Πνευμονική υπέρταση και περικαρδιακή συλλογή. Τρόποι αντιμετώπισης Γεώργιος Λάζαρος Καρδιολόγος, Διευθυντής ΕΣΥ Α Πανεπιστημιακή Καρδιολογική Κλινική Ιπποκράτειο Γ.Ν. Αθηνών
Pericardial syndromes o Acute and recurrent pericarditis, isolated pericardial effusion, and constrictive pericarditis represent the main pericardial syndromes. Imazio M. et al. Curr Pharm Des 2015;21:525-30.
o Acute pericarditis is diagnosed in approximately 0.1% of hospitalized patients and accounts for 5% of emergency department visits for chest pain in the absence of myocardial infarction. o The incidence of acute pericarditis was 27.7 cases per 100.000 population/year and in 2/3 of cases affect males. Lazaros G, et al. Hellenic J Cardiol 2009;5:345-351. Imazio, M, et al. 2008:94:498-501.
One year mortality
Pericardial disorders in pulmonary hypertension I. Acute (and recurrent) infectious pericarditis with or without effusion. II. Chronic pericardial effusion in the absence of systemic inflammation (most common).
i. Distinct features of acute pericarditis in patients with pulmonary hypertension o Actually the are no significant differences with respect to etiology, diagnostic work-up and short term outcome of acute pericarditis in patients with pulmonary hypertension. o However, in the above patients there is concern about the fluid retention due to NSAIDs administration which may further decompensate those vulnerable patients. o Moreover, the eventual increase of blood pressure due to NSAIDs could eventually contribute to further decompensation.
o For the above mentioned reasons and given the high prevalence of chronic kidney disease in pulmonary hypertension with right heart failure patients (~40%) NSAIDs should be administered at the lower effective doses and for the shorter possible period in patients with creatinine clearance <50ml/min. o They are contraindicated in patients with clearance below 30ml/min (aspirin is allowed for clearance>10ml/min). o In the above patients corticosteroids may constitute an alternative approach under medical surveillance.
33-year-old-man with complex cyanotic congenital heart disease* and pulmonary hypertension *Tricuspid atresia, double outlet right ventricle, ventricular septal defect, transposition of great vessels, severe pulmonary valve stenosis
ii. Pericardial effusion in pulmonary hypertension In normal conditions o The normal pericardial fluid is an ultrafiltrate of plasma and characteristically has a low protein concentration similar electrolyte composition and low specific gravity. o It is produced by the serosal layer of the pericardium and it is drained by the subepicardial venous and lymphatic lymphatics drainnage plexus of parietal pericardium.
Pathogenesis of pericardial effusion in pulmonary hypertension Pulm Circ 2013;3:467 477.
o The prevalence of pericardial and pleural effusions has been reported at 12% - 20% and 87%, respectively in CHF. o Pericardial effusion forms only with elevation of the right-sided filling pressure in the heart. Natanzon A, et al. Am J Med Sci 2009;338:211-216. Kataoka H. Am Heart J 2000;139:918 923. Maisch B. Curr Opin Cardiol 1994;9:379 388. Kessler KM, et al. Chest 1980;78:736 470.
Parameters of the right ventricular function and dimension. RVareaD (cm 2 ) Fractional area change % TAM (mm) Frohlich G, et al. Eur Heart J 2013:34:1414 1423.
Pericardial involvement in pulmonary arterial hypertension o Pericardial effusion in the setting of pulmonary artery hypertension (PAH) is common (25 30%) and typically small in size and rarely causes haemodynamic compromise. o Pericardial effusion development in PAH appears to relate to right ventricular failure and a subsequent increase in right-sided filling pressures.
Features of cardiac tamponade in pulmonary arterial hypertension o Diagnosis of cardiac tamponade in a patient with severe PAH is challenging. o High right-sided pressures can mask many of the typical right-sided clinical and echocardiographic findings of tamponade (right-sided chamber collapse is uncommon) o In contrast since left atrial pressure is typically lower in PAH and therefore left atrial early diastolic collapse is more commonly seen as well as exaggerated interventricular interdependence with inspiration.
o Moreover, pulsus paradoxus and hypotension are usually absent. o The absence of pulsus paradoxus is explained by the incapacity of the noncompliant right ventricle to alter its filling volumes in response to the respiratory cycle. o Hypotension may be absent in some of these patients because of a compensatory increase in systemic vascular resistance. Pulm Circ 2013;3:467 477.
o Even a small quantity of excess pericardial fluid in a patient with PAH portends a poor prognosis and has been associated with connective tissue disease, shorter 6-minute walk distance and an elevated B- type natriuretic peptide level.
76-year-old-man with ASD and pulmonary hypertension
Management of pericardial effusion in patients with pulmonary arterial hypertension
o Cardiac tamponade is a clear indication for drainage. o However, an unexpectedly high rate of deaths has been reported during or immediately after drainage. Pulm Circ 2013;3:467 477.
o It is postulated that removal of the pericardial effusion leads to the enlargement of the right ventricle cavity, which further pushes the interventricular septum, compressing the left ventricle and leading to hypotension and death. o A reduction in coronary blood flow during diastole in a hypertrophic right ventricle can also cause right ventricular ischemia with hemodynamic deterioration. o A slow flow removal of fluid through pericardial catheter placement is probably warranted. South Med J 2008;101:490 494.
Management of pericardial effusion in patients with pulmonary arterial hypertension
Impact of PAH-specific therapy in the management of pericardial effusion o A controlled, randomized, multicenter trial involving patients with PAH evaluated the size of the pericardial effusion before and after 16 weeks of bosentan treatment. o The authors reported an improvement in the amount of pericardial effusion in treated patients (56pts) compared with placebo (29pts). o Resolution of pericardial effusion with therapy suggests better prognosis. J Am Coll Cardiol 2003;41:1380 1386. Echocardiography 2015;32:1471 1476.
J Am Coll Cardiol 2003;41:1380 1386.
Conclusions The presence of pericardial effusion in patients with PAH is an indicator of right heart failure associated with poor outcome The treatment of larger pericardial effusion in the absence of tamponade remains controversial. Resolution of pericardial effusion with therapy is feasible and suggests better prognosis.