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Hemodynamic Conference. Eckhard Alt, M.D. Holger Salazar, M.D. Robert Smith, M.D., M.Sc. Tulane University School of Medicine Cardiac Cath Conference December 23, 2003. Outline. Right Heart Catheterization Overview Review of Waveform Analysis Practice Case

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Hemodynamic conference

Hemodynamic Conference

Eckhard Alt, M.D.

Holger Salazar, M.D.

Robert Smith, M.D., M.Sc.

Tulane University School of Medicine

Cardiac Cath Conference

December 23, 2003


Outline
Outline

  • Right Heart Catheterization Overview

  • Review of Waveform Analysis

  • Practice Case

  • Case Presentation with RHC Results

  • Discussion of Differential Diagnosis

  • Review of Echocardiographic Findings and Follow up

  • Discussion


Right heart catheterization
Right Heart Catheterization

  • Measures Central Venous Pressure/Right Atrial Pressure

  • Measures RV Pressures and PA Pressures

  • Gives Indirect Measure of Left Atrial Pressure (PCWP)

  • Avoids Septal Puncture

  • Estimates Cardiac Output

  • Quantifies Oxygen Utilization

  • Useful in Diagnosis of Shock Etiology

  • Useful for Peri-Operative Volume Management











Diagnosis1

Diagnosis

Non-Ischemic Cardiomyopathy


Case presentation
Case Presentation

CC is a 19 yo AAM with no significant PMHx who presented with a 2 year history of progressive abdominal distention. Pt. reported that the abdominal distention had particularly worsened during the six months prior to presentation and he presented to the medicine clinic at the insistence of his family. He reported that he was active in sports and denied LE edema, SOB, PND, and orthopnea. In fact, he reported that, aside from his worsening abdominal distention, he generally felt well. He was admitted from the clinic for workup of his abdominal distention.


PMHx: None

Medications: None

Family History: No family h/o heart disease

Social History: Denies EtOH, Tobacco, Drugs. One lifetime sexual partner


Physical exam
Physical Exam

  • 123/72 62 16 97.2

  • Comfortable, NAD

  • JVD present at 9 cm, + hepatojugular reflux

  • nlS1S2, 2/6 HSM  apex

  • Decreased breath sounds at bilateral bases

  • Abd distended with + fluid wave. Liver was palpable 3 cm below the costal margin and the spleen tip was palpable

  • No LE edema


Na 134

K+ 3.9

Cl- 100

HCO3- 27

BUN 13

Cr 0.9

Glucose 89

Ca 8.9

LDH 118

AST 37

ALT 11

AP 75

TP 7.9

Alb 3.0

TB 1.8

CK 21

CKMB 0.4

Troponin <0.05

TSH 3.17

Labs


Labs cont

WBC 12.2

Hgb 12.2

Hct 36.6

Plt 190

MCV 90

Neutrophils 70%

Lymphocytes 22%

Basophils 0%

Eosinophils 1%

Monocytes 7%

INR 1.4

PTT 35.6

Blood Cultures Drawn

Labs (cont)


Ascites fluid
Ascites Fluid

  • Clear and Yellow

  • WBC’s 21

  • RBC’s 453

  • Albumin 2.6

  • TP 4.8

  • LDH 74

  • Glucose 104

  • Cholesterol 20

  • Gram Stain and cultures sent

  • Cytology sent








During this admission, a TTE was performed and showed a large pericardial effusion without evidence of tamponade (the study has been lost). Blood cultures were negative for bacterial infection and fluid cultures were smear negative and culture negative for AFB, fungus and bacteria Clinically, he looked well and was discharged by the primary service for outpatient workup. He failed to keep his appointments and presented to the ER with SOB approx. 1 month after discharge. During this second admission, workup included echocardiography, left and right heart cath.The echocardiographic findings will be discussed at the end of the case.


C5 large pericardial effusion without evidence of tamponade (the study has been lost). Blood cultures were negative for bacterial infection and fluid cultures were smear negative and culture negative for AFB, fungus and bacteria Clinically, he looked well and was discharged by the primary service for outpatient workup. He failed to keep his appointments and presented to the ER with SOB approx. 1 month after discharge. During this second admission, workup included echocardiography, left and right heart cath.


C8 large pericardial effusion without evidence of tamponade (the study has been lost). Blood cultures were negative for bacterial infection and fluid cultures were smear negative and culture negative for AFB, fungus and bacteria Clinically, he looked well and was discharged by the primary service for outpatient workup. He failed to keep his appointments and presented to the ER with SOB approx. 1 month after discharge. During this second admission, workup included echocardiography, left and right heart cath.


