Pericardial Surgery and Cardiac Tumors Flashcards
Blood Supply of the Pericardium
- Pericardiophrenic arteries
- Branches if the IMAs
- Branches directly from the Aorta
Innervation of the Pericardium
- Vagal Fibers from the Esophageal Plexus
- Phrenic Nerve Branches
Pericardial Sinuses
- Oblique Sinus - pulmonary venous confluence
- Transverse Sinus - between the great arteries and dome of the LA and RPA
Normal Pericardial Fluid Volume
10-20mL
Ventricular Interdependence
Intrapericardial pressure reflects intrathoracic pressure. During inspiration intrathoracic pressure and PVR decreases increasing RV preload causing a leftward shift of the IVS resulting in decreased LV preload and resultant SV reflected by a decrease in BP.
Pulsus Paradoxus
Exaggerated Ventricular Interdependence
(during inspiration PVR decreases increasing RV preload causing a leftward shift of the IVS resulting in decreased LV preload and resultant SV reflected by a decrease in BP)
Greater than 10mmHg drop in SBP during inspiration.
Describe the changes to the JVP trace for
Tamponade
vs.
Constrictive Pericarditis
vs.
Restrictive Cardiomyopathy
Tamponade
Prominant ‘‘x”
Blunted “y”
Constrictive Pericarditis
Prominant “x”
Prominant “y”
Restrictive Cardiomyopathy
Blunted “x”
Prominant “y”
Partial or Complete Agenesis of the Pericardium
Partial Absence of the Pericardium
- 70% Left
- 20% Right; Usually Complex and Lethal
Complete Agenesis of the Pericardium
- Rare
- Usually asymptomatic and of no consequence
- Can result in incarceration of the LAA or LV due to excessive mobility within the chest
Pericardial Cysts
Most Common Peridarial Disorder
70% Occur at the Right Costalphrenic Angle
Usually Incidental Finding
Symptoms (related to complession or inflammation)
- Pain
- SOB
- Cough
- Arrhythmias
Indications for Resection
- Large Size
- Symptoms
- Patient Concern
- Question of Malignancy
Beck’s Triad
Clinical Manifestations of Tamponade
- HoTN
- Jugular Venouse Distention
- Muffled Heart Sounds
Compenatory Responses to Increased Diastolic Filling Pressures
- Parallel Increase in PVR and SVR
- Tachycardia
- Chronic Pericardial Stretch
- Increased Preload (expand blood volume)
Symptoms of Pericardial Constriction
- Fatigue
- Exercise Intolerance
- Dyspnea/Orthopnea
- Peripheral Edema
- Ascites
Pathophysiology of Pericardial Constriction
- Impairment of Late Diastolic Ventricular Filling
- Ventricular Interdependence causes an abrupt leftward shift of IVS (Septal Bounce) and Pulsus Paradoxus
Kussmaul’s Sign
JV distension during inspiration
Echocardiographic Findings of Pericardial Constriction
- Septal Bounce
- Pericardial Thickening
- Plethoric IVC
- Underfilled Chambers
Hemodynamic Indicators of Pericardial Constriction on Cath
- Square Root Sign
Sudden increase in RV filling pressure in late diastole followed by equilization of diastolic filling pressures
- Steep “x” and “y” descent (Restrictive will have blunted “x”)
- ***Ventricular Interdependence
discordant increase in RV and decrease in LV pressure curve during inspiration
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Constrictive Pericarditis vs. Restrictive Cardiomyopathy
Constrictive Pericarditis
- Dissociation of intrathoracic and intracardiac filling pressures measured by respiratory variation in the gradient between the LVP and PCWP during the rapid filling phase of diastole
- ***Ventricular Interdependence - discordant increase in RV and decrease in LV pressure curve during inspiration
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Causes of Pericarditis
- Infectious (viral, bacterial, fungal)
- Metabolic (uremia, drug induced)
- Autoimmune (arthritis, thyroid)
- Post-Radiation
- Neoplastic
- Traumatic
- Post-Infarct (Dressler’s Syndrome; 10-15%)
- Postcardiotomy Syndrome (5-30%)
- Idiopathic
ECG Findings of Pericarditis
- Diffuse ST elevation (without reciporical changes or Q-waves)
- PR depression
Trials on the Treatment of Pericarditis
ICAP
- RCT; NSAIDs vs. Colchicine for First Episode Pericarditis
- Reduced Persistence and Reccurence
CORP and CORP-2
- NSAIDs vs. Colchicine
- Reduced Recurrence
Most Common Bacteria Causing Pericarditis
- Haemophilus Influenzae
- Meningococci
- Pneumococci
- Staphylococci
- Streptococci
- Salmonella
- TB (developing nations or HIV)
