pericardial diseases illustrative cases · after pericardiocentesis 2 months later. 1/9/2018 9...

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Pericardial DiseasesIllustrative Cases

Jae K. Oh, MD

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47 year old man

•Chest pain

•Not exertional

•Normal Examination

Case #1

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47 year old man with chest pain

• Usually left side

• Heart shifted to left

• Mostly asymptomatic

• Strangulation can happen

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Congenital Absence of the Pericardium

Snoopy Sign

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Pericardial CystCase #2

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A large pericardial cyst

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Case #351 year old with SLE and BP 150/115

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57 year old male with STEMIThrombolysis and Stent

Hypotensive and tachycardic

Case # 4Case #4

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57 year old man with STEMI

Hepatic vein diastolic reversal with expiration

RV Diastolic Collapse

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Tamponade Physiology

Pressure

Volume over time

Rapid effusion Slow effusion

Criticaltamponade

Limit of pericardial stretch

NEJM 349: 684, 2003CP1299236-6

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Cardiac Tamponade

RV collapse Mitral inflow variation HV expiratory reversal

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Hemo‐pericardiumCase #5

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Intramural Hematoma

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66 year old woman with dyspneaPneumo-pericardium

PneGastro-pericardial fistulau

Case #6

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77 yo man with severe aortic stenosisTAVR and PM implantation & RV Perforation

Pericardiocentesis yielded 125 cc of bloody fluid

Case #7

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77 yo man with severe aortic stenosisIncreasing dyspnea 2 months after pericardiocentesis

After Pericardiocentesis 2 months later

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Effusive-Constrictive Pericarditis

Interventricular Dependence

Expiratory diastolic flow reversal

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Tamponade vs Effusive CP

Miranda et al. In Preparation

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MRI DE in 2 patients with Constriction

Circulation Oct 3rd 2011

Baseline

Medical RX

3 Months

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One week of Steroid RxTransient Constrictive Pericarditis

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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

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35 yo man presents with dyspnea and feverBP 80/40 mmHg

Case #8

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35 yo man with tamponade and feverTEE after pericardiocentesis

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36 yo man with dyspnea, chest pain, and abd pain

Case #9

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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

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Thank You !

[email protected]

[email protected]

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Welles-04-07.mov

Echo-Guided Pericardiocentesis

18%3%

Chest wall 79%

SubcostalLocation

pericardial diseases illustrative cases · after pericardiocentesis 2 months later. 1/9/2018 9...

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