C2 large pericardial effusion without evidence of tamponade (the study has been lost). Blood cultures were negative for bacterial infection and fluid cultures were smear negative and culture negative for AFB, fungus and bacteria Clinically, he looked well and was discharged by the primary service for outpatient workup. He failed to keep his appointments and presented to the ER with SOB approx. 1 month after discharge. During this second admission, workup included echocardiography, left and right heart cath.


RA large pericardial effusion without evidence of tamponade (the study has been lost). Blood cultures were negative for bacterial infection and fluid cultures were smear negative and culture negative for AFB, fungus and bacteria Clinically, he looked well and was discharged by the primary service for outpatient workup. He failed to keep his appointments and presented to the ER with SOB approx. 1 month after discharge. During this second admission, workup included echocardiography, left and right heart cath.


RV large pericardial effusion without evidence of tamponade (the study has been lost). Blood cultures were negative for bacterial infection and fluid cultures were smear negative and culture negative for AFB, fungus and bacteria Clinically, he looked well and was discharged by the primary service for outpatient workup. He failed to keep his appointments and presented to the ER with SOB approx. 1 month after discharge. During this second admission, workup included echocardiography, left and right heart cath.


PA large pericardial effusion without evidence of tamponade (the study has been lost). Blood cultures were negative for bacterial infection and fluid cultures were smear negative and culture negative for AFB, fungus and bacteria Clinically, he looked well and was discharged by the primary service for outpatient workup. He failed to keep his appointments and presented to the ER with SOB approx. 1 month after discharge. During this second admission, workup included echocardiography, left and right heart cath.


PCW large pericardial effusion without evidence of tamponade (the study has been lost). Blood cultures were negative for bacterial infection and fluid cultures were smear negative and culture negative for AFB, fungus and bacteria Clinically, he looked well and was discharged by the primary service for outpatient workup. He failed to keep his appointments and presented to the ER with SOB approx. 1 month after discharge. During this second admission, workup included echocardiography, left and right heart cath.


Rv lv
RV/LV large pericardial effusion without evidence of tamponade (the study has been lost). Blood cultures were negative for bacterial infection and fluid cultures were smear negative and culture negative for AFB, fungus and bacteria Clinically, he looked well and was discharged by the primary service for outpatient workup. He failed to keep his appointments and presented to the ER with SOB approx. 1 month after discharge. During this second admission, workup included echocardiography, left and right heart cath.


Differential diagnosis
Differential Diagnosis large pericardial effusion without evidence of tamponade (the study has been lost). Blood cultures were negative for bacterial infection and fluid cultures were smear negative and culture negative for AFB, fungus and bacteria Clinically, he looked well and was discharged by the primary service for outpatient workup. He failed to keep his appointments and presented to the ER with SOB approx. 1 month after discharge. During this second admission, workup included echocardiography, left and right heart cath.

  • Constrictive Pericarditis

  • Restrictive Cardiomyopathy


Etiologies of constrictive pericarditis

Common Causes large pericardial effusion without evidence of tamponade (the study has been lost). Blood cultures were negative for bacterial infection and fluid cultures were smear negative and culture negative for AFB, fungus and bacteria Clinically, he looked well and was discharged by the primary service for outpatient workup. He failed to keep his appointments and presented to the ER with SOB approx. 1 month after discharge. During this second admission, workup included echocardiography, left and right heart cath.

-Idiopathic

-Infection

Bacterial: TB

Fungal: Histoplasmosis,

Coccidiomycosis

Viral: Coxsackie

Parasitic: Amebiasis, Echinococcus

-Drugs

-Neoplastic

Lymphoma, Melanoma, Primary

Mesothelioma, Breast & Lung cancer

-Following Cardiac Surgery

-Connective Tissue Disease

RA, SLE, Scleroderma,

Dermatomyositis

-Trauma

-Renal Failure

-Radiation

-AICD/Pacer placement

Uncommon causes

-Sarcoidosis

-Post MI

-Asbestosis

-Amyloidosis

-Drug Induced Lupus

-Acute Rheumatic Fever

Rare Causes

-Actinomycosis

-Asbestosis

-Whipples Disease

-Lassa Fever

-Sclerotherapy of Esophageal

Varices

Etiologies of Constrictive Pericarditis


Restrictive cardiomyopathy

Primary RCM large pericardial effusion without evidence of tamponade (the study has been lost). Blood cultures were negative for bacterial infection and fluid cultures were smear negative and culture negative for AFB, fungus and bacteria Clinically, he looked well and was discharged by the primary service for outpatient workup. He failed to keep his appointments and presented to the ER with SOB approx. 1 month after discharge. During this second admission, workup included echocardiography, left and right heart cath.