Fungal Causes of Pericarditis
- Nocardia
- Aspergillus
- Candida
- Coccidioides
- Histoplasma
Drugs Associated with Pericarditis
- Hydralizine
- Procainamide
- Isonaizid
- Methysergide
- Cromolyn
- Penicillin
- Emetine
- Minoxidil
Most Common Secondary Tumors of the Pericardium
Males
- Carcinoma of the Lung (30%)
- Carcinoma of the Esophagus (30%)
- Lymphoma (10%)
Females
- Carcinoma of the Lung (35%)
- Lymphoma (20%)
- Carcinoma of the Breast (10%)
Risk Factors for Postop Pericardial Effusion
- Increased BSA
- PE
- Immunosuppression
- Surgery (Transplant or Aortic Aneurysm)
- Long CPB Time
- Urgency
- Renal Failure
Findings of Postoperative Tamponade
- Early Postop Bleeding with Decreased or No CT Output
- Tachycardia
- Narrow Pulse Pressure
- Pulsus Paradoxus
- Increased CVP
- Oliguria
- Acidosis
- Elevated Lactate
- Escalating Inotropes/Vasopressors
- Decreased Cardiac Index
- Decreased MVO2
- Electrical alternans
- Pericardial effusion
Management of Postoperative Tamponade
Correct…
- Coagulopathy
- Hypothermia
- Acidosis
- Hypovolemia
Urgent Surgical Mediatrinal Exploration
Outcomes following Emergent Mediastinal Exploration in the ICU for Tamponade
Perioperative Mortality - 85%
Sternal Wound Infection - 5%
Echocardiographic Findings of Tamponade
- Early Diastolic RV Collapse
- Early Systolic RA Collapse
- IVC Dilitation (>50%)
- Increased Ventricular Interdependence with respiration
- Decreased mitral inflow with inspiration
Approaches to the Pericardial Window
- Thorascoscopy
- Anterior Thoracotomy
- Subxiphoid
Waffle Procedure
- For Constrictive Pericarditis of the Viseral Pericardium/Epicardium
- Longitudinal and Transverse Incisions in the Epicardium 1cm Apart
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Principle and Margins of Dissection for Surgical Pericardiectomy
Principle
- Complete Pericardial Resection
Margins
- Anterior from Phrenic-to-Phrenic Nerve
- Posterior from the Reflection Around the Vena Cava to the Pulmonary Veins
Outcomes Following Surigcal Pericardiectomy
Operative Mortality 5-10%
1-year Survival 90%
10-year Survival 85%
*Except Post-Radiation Constrictive Pericarditis - 60/0%
Frequency of Benign vs. Malignant Primary Cardiac Tumors
75% Benign
25% Malignant (of which 75% are sarcomas)
Pathological Origins of Cardiac Tumors
- Pseudotumors (thrombus)
- Heterotopias/Ectopic Tissue Tumors (AV Node, Teratomas, Thyroid Tumors)
- Mesenchymal (Endocardial Hamartomas, Papillary Fibroelastoma)
- Myocardial Hamartomas (Rhabdomyoma, Purkinje Cell)
- Fat (Lipomatous hypertrophy of the IAS, Lipoma, Liposarcoma)
- Fibrous or Myofibroblastic Tissue (Fibroma, Fibrosarcoma, Leiomyosarcoma)
- Vascular Tumors (Hemangioma, Angiosarcoma)
- Mix/Unknown Histogenesis (Myxoma)
- Neural Tumors (Granular Cell, Schwannoma/Neurofibroma)
- Paraganglioma
- Lymphoma
- Mesothelioma
Frequency of Benign Cardiac Tumors in Adults
- Myxoma (50%)
- Lipoma (20%)
- Papillary Fibroelastoma (20%)
- Hemangioma (5%)
- AV Node Mesothelioma (5%)
- Fibroma
- Teratoma
- Granualr Cell Tumor
- Neurofibroma
- Lymphangioma
- Rhabdomyoma (<1%)
Frequency of Benign Cardiac Tumors in Children
- Rhabdomyoma (50%)
- Teratoma (20%)
- Fibroma (15%)
- Myxoma (15%)
- Hemangioma
- AV Node Mesothelioma
- Neurofibroma
Myxomas
- 50% of Adult Cardiac Tumors
- 15% of Childhood Cardiac Tumors (Rare in infants)
- F > M
- Peak Incidence 3-6th Decade
- Solitary (95%)
-
75% in Left Atrium (10-20% Right Atrium)
- Right atrial myxomas have a higher association with multiple lesions
- Low Recurrence Rate (1-5%)
- Majority Sporatic (5% Familial)
Familial Myxomas
- 5% of Myxomas
- Autosomal Dominant
- Abnormal Chromosomal Genotype
- Present at Younger Age
- F = M
- 20% Multiple Tumors in the Atria or Ventricles
- Higher Recurrence Rate (20-60%)
-
20% Complex Myxomas with Assoc. Conditions
- Adrenocortical Nodule Hyperplasia
- Sertoli Cell Tumors
- Pituitary Tumors
- Multiple Myxoid Breast Fibroadenomas
- Cutaneous Myomas
- Facial or Labial Pigmented Spots
Carney’s Syndrome
Familial Syndrome
Autosomal Dominant (chromosome 17)
X-Linked Inheritance
M > F
Primary Pigmented Nodular Adrenocortical Disease
- Hypercortisolism
- Cutaneous Pigmentous Lentigines and Blue Nevi
- Cardiac Myxomas
- Other endocrine tumors
- Thyroid
- Testes
- Ovaries
