Pericardial Pathology - Casecag.com
Pericardial Pathology - Casecag.com
Pericardial Pathology - Casecag.com
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Objectives<strong>Pericardial</strong> anatomy<strong>Pericardial</strong> pathophysiologyEchocardiographic analysis of pericardial diseaseReview a case of pericardial pathologyCASE CARDIAC ANESTHESIA GROUP
<strong>Pericardial</strong> AnatomyCASE CARDIAC ANESTHESIA GROUP
<strong>Pericardial</strong> Anatomy
Avery E, Shernan S Comp Text Periop TEE 2010<strong>Pericardial</strong> Anatomy1: Visceral pericardium 2: Parietal pericardiumCASE CARDIAC ANESTHESIA GROUP
Google Images 2006<strong>Pericardial</strong> AnatomyMicrovilli2-3 mm5 – 50 mLsPlasma ultrafiltrate
<strong>Pericardial</strong> AnatomyAvery E, Shernan S Comp Text Periop TEE 2010
<strong>Pericardial</strong> AnatomyME 2C viewFiegenbaum. Echocardiography 2004. Fig. 9-12
Avery E, Shernan S Comp Text Periop TEE 2010<strong>Pericardial</strong> AnatomyME LAX viewCASE CARDIAC ANESTHESIA GROUP
Normal <strong>Pericardial</strong> PhysiologyCASE CARDIAC ANESTHESIA GROUP
Google Images 2006Normal <strong>Pericardial</strong> PhysiologyRestraintReduced frictionShapeFibrinolysis
NEJM 2003 (347) 7Normal <strong>Pericardial</strong> PhysiologyNormalChronic pericardial effusionCASE CARDIAC ANESTHESIA GROUP
Normal <strong>Pericardial</strong> PhysiologyRespirophasic Variation: Spontaneous Respiration
Avery EG 2008Normal <strong>Pericardial</strong> PhysiologySpontaneous Ventilation – Right HeartIP: Intrapericardial pressure; RA: Right atrial pressure
Normal <strong>Pericardial</strong> PhysiologySpontaneous Ventilation – Right HeartAvery EG 2008
Avery E, Shernan S Comp Text Periop TEE 2010Normal <strong>Pericardial</strong> PhysiologyRespirophasic Variation: Spontaneous RespirationTranstricuspid valve Pulse Wave Doppler (TEE)ExpirationInspiration+20%CASE CARDIAC ANESTHESIA GROUP
Avery EG 2008Normal <strong>Pericardial</strong> PhysiologySpontaneous Ventilation – Left HeartAo DBP: Aortic diastolic blood pressureIP: Intrapericardial pressure
Normal <strong>Pericardial</strong> PhysiologySpontaneous Ventilation – Left HeartAvery EG 2008
Normal <strong>Pericardial</strong> PhysiologyRespirophasic Variation: Spontaneous RespirationTransmitral valve Pulse Wave Doppler (TEE) -10%Avery E, Shernan S Comp Text Periop TEE 2010
Normal <strong>Pericardial</strong> PhysiologyRespirophasic Variation: IPPVCASE CARDIAC ANESTHESIA GROUP
Avery EG 2008Normal <strong>Pericardial</strong> PhysiologyIntermittent Positive Pressure Ventilation – Right HeartIP: Intrapericardial pressure; RA: Right atrial pressure
Normal <strong>Pericardial</strong> PhysiologyIntermittent Positive Pressure Ventilation – Right HeartAvery EG 2008
Normal <strong>Pericardial</strong> PhysiologyRespirophasic Variation: IPPVTranstricuspid valve Pulse Wave Doppler (TEE) Not quantifiedAvery E, Shernan S Comp Text Periop TEE 2010
Ao DBP: Aortic diastolic blood pressureIP: Intrapericardial pressureAvery EG 2008Normal <strong>Pericardial</strong> PhysiologyIntermittent Positive Pressure Ventilation – Left Heart