-Loeffler’s cardiomyopathy

-Idiopathic RCM

-Endomyocardial Fibrosis

Secondary RCM

Infiltrative Noninfiltrative

-Sarcoidosis -Fabry’s Disease

-Amyloidosis -Hemochromatosis

-Post Radiation -Glycogen Storage

Therapy Disease

-Gaucher’s Disease -Scleroderma

-Hurler’s Disease -Pseudoxanthoma

Elasticum

-Storage Disease

Restrictive Cardiomyopathy


Echocardiographic presentation

Echocardiographic Presentation large pericardial effusion without evidence of tamponade (the study has been lost). Blood cultures were negative for bacterial infection and fluid cultures were smear negative and culture negative for AFB, fungus and bacteria Clinically, he looked well and was discharged by the primary service for outpatient workup. He failed to keep his appointments and presented to the ER with SOB approx. 1 month after discharge. During this second admission, workup included echocardiography, left and right heart cath.

Holger Salazar, M.D.


Chene3 23
Chene3-23 large pericardial effusion without evidence of tamponade (the study has been lost). Blood cultures were negative for bacterial infection and fluid cultures were smear negative and culture negative for AFB, fungus and bacteria Clinically, he looked well and was discharged by the primary service for outpatient workup. He failed to keep his appointments and presented to the ER with SOB approx. 1 month after discharge. During this second admission, workup included echocardiography, left and right heart cath.


Chene3 8
Chene3-8 large pericardial effusion without evidence of tamponade (the study has been lost). Blood cultures were negative for bacterial infection and fluid cultures were smear negative and culture negative for AFB, fungus and bacteria Clinically, he looked well and was discharged by the primary service for outpatient workup. He failed to keep his appointments and presented to the ER with SOB approx. 1 month after discharge. During this second admission, workup included echocardiography, left and right heart cath.


Chene3 9
Chene3-9 large pericardial effusion without evidence of tamponade (the study has been lost). Blood cultures were negative for bacterial infection and fluid cultures were smear negative and culture negative for AFB, fungus and bacteria Clinically, he looked well and was discharged by the primary service for outpatient workup. He failed to keep his appointments and presented to the ER with SOB approx. 1 month after discharge. During this second admission, workup included echocardiography, left and right heart cath.


Chene3 3
Chene3-3 large pericardial effusion without evidence of tamponade (the study has been lost). Blood cultures were negative for bacterial infection and fluid cultures were smear negative and culture negative for AFB, fungus and bacteria Clinically, he looked well and was discharged by the primary service for outpatient workup. He failed to keep his appointments and presented to the ER with SOB approx. 1 month after discharge. During this second admission, workup included echocardiography, left and right heart cath.


Chene3 13
Chene3-13 large pericardial effusion without evidence of tamponade (the study has been lost). Blood cultures were negative for bacterial infection and fluid cultures were smear negative and culture negative for AFB, fungus and bacteria Clinically, he looked well and was discharged by the primary service for outpatient workup. He failed to keep his appointments and presented to the ER with SOB approx. 1 month after discharge. During this second admission, workup included echocardiography, left and right heart cath.


Chene3 12
Chene3-12 large pericardial effusion without evidence of tamponade (the study has been lost). Blood cultures were negative for bacterial infection and fluid cultures were smear negative and culture negative for AFB, fungus and bacteria Clinically, he looked well and was discharged by the primary service for outpatient workup. He failed to keep his appointments and presented to the ER with SOB approx. 1 month after discharge. During this second admission, workup included echocardiography, left and right heart cath.


Chene3 preop continuing 14
Chene3-preop,continuing 14 large pericardial effusion without evidence of tamponade (the study has been lost). Blood cultures were negative for bacterial infection and fluid cultures were smear negative and culture negative for AFB, fungus and bacteria Clinically, he looked well and was discharged by the primary service for outpatient workup. He failed to keep his appointments and presented to the ER with SOB approx. 1 month after discharge. During this second admission, workup included echocardiography, left and right heart cath.


Chene3 14
Chene3-14 large pericardial effusion without evidence of tamponade (the study has been lost). Blood cultures were negative for bacterial infection and fluid cultures were smear negative and culture negative for AFB, fungus and bacteria Clinically, he looked well and was discharged by the primary service for outpatient workup. He failed to keep his appointments and presented to the ER with SOB approx. 1 month after discharge. During this second admission, workup included echocardiography, left and right heart cath.


Chene3 preop continuing 5
Chene3-preop, continuing 5 large pericardial effusion without evidence of tamponade (the study has been lost). Blood cultures were negative for bacterial infection and fluid cultures were smear negative and culture negative for AFB, fungus and bacteria Clinically, he looked well and was discharged by the primary service for outpatient workup. He failed to keep his appointments and presented to the ER with SOB approx. 1 month after discharge. During this second admission, workup included echocardiography, left and right heart cath.


