Pericardial Disease Simulation training Curriculum Constrictive Pericarditis Etiology

Pericardial Disease Simulation training Curriculum

Constrictive Pericarditis Etiology • • • Idiopathic Irradiation Post-surgical Infectious Neoplastic Connective tissue disorder • • • Uremia Trauma Sarcoid Methysergide therapy Epicardial implantable defibrillator patches CATHSAP 6: Coronary Angiography and Intervention

CATHSAP 6: Coronary Angiography and Intervention

CATHSAP 6: Coronary Angiography and Intervention

CATHSAP 6: Coronary Angiography and Intervention

CATHSAP 6: Coronary Angiography and Intervention

Kussmaul’s Sign CATHSAP 6: Coronary Angiography and Intervention

CATHSAP 6: Coronary Angiography and Intervention

CATHSAP 6: Coronary Angiography and Intervention

Cardiac Tamponade 40 20 0 CATHSAP 6: Coronary Angiography and Intervention

Balloon Pericardiotomy

Case 1: Constrictive Pericarditis • • • 64 year old female 1 Year s/p 3 -vessel CABG Presents with 6 months of progressive dyspnea and atypical chest pain At angiography, all grafts are patent Hemodynamics

40 Right atrium 20 0

40 20 0 LV vs. RV

40 20 0 LV vs. RV with Valsalva

Constrictive Pericarditis Right Atrial Tracing X-descent y-descent

Constrictive Pericarditis – LV vs. RV. Tachycardia Obscures Evaluation PVB

Kussmaul sign

CATHSAP 6: Coronary Angiography and Intervention

CATHSAP 6: Coronary Angiography and Intervention

CATHSAP 6: Coronary Angiography and Intervention

Restrictive Cardiomyopathy

Ventricular Interdependence During Respirations Differentiates Constrictive Pericarditis from Restrictive Cardiomyopathy Constrictive Pericarditis (LV and RV discordant) Hurrell et al, Circulation 1996; 93: 2007 Restrictive Cardiomyopathy (LV and RV concordant)

Sensitivities, Specificities, Positive Predictive Values, and Negative Predictive Values as a Function of Criteria Hurrell et al, Circulation 1996; 93: 2007

Constrictive Pericarditis vs. Restrictive Cardiomyopathy • Greater ventricular interdependence in constrictive pericarditis • Greater separation of diastolic pressure in restrictive cardiomyopathy • LV and RV diastolic filling more rapid in constrictive pericarditis • Pulmonary pressures higher in restrictive cardiomyopathy • Adjunctive tests: evidence of pericardial thickening (normal 1 -2 mm; thickening ≥ 3 mm); pericardial calcification, RV biopsy, exploratory thoracotomy

Case 3: Pericardial Tamponade • 37 year old female • 2 day history of dyspnea, fatigue and dizziness • Mastectomy for breast cancer 3 years ago • Echocardiogram suggests pericardial tamponade • Hemodynamics

Cardiac Tamponade Pulsus Paradoxus 200 Femoral artery inspiration 100 0 expiration

40 Right atrium 20 0

40 20 0 Right ventricle

40 20 0 Pulmonary artery

40 20 0 Pulmonary capillary wedge

40 Before Pericardiocentesis; Pericardium vs. RA 20 0

After Pericardiocentesis 40 20 Right atrium Pericardium 0

After Pericardiocentesis 40 20 0 Right ventricle

After Pericardiocentesis 40 20 0 Pulmonary capillary wedge

Long-Term Effectiveness of Pericardiocentesis • 2/3 of patients with malignant pericardial effusions redevelop tamponade after a median of 7 days • More than 80% of patients with non-malignant pericardial effusion require no further intervention Laham et al, Heart 1996; 75: 67

Variants on Constrictive-Restrictive Physiology • Acute enlargement of the heart with constriction by normal pericardium – right ventricular infarct, tricuspid regurgitation, mitral regurgitation • Low pressure tamponade • Effusive-constrictive pericarditis • Single chamber tamponade • Localized constriction • Occult constrictive pericarditis

Severe, Acute Tricuspid Regurgitation Associated With Constrictive. Restrictive Physiology

Severe, Acute Mitral Regurgitation Associated With Constrictive-Restrictive Physiology

Variants on Constrictive-Restrictive Physiology • Acute enlargement of the heart with constriction by normal pericardium – right ventricular infarct, tricuspid regurgitation, mitral regurgitation • Low pressure tamponade • Effusive-constrictive pericarditis • Single chamber tamponade • Localized constriction • Occult constrictive pericarditis