pericardium tumor Flashcards
acute pericarditis causes?
Causes
Idiopathic (80%)
Viral
Inflammation of pericardium
± myocarditis
categories of pericarditis causes?
symptoms of pericarditis?
`Chest pain
Severe, sharp, pleuritic
Substernal, left sided
Radiates to trapezius ridge
(Radiates to L arm)
lying down, sitting forward
Dyspnoea
Fever
signs of pericarditis?
Unwell
Fever
Tachycardia
Pericardial rub
Systolic, early and late diastolic
“Rubbing/crunchy”
Left sternal edge apex
Leaning forward, variable
acute pericrditis tests?
ECG
Most important investigation
Sinus tachycardia
ST elevation
Usually all leads (except aVr, V1)
Concave upwards
PR depression
T wave inversion
Blood Tests
increaseWBC, increase ESR
increase cardiac enzymes (Troponin)= myocarditis
CXR
Usually normal
Pulmonary infection/inflammation
Pneumonia
TB
Cardiac enlargement
Large effusion
echo
Usually normal
Detection of effusion
how to manage acute pericarditis?
Idiopathic = self-limiting
No recurrence in 70-90%
15% relapsing
Rx: NSAID’s
Detect underlying cause if suspected / relapsing
Screen for effusion
cardiac tamponade?
Pericardial space has little reserve volume
Small amounts of fluid, if rapidly accumulated, cause increase pericardial pressure
Leads to cardiac chamber compression
increase HR
decrease Right Heart filling, raised JVP, loss of y descent
Paradoxical pulse
>10mmHg drop in BP during inspiration
FIGURE 64-6B A, Schematic illustration of leftward septal shift with encroachment of left ventricular volume during inspiration in cardiac tamponade. B, Respiration marker and aortic and right ventricular pressure tracings in cardiac tamponade. Note paradoxical pulse and marked, 180 degrees out of phase respiratory variation in right- and left-sided pressures. Ao = aortic pressure; ECG = electrocardiogram; Exp = expiration; Insp = inspiration; RV = right ventricular pressure. (From Shabetai R: The Pericardium. New York, Grune & Stratton, 1981, p 266.)
constrictuive pericaritis?
Fibrosis and calcification of the pericardium
Rigid ‘case’ inhibits diastolic filling
Remains a diagnostic challenge
Constrictive pericarditis is due to a thickened, fibrotic pericardium that forms a non-compliant shell around the heart. This shell prevents the heart from expanding when blood enters it. This results in significant respiratory variation in blood flow in the chambers of the heart.
During inspiration, the negative pressure in the thoracic cavity will cause increased blood flow into the right ventricle. This increased volume in the right ventricle will cause the interventricular septum to bulge towards the left ventricle, leading to decreased filling of the left ventricle. Due to the Frank–Starling law, this will cause decreased pressure generated by the left ventricle during systole.
During expiration, the amount of blood entering the right ventricle will decrease, allowing the interventricular septum to bulge towards the right ventricle, and increased filling of the left ventricle and subsequent increased pressure generated by the left ventricle during systole.
This is known as ventricular interdependence, since the amount of blood flow into one ventricle is dependent on the amount of blood flow into the other ventricle.
cardiac temponade treatment?
iv fluid hydration
Pericardiocentesis
Analysis of fluid (blood, microbiology, cytology)
constrictive pericarditis?
Idiopathic
Infective - TB most commonest worldwide
Malignant
Post thoracotomy
Drug related
Post radiation
Connective tissue diseases
Renal failure
constrictive pericarditis?
Insidious onset
Right sided heart failure
Disproportionate to LV dysfunction or valve disease
Reflect increase right heart pressures
Tachycardia
JVP increase (Kussmaul’s sign)
Apex beat impalpable
Pericardial knock
Hepatomegaly
Ascites
Peripheral oedema
differential diagnoss of RHF?
Exclude other causes of RHF
Pulmonary embolus
Pulmonary hypertension
RV infarct
Mitral stenosis/tricuspid valve disease
LV dysfunction
Restrictive cardiomyopathy
RA myxoma
SVC obstruction
Nephrotic syndrome
Liver disease
Intra-abdominal malignancy
constrictive pericarditis investigstions?