Chene3 preop continuing 9
Chene3-preop, continuing 9 large pericardial effusion without evidence of tamponade (the study has been lost). Blood cultures were negative for bacterial infection and fluid cultures were smear negative and culture negative for AFB, fungus and bacteria Clinically, he looked well and was discharged by the primary service for outpatient workup. He failed to keep his appointments and presented to the ER with SOB approx. 1 month after discharge. During this second admission, workup included echocardiography, left and right heart cath.


Chene3 11
Chene3-11 large pericardial effusion without evidence of tamponade (the study has been lost). Blood cultures were negative for bacterial infection and fluid cultures were smear negative and culture negative for AFB, fungus and bacteria Clinically, he looked well and was discharged by the primary service for outpatient workup. He failed to keep his appointments and presented to the ER with SOB approx. 1 month after discharge. During this second admission, workup included echocardiography, left and right heart cath.


Chene3 5
Chene3-5 large pericardial effusion without evidence of tamponade (the study has been lost). Blood cultures were negative for bacterial infection and fluid cultures were smear negative and culture negative for AFB, fungus and bacteria Clinically, he looked well and was discharged by the primary service for outpatient workup. He failed to keep his appointments and presented to the ER with SOB approx. 1 month after discharge. During this second admission, workup included echocardiography, left and right heart cath.


Chene3 20
Chene3-20 large pericardial effusion without evidence of tamponade (the study has been lost). Blood cultures were negative for bacterial infection and fluid cultures were smear negative and culture negative for AFB, fungus and bacteria Clinically, he looked well and was discharged by the primary service for outpatient workup. He failed to keep his appointments and presented to the ER with SOB approx. 1 month after discharge. During this second admission, workup included echocardiography, left and right heart cath.


Chene3 preop continuing 1
Chene3-preop, continuing 1 large pericardial effusion without evidence of tamponade (the study has been lost). Blood cultures were negative for bacterial infection and fluid cultures were smear negative and culture negative for AFB, fungus and bacteria Clinically, he looked well and was discharged by the primary service for outpatient workup. He failed to keep his appointments and presented to the ER with SOB approx. 1 month after discharge. During this second admission, workup included echocardiography, left and right heart cath.


Chene3 preop continuing 4
Chene3-preop, continuing 4 large pericardial effusion without evidence of tamponade (the study has been lost). Blood cultures were negative for bacterial infection and fluid cultures were smear negative and culture negative for AFB, fungus and bacteria Clinically, he looked well and was discharged by the primary service for outpatient workup. He failed to keep his appointments and presented to the ER with SOB approx. 1 month after discharge. During this second admission, workup included echocardiography, left and right heart cath.


Diagnosis2

Diagnosis large pericardial effusion without evidence of tamponade (the study has been lost). Blood cultures were negative for bacterial infection and fluid cultures were smear negative and culture negative for AFB, fungus and bacteria Clinically, he looked well and was discharged by the primary service for outpatient workup. He failed to keep his appointments and presented to the ER with SOB approx. 1 month after discharge. During this second admission, workup included echocardiography, left and right heart cath.

Constrictive Pericarditis


Follow up
Follow Up large pericardial effusion without evidence of tamponade (the study has been lost). Blood cultures were negative for bacterial infection and fluid cultures were smear negative and culture negative for AFB, fungus and bacteria Clinically, he looked well and was discharged by the primary service for outpatient workup. He failed to keep his appointments and presented to the ER with SOB approx. 1 month after discharge. During this second admission, workup included echocardiography, left and right heart cath.

  • Pericardial biopsy (done during pericardectomy) showed dense fibrous tissue with focal dystrophic calcification and mesothelial hyperplasia

  • The pericardium was densely calcified and adherent

  • Epicardial biopsy showed dense fibrous tissue without evidence of active inflammation or malignancy

  • Pericardial fluid was bloody and contained atypical mesothelial cells

  • Pericardial fluid was smear and culture negative for AFB

  • Pericardial fluid was smear and culture negative for bacteria and fungi

  • Serum ANA was negative

  • PPD was negative

  • HIV was negative


Follow up cont
Follow Up (cont) large pericardial effusion without evidence of tamponade (the study has been lost). Blood cultures were negative for bacterial infection and fluid cultures were smear negative and culture negative for AFB, fungus and bacteria Clinically, he looked well and was discharged by the primary service for outpatient workup. He failed to keep his appointments and presented to the ER with SOB approx. 1 month after discharge. During this second admission, workup included echocardiography, left and right heart cath.

  • The underlying etiology remains unclear

  • The patient has developed refractory atrial fibrillation with RVR

  • Anticoagulation has been complicated by a lower GI bleed

  • He failed to improve after pericardectomy, and has recently been referred to transplant clinic


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