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Pericardial disease Flashcards

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1
Q

What are functions of the pericardium?

A
  1. barrier to infection + inflammation from adjacent tissues
  2. balances the output of the RV + LV

0.25ml/kg of clear, serous fluid = lubricant between vsiceral pericardium (=epicardium) + parietal pericadium

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2
Q

What characterizes haemorrhagic pericardial effusion?

A
  • PCV >7%
  • spec. Gravity >1.015
  • TP > 3g/dl

PCV refers to packed cell volume, TP is total protein.

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3
Q

Name 8 cardiac neoplasms starting with the 2 most common.

A
  1. Haemangiosarcoma
  2. heart base tumor

Others:
3. Pericardial mesothelioma
4. Malignant hystocytosis
5. Cardiac lymphoma
6. Metastatic carcinoma
7. Myxoma
8. different sarcoma types

Rare in cats.

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4
Q

Name 5 causes of haemorrhagic pericardial effusion?

A
  • Neoplastic
  • Idiopathic
  • Left atrial rupture
  • Coagulopathy
  • Penetrating trauma

Coagulopathy can be due to rodenticide toxicity or DIC.

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5
Q

Which neoplasms can