ECG:
Tachycardia
Low voltage
AF in < 50%
CXR
Lateral most useful
Calcification (but doesn’t necessarily = constriction)
Heart size variable
CT/MRI
Best for pericardial thickness ( > 2 mm)
But:
Thick may not be constrictive
Normal can be constrictive (20% epicardial)
constrictive pericarditis management?
catheterisation
Elevated/equalised EDP in all 4 chambers
difference between RVEDP and LVEDP < 5 mmHg
RV systolic pressure < 50 mmHg
RVEDP > 1/3 RVSP
Dip and plateau diastolic filling (sq root sign)
normal effects of respiration?
Inspiration causes decrese intrathoracic pressure
Transmitted to intracardiac cavities as well as lungs
Transmitted to both pulmonary veins and LV
Pressure gradient from pulmonary veins to LV does not change with respiration
Mitral inflow ~unchanged with inspiration
constriction?
- Heart isolated from lungs
decrease intrathoracic pressure during inspiration NOT transmitted to cardiac chambers
Pulmonary veins are extra-pericardial so are still influenced by decrease intrathoracic pressure
decrease left-sided filling gradient in inspiration
decrease mitral inflow velocity
decrease PV diastolic forward flow - Ventricular Coupling
Total cardiac volume is fixed by constrictive pericardium
increase filling of one side = decrease filling of other side (through displacement of ventricular septum)
decrease LV filling in inspiration
MV inflow
increase RV filling in inspiration
decrease RV filling in expiration
TV inflow, Hep V flow reversal
septal bounce
constrictive pericarditis treeatment?
Underlying cause
Diuretics
Pericardial resection
Outcome
80% 5 year survival
cardiac tumors?
Primary
Benign (75%)
Malignant (25%)
Secondary
bening cardiac tumours?
clinial effects of cardiac tumours?
Clinical effects
Heart failure
Obstructive
Pump
Arrhythmias
Embolic phenomena
cardiac myxoma?
Most common cardiac tumour (50%)
Benign neoplasia of subendocardial mesenchymal cells
75% - left atrium, attached to atrial septum (limbus of fossa ovalis)
15-20% - right atrium
5-10% - left or right ventricle
Occasionally – AV valves
90% are solitary
Multiple (biatrial / atrial & ventricular …)
Familial
myxoma clinical?
Mean age at presentation: 50 years (0 - 95)
66% ♀
Rarely, familial (Carney complex)
Multiple myxomas, skin pigmentation, endocrine overactivity
Symptoms
Intracardiac obstruction (heart failure)
Prolapse into MV orifice
Systemic embolisation (30%)
Stroke, limb, organs, multiple
Constitutional symptoms
Unique amongst cardiac tumours
Myalgia, arthralgia, rash, fever, weight loss
Raynauds, clubbing
ESR, anaemia, WCC, plts
Caused by secretion of IL-6
carney complex?
Carney complex and its subsets LAMB syndrome[1] and NAME syndrome[1] are autosomal dominant conditions comprising myxomas of the heart and skin, hyperpigmentation of the skin (lentiginosis), and endocrine overactivity.[2][3] It is distinct from Carney’s triad. Approximately 7% of all cardiac myxomas are associated with Carney complex.[4]
myxoma signs?
Loud S1
Pansystolic murmur (mitral)
Mid-diastolic murmur (mitral)
Tumour “plop”
Pulmonary congestion
Clubbing
myxoma investigations?
CXR – may be normal
LA, pulmonary congestion
Echocardiogram
CT or MRI
Treatment
Cardiac surgery
papillary fibroelastoma?
Most common valve tumour
Benign tumour of endocardium
Mean age 60 years (0 – 92)
♀ = ♂
Single, mean size 8mm
Embolic events (CVA) 25% risk over 3 years
papillary fibroelastoma efho and treatment?
Echocardiogram
TTE transthoracic echocardiogram (TTE) & TOE Transoesophjageal
Treatment
Cardiac surgery
malignant tumours?
95% sarcomas
Usually fatal, rarely resectable
echo in stroke?
CVA - Haemorrhagic (19%)
- Infarction (69%) 1. large branch occluion, 2. small vessel lacunar
embolic stroke?
Abrupt onset
Previous infarction in other cerebral territory
Peripheral embolus
Multiple lesions on CT or MRI
Anterior (or posterior) circulation syndrome (vs lacunar syndrome)
Migraine with aura
cardioembolic source?
patent foramen ovale?
Remnant of fetal circulation
Incidence
25% “probe patent”
<10% echo
No cardiac sequelae
R L shunt
Provoked by valsalva
Detected by echo
