Pericardial Diseases 2015 Update BRUCE W. USHER, MD PROFESSOR OF MEDICINE CARDIOLOGY DIVISION MEDICAL UNIVERSITY SOUTH CAROLINA CHARLESTON, SOUTH CAROLINA GUIDELINES: PERICARDIAL DISEASES Ø European Society of Cardiology 2004 1
OUTLINE u Review the anatomy and physiology u Role of Echo 2015 u Pericardial Effusion u Pericardial Tampanade u Pericardiocentesis u Balloon pericardial window vs surgical pericardial window u Pericarditis acute, chronic recurrent management colchicine u Transient constrictive pericarditis ANATOMY 2 LAYERS: u Outer thick fibrous, blends with adventitia of Ao and PA support u Inner serous membrane (single layer of mesothelial cells (Visceral) reflects back on itself to line the inside of the fibrous layer to form (Parietal) pericardium 2
VASCULAR AND NERVE SUPPLY u u u u ARTERIAL SUPPLY: Pericardiophrenic Art. ( branch of internal thoracic ) VENOUS DRAINAGE: Pericardiophrenic vein SENSORY INNERVATION: Phrenic nerve VASOMOTOR INNERVATION: sympathetic trunks PERICARDIAL FLUID u Normal = 10-50ml lubricates the contact of serosal layers u Ultrfiltrate of plasma proteins, electrolytes, & phospholipids (formed in visceral pericardium) u Drains via thoracic & right lymphatic ducts 3
FUNCTION u Reduce friction between heart & mediastinal structures u Barrier against local spread of infection and malignancy u Constrains cardiac filling PERICARDIUM RESTRAINT Intrapericardial pressure rises rapidly as intra pericardial volume is increased acutely Rapid Slow accumul. Edmunds HL: Cardiac surgery in the Adult, New York, McGraw-Hill, 1997, p1305 4
PERICARDIAL DISEASE: ROLE OF ECHO u Detection u Quantification u Hemodynamic significance u Echo guidance - pericardiocentesis PERICARDIAL EFFUSION - ECHO u The technique that probably provided the greatest impetus to the development of echocardiography in this country was the detection of pericardial effusion Harvey Feigenbaum, MD Echocardiography Lea & Febiger 1972 5
QUANTIFICATION ECHO u M Mode, 2D, 3D u 2 D: Minimal (physiologic) normal amount of fluid in a disease free state Small (<100ml) only posterior to the LV, distal to the AV groove, & with <1cm separation of layers Moderate (100-500ml) circumferential, extends posterior to LA, separation of layers 1-2cm Large (>500ml) same as moderate + separation of layers >2cm, & anteroposterior or mediolateral heart swinging in sac ETIOLOGY OF PERICARDIAL INFLAMMATION u Idiopathic u Infectious: bacterial, fungal, viral, parasitic u Connective tissue disorders u Neoplasia u Metabolic Disorder u Myocardial Infarction (Dressler s) u Irradiation u Asbestosis u Trauma perforation pacemaker, AFib ablation CVD Surgical 6
VERY LARGE PE: SWINGING HEART Accumulation >1000ml Usually malignant Electrical alternans MALIGNANT PERICARDIAL EFFUSION u MELANOMA* u LYMPHOMA u LEUKEMIA u BREAST** u LUNG ** u ESOPHAGEAL * Tumor with highest incidence of metastasis to the heart ** Most frequent tumors seen with metastasis to heart 7
INDICATIONS: Pericardiocentesis: u Cardiac tamponade u Moderate to large effusion refractory to medical therapy and with severe symptoms u Suspected bacterial or neoplastic etiology Pericardial window: u Recurrent tamponade u Recurrent moderate to large effusion refractory PERICARDIOCENTESIS: ECHO GUIDANCE u Feasibility: u Approach: location size loculation subxiphoid apical u Needle location confirmation 8
PERICARDIOCENTESIS: ECHO GUIDANCE u Feasibility: u Approach: location size loculation subxiphoid apical u Needle location confirmation PERICARDIOCENTESIS: ECHO GUIDANCE u Feasibility: location size loculation u Approach: subxiphoid apical u Needle location confirmation 9
PERICARDIOCENTESIS: ECHO GUIDANCE u Feasibility: u Approach: location size loculation subxiphoid apical u Needle location confirmation Pericardial Window u Surgical window u Percutaneous Balloon pericardiotomy u Drainage time 10
PERCUTANEOUS BALLOON PERICARDIOTOMY u u u u 1991 Palacios proposed for recurrent malignant PE Recurrence: pericardiocentesis 13 50% subxiphoid surgical window 5% Survival not improved with surgical window Modest perioperative risk Ziskind et al JACC Vol. 21, No. 1 January 1993:1-5 PERCUTANEOUS BALLOON PERICARDIOTOMY 11
PERCUTANEOUS BALLOON PERICARDIOTOMY Ziskind et al JACC Vol. 21, No. 1 January 1993:1-5 Pericardial Window u Surgical window u Percutaneous Balloon pericardiotomy u Drainage time: The key to preventing recurrence is maintaining a fluid free pericardial space for a prolonged period so that autosclerosis can occur!! 12
