Cath Conference August 6, 2008

1. Cath ConferenceAugust 6, 2008 Priya Pillutla, M.D. Kimble Poon, M.D.

2. History • 34 y/o M, no PMH • 2 months prior to admission - URI • URI resolved but +SOB, LE edema • OVMC – Dx’d with pericarditis and R heart failure • NSAIDs: no improvement • Repeat TTE: thickened pericardium • Transferred here for further management Priya Pillutla, M.D.

3. Still complains of SOB and LE edema • No fevers or constitutional symptoms • Meds – Ibuprofen • NKDA • Social - +tobacco Priya Pillutla, M.D.

4. Physical Exam BP 130/84, HR 80, RR 14, sat 100% RA Morbidly obese JVP 15 cm Normal carotid upstrokes RRR nl s1/s2. +S3 +pericardial knock Lungs clear Lower extremity edema Priya Pillutla, M.D.

5. Electrocardiogram Priya Pillutla, M.D.

6. Transthoracic Echocardiography Priya Pillutla, M.D.

7. Echocardiographic evidence for pericardial constriction

8. Echocardiographic evidence for pericardial constriction • Thickened pericardium and tram-tracking • Ventricular interdependence • Septal bounce • Respiratory variation of inflow velocities • Normal or elevated mitral annulus motion • Resolution after therapy

9. Thickened pericardium and tram-tracking • Pericardial thickness >3mm is abnormal but not sensitive or specific for constriction • Tram-tracking: during diastole, the parietal pericardium and visceral pericardium are straight and fixed • This is in contrast to normal pericardial movement and cardiac tamponade

11. Tram-tracking in pericardial constriction

12. Tram-tracking in pericardial constriction

13. Absence of tram-tracking in a patient with cardiac tamponade During diastole, the visceral pericardium expands outward as the ventricle fills

14. Absence of tram-tracking in a patient with no pericardial disease

15. Ventricular interdependence • During inspiration, the RV is preferentially filled at the expense of the LV

17. During expiration, the LV fills at the expense of the RV

18. Septal bounce • 2D manifestation of ventricular inter-dependence

20. Respiratory variation of inflow velocities • MV variation >25% • TV variation >40%

21. Peak 99 cm/s Trough 57 cm/s Difference 42 cm/s % variation 42/57 = 74%

22. Peak 80 cm/s Trough 38 cm/s Difference 42 cm/s % variation 42/38= 110%

23. Normal or elevated mitral annulus motion • Because the lateral motion of the ventricle is constricted, motion along the basal to apical axis is exaggerated • E’ > 7 is consistent with constriction

24. E’ = 17

25. Resolution after therapy • Variation disappears after definitive therapy

26. Peak 110 cm/s Trough 105 cm/s Difference 5 cm/s % variation 5/105 = 5%

27. Peak 60 cm/s Trough 50 cm/s Difference 10 cm/s % variation 10/50 = 20%

28. Presence of effusion

29. Diagnosis Effusive-pericardial constriction

30. Right heart catheterization Priya Pillutla, M.D.

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39. Summary • Pericardial effusion • Thickened pericardium • Severely restricted cardiac motion • Steep x and y descent on RA pressure waveform • Near equalization of diastolic pressures in all chambers Findings consistent with effusive-constrictive pericaditis Priya Pillutla, M.D.

40. Management • Pericardiectomy was performed • Large effusion • Pericardial thickening especially adjacent to right ventricle • Difficult dissection • Visceral pericardium removed up to the phrenic nerve laterally and the diaphragm inferiorly • Intraoperative TEE showed improved diastolic filling Priya Pillutla, M.D.

41. At discharge: • Resolution of shortness of breath and edema • Pericardial biopsy - nonspecific inflammation, thickening of the pericardium • Effusion – micro, chemistry negative Priya Pillutla, M.D.

42. Effusive-Constrictive Pericarditis • First characterized by Hancock in 1971 • Constriction caused by visceral pericardium in presence of tense pericardial effusion • Usually diagnosed after pericardiocentesis for tamponade • Elevated RAP despite normal intrapericardial pressure • In this case, mixed findings during RHC suggested diagnosis Priya Pillutla, M.D.

43. Priya Pillutla, M.D. NEJM, 2004

44. Priya Pillutla, M.D. NEJM, 2004

45. From Guide to Hemodynamic Data in the Coronary Care Unit(Sharkey) Priya Pillutla, M.D.

46. N = 15 (largest series to date) Priya Pillutla, M.D.

47. Diagnostic criteria: • Tamponade that evolved into constriction (failure of RAP to fall by at least 50% or less than 10 mmHg) after reduction of intrapericardial pressure to 0 • Methods • Complete pressure measurements obtained prior to and following pericardiocentesis (all chambers, IPP, femoral pulsus) • Pericardial fluid sent for chemistry, cyto, micro, AFB Priya Pillutla, M.D.

48. Treatment varied • NSAIDs • Avoided steroids • Pericardiectomy for constriction and severe/persistent heart failure • If milder heart failure, medical therapy to allow possible spontaneous resolution • F/U – every 3 months for a year (if pericardiectomy) then q3-5 years Priya Pillutla, M.D.

49. Results • 15 patients met criteria (~1200 consecutive patients with pericarditis; prevalence 1.3%) • All had signs of R heart failure • 2/3 had pulsus paradoxus • Effusions predominantly serosanguinous Priya Pillutla, M.D.

50. Management • Inflammatory symptoms – NSAIDs • All patients – pericardiocentesis (13/15 had improvement) • 7/14 had pericardiectomy for persistent R heart failure • 4 idiopathic, 1 radiation, 1 TB, 1 postsurgical • Nonspecific inflammation of the pericardium Priya Pillutla, M.D.