Case report no . 3, Department of P athological Physiology

1. Casereport no. 3,Department of Pathological Physiology V. Danzig, MD, PhD,2nd Dept. Internal MedicineCardiology andAngiologyDivision 1st Med.F CUNI Case-report seminar 3 1

2. Patient history • Female, 57 years old • Family history: father died aged 78, diabetes, prostate cancer • (Ab)usus: “reduced smoking” to 1 cigarette/ day half year ago, it used to be 10 cigarettes daily before, alcohol drinking denies • Gynecological history: 2 childbirths, 4 months breastfeeding, menopausis • 4 years ago incidental mammographic finding of breast cancer in upper left quadrant, treated by: excision, then repeated excision, axillary exenteration, adjuvant chemo-therapyand radio-therapy, histologically: invasive ductal carcinoma, highly malignant. Case-report seminar 3 2

3. Patient history - questions • Can you find some risk factors in the patient history at the onset of carcinoma? (roll back one slide) • What are dangers of possible generalizations of early captured breast cancer? • Can cancer therapy have adverse effects on heart? Case-report seminar 3 3

4. Patient history – answers Can you find some risk factors in the patient history at the onset of carcinoma? Important is family history (ca mammae in family), gynecological history, breastfeeding and its duration, smoking. What is the risk of possible generalizations of early diagnosed breast cancer? Exceptionally early generalization is possible in case of invasive and little differentiated tumor. Can cancer therapy have adverse effects on heart? Yes, cardiotoxic chemoterapy, radiotherapy. Case-report seminar 3 3b

5. Currentdisorder • Two years agoduring oncological checkup, a generalization of cancer has been found, with mediastinal lymphatic adenopathy, and affected liver. • One year ago, on PET/CT scan, besides progression of the lymphatic adenopathy, alsofound pericardial and pleural effusion • Pericardial effusion classified as highly suspected as malignant, chemotherapy adjusted/ changed • Both clinically and on ECGwithout signs of cardiac tamponade Case-report seminar 3 4

6. Pericardial effusion notable especially at right atrium (betweennos. 6 and 9 on the yellow scale on left) RV Effusion(cca 0,5 cm) RA LV Effusion(cca 3 cm) LA Case-report seminar 3 Apical projection 4AC 5

7. Pericardial effusion In area of RA and slightly around LV enlargement of pericardium is visible, presence of fluid (effusion) RA wall is not yet compressed Case-report seminar 3 6

8. Pericardial effusionshown in M-mode- before right ventricle and behind back wall of left ventricle,larger in systole, +++ denoted by blue crosses +++ RV wall RV Septum LV with mitralvalve * * Back wall of pericardium Case-report seminar 3 diastole systole 7

9. Pericardial effusionshown in M-mode- before right ventricle and behind back wall of left ventricle,larger in systole, +++ denoted by blue crosses +++ Behind the back wall of the ventricle enlargement is visible (effusion – separation of two pericardium sheets); it changes with heart action (larger in the systole – „more space“) Case-report seminar 3 8

10. Currentdisorder – questions • What are mechanisms of propagation of malignant tumor in organism? • What does the “PET/ CT scan” stand for? What physiological principle this imaging method uses in detection of malignant and inflammatory processes? • Under what circumstances can pericardial effusion cause tamponade and what are conditions of its emergence? • What heart cavities are more prone to compression and why? • What physical phenomena (in palpation and listening) are found in pericardial effusion? Case-report seminar 3 9

11. Currentdisorder – answers What are mechanisms of propagation of malignant tumor in organism? Per continuitatem, lymfogenic, hematogenic. What does the “PET/ CT scan” stand for? What physiological principle this imaging method uses in detection of malignant and inflammatory processes?Positron emission tomography in the combination with CT; hypermetabolisms of glucose in inflammation and even more in tumorous tissue. Under what circumstances can pericardial effusion cause tamponade and what are conditions of its emergence?Mainly amount of effusion and time during it developed. What heart cavities are more prone to compression and why?Those with low intracavital pressure, mainly right atrium. What physical phenomena (in palpation and listening) are found in pericardial effusion?Apex non palpable, heart sounds weak or not heard due to the isolation by the effusion. In which moment of heart cycle is the effusion more visible and why? In the systole, there is more space. Case-report seminar 3 9b

12. Next development of the disorder • Last year in summer, clinical signs of cardiac tamponade showed for the first time, confirmed by the echo-cardiography. • Patient indicated to pericardial puncture. In hemorrhagic effusion, tumor elements have been found. • Due to recurrences of pericardial effusion with signs of tamponade, punctures have been indicated repeatedly, one together with cytostatic application into pericardium Case-report seminar 3 10

