease. Se-Jung Yoon Cardiology division NHIS Ilsan hospital

Transcription

1 Pericardial disease Se-Jung Yoon Cardiology division NHIS Ilsan hospital

2 Normal pericardial effusion

3 Normal pericardium

4 Normal pericardium Pericardial Layers: Visceral layer Parietal layer Fibrous pericardium

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6 Anatomy of pericardium thin avascular sac comprising two layers ; the visceral and parietal pericardium encompass the heart and a portion of the adjoining great vessels Sagristà-Sauleda J, et al. N Engl J Med 2004; 350: Faisal FS, et al. Heart Fail Rev 2013; 18:

7 Normal pericardium

8 Normal pericardium Normally <2 mm thick normal amount of pericardial fluid is < 50 ml transudative with a low protein content pressure differential between the pericardium and the cardiac chambers (transmural pressure) is about 3 mm Hg

9 The role of pericardium 1. provides structural support 2. optimizes cardiac pressure volume relationships 3. act as barrier to infection, metastasis.. Spodick DH Marcel Dekker, New York Faisal FS, et al. Heart Fail Rev 2013; 18:

10 Pericardial Agenesis

11 Pericardial Disease The common underlying physiologic abnormality impaired diastolic filling of the heart Significant constrictive pericarditis right-sided heart failure Pericardial tamponade systemic hypotension Combinations of the disease effusive-constrictive pericarditis

12 Pericardial Effusion in Echo? 1. Amount 2. Location 3. Character 4. Hemodynamic significance

13 Effusion

14 Cardiac Tamponade

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19 Variation of cardiac pressure

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22 Pericarditis

23 Pericarditis

24 Constrictive pericarditis Constrictive pericarditis was recognized at autopsy in the 19th century and described as a chronic fibrous callous thickening of the wall of the pericardial sac that is so contracted that the normal diastolic filling of the heart is prevented

25 The difference between the subacute & chronic forms of constrictive pericarditis whether only the visceral pericardium is fused to the epicardium of the heart (subacute) both the visceral and the parietal pericardial layers are fused together (chronic) In both instances, the diastolic pressures in the atria are elevated due to the restriction of ventricular diastolic inflow.

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27 Constriction? Tamponade? and the Effect?

28 Flow pattern in constrictive pericarditis Inspiration Expiration

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30 Significant respiratory variations in the mitral E velocities

31 Perimyocarditis Myopericarditis Myocarditis Pericarditis ACS-like Myocarditis

32 Etiology Acute Pericarditis Infectious Viral : Coxsackie, Echo, EBV, Influenza, HIV Bacterial: TB, staph, hemophillus, pneumococcal, salmonella Fungal/other: histo/blasto/coccidio, rickettsia Rheumatologic SLE, Sarcoid, RA, Dermatomyositis, Ankylosing Spondylitis, Scleroderma, PAN Neoplastic Primary: angiosarcoma, mesothelioma Metastatic: breast, lung, lymphoma, melanoma, leukemia Immunologic Celiac sprue, Inflammatory Bowel Disease Drug Hydralizine, Procainamide Other MI, Dressler s, Post Pericardiotomy, Chest Trauma, Aortic dissection Uremic, Post Radiation IDIOPATHIC

33 Etiology Acute Pericarditis Common causes T = Trauma, TUMOR U = Uremia M = Myocardial infarction (acute, post) Medications (hydralazine, procain) O = Other infections (bacterial, fungal, TB) R = Rheumatoid, autoimmune disorder Radiation

34 Tuberculous pericarditis F/55 C.C ; chest discomfort, palpitation, fever for 2 months EKG ; a fib

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37 2 months later : After window formation and NSAID

38 Initial 2 months 1yr

39 Effusive Constrictive Pericarditis

40 C.C ; DOE, fever for 2 weeks M/54

41 After window formation

42 Pericardial inflammation in tuberculous effusive-constrictive pericarditis on MR imaging Russell JB, et al. Cardiovasc J Afr 2008; 19(4):200 1

43 The reported prevalence of ECP among patients with a pericardial effusion has ranged widely, from 1% to 2% to more than 50% Sagrista-Sauleda J, et al. N Engl J Med 2004; 350: Nugue O, et al. Circulation 1996;94: Ntsekhe M, et al. Cardiovasc J Afr 2012;23: van der Bijl P, et al. J Cardiovasc Ultrasound 2016;24:

44 Effusive Constrictive Pericarditis Clinical hemodynamic syndrome in which constriction of the heart by the visceral pericardium occurs in the presence of tense effusion in a free pericardial space. Sagristà-Sauleda J, et al. N Engl J Med 2004; 350:

45 The hallmark of effusive constrictive pericarditis persistence of elevated RA pressure after intrapericardial pressure has been reduced to normal levels by removal of pericardial fluid Sagristà-Sauleda J, et al. N Engl J Med 2004; 350: Faisal FS, et al. Heart Fail Rev 2013; 18:

46 Definitions of effusive constrictive pericarditis On the basis of hemodynamic findings during combined pericardiocentesis and cardiac catheterization. The diagnostic criterion was tamponade that evolved into constriction (with failure of the RA pressure to fall by 50 % or more or to a level below 10 mm Hg) after intrapericardial pressure was lowered to near 0 mm Hg by the removal of pericardial fluid. Sagristà-Sauleda J, et al. N Engl J Med 2004; 350: Faisal FS, et al. Heart Fail Rev 2013; 18: Ntsekhe M, et al. J Am Coll Cardiol 2009; 53(10):A169

47 The component of effusive constrictive pericarditis Pericardial inflammation Constriction Pericardial effusion under pressure Sagristà-Sauleda J, et al. N Engl J Med 2004; 350: Faisal FS, et al. Heart Fail Rev 2013; 18:

48 Echo in EPC persistence of IVC dilatation Significant respiratory variations in the mitral E velocities Expiratory diastolic flow reversals in the hepatic veins

49 Marked respirophasic shift in ECP Expiration Inspiration

50 Pericardial effusion in CT and MR moderate pericardial effusion Pericardial thickening in late Ga enhancement

51 Pericardial effusion in CT and MR CT T1-weighted MR balanced SSFP CMR Large oval-shaped pericardial effusion

52 Pericarditis in CT

53 Pericardial effusion in MR Systolic collapse of the right atrial wall during systole

54 Pericarditis in MR : delayed enhancement imaging initial F/U

55 Acute viral pericarditis in MR Diffuse hyperintense appearance of the pericardium on T2-weighted image

56 Constrictive pericarditis in MR Short-axis T1- weighted spin-echo CMR LGE CMR Diffusely thickened pericardium, with strong enhancement of the pericardial layers after Ga enhancement

57 Effusive pericardial constriction Little WC, et al. Circulation 2006;113:

58 Others

59 Dressler s syndrome F/85 Cc. : dyspnea PHx : STEMI (1w ago), CAD 1vd, s/p PCI c stent at mlad, A-fib, Asthma, Old CVA

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61 Post window formation

62 Uremic pericarditis M/58 Cc. : dyspnea PHx : DM, HTN, hypothyroidism, ESRD on HD

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64 Metastasis F/86

65 Post window formation

66 Metastasis F/85

67 Respiratory variation of Mitral E velocity

68 Chest CT and PET CT

69 Take Home Message 1. The understanding of pericardium 2. The significance of hemodynamics

70 Thank you!

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72 Normal cardiac blood flow during inspiration and expiration

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75 Post op adhesion