Constriction

369 views
306 views

Published on

0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
369
On SlideShare
0
From Embeds
0
Number of Embeds
10
Actions
Shares
0
Downloads
6
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide

Constriction

  1. 1. DC Fellows Forum Raj Khandwalla M.D. Georgetown/Washington Hospital Center
  2. 2. History of Present Illness <ul><li>65 yo M with PMH of MV replacement in 1975 s/p Bjork Shiley mitral valve who presents to the cath lab with a two month history of decreased exercise tolerance. </li></ul><ul><li>Patient has a history of paroxysmal AF for the past ten years with multiple cardioversions. </li></ul><ul><li>Last cardioversion was in May, but his AF recurred and has persisted for the past two months. Previously, the patient was able to run 2.5 miles, but now he cannot run. </li></ul><ul><li>Patient underwent an exercise stress test in which he was only able complete stage II Bruce Protocol and had an echo which showed a normal EF, but the mitral valve was not able to be evaluated. </li></ul>
  3. 3. History of Present Illness <ul><li>As such, the patient was referred for cardiac cath in order to assess his coronary arteries and measure the gradient across the mitral valve. </li></ul>
  4. 4. History of Present Illness <ul><li>PMHX: as above, GERD </li></ul><ul><li>MEDS: Propafenone, Warfarin </li></ul><ul><li>ALL: NKDA </li></ul><ul><li>SOCHX: social drinker, quit smoking 40 years ago </li></ul><ul><li>FH: denies </li></ul>
  5. 5. Physical Exam <ul><ul><li>Gen: no apparent distress, appears younger than stated age </li></ul></ul><ul><ul><li>VS: T 98.0 BP129/77 HR 60 RR 16 98% RA </li></ul></ul><ul><ul><li>Neck: JVD elevated to angle of jaw </li></ul></ul><ul><ul><li>Chest: Well healed sternotomy scar </li></ul></ul><ul><ul><li>Heart: irreg, irreg, +valve clicks appreciated </li></ul></ul><ul><ul><li>Lungs: clear to auscultation </li></ul></ul><ul><ul><li>Abdomen: soft, NT, ND, + hepatojugular reflex </li></ul></ul><ul><ul><li>Ext: 2+ pitting edema to the shins </li></ul></ul>
  6. 6. Laboratory Assessment: 1.6 11.3 – 13.3 INR 33.6 22.1 – 35.1 Partial-thromboplastin time (sec) 118 150,000 – 300,000 Platelet Count (per mm 3 ) 4.5 0 – 8 Eosinophils 17.6 4 – 11 Monocytes 37.5 22 – 44 Lymphocytes 40 40 – 70 Neutrophils Differential Count (%) 4.0 4,500 – 11,000 White-cell count (per mm 3 ) 36.2 41.0 – 53.0 Hematocrit (%) 12.3 13.5 – 17.5 Hemoglobin (g/dl) HEMATOLOGY ON ADMISSION REFERENCE RANGE TEST
  7. 7. Laboratory Assessment: 218 0.0-99 Brain Naturitic Peptide (pg/ml) 1.3 0.6 – 1.5 Creatinine (mg/dl) 22 8 – 25 Urea nitrogen (mg/dl) 24 23.0 – 31.9 Carbon dioxide (mmol/liter) 107 100 – 108 Chloride (mmol/liter) 4.3 3.4 – 4.8 Potassium (mmol/liter) 140 135 – 145 Sodium (mmol/liter) CHEMISTRY ON ADMISSION REFERENCE RANGE TEST
  8. 9. Tracings
  9. 10. Tracings
  10. 11. Tracings
  11. 12. Tracings
  12. 13. Tracings
  13. 14. Tracings
  14. 15. What is the differential diagnosis for these tracings? How do we make the diagnosis?
  15. 16. Tracings
  16. 17. Tracings
  17. 18. Ventricular Interdependence Restrictive Constrictive
  18. 23. <ul><li>Normal pericardial thickness </li></ul><ul><li>Multiple adhesions between the pericardium and the heart </li></ul><ul><li>RV directly below the sternum </li></ul>
  19. 28. Constrictive Pericarditis <ul><li>Represents the end stage of an inflammatory process </li></ul><ul><ul><li>Can occur in months, but usually takes years to develop </li></ul></ul><ul><li>Etiologies </li></ul><ul><ul><li>Idiopathic </li></ul></ul><ul><ul><li>Irradiation </li></ul></ul><ul><ul><li>Postsurgical </li></ul></ul><ul><ul><li>Infectious </li></ul></ul><ul><ul><li>Neoplastic </li></ul></ul><ul><ul><li>Autoimmune disorder </li></ul></ul><ul><ul><li>Uremia </li></ul></ul><ul><ul><li>Posttraumatic </li></ul></ul><ul><ul><li>Sarcoid </li></ul></ul><ul><ul><li>Methysergide therapy </li></ul></ul><ul><ul><li>Implantable defibrillator patches </li></ul></ul>
  20. 29. Pathophysiology <ul><li>Pericardial scarring restricts filling of all chambers which symmetrically results in the elevation of filling chambers </li></ul><ul><li>Early diastole </li></ul><ul><ul><li>Rapid filling of the ventricles due to high atrial pressures and increased diastolic suction (due to small end-systolic volumes) </li></ul></ul><ul><li>Mid diastole </li></ul><ul><ul><li>Ventricular filling is abruptly stopped when the intracardiac volume can no longer expand due to the noncompliant pericardium </li></ul></ul>
  21. 30. Hemodynamics Constrictive pericarditis RV infarct Tamponade Restrictive cardiac disease Pulses paradoxus < 1/3 Occasional Frequent Rare RA waveforms Prominent y descent Prominent y descent Prominent x descent Insp.  Variable y descent Equalization of diastolic pressures Frequent Frequent Frequent Rare “ Square root” sign Frequent Frequent Absent Variable

×