Pericardial disease questions Flashcards

1
Q

What is pulsus paradoxus

A

abnormally excessive fall in systolic blood pressure on inspiration > 10 mmHg

Normally on inspiration there is a slight fall in systolic blood pressure (< 5mmHg).
In cardiac tamponade, the increased venous return that occurs on inspiration causes filling of the right heart, thereby displacing the interventricular septum to the left (rigid box with tamponade) resulting in less filling possible in the left heart producing a reduced cardiac output and systemic blood pressure

Other causes of PP include constrictive pericarditis and status asthmaticus

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2
Q

What are the typical findings on investigations with pericardial tamponade

A

1) ECG–low voltage QRS complexes, electric alternans (due to the heart moving within a fluid-filled sac)
2) CXR–symmetrical globular enlargement of the heart
3) Echocardiography
a) large pericardial collection
b) heart swinging freely within the pericardial sac
c) early diastolic collapse of the right ventricle
d) late diastolic collapse of the right atrium
e) marked respiratory tricuspid valve (>40%) and and mitral valve (>25%) inflow variation

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3
Q

What are the causes of constrictive pericarditis

A

Idiopathic, which is the major cause in the developed world
Infection—tuberculosis, viral (coxsackie), fungal (hisotplasma)
Mediastinal radiotherapy, which is dose-dependent (lymphoma)
Post Cardiac surgery
tumor, drugs (procainamide),
Sarcoidosis, amyloidosis,
carcinoid syndrome,
myocardial infarction,
uremia,
trauma

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4
Q

Clinical features of constrictive pericarditis

A
symptoms of left and right heart failure (anorexia, ascites, peripheral edma, fatigue, weakness
Raised jugular venous pressure
Ascites
Peripheral edema
Heptosplenomegaly
displaced apex beat
muffled heart sounds
Narrowed pulse pressure
Kussmaul's sign
palsus paradoxus
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5
Q

what are features of cxr and echo of constrictive pericarditis

A

CXR- pericardial calcification and bilateral pleural effusions
Echocardiogram
impaired diastolic ventricularfilling, thickened echo bright pericardiaum,and dilated right atrium, inferior vena cava and hepatic veins
Doppler echocardiography
increased E:A ratio (rapid early filling and diastasis) and decreased inspiratory flow reduction in the hepatic veins.

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6
Q

Role of Cardiac Cath in constrictive cardiac cath

A

Cardiac Catheterisation (important for differentiation of constrictive pericarditis from restrictive cardiomyopathy)

a) equalisation (within 5mmHg) of raised left and right ventricular end-diastolic pressures at any phase of respiration
b) Equalisation of raised (>10mmHg) left and right atrial pressures with prominent x and y descents
c) square root sign—dip and plateau pattern of ventricular pressure with most of the diastolic filling occurring in early diastole, due to raised venous pressure, which then halts abruptly in mid-diastole.
d) left ventricular systolic function is usually normal but may be impaired in severe cases
e) pulmonary artery systolic pressure <50mmHg
f) right ventricular end-diastolic pressure ratio >1:3

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7
Q

How is constrictive pericarditis differentiated from restrictive cardiomyopathy(RCM)

A

Features for RCM and CP
1) increased EA ratio on the mitral valve inflow pattern
2) dip and plateau ventricular waveform
3) Prominent x and y descents on the atrial waveform
Patients with RCM more likely to have
1) Pulmonary hypertension (PASP > 50mmHg)
2) Reduced left ventricular function
3) endomocardial biopsy evidence of an infiltrative process
Patients with CP are more likely to have
1) Equalization of left and right ventricular end-diastolic pressure (<5mmH)
2) Kussmaul’s sign
3) Right ventricular end-diastolic to systolic ressure > 1:3
4) CT or echocardiographic evidence of a thickened pericardium

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8
Q

What are the principles of pericardiectomy

A

Aim to achieve complete removal of all thickened pericardium and epicardium from the left and right ventricle and diaphragm whilst preserving both phrenic nerves

CPB and cardioplegia arrest is usually required for posterior pericardium

Operative mortality is 10- 15% with a 5 year survival of 70% following pericardiectomy

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9
Q

What are the causes of restrictive cardiomyopathy

A
Scleroderma
Amyloidosis
Iron storage disease
Loeffler's eosinophilic/endomyocaridal fibrosis
Sarcoidosis
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10
Q

List 5 cardiac catheterization findings of a patient with constrictive pericarditis

A
Equalization of filling pressure
Elevation of mean atrial pressure
square root sign
prominent Y decent on the right atrial pressure tracing
elevated RV end diastolic pressure
LV ejection fraction must be > 40%
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11
Q

List 5 criteria for distinguishing restrictive cardiomyopathy from constrictive pericarditis

A
  1. Early diastolic filling–decreased in restrictive–normal in CP
  2. Left and right ventricular end-diastolic pressures after fluid challenge–diverge in restrictive cardiomyopathy, parallel in CP
  3. endomyocardial biopsy–may show fibrosis in restrictive cardiomyopathy (normal in CP)
  4. systolic contraction velocity–may be slow in restrictive cardiomyopathy (normal in CP)
  5. CT Scan/MRT/Echocardiography—may demonstrate thickened pericardium with pericarditis
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12
Q

Name 5 important issues with surgery for constrictive pericarditis

A
  1. Median sternotomy with full cardiopulmonary bypass
  2. pericardium needs to be removed from phrenic to phrenic and posterior to left phrenic nerve (best done on CPB)
  3. Areas of grafts have to be protected
  4. likley to be bloody
  5. in general a high risk procedure
  6. Usually want to remove the pericardium from the left ventricle first, then the right ventricle and then both atria
    strip it off the vena cavae
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13
Q

How is diagnosis of Cardiac Tamponade

A

Intrapericardial fluid causing hemodynamic compromise
Echo Hallmark: RA and RV compression
Equalization of RA, LA, LVEDP, RVEDP, wedge pressures

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14
Q

What is Becks triad

A

Distended neck veins
Hypotension
reduced heart sounds

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15
Q

List common causes of pericarditis

A
Infectious
Post MI, surgical traum
Uremic
Drug induced 
Collagen vascular disease
Radiation
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16
Q

List common drug causes for pericarditis

A

Hyrdalazine

Procainamide

17
Q

List features of infectious pericarditis

A

occurs from contiguous spread or septicemia
Staph, Pneumoccus, Haemophilis, fungal, and TB
percutaneous drainage and antibiotic treatment of choice
TB
surgical drainage and 9 months of triple therapy
6 months treatment after negative culture

18
Q

List features of uremic pericarditis

A

usually treat with NSAID and aggressive dialysis
Pericardiocentesis if persists > 2 weeks after medical treatment
Surgical drainage only if hemodynamic instability

19
Q

List surgical approach to pericariectomy

A

Median sternotomy
Decorticate as completely as possible(visceral and parietal)
Left Ventricle first!!!
Mortality 5-10% long term survival is good
Most stay in NHYA I or II

20
Q

List features of radiation pericarditis

A

Dose response for pericarditis, carditis
May cause accelerate CAD, myocardial fibrosis
20% eventually develop constriction

21
Q

What are clinical features of pericardial tamponade

A

Hemodynamic compromise with acute dyspnea and tachypnea
low pulse volume with pulsus paradoxus
Low and undetectable blood pressure
Raised jugular venous pulse (JVP) with a prominent x descent but no y descent
Muffled heart sounds
Oilguria or anuria