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  • 1. MR   Cardiology    2/18/14   Jon  Halevy    
  • 2. Causes  of  Pericardial  disease   •  Idiopathic   •  Infec.ous  (viral,  bacterial,  fungal,  parasiAc,  IE  with  abscess)   •  Radia.on   •  Neoplas.c  /  paraneoplasAc   •  Cardiac  –  early/late  post-­‐MI.  MyocardiAs,  dissecAon,  post-­‐ cardiac  surgery   •  Trauma   •  Autoimmune  –  rheumaAc,  IBD,  sarcoid,  vasculiAs,   whipples,  behcet’s   •  Drugs  –  drug-­‐induced  lupus,  others  (incl  penicillins   •  Metabolic  –  hypothyroid,  uremia,  ovarian  oversAm)  
  • 3. Sagrista,  2000  (N=322)   •  Mod-­‐large  pericardial  effusion  (>10  mm)   •  37%  with  tamponade   •  Idiopathic  –  29%;  Iatrogenic  –  16%;   Malignancy  13%;  uremia  –  6%;  post  acute  MI   8%;  infecAon  6%;  Collagen  Vascular  5%;   Hypothyroid  2%,  other  15%  
  • 4. hp://www.cardiothoracicsurgery.org/ content/2/1/30/figure/F2?highres=y  
  • 5. •  Large/acute  Pericardial  effusion   •  CompeAAon  with  heart  and  pericardial  volume  for   space  à  constrained  cardiac  filling   •  Normally  venous  return  bimodal  peaking  in   ventricular  systole  and  early  diastole,  heart  volume   minimal  during  systole/ejecAon.  Lose  early  diastole   filling  peak.  Relying  on  systole  to  fill.     •   Tamponade  when  this  impairs  filling  of  ventricles   à  can  cause  shock     •  Volume  DepleAon  =  BAD  (avoid  diuresis!)  
  • 6. Pericardial  FricAon  Rub   hp://www.youtube.com/watch? v=fI4XXFRotNE   -­‐  Actual  sounds  are  only  last  20  seconds  
  • 7. Pulsus   alternans  (q2   beats,  LV   systolic   faiure)  versus   Pulsus   paradoxus   (lower  during   inspiraAon)  
  • 8. Electrical  alternans  
  • 9. Respiratory  VariaAon   •  Normally  about  10  pt  drop  in  SBP  during  inspira.on   •  Inspiratory  decline  in  thoracic  pressure  is  transmied  through  the   pericardium  to  the  right  side  of  the  heart  and  the  pulmonary  vasculature.   As  a  result,  systemic  venous  return  to  the  right  heart  increases  with   inspiraAon,  and  pulmonary  venous  return  to  the  lej  heart  decreases  with   inspiraAon.   •   In  cardiac  tamponade,  the  rigid  pericardium  prevents  the  free  wall  from   expanding.  The  ensuing  distension  of  the  right  ventricle  is  limited  to  the   interventricular  septum,  which  along  with  relaAve  underfilling  of  the  lej   ventricle  causes  the  septum  to  bulge  to  the  lej,  reducing  lej  ventricular   compliance  and  contribuAng  to  further  decreased  filling  of  the  lej   ventricle  during  inspiraAon.  This  concept  is  referred  to  as  "ventricular   interacAon"  or  "ventricular  interdependence".       •  RA  Pressure  =  RVEDP  and  LVEDP  =  PA  Diastolic  Pressure  
  • 10. Acuity  Maers   •  Hyperacute  Coronary  laceraAon  (acute  -­‐  red)   versus  presumed  viral  pericardiAs  (chronic  –  blue)   Data  from  pericardiocentesis