Normal <strong>Pericardial</strong> PhysiologyIntermittent Positive Pressure Ventilation – Left HeartAvery EG 2008
Normal <strong>Pericardial</strong> PhysiologyRespirophasic Variation: IPPVTransmitral valve Pulse Wave Doppler (TEE)↑30%Avery E, Shernan S Comp Text Periop TEE 2010
<strong>Pericardial</strong> <strong>Pathology</strong>CASE CARDIAC ANESTHESIA GROUP
<strong>Pericardial</strong> <strong>Pathology</strong>Congenital pericardial defectsPericarditisConstrictive Pericarditis<strong>Pericardial</strong> effusion<strong>Pericardial</strong> tamponade<strong>Pericardial</strong> MassesCASE CARDIAC ANESTHESIA GROUP
<strong>Pericardial</strong> <strong>Pathology</strong>Congenital pericardial defectsCASE CARDIAC ANESTHESIA GROUP
<strong>Pericardial</strong> <strong>Pathology</strong>: Congenital Absence ofthe PericardiumOverall Incidence 0.01% Partial Left Absence 70%Total Bilateral Absence - RarePartial Right Absence 17%Google images
<strong>Pericardial</strong> <strong>Pathology</strong>PericarditisCASE CARDIAC ANESTHESIA GROUP
<strong>Pericardial</strong> <strong>Pathology</strong>: PericarditisAvery E, Shernan S Comp Text Periop TEE 2010
ME 4C view<strong>Pericardial</strong> <strong>Pathology</strong>: PericarditisCASE CARDIAC ANESTHESIA GROUP
TG SAX Mid-pap<strong>Pericardial</strong> <strong>Pathology</strong>: PericarditisCASE CARDIAC ANESTHESIA GROUP
TG SAX Mid-pap<strong>Pericardial</strong> <strong>Pathology</strong>: PericarditisCASE CARDIAC ANESTHESIA GROUP
<strong>Pericardial</strong> <strong>Pathology</strong>: PericarditisM-modeAvery E, Shernan S Comp Text Periop TEE 2010
Avery E, Shernan S Comp Text Periop TEE 2010<strong>Pericardial</strong> <strong>Pathology</strong>: PericarditisCardiac Magnetic Resonance ImageHigher fidelitymeasurements
<strong>Pericardial</strong> <strong>Pathology</strong>: PericarditisConstrictive PericarditisCASE CARDIAC ANESTHESIA GROUP
<strong>Pericardial</strong> <strong>Pathology</strong>: Constrictive PericarditisAvery 2005
<strong>Pericardial</strong> <strong>Pathology</strong>: Constrictive Pericarditis
<strong>Pericardial</strong> <strong>Pathology</strong>: Constrictive PericarditisSquare root signM signa vySkubas NJ. A&A 2001;92:1424
<strong>Pericardial</strong> <strong>Pathology</strong>: Constrictive PericarditisHigher Fidelity ImagingCASE CARDIAC ANESTHESIA GROUP
<strong>Pericardial</strong> <strong>Pathology</strong>: Constrictive PericarditisRespirophasic VariationEXAGGERATED!&CASE CARDIAC ANESTHESIA GROUP
<strong>Pericardial</strong> <strong>Pathology</strong>: Constrictive PericarditisRespirophasic variation ( )Transmitral PW Doppler
<strong>Pericardial</strong> <strong>Pathology</strong>: Constrictive PericarditisRespirophasic VariationCASE CARDIAC ANESTHESIA GROUP
Respirophasic variation ( )
<strong>Pericardial</strong> <strong>Pathology</strong>: Constrictive PericarditisRespirophasic variation (IPPV)Transmitral PW Doppler
Ibdalla I. JASE 2000;13:827<strong>Pericardial</strong> <strong>Pathology</strong>: Constrictive PericarditisPulmonary Vein DopplerInspirationaS D SaDV=28%tNormal S:D > 1Restrictive Cardiomyopathy&Constrictive Pericarditis S:D < 1
