Diese Präsentation wurde erfolgreich gemeldet.
Wir verwenden Ihre LinkedIn Profilangaben und Informationen zu Ihren Aktivitäten, um Anzeigen zu personalisieren und Ihnen relevantere Inhalte anzuzeigen. Sie können Ihre Anzeigeneinstellungen jederzeit ändern.

Pericardial diseases 2

113 Aufrufe

Veröffentlicht am

Continuation of pericardial diseases...worth to go through..wont disappoint

Veröffentlicht in: Gesundheit & Medizin
  • Did u try to use external powers for studying? Like ⇒ www.HelpWriting.net ⇐ ? They helped me a lot once.
    Sind Sie sicher, dass Sie …  Ja  Nein
    Ihre Nachricht erscheint hier

Pericardial diseases 2

  1. 1. PERICARDIAL DISEASES-2 Ajay Kumar Yadav PGY3,Medicine IOM-TUTH, Kathmandu
  3. 3. ETIOLOGY • End stage of an inflammatory process involving the pericardium. • In the developed world the disorder is most commonly idiopathic or due to surgical complications or radiation injury. • TB : most common cause in developing countries. • The end result is fibrosis, often calcification, and adhesions of the parietal and visceral pericardium. • Scarring is usually more or less symmetric and impedes filling of all heart chambers.
  4. 4. Pathogenesis of TB CCP • Extension of infection from the lung or tracheobronchial tree, adjacent lymph nodes, spine, sternum, or via miliary spread. • Mostly reactivation disease, and the primary focus of infection may be inapparent. • Four pathological stages of tuberculous pericarditis have been described Fibrinous exudation with PMN leukocytosis, abundant mycobacteria, and early granuloma formation with loose organization of macrophages and T cells Serosanguineous effusion with lymphocytic exudate and high protein concentration; tubercle bacilli present in low concentrations Absorption of effusion with granulomatous caseation and pericardial thickening with subsequent fibrosis Constrictive scarring; fibrosing visceral and parietal pericardium contracts on the cardiac chambers and may become calcified, leading to constrictive pericarditis, which impedes diastolic filling
  5. 5. PATHOPHYSIOLOGY • The consequence of pericardial scarring is markedly restricted filling of the heart  results in elevated and equal filling pressures in all chambers and systemic and pulmonary veins. • In early diastole the ventricles fill rapidly because of markedly elevated atrial pressures and accentuated early diastolic ventricular suction related to small end-systolic volumes. • During early to mid-diastole, ventricular filling abruptly ceases when the cardiac volume reaches the limit set by the pericardium. • Thus, almost all filling occurs early in diastole. • Systemic venous congestion results in hepatic congestion, peripheral edema, ascites, anasarca, and cardiac cirrhosis. • Reduced cardiac output also results from impaired filling and causes fatigue, muscle wasting, and weight loss.
  6. 6. CLINICAL MANIFESTATIONS • S/S of RHF  Pedal edema  Congestive tender hepatomegaly  Ascites Precox  Anasarca  Jaundice (cardiac cirrhosis) • S/S of LHF  Dyspnea  Cough  PND and/or orthopnea • Atrial fibrillation and TR : common • Recurrent pleural effusions and syncope.
  7. 7. PHYSICAL EXAMINATION • Markedly elevated JVP • Apical impulse is reduced and may retract in systole (Broadbent’s sign ) • Prominent, rapidly collapsing y descent combined with normal x descent  venous pressure contour. M- or W-shaped • In patients with AF, the x descent is lost. • Kussmaul sign : usually present : inspiratory increase in JVP or the pressure may simply fail to decrease on inspiration. • Reflects loss of the normal increase in right heart venous return on inspiration.
  8. 8. Cont.. • The most notable cardiac physical finding is the pericardial knock • Early diastolic sound best heard at the left sternal border and/or the cardiac apex. • Occurs slightly earlier and has a higher frequency content than a third heart sound. • Corresponds to early, abrupt cessation of ventricular filling. • P/A examination : hepatomegaly, often with palpable venous pulsations, with ascites(precox). • Other signs of hepatic congestion/cirrhosis • Lower extremity edema is the rule. • Muscle wasting, cachexia
