pericardial diseases illustrative cases · after pericardiocentesis 2 months later. 1/9/2018 9...
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©2018 MFMER | 3712003-1
Pericardial DiseasesIllustrative Cases
Jae K. Oh, MD
©2018 MFMER | 3712003-2
47 year old man
•Chest pain
•Not exertional
•Normal Examination
Case #1
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©2018 MFMER | 3712003-3
47 year old man with chest pain
• Usually left side
• Heart shifted to left
• Mostly asymptomatic
• Strangulation can happen
©2018 MFMER | 3712003-4
Congenital Absence of the Pericardium
Snoopy Sign
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Pericardial CystCase #2
©2018 MFMER | 3712003-6
A large pericardial cyst
©2011 MFMER | slide-6
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©2018 MFMER | 3712003-7
Case #351 year old with SLE and BP 150/115
©2018 MFMER | 3712003-8
57 year old male with STEMIThrombolysis and Stent
Hypotensive and tachycardic
Case # 4Case #4
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©2018 MFMER | 3712003-9
57 year old man with STEMI
Hepatic vein diastolic reversal with expiration
RV Diastolic Collapse
©2018 MFMER | 3712003-10
Tamponade Physiology
Pressure
Volume over time
Rapid effusion Slow effusion
Criticaltamponade
Limit of pericardial stretch
NEJM 349: 684, 2003CP1299236-6
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©2018 MFMER | 3712003-11
Cardiac Tamponade
RV collapse Mitral inflow variation HV expiratory reversal
©2018 MFMER | 3712003-12
Hemo‐pericardiumCase #5
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©2018 MFMER | 3712003-13
Intramural Hematoma
©2018 MFMER | 3712003-14
66 year old woman with dyspneaPneumo-pericardium
PneGastro-pericardial fistulau
Case #6
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©2018 MFMER | 3712003-15
77 yo man with severe aortic stenosisTAVR and PM implantation & RV Perforation
Pericardiocentesis yielded 125 cc of bloody fluid
Case #7
©2018 MFMER | 3712003-16
77 yo man with severe aortic stenosisIncreasing dyspnea 2 months after pericardiocentesis
After Pericardiocentesis 2 months later
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©2018 MFMER | 3712003-17
Effusive-Constrictive Pericarditis
Interventricular Dependence
Expiratory diastolic flow reversal
©2018 MFMER | 3712003-18
Tamponade vs Effusive CP
Miranda et al. In Preparation
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©2018 MFMER | 3712003-19
©2011 MFMER | slide-19
MRI DE in 2 patients with Constriction
Circulation Oct 3rd 2011
Baseline
Medical RX
3 Months
©2018 MFMER | 3712003-20
©2011 MFMER | slide-20
One week of Steroid RxTransient Constrictive Pericarditis
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©2018 MFMER | 3712003-21
©2011 MFMER | slide-21
Transient ConstrictionReversible (N=14) Persistent (N=15)
Age 54 ± 17 59 ± 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 15
©2018 MFMER | 3712003-22
35 yo man presents with dyspnea and feverBP 80/40 mmHg
Case #8
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©2018 MFMER | 3712003-23
35 yo man with tamponade and feverTEE after pericardiocentesis
©2018 MFMER | 3712003-24
36 yo man with dyspnea, chest pain, and abd pain
Case #9
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©2018 MFMER | 3712003-25
36 yo man with dyspnea, chest pain, and abd pain
Case #9
©2018 MFMER | 3712003-26
36 yo man with dyspnea, chest pain, and abd pain
Case #9
Sarcoidosis
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©2018 MFMER | 3712003-27
Pericardial Diseases and TamponadeTake 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• Interventricular dependence• Diastolic HV flow reversal with expiration
• We may be able to identify the patients who may develop effusive-constrictive pericarditis at the time of pericadiocentesis
©2018 MFMER | 3712003-28
Thank You !
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©2018 MFMER | 3712003-29
©2012 MFMER | 3213949-29
©2018 MFMER | 3712003-30
Questions & Discussion
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©2018 MFMER | 3712003-31
Welles-04-07.mov
Echo-Guided Pericardiocentesis
18%3%
Chest wall 79%
SubcostalLocation