THE PERICARDIUM: LOOKING OUTSIDE THE HEART

THE PERICARDIUM: LOOKING OUTSIDE THE HEART

DISCLOSURE Relevant relationships with commercial entities none Potential for conflicts of interest within this presentation none Steps taken to review and mitigate potential bias N/A

LEARNING OBJECTIVES This lecture is designed to meet the following end-of-week learning objective(s): 1. Please copy from the objective(s) previously designed and confirmed. 2. The subsection lead(s) is/are responsible for accuracy of this slide by confirming with CPLAN, our curriculum map, or Course Director.

MODULE OBJECTIVES By the end of this module, you should be able to: Describe the anatomy and physiology of the pericardium Describe clinical presentation, pathophysiology, diagnosis, and management of pericardial syndromes

PHYSIOLOGY Mechanical protection and reduces friction Distributes pressure Mediates ventricular coupling

PERICARDIAL SYNDROMES Pericarditis: acute, incessant, chronic and recurrent Pericardial effusion Pericardial tamponade Constrictive pericarditis

DIAGNOSIS Adler et al Eur Heart J 2015; ESC Guidelines

DIAGNOSIS

DIAGNOSIS Echo is a part of the diagnostic algorithm No finding is pathognomonic Assessment for complications and potentially give insight into etiology

ETIOLOGY Infectious Virus - enteroviruses, herpesviruses, adenoviruses, parvovirus B19 Bacterial -TB Fungal Parasitic

ETIOLOGY Non-infectious Autoimmune Neoplastic Metabolic Traumatic/Iatrogenic Drug related

Adler et al Eur Heart J 2015; ESC Guidelines

Adler et al Eur Heart J 2015; ESC Guidelines

Adler et al Eur Heart J 2015; ESC Guidelines

Adler et al Eur Heart J 2015; ESC Guidelines

PROGNOSIS Severe complications are related to etiology Quality of life can be severely affected

CLINICAL CASE 38 yo male presents with retrosternal non radiating chest pain exacerbated by deep inspiration Vitals: 132/80, HR 92 regular, temp 38 ECG: PR depression with isolated ST elevation in inferior leads CXR: normal CRP: elevated, troponin normal

Adler et al Eur Heart J 2015; ESC Guidelines

FOCUS POINTS Pericarditis is an inflammatory condition Most common aetiology idiopathic/presumed viral Diagnostic tools: history, physical exam, CXR, ECG, echo Risk stratify to determine need for hospitalization Treat with exercise restriction, antiinflammatories and colchicine

PERICARDIAL EFFUSION normal pericardial sac contains 10-50 ml of pericardial fluid, a plasma ultrafiltrate pathologic processes can result in accumulation of fluid either exudative or transudative

ETIOLOGY Idiopathic Neoplasm Infectious Iatrogenic CTD CHF Pulmonary hypertension

CLASSIFICATION Adler et al Eur Heart J 2015; ESC Guidelines

CLINICAL PRESENTATION Depends on the rate and amount of fluid accumulation Increase in pericardial pressure results in an inability of the heart to fill in diastole

PATHOPHYSIOLOGY Increased pericardial pressure Exaggerated ventricular interdependence Dissociation of intrathoracic pressures

CARDIAC TAMPONADE Classic presentation: Beck s Triad Elevated jugular venous pressure Pulsus paradoxus Muffled heart sounds

CARDIAC TAMPONADE Jugular Vein Pulsus Paradoxus

DIAGNOSIS ECG: low QRS voltage and electrical alternates CXR: enlarged cardiac silhouette Echo: identifies effusion, estimate size, location and degree of hemodynamic compromise

PERICARDIAL TAMPONADE M-Mode/2-D Doppler early diastolic collapse of the RV late diastolic inversion of the RA abnormal septal motion respiratory variation in chamber size IVC dilation MV inflow variations >30% HV expiratory diastolic flow reversals

PERICARDIOCENTESIS

CLINICAL CASE 35 yo male stabbed in a knife fight Vitals: HR 102, SBP 90 mmhg, pulsus paradoxus of 18 mmhg Physical: JVP at 10 cm, diminished diastolic descent, muffled heart sounds

FOCUS POINTS Pericardial effusion can result from an exudative or transudative process Classify based on rate of accumulation, amount of fluid, location and hemodynamic compromise Increases in pericardial pressure impedes diastolic filling and enhances interdependence Tamponade is a clinical diagnosis and is life threatening Echo is key in chara

CONSTRICTIVE PERICARDITIS Ling et al Circulation 199;100:1380

CLINICAL PRESENTATION Characterized by signs and symptoms of right sided heart failure unique physical exam findings: Kussmaul s sign and pericardial knock Absence of myocardial disease

KUSSMAUL S SIGN Johnson et al Clin Med Res 2009; 7(3): 107-112

PATHOPHYSIOLOGY Hatle et al Circulation 1989;79:357 Oh et al JACC 1994;23:154

PATHOLOPHYSIOLOGY

DIAGNOSIS Based on the association of the signs and symptoms of right heart failure and impaired diastolic filling due to pericardial constriction as determined by: CMR Echo CT Cardiac catheterization

TREATMENT Mainstay of treatment is surgical - pericardiectomy Poor predictors: prior radiation reduced renal function elevated PASP abnormal systolic function reduced Na levels older age

TREATMENT In the absence that the condition is chronic and there is evidence of inflammation a trial of anti inflammatory therapy is recommended transient constrictive pericarditis

CLINICAL CASE 29 yo male originally from Nigeria 10 week history of fevers and progressive shortness of breath, exercise intolerance 102/62, 100 bpm, JVP distended, Kussmaul s sign present, prominent Y descent Muffled heart sounds, nl S1 and S2, early diastolic sound

FOCUS POINTS Constrictive pericarditis is the result of a non compliant pericardium that limits filling Should be considered when patients present with heart failure and preserved systolic function Multimodality imaging used in diagnosis Chronic condition treated surgically

MODULE OBJECTIVES By now, you should be able to: Describe the anatomy and physiology of the pericardium Describe clinical presentation, pathophysiology, diagnosis, and management of pericardial syndromes