  9. 9. Laboratory Testing • No specific ECG findings. • Nonspecific T-wave abnormalities, reduced voltage, and LA enlargement may be present. • AF is very common. • CXR • Cardiac silhouette can be enlarged due to a coexisting pericardial effusion. • Pericardial calcification is seen in a minority of patients and suggests TB. • Pleural effusion common.
  10. 10. ECHOCARDIOGRAPHY • M-mode and two-dimensional transthoracic and Doppler echocardiography are primary imaging modalities in the evaluation of constrictive pericarditis . • Major findings include • Pericardial thickening and calcification (best appreciated with TEE), • Abrupt displacement of the IVS during early diastole (septal bounce), and • Signs of systemic venous congestion (dilation of hepatic veins, inferior vena caval distention with blunted respiratory variation). • LVEF is usually normal. • Mild to moderate (but not severe) biatrial enlargement is common
  11. 11. Cardiac Catheterization and angiography • The RA and RV diastolic pressure, pulmonary capillary wedge pressure, and pre–a wave LV diastolic pressure are elevated and equal, or nearly so, at around 20 mm Hg. • Differences of more than 3 to 5 mm Hg between the left and right heart filling pressures are rare. • The RA pressure tracing shows a preserved x descent, a prominent y descent, and roughly equal a-wave and v-wave heights, with a resultant M or W configuration. • RV and LV pressures reveal an early, marked diastolic dip followed by a plateau (dip-and plateau, or square root sign).
  12. 12. Cont.. • Respiratory variation in the LV and RV systolic and diastolic pressures is increased. • Quantified using the systolic area index (ratio of RV to LV systolic pressures × time area in inspiration versus expiration). • A ratio higher than 1.1 strongly suggests constriction • Pulmonary artery and RV systolic pressures are often modestly elevated to 35 to 45 mm Hg. • Hypovolemia (e.g., due to diuretic therapy) can mask hemodynamic findings Infusion of 1 L of normal saline over 6 to 8 minutes may reveal typical features. • The SV is reduced, but cardiac output can be preserved because of tachycardia.
  13. 13. CT and MRI • CT • Helpful in detecting even minute amounts of pericardial calcification and is the most accurate method for measuring thickness (normal < 2 mm) • Its major disadvantage is the frequent need for iodinated contrast medium to best display pericardial pathology. • MRI • Detailed examination of the pericardium without the need for contrast or ionizing radiation. • Less sensitive for detecting calcification than CT and less accurate for measuring thickness. • The “normal” pericardium visualized by MRI is up to 3 to 4 mm in thickness.
  14. 14. Constrictive Vs Restrictive Cardiomyopathy
  15. 15. MANAGEMENT • Surgical pericardiectomy is the definitive treatment. • Pericardiectomy can be performed through a median sternotomy or a left fifth interspace thoracotomy and involves radical excision of as much parietal pericardium as possible • Relatively high perioperative mortality rate, ranging from 2% to nearly 20% • Risk factors for poor outcomes • Radiation-induced disease; • Comorbidities, esp. COPD and renal insufficiency; CAD and prior cardiac surgery; • Reduced LV EF; • Cardiopulmonary bypass; and • NYHA stage IV symptoms.
  16. 16. • Diuretics and salt restriction are used to relieve the volume overload, but patients ultimately become refractory. • Because sinus tachycardia is compensatory, beta-adrenergic blockers and CCBs that slow the HR should be avoided. • In patients with AF and FVR : digoxin is recommended for rate control. • WAFFLE PROCEDURE • Multiple transverse and longitudinal incisions are made in the epicardial layer. • An alternative t/t in pts with extensive epicardial involvement.
  18. 18. • ECP combines elements of effusion/ tamponade and constriction. • A proposed definition of underlying constriction is the failure of RA pressure to decline by at least 50% to a level below 10 mm Hg when pericardial pressure is reduced to almost 0 mm Hg by pericardiocentesis and/or all detectable fluid is removed. • Incidence : 1-15% , high in TB. • The most common causes of ECP are cancer, irradiation, TB, complications following pericardiotomy, and CTD. • Management is tailored to the specific cause, if known. • Pericardiectomy is ultimately required in many pts.
  19. 19. REFERENCE • Braunwald’s Heart Disease 11th Edition • Harrison 19th Edition • UpToDate 2018 • Davidson’s 23rd Edition