Pericardite cronica-costrittiva

Question 1

clinica

Il polso paradosso è più frequente nel tamponamento mentre il segno di Kussmaul è tipico della pericardite costrittiva

La pericardite cronica costrittiva raramente si verifica dopo una pericardite acuta👓

Answer 1

-Symptoms of fluid overload (i.e., backward failure)
Jugular vein distention, ↑ jugular venous pressure
-Kussmaul sign
-Hepatic vein congestion: hepatomegaly, painful liver capsule distention, hepatojugular reflux
-Peripheral edema or anasarca, ascites with abdominal discomfort
-Symptoms of reduced cardiac output (i.e., forward failure), ma attenzione la FE è normale o aumentata👓
-Fatigue, dyspnea on exertion
-Tachycardia

🧨Pericardial knock, onda H: sudden cessation of ventricular filling during early diastole that is heard best at the left sternal border (non confondere con s3)

-Pulsus paradoxus: ↓ blood pressure amplitude by at least 10 mm Hg during deep inspiration

Effusive-constrictive pericarditis:
Effusive-constrictive pericarditis is characterized by symptoms of chronic constrictive pericarditis, pericardial effusion, or a mixture of both.

Question 2

Diagnosi! Imaging👓

NB C’è fibrillazione atriale!!!

Ispessimento pericardio maggiore di 2 mm

Answer 2

The diagnosis of constrictive pericarditis is based on characteristic imaging findings (most commonly echocardiography but MRI and CT may be used).

-Echocardiography
↑ Pericardial thickness
Abnormal ventricular filling with sudden halt during early diastole

-Variation in ventricular filling with inspiration

💥Across the tricuspid valve: The velocity of blood flow increases.
💥Across the mitral valve: The velocity of blood flow decreases.

Moderate biatrial enlargement !!👓

Excludes right ventricular hypertrophy and cardiomyopathy

Imaging
CT and cardiac MRI
Pericardial thickening > 2 mm

Calcifications, nel 50 % dei casi!!!

💥Normal cardiac silhouette

Chest x-ray

1. Heart size: normal or slightly increased
2. Pericardial calcifications
3. Clear lung fields

Cardiac catheterization
Indications: if noninvasive methods have failed to provide a definitive diagnosis!

Findings
Similar pressures in the left and right atria and right ventricle at the end of diastole (e.g., “equalization of pressures”) ma non nelle arterie polmonari!!

💥Normal pulmonary artery systolic pressure < 40 mm Hg. (This helps to differentiate constrictive pericarditis from restrictive cardiomyopathy, in cui tutte le pressioni, dalle camere cardiache alle arterie polmonari sono uguali ed aumentate.)

-Mean right arterial pressure > 15 mm Hg
Square root sign
Also known as dip-and-plateau waveform
Sudden dip in the right and left ventricular pressure in early diastole followed by a plateau during the last stage of diastole (la morfologia del polso giugulare è simile a quella della cardiomiopatia restrittiva, ‘‘W’’ sign)

ECG
No conclusive findings: generalized flat/inverted T waves, low QRS voltage
Atrial fibrillation can occur in severe disease.

Effusive-constrictive pericarditis
The diagnostic findings of effusive-constrictive pericarditis are similar to those of pericardial effusion, with the exception that in addition to pericardial effusion, pericardial thickening may also be seen. Elevation of right atrial pressures despite pericardiocentesis is strongly suggestive of effusive-constrictive.

Question 3

Trattamento

Answer 3

Surgical therapy
Pericardiocentesis: indicated for cardiac tamponade, large pericardial effusion, acute management of effusive-constrictive pericarditis

💥Pericardiectomy: complete removal of the pericardium

Question 4

ECG

Answer 4

The ECG is more often normal, but may show low QRS voltage, nonspecific ST-segment changes, biatrial enlargement, sinus tachycardia, or atrial fibrillation. B-type natriuretic peptide and N-terminal pro–B-type natriuretic peptide levels are normal or mildly elevated . Chest x-ray in patients with constrictive pericarditis may show pleural effusions without significant alveolar edema and biatrial enlargement. LV and RV and pulmonary vessels are normal in size. Pericardial calcifications are rare, occurring in 20% to 40% of constrictive cases and, more commonly, in tuberculous pericarditis .