<strong>Pericardial</strong> <strong>Pathology</strong>: Constrictive Pericarditis15 cm/sec38% Inspiration24 cm/sec
<strong>Pericardial</strong> <strong>Pathology</strong>: Constrictive PericarditisAvery E, Shernan S Comp Text Periop TEE 2010CASE CARDIAC ANESTHESIA GROUP
<strong>Pericardial</strong> <strong>Pathology</strong>: Constrictive PericarditisCASE CARDIAC ANESTHESIA GROUP
<strong>Pericardial</strong> <strong>Pathology</strong>: Constrictive PericarditisCASE CARDIAC ANESTHESIA GROUP
<strong>Pericardial</strong> <strong>Pathology</strong>: Constrictive Pericarditis+ +CASE CARDIAC ANESTHESIA GROUP
Am J Card 2001;87:86Newer Diastolic Assessment ModalitiesColor M-mode (flowpropagation velocity, Vp)RestrictiveCardiomyopathyInsp35 cm/sConstrictivePericarditis110 cm/sInsp
Newer Diastolic Assessment ModalitiesVp or flow propagation with color M-mode
ME 4C view w/color M-modeNewer Diastolic Assessment ModalitiesConstrictive Pericarditis – Flow Propagation, V p95.9 cm/sec
Newer Diastolic Assessment ModalitiesTissue Doppler ImagingRestrictiveCardiomyopathy10 cm/sConstrictivePericarditis10 cm/sAm J Card 2001;87:86
Newer Diastolic Assessment ModalitiesTissue Doppler ImagingME 4C view lateral MV annulusConstrictivePericarditis9.6 cm/sec
Am J Cardiol 2001; 87:86-94Constrictive vs. Restrictive <strong>Pathology</strong>Sensitivity (%) Specificity (%)E wave peak MV(resp. variation ≥ 10%)84 91D wave peak(resp. variation ≥ 18%)Color M-modeVp (slope ≥ 100 cm/s)Tissue Doppler,(E m ≥ 8 cm/s)79 9174 9189 100
<strong>Pericardial</strong> <strong>Pathology</strong>: Constrictive Pericarditis“Septal Bounce”
<strong>Pericardial</strong> <strong>Pathology</strong>: Constrictive PericarditisPremature mid-diastolic PV Opening
<strong>Pericardial</strong> <strong>Pathology</strong>: Constrictive PericarditisPremature mid-diastolic PV Opening
<strong>Pericardial</strong> <strong>Pathology</strong><strong>Pericardial</strong> effusionCASE CARDIAC ANESTHESIA GROUP
<strong>Pericardial</strong> <strong>Pathology</strong>: <strong>Pericardial</strong> EffusionElectrical AlternansAvery E, Shernan S Comp Text Periop TEE 2010CASE CARDIAC ANESTHESIA GROUP
<strong>Pericardial</strong> <strong>Pathology</strong>: <strong>Pericardial</strong> Effusion<strong>Pericardial</strong> Effusion CharacteristicsSeverityWidth byEchoVolume(mL)Localization RegionSmall < 5 mm < 100 Behind posterior LV wallModerate 5 - 20 mm 100 - 150Large > 20 mm > 500Expand laterally andapicallyEvenly distributed aroundthe heartAvery E, Shernan S Comp Text Periop TEE 2010CASE CARDIAC ANESTHESIA GROUP
<strong>Pericardial</strong> <strong>Pathology</strong>: <strong>Pericardial</strong> EffusionCASE CARDIAC ANESTHESIA GROUP
<strong>Pericardial</strong> <strong>Pathology</strong>: <strong>Pericardial</strong> EffusionCASE CARDIAC ANESTHESIA GROUP
<strong>Pericardial</strong> <strong>Pathology</strong>: <strong>Pericardial</strong> EffusionChronic Effusion – Fibrinous StrandingCASE CARDIAC ANESTHESIA GROUP
<strong>Pericardial</strong> <strong>Pathology</strong><strong>Pericardial</strong> tamponadeCASE CARDIAC ANESTHESIA GROUP
