Laflamme- Chapter 5 (Cardiomyopathy and Pericardial Disease) Flashcards
What are three phases of a Pericardial friction rub?
Atrial Kick, Ventricular systole, Ventricular filling
What are 8 indications to hospitalize with Pericarditis?
- HD instability
- Large effusion/Tamponade
- Myocardial Involvement
- Anticoagulated
- Trauma associated
- Recurrent/persistent despite outpatient management (7 days)
- Fever
- Immunosuppressed
What is difference between Incessant and Recurrent Pericarditis?
Incessant: Symptoms come back after withdrawal of treatment
Recurrent: Returns after 6 weeks of symptom free period
What is the normal amount of pericardial fluid?
-50 cc
What does the intrapericardial pressure need to be to cause tamponade?
-15-20mmhg, same as the diastolic pressure in the ventricles/atria
What do you see in JVP in tamponade?
-Attenuated y descent
What is the ddx for tamponade in the absence of pulsus? (8)
- AR
- ASD
- Severe LV dysfunction
- LVH
- RVH
- Severe Hypotension
- Pericardial adhesions
- Localized effusions
What is the Ddx of Pulsus (7)?
- PE
- RV failure
- Ascites
- Constriction
- Lung disease (COPD, Asthma)
- Chest wall deformity
- Obesity
- Severe Hypotension
Name 6 findings of Constriction on echo?
- Septal E’ > 8
- MV/TV inflow variation
- Hepatic vein flow reversal in diastole with expiration
- Abnormal septal motion
- Predominance of diastolic flow in pulmonary veins
- Pericardial thickening
What are 5 patterns of constriction seen on hemodynamic study
- M/W sign in atria
- Prominent Y descent in atria
- Square root sign in ventricle/diastole
- Equalization of pressures in ventricles with respirations
- Equalization of end diastolic pressures
What is perioperative mortality of Pericardectomy?
- 10-15%
What is obstructive HCM?
30mmhg
9 ways to tell the difference between athlete’s heart and HCM?
- Scar on CMR
- Diastolic dysfunction
- LVEDD
- Genetic testing
- Asymmetric LVH
- Extreme LVH (> 17mm)
- VO2 Max > 110% predicted
- SAM
- Regression of LVH post stopping training
What is indication for septal reduction in HCM?
-NYHA II+ symptoms, LVOT-O > 50mmhg despite max therapy
What kind of conduction disease does septal myomectomy cause?
LBBB
What is pacemaker risk for septal ablation?
-10-20%
7 indications for ICD in HCM?
- Arrest/VT (1)
- FH SCD (2a)
- Apical aneurysm (2a)
- Unexplained syncope (2a)
- EF < 50% (2a)
- CMR scar++ (2b)
- NSVT (2b)
What are two reasons for obesity related CMO (pathology)?
- High CO state
- Myocardial fat infiltration
What 3 findings are characteristic of Early infection of Chagas CMO?
-Early Infection: Acute Myocarditis, Meningoencephalitis, Skeletal muscle involvement
What is characteristic of Latent infection of Chagas CMO?
-Mild lymphocytic myocarditis
What is characteristic of Chagas CMO?
-Dilatation of chambers, Ventricular dysfunction, ventricular arrhythmias, apical thrombus, heart block
6 differences between RCM and Constriction?
- There is equalization of diastolic pressures in CP but not RCM
- No respiratory variation
- Septal E prime
- Pericardial thickness
- Biatrial enlargement
- Abnormal respiratory movement of the septum
What is inheritance and issue in Fabry’s disease?
-X-linked, alpha galactosidase A deficiency -> leading to accumulation of glycosphingolipids in lysosomes
What level of Eos do you have to worry about Loefflers?
Eos > 1.5
What are phases of Lofflers?
Myocarditis followed by the replacement of myocardium by thrombus -> then the formation of endomyocardial fibrosis
How to treat lofflers?