13. Pericardial tamponade effusion effusion Case-report seminar 3 11

14. Pericardial tamponade Case-report seminar 3 12 The amount of fluid has substantially increased The compression of RA walls is visible

15. Vena cava inferior dilated,with absent respiratory variability liver Vena cavainf. RA Case-report seminar 3 13

16. Dilatation of vena cava inferior and the absence of its respiratory variability Case-report seminar 3 14 The vein is borderline enlarged (cca 20 mm) In animation the variantion of its size (width) would depending on the respiratory cycle would not be visible (the pressure in the pericardium is higher than the impact of pressure changes induced by breathing)

17. Fluctuations of trans-mitralflow Case-report seminar 3 15

18. Fluctuations of trans-mitralflow Case-report seminar 3 … are evident in larger tamponade even in left parts of the heart – on the picture it is visible on ECHO, causing pulsus paradoxus 16

19. Tamponade Case-report seminar 3 17 Collapse of RA Dilatation of vena cava inferior and the absence of the respiration induced change of its size Fluctuations of trans-mitralflow Depends onamount of the fluidvelocity of its formation

20. Next development of the disorder – questions • Under what conditions is cardiac tamponade manifested? What are pressures and pressure relations in pericardium and in the right heart cavities? • Why the compression of parts of left heart are much more rare compared to the right heart? • What are clinical signs of cardiac tamponade? Into what two groups can be these signs divided according to their origin? • What is “pulsus paradoxus”, can you explain its cause? Case-report seminar 3 18

21. Next development of the disorder – answers Case-report seminar 3 18b Under what conditions is cardiac tamponade manifested? What are pressures and pressure relations in pericardium and in the right heart cavities?The pressure of the increasing amount of fluid becomes higher than the pressure in the right atrium and later than the right ventricle. Why the compression of parts of left heart are much more rare compared to the right heart?The pressure is about 5x higher. What are clinical signs of cardiac tamponade? Into what two groups can be these signs divided according to their origin?1. From the accumulation of blood before the right heart 2. from the decreased cardiac output. What is “pulsus paradoxus”, can you explain its cause?Fluctuation of puls wave depending on the respiratory cycle.

22. Last developments – last hospital admission to date Patient admitted to hospital with developed edemas of lower extremities (symmetrical on both legs under knees), right side chest pain and with hepatomegalia As highly suspect cause of right heart insufficiency was given diagnosis of constrictive pericarditis. Because of cancer with prognostic pessimism, a conservative (= pharmacological) treatment was recommended Case-report seminar 3 19

23. Last developments – questions • What are the causes of progression of constrictive pericarditis after its several recurring attacks (and after attacks of pericardial infiltration by cancer)? What can be other factors involved in this patient? • What are other manifestations of right heart insufficiency besides the leg edemas and hepatomegalia? • What other alternative to conservative treatment of recurring idiopatic pericarditis can can be chosen in case of more optimistic prognosis (=it is a surgical procedure…)? Case-report seminar 3 20

24. Last developments – answers Case-report seminar 3 20b What are the causes of progression of constrictive pericarditis after its several recurring attacks (and after attacks of pericardial infiltration by cancer)? What can be other factors involved in this patient?Adhesion and often calcifications in them; intrapericardial administration of cytostatics. What are other manifestations of right heart insufficiency besides the leg edemas and hepatomegalia?Increased filling of neck veins and in the area of vena cava superior. What other alternative to conservative treatment of recurring idiopatic pericarditis can can be chosen in case of more optimistic prognosis (=it is a surgical procedure…)?Total perikardectomy.

25. Conclusions • There are several conditions, which can cause pericardial effusion. • Amount of fluid in pericardium and the speed of the fluid production (slower production enables adaptive mechanisms of parietal pericardium) are factors important for the development of this condition. • Cardiac tamponade occurs when the pressure in pericardial cavity is higher than pressure in right heart and subsequently in other heart partitions. • Signs of tamponade have clear patho-physiological cause and can be divided into 2 groups : 1- due to low cardiac output, 2- due to congestion of blood before the right heart. Case-report seminar 3 20c

26. Conclusions II • The threat of cardiac tamponade can be detected before its full development by echo-cardiographic imaging. • Echo-cardiography is crucial in diagnosis of pericardial effusion and the puncture is performed under ultrasonographic guidance. • Pericardial adhesions and their subsequent calcifications lead to a fixed constrictive pericarditis picture. • A surgical treatment of choice is pericard-ectomia. This is however a patient challenging cardiac surgery which is typicaly not possible in cancer patients. Case-report seminar 3 20d