- Pituitary Adenoma
Common Presentations of Myxomas
CHF (Obstruction) 60%
Embolization 30%
Constitutional Sx 20%
Death occurs from obstruction or emoblization in 8% of paitents awaiting surgery
Surgical Approach to Myxoma Excision
Intraoperative TEE to check for other assoc. tumors
Bicaval cannulation
Cross clamp the aortia prior to manipulating the LA
Transmural excision of the stalk/attachment
Wall suction wil tumor exposed to prevent systemic embolization
Mortality risk 5% (10% if ventricular myxoma)
Lipomas
Encapsulated
Pericardium
Subepicardium
assoc. with pericardial effusions
Subendocardium
Intra-atrial septum
assoc. with compressive/obstructive Sx or arrhythmias
M=F
Most commonly RA or LV
Lipomatous Hypertrophy of the Intra-Atrial Septum
Non-encapsulated
- Elderly
- Obese
- Females
Benign, may be assoc. with arrhythmias
MRI helpful for tissue characterization for diagnosis
Papillary Fibroelastomas
Heart valves or adjacent endocardium
Asymptomatic until they embolize or obstruct (usually coronary ostia)
AV=Semilunar valves
Rhabdomyomas
Most frequent tumor in Children
Sporadic
Assoc. with Tuberous Sclerosis
- Epilsepsy
- Mental retardation
- Sebaceous Adenomas
Ventricles > Atrium
90% Multi-site involvement
Presentation of Rhabdomyomas
Valvular or subvavlular stenosis
Ventricular Tachycardia
Sudden Death
Surgery for Rhabdomyomas
Surgical resection with enucleation before 1-year of NO tuberous sclerosis
Tuberous sclerosis assoc. with multiple lesions and has a very poor prognosis
Fibromas
2nd most common benign tumor
80% in children
M=F
Occur in the Ventricule or Ventricular Septum
Non-encapsulated elongated fibroblasts
Presentation of Fibromas
Chamber obstruction
Contractile dysfunction
Arrhythmias
Sudden Death (25%)
Surgical Resection of Fibromas
Resection/enucleation recommended if vital structures NOT involved
Complete resection is curative
If vital structures are involved then partial resection can be performed but is palliative
Transplantation is an option
Mesothelioma of the AV Node
AKA…
- Polycystic tumor
- Purkinje tumor
- Conduction tumor
Presents with…
- AV block
- Ventricular fibrillation
- Sudden death
Pheochromocytomas
Chromaffin cells of the sympathetic nervous system
Produce catecholamines (norepinephrine)
Young Adults
M=F
60% in the roof of the LA
Paragangliomas
Endocrine tumor
Secretes catecholamines
Most commonly in the posterior mediastinum
High vascularity contributes to risk assoc. with surgical resection
Teratoma
Most common in infants and young children
80% Benign
Castleman Tumor
Lymphoproliferative Disorder
Histological types
- 90% Hyaline Vascular (benign)
- 10% Mixed-cell type (malignant)
Primary malignant tumors (sarcomas)
Histological Types
- Angiosarcomas
- Rhabdomyosarcomas
- Malignant mesotheliomas
- Fibrosarcomas
Anatomical Types
- Right sided (most angiosarcomas; infiltrative; metastisize early; neoadjuvant chemo)
- Left sided (more solid; present with CHF; mistaken as myxomas; rapidly recure)
- PA (present with R-sided HF/PE Sx; better prognosis)
Survival only 10% at 1-year
Angiosarcomas
M > F
80% RA
Invade adjacent structures
Present with Obstruction and right-sided HF
Histology - vascular channels lined with typical anaplastic epithelail cells
Metastasize to the lung/liver/brain
90% dead within 9-12 months of Dx
Malignant Fibrous Histiocytomas
Histology - fibroblasts of histioblasts - mixture of spindle cells in a storiform pattern and polygonal cells
Often mistaken for myxomas
Patients die of local recurrence more commonly than metastatic disease
Rhabdomyosarcomas
M = F
Commonly multicentric, arising in both ventricles
Invasive
Histology - pleomorphic nuclei, spidery streaming eosinophilic cytoplasm, muscle-like pattern
Survival < 12-months
Secondary/Metastatic Cardiac Tumors arise from what types of cancer?
- Leukemia
- Melanoma
- Lung cancer
- Sarcoma
- Breast cancer
- Esophageal cancer
- Ovarian cancer
- Kidney cancer
- Gastric cancer
- Prostate cancer
- Colon cancer
- Lymphoma
Most common cardiac sites of metastasis
- Pericardium
- Epicardium
- Myocardium
- Endocardium
Frequency of Renal Cell Carcinoma invasion of the IVC and RA
Invades the IVC in 10% of cases
Reaches the RA in 40% of these cases
If renal primary fully resectable survival is 75% at 5-years