-Anticoagulation, Corticosteroids, Hydroxyurea
Name 6 cardiac manifestations of Sarcoid?
- LV dilatation
- LV dysfunction
- VT
- Bradyarrhythmias
- RWMA
- Myocarditis
What is the pathology of Carcinoid syndrome?
-Gi or Bronchial tumor -> release of serotonin by the tumore -> increase urinary 5-HIAA
Management of Carcinoid syndrome?
- Somatostatin analogs
- Embolization of liver metastases
- TVR is severe symptoms
What is the triangle of dysplasia in ARVC?
- RV inflow tract
- RVOT
- RV apex
Inheritance of ARVC?
Autosomal Dominance
What are the 4 phases of ARVC?
Asymptomatic -> VT -> RHF -> BiV failure
What are the major features of AARVC?
- Regional akinesia/WMA
- <60% of myocytes with fatty replacement
- TWI V1-V3 (in absence of RBBB)
- Epsilon wave
- VT with LBBB morphology
- Family history
What is pathology of LV non compaction?
- Thin epicardial layer with thick non compacted endomyocardial layer
- (non compacted / compacted layer) > 2 ( >2.3 in diastole)
What is the Dallas criteria in Myocarditis?
-Presence of inflammatory cells and myocyte necrosis on biopsy in a pattern not consistent with Coronary disease
4 types of myocarditis that require immunosuppression?
- Giant Cell myocarditis
- Sarcoidosis
- Eosinophilic myocarditis
- Autoimmune myocarditis (SLE)
Indications for endomyocardial biopsy?
- HF for < 2 weeks with hemodynamic instability
- 2 weeks to 3 months with LV dilatation and ventricular arrhythmias or AV block
- > 3 months with LV dilatation and ventricular arrhyhtmias or Av block (sarcoid, chagas)
Name 8 risk factors for Anthracycline CMO?
> 350 mg/m2
Females
> 65 years
LVEF <55%
RF for ischemic heart disease
Concomitant radiation, Tratzumad
Echo surveillance during Anthracycline therapy?
- Baseline
- 240 mg/m2 and then every 50mh/m2 more
What radiation dose put one at risk for cardiac calcification?
> 30 gray
What % of myxomas in LA compared to RA?
80% compared to 10%
What is recurrence of atrial myxoma after resection?
3%
What does Lipomatous Hypertrophy of the Interatrial septum look like?
Dumbell appearance, thickening spares the fossa ovale
5 Bacteria that cause Pericarditis?
- Staph
- Strep
- TB
- Lyme
- Mycoplasma
- Meningococcus
- Coxiella
2 Parasites that cause Pericarditis?
- Toxoplasmosis
- Echinococcus
- Chagas
5 Inflammatory causes of Pericarditis?
- RA
- SLE
- Sarcoidosis
- IBD
- PAN
- Takayasu’s Arteritis
- Scleroderma
- Sjrogen
- GCA
- Acute Rheumatic fever
Name 5 medications that can cause Pericarditis?
- Hydralazine
- Procainamide
- Doxorubicin / Anthracyclines
- Cyclosporine
- Cyclophosphamide
- Clozapine
- 5FU
What is Lake Louise Criteria?
- T2 weighted imaging positive indicated Edema
- Early T1 weighted imaging positive indicated inflammation in non coronary distribution
- LGE indicating fibrosis in non coronary distribution
3 complications of congenital absent Pericardium?
Chest pain
Hernia/Strangulation of a part of the heart
Syncope/Sudden Death
Pericardioplasty if symptomatic absent pericardium
What are three mechanisms of metastasis to the heart?
- Direct Extension
- Hematogenous
- Extension via the IVC
What % of primary cardiac tumors are benign?
75%
How big does a mass have to be to be seen on imaging?
1 cm or larger
What is incidence of myxoma recurrence after resection?
3%
Where do Angiosarcomas present most of the time (Which chamber?)
RA (90%)