TRANSIENT CONSTRICTIVE PERICARDITIS (CP) u 1987 Sagrista-Sauleda 16 pts transient form of CP resolved without surgery Etiology: collagen vascular disorder, purulent bacterial, chemotherapy u 2004 Haley et al (Mayo Clinic) 1988-1999 212 pts CP/ 36 resolution of echo hemodynamic abn. without pericardiectomy most frequent etiology prior CV surgery (25%) resolution : average 8.3 wks from diagnosis TRANSIENT CONSTRICTIVE PERICARDITIS (CP) 1980 Hancock* described 2 forms of CP u Elastic or fibroelastic form represents acute or subacute phase and present with more subtle signs and symptoms u Rigid or chronic form inflammation continues > fibrosis and/or calcification * Hancock EW, Am Heart J 1980;100;917-23 13
TRANSIENT CONSTRICTIVE PERICARDITIS (CP) 1980 Hancock* described 2 forms of CP u Elastic or fibroelastic form represents acute or subacute phase and present with more subtle signs and symptoms u Rigid or chronic form inflammation continues > fibrosis and/or calcification * Hancock EW, Am Heart J 1980;100;917-23 Colchicine in Addition to Conventional Therapy for Acute Pericarditis Massimo Imazio, Marco Bobbio, Enrico Cecchi, Daniela Demarie, Brunella Demichelis, Franco Pomari, Mauro Moratti, Gianni Gaschino, Massimo Giammaria, Aldo Ghisio, Riccardo Belli, and Rita Trinchero Circulation Volume 112(13):2012-2016 September 27, 2005 14
Figure 1. Trial profile. Imazio M et al. Circulation. 2005;112:2012-2016 Copyright American Heart Association, Inc. All rights reserved. Figure 2. Kaplan-Meier event-free survival curves according to treatment groups (see text for details). Imazio M et al. Circulation. 2005;112:2012-2016 Copyright American Heart Association, Inc. All rights reserved. 15
CORE TRIAL: COLCHICINE RECURRENT PERICARDITIS Group 1 Group 2 Imazio M et al Arch Intern Med 165 2005: 1987-91 COLCHICINE PHARMOKINETICS u Lipid soluble u 44% viability u Peak plasma conc. 1 hr. u Long half- life u Enters RBC and leucocytes u Eliminated by liver (80-90%) u Hepatic cytochrome CY3A4 MECHANISM OF ACTION u Anti - inflammatory u Inhibits microtubule dynamics low conc. Inhibits formation high conc. promotes depolymerization u Impairs adhesion of neutrophils to vascular endothelium Deftereos, S et al JACC vol 62 No 20, 2013: 1817-25 16
COLCHICINE Deftereos, S et al JACC vol 62 No 20, 2013: 1817-25 CORP TRIAL COLCHICINE FOR RECURRENT PERICARDITIS Prospective, Randomized Double blind Placebo controlled Multicenter (4 hosp. Italy) 120 pts. first recurrence Imazio M et al Ann Intern Med. 2011; 155:409-414 17
COLCHICINE: CLINICAL STUDIES u Pericarditis initial onset recurrent u Atrial Fibrillation post op cardiac Surgery recurrence after ablation u CAD angioplasty (POBA, STENTS) Potential areas for study: Arrhythmias heart failure cardiac hypertrophy Defereos S et al J Am Coll Cardiol 2013;62:1817-25 OUTLINE u Review the anatomy and physiology u Role of Echo 2015 u Pericarditis acute, chronic recurrent management colchicine u Transient constrictive pericarditis u Pericardial Tamponade u Balloon pericardial window vs surgical pericardial window 18
REFERENCES u WC Little and Gregory L Freeman, Pericardial Disease Circulation 2006;113:1622 1632 u M Imazio et al, Controversial Issues in the Management of Pericardial Diseases Circulation, 2010;121:916-928 u Guidelines on the Diagnosis and Management of Diseases Euorpean Heart Journal n 2004;25:587-610 u M Imazio et al, Management of Pericardial Effusion European Heart Journal 2012 u Y Adler et al Colchicine Treatment for Recurrent Pericarditis: A Decade of Experience Circulation. 1998; 97:2183 2185 u M Imazio et al Colchicine as First-Choice Therapy for recurrent Pericarditis (CORE Trial) Arc Intern Med 2005; 165:1987-1991 u M Imazio et al Colchicine for Recurrent Pericarditis (CORP Trial) Annals Intern Med 2011;155:409-414 u S Deftereos et al Colchicine and the Heart J Am Coll of Cardiol 2013;62:1817-25 u JH Haley et al Transient constrictive pericarditis : causes and natural history J Am Coll Cardiol 2004;43:271 275 u Hancock EW On the elastic and rigid forms of constrictive pericarditis Am Heart J 1980;100:917-23 19
PERCUTANEOUS BALLOON PERICARDIOTOMY Ziskind et al JACC Vol. 21, No. 1 January 1993:1-5 20
OUTLINE u Review the anatomy and physiology u Role of Echo 2015 u Pericarditis acute, chronic recurrent management colchicine u Transient constrictive pericarditis u Pericardial Tamponade u Balloon pericardial window vs surgical pericardial window 21
VERY LARGE PE: SWINGING HEART Accumulation >1000ml Usually malignant Electrical alternans 22