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Pericardial Diseases 7/19/2020 Pericardial Diseases Mahi L. Ashwath MD, MBA, FACC, FASE, FSCMR President, Iowa ACC Director, Cardiac MRI Associate Professor of Medicine and Radiology University of Iowa Hospitals and Clinics Outline 1. Anatomy of pericardium 2. Pericardial disease • Pericarditis – Acute or recurrent • Pericardial effusion • Pericardial tamponade • Constrictive pericarditis • Pericardial Cysts, Malignancy, Congenital absence of pericardium 1 7/19/2020 Normal Pericardium • Two layers: – Outer layer is parietal pericardium and consists of layers of fibrous and serous tissue – Inner layer is visceral pericardium and consists of serous tissue only • Normal amount of pericardial fluid: 15-50 cc Diseases of the Pericardium 1. Acute pericarditis • Recurrent pericarditis 2. Pericardial effusion • Pericardial Tamponade 3. Constrictive pericarditis • Restrictive Cardiomyopathy 4. Pericardial Cysts 2 7/19/2020 Acute Pericarditis • Defined as – Inflammation of the pericardial sac • Myopericarditis, or perimyocarditis – acute pericarditis that also demonstrate myocardial inflammation • Myopericarditis – prevalent pericarditis and normal ventricular function • Perimyocarditis – prevalent myocarditis and ventricular function is reduced (new wall motion abnormalities or reduced ventricular function) Etiology of Acute Pericarditis: Infection • Viral: • Bacterial • Adeno • Staphylococcus • Entero • Streptococcus • CMV • Pneumococcus • Influenza • Hemophilus • Hepatitis B • • Herpes Simplex Neisseria • Echo virus • Chlamydia • Mumps • Legionella • COVID - 19 • Tuberculosis • Fungal • Lyme Disease • Parasitic 3 7/19/2020 Etiology Continued • Radiation • Trauma • Neoplasm – Blunt – Metastatic – Iatrogenic (perforations, – Primary Cardiac post surgical) – Paraneoplastic • Autoimmune • Cardiac – Rheumatic disease – Early infarction – Non- rheumatic • Wegner's, sarcoid, IBD – Dressler’s • Myocarditis • Aortic dissection Etiology Continued • Drugs: • Metabolic – Drug induced lupus – Hypothyroid • Hydralazine – Uremia • Isoniazid – Ovarian Hyperstimulation • Procainamide • Doxorubicin • Phenytoin 4 7/19/2020 Typical features of Acute Pericarditis • Chest pain >85-90% – sudden in onset – anterior chest – sharp and pleuritic in nature – exacerbation by inspiration or coughing – Decrease in intensity with sitting up and leaning forward • Friction Rub <40% – triphasic, with a superficial scratchy or squeaking quality – intermittent – three phases, - atrial systole, ventricular systole, and the rapid filling phase of early ventricular diastole • Classic ECG 60% • Effusion 60% Acute Pericarditis 5 7/19/2020 Testing for Acute Pericarditis • ECG • Chest X Ray • Labs – CBC – Troponin – ESR and CRP • Optional – Blood culture/ Viral studies – Rheumatologic workup – Multimodality imaging – Pericardiocentesis – Pericardial Biopsy Effusion: Echo Findings: 6 7/19/2020 Acute Pericarditis 13 Normal Pericardium 14 7 7/19/2020 Predictors of poor prognosis: • Fever >380 C • Subacute onset • Large pericardial effusion • Cardiac tamponade • No response to NSAIDs in first Need admission week • Myopericarditis • Immunosuppression • Trauma • Oral anticoagulant therapy Acute Pericarditis: Management • Goal: – Relief of pain – Reduction of inflammation – Prevention of recurrence/ complications • Treatment: – Activity restriction until resolution of symptoms – NSAID agent for 1-2 weeks • Aspirin 750 - 1000 mg q8 • Ibuprofen 800 mg q8 – Colchicine 0.6 mg bid X 3 months • COPE and ICAP studies – Avoid steroids – unless above agents are contraindicated • (Eg: Pregnancy, Renal insufficiency) – Duration determined by symptoms and CRP 8 7/19/2020 Recurrent Pericarditis • Prolonged NSAIDs and Colchicine – guided by symptoms and inflammatory markers • Triple therapy – Add steroid to above agents • Moderate doses with very slow taper • Gradual taper with improvement in symptoms and inflammatory markers – Taper Steroids – Followed by NSAIDs – Followed by Colchicine Colchicine – Adverse effects • Blood dyscrasias: – Myelosuppression – Thrombocytopenia, leukopenia, granulocytopenia, pancytopenia and aplastic anemia • Gastrointestinal symptoms: – anorexia, diarrhea, nausea, vomiting • Neuromuscular toxicity: – Myotoxicity (including rhabdomyolysis) – Renal dysfunction and elderly patients - increased risk – Concomitant use of cyclosporine, diltiazem, verapamil, fibrates, and statins – Symptoms typically resolve within 1 week to several months of colchicine discontinuation • Hepatic impairment: Clearance is decreased in hepatic impairment • Renal impairment: Clearance is decreased in renal impairment 9 7/19/2020 Myopericarditis • If troponin is elevated • MRI to confirm no extensive myocarditis • Consider coronary angiogram to exclude Coronary artery disease • Hospitalization • Return to competition (6 months after onset) Summarize Acute Pericarditis: • Inflammation of the pericardium usually due to a viral infection • Diagnosed by history, pericardial rub, elevated CRP, Abnormal ECG • Troponin helpful in knowing if any component of myocarditis is also present • Management: NSAIDs and Colchicine 10 7/19/2020 Diseases of the Pericardium 1. Acute pericarditis • Chronic pericarditis 2. Pericardial effusion • Pericardial Tamponade 3. Constrictive pericarditis • Restrictive Cardiomyopathy 4. Pericardial Cysts Pericardial effusion and tamponade • Recognize presentation • Appropriate testing • Management strategies 11 7/19/2020 Presentation • Usually discovered incidentally • Pericarditis • Hemodynamically significant effusion – signs and symptoms of impaired cardiac function – dyspnea, elevated JVP, hypotension and impaired perfusion Etiology • Infection – Viral, Bacterial • Malignancy • Post Cardiac Injury – Post MI syndrome – Post Pericardiotomy syndrome – Post traumatic • Radiation • Drugs • Systemic Disorders – Collagen Vascular Disease – Uremia and dialysis – Hypothyroidism • Idiopathic 12 7/19/2020 Etiology of symptomatic effusions (173 patients) • Malignancy – 33% • Chronic-idiopathic – 14 % • Acute pericarditis – 12% • Trauma – 12 % • Uremia – 6 % • Post-pericardiotomy – 5 % • Indeterminate – 8 % • Other causes (including infection, collagen vascular disease, radiation, heart failure, etc) – 10 % Medicine (Baltimore) . 2006; 85:49 Chest X Ray • Requires about 200 cc of fluid 13 7/19/2020 Pericardial effusion • Low voltage and electrical alternans Effusion: Echo Findings: 14 7/19/2020 After effusion is diagnosed, assess for presence of tamponade 15 7/19/2020 Cardiac Tamponde • Sinus tachycardia • Elevated Jugular Venous Pressure • Pulsus Paradoxus Effusion with tamponade 16 7/19/2020 M mode Respiratory inflow variation • Drop in • Mitral flow by 30 percent - first beat of inspiration , • Tricuspid valve flow by 60 percent – first beat of expiration 34 17 7/19/2020 IVC Plethora 18 7/19/2020 Pericardiocentesis • Done for – Tamponade – Diagnosis – especially for malignancy history • Don’t do – Concern for aortic dissection Summarize Pericardial Effusion: • Wide spectrum in presentation and severity • Recognize presentation and imaging features of tamponade • Pericardiocentesis if needed 19 7/19/2020 Diseases of the Pericardium 1. Acute pericarditis • Chronic pericarditis 2. Pericardial effusion • Pericardial Tamponade 3. Constrictive pericarditis • Restrictive Cardiomyopathy 4. Pericardial Cysts Pericardial Constriction • Recognize presentation • Select appropriate testing • Select appropriate management • Differentiate between Constrictive Pericarditis and Restrictive Cardiomyopathy 20 7/19/2020 Pathophysiology • Result of scarring and consequent loss of the normal elasticity of the pericardial sac • Cardiac filling is impeded by an external force – Virtually inelastic parietal and/or visceral pericardial tissue, which is thickened, fibrotic, and sometimes calcified – Results in a markedly impaired ability to adapt to volume changes – greatly enhanced ventricular interdependence, in which the hemodynamics of the left and right heart chambers are directly influenced by each other to a much greater degree than normal Constrictive Pericarditis Presenting symptoms: • CHF 67% • Chest pain 8% • GI Symptoms 6% • Tamponade 5% • Arrhythmia 4% • Liver Disease 4% 21 7/19/2020 Constrictive Pericarditis Presenting signs: • Elevated JVP 88% • Peripheral edema 64% • Hepatomegaly 53% • Pericardial knock 47% • Ascites 37% • Kussmaul’s 21% • Pulsus paradoxus 19% JVP 22 7/19/2020 Constrictive Pericarditis: CXR and CT Geske et al. JACC 68, 2016:2329-47 Constrictive Pericarditis • Hallmark – Ventricular interdependance • Dynamic hemodynamics during respiratory cycle • Reflect increased ventricular interaction • Dissociation between intrathoracic and intracardiac pressures 23 7/19/2020 48 24 7/19/2020 Constrictive Pericarditis 50 25 7/19/2020 Constrictive Pericarditis - Treatment • Exclude acute pericarditis • Medical management • Surgery – pericardial stripping • Acute/ transient effusive constrictive pericarditis can be treated with aggressive anti-inflammatory therapy Effusive-constrictive pericarditis • Constrictive physiology with a coexisting pericardial effusion, often with cardiac tamponade • Results in a mixed hemodynamic picture with features of both constrictive pericarditis and cardiac tamponade • Mistakenly thought to have only cardiac tamponade • Elevation of the right atrial and pulmonary wedge pressures after drainage of the pericardial fluid points to the underlying constrictive process 26 7/19/2020 Think Constriction • Heart failure - Right heart failure – out of proportion to myocardial or valve
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