<strong>Pericardial</strong> <strong>Pathology</strong>: <strong>Pericardial</strong> TamponadeAvery E, Shernan S Comp Text Periop TEE 2010CASE CARDIAC ANESTHESIA GROUP
<strong>Pericardial</strong> <strong>Pathology</strong>: <strong>Pericardial</strong> TamponadeInspirationAvery E, Shernan S Comp Text Periop TEE 2010CASE CARDIAC ANESTHESIA GROUP
<strong>Pericardial</strong> <strong>Pathology</strong>: <strong>Pericardial</strong> TamponadeCASE CARDIAC ANESTHESIA GROUP
<strong>Pericardial</strong> <strong>Pathology</strong>: <strong>Pericardial</strong> TamponadeRA Wall Systolic CollapseRAPERVCASE CARDIAC ANESTHESIA GROUP
<strong>Pericardial</strong> <strong>Pathology</strong>: <strong>Pericardial</strong> TamponadeRV Wall Diastolic CollapseRVLVCASE CARDIAC ANESTHESIA GROUP
<strong>Pericardial</strong> <strong>Pathology</strong>: <strong>Pericardial</strong> TamponadeRespirophasic VariationEXAGERATED!CASE CARDIAC ANESTHESIA GROUP
<strong>Pericardial</strong> <strong>Pathology</strong>: <strong>Pericardial</strong> TamponadeRespirophasic Variation: Spontaneous RespirationTranstricuspid valve Pulse Wave Doppler (TEE)CASE CARDIAC ANESTHESIA GROUP
<strong>Pericardial</strong> <strong>Pathology</strong>: <strong>Pericardial</strong> TamponadeRespirophasic Variation: Spontaneous RespirationTransmitral valve Pulse Wave Doppler (TEE)CASE CARDIAC ANESTHESIA GROUP
<strong>Pericardial</strong> <strong>Pathology</strong>: <strong>Pericardial</strong> TamponadeRespirophasic Variation: IPPVFaehnrich J. JCTVA 2003;17:45
<strong>Pericardial</strong> <strong>Pathology</strong>: <strong>Pericardial</strong> TamponadeHepatic Vein Doppler ProfileCASE CARDIAC ANESTHESIA GROUP
Avery E, Shernan S Comp Text Periop TEE 2010<strong>Pericardial</strong> <strong>Pathology</strong>: <strong>Pericardial</strong> TamponadeHepatic Vein Doppler Profile - Spontaneous VentilationNormalTamponade
<strong>Pericardial</strong> <strong>Pathology</strong>: MassesCASE CARDIAC ANESTHESIA GROUP
Avery E, Shernan S Comp Text Periop TEE 2010<strong>Pericardial</strong> <strong>Pathology</strong>: Masses64-slice Computed Tomography
<strong>Pericardial</strong> <strong>Pathology</strong>: MassesAvery E, Shernan S Comp Text Periop TEE 2010CASE CARDIAC ANESTHESIA GROUP
CASE CARDIAC ANESTHESIA GROUPCase Study
Case Studyt = 6 months t = 6 monthsTEECASE CARDIAC ANESTHESIA GROUP
Case Study?CASE CARDIAC ANESTHESIA GROUP
Case StudyLARARVCASE CARDIAC ANESTHESIA GROUP
Case StudyMV Peak Gradient = 5 mm HgMV Mean Gradient = 2 mm HgCardiac Index = 2.7 L/min/m 2CASE CARDIAC ANESTHESIA GROUP
Case Study – Septal bounce?CASE CARDIAC ANESTHESIA GROUP
CASE CARDIAC ANESTHESIA GROUPCase Study
Case Study1 cmCASE CARDIAC ANESTHESIA GROUP
CASE CARDIAC ANESTHESIA GROUPCase Study
Case StudyE : A > 2CASE CARDIAC ANESTHESIA GROUP
CASE CARDIAC ANESTHESIA GROUPCase Study
CASE CARDIAC ANESTHESIA GROUPCase Study
CASE CARDIAC ANESTHESIA GROUPCase Study
Case StudyV = 60%E= 30I= 80CASE CARDIAC ANESTHESIA GROUP
Case StudyV4ArtRVCVP
Case Study
CASE CARDIAC ANESTHESIA GROUPCase Study
Updated syllabus, slides & video presentation available on-Linewww.casecag.<strong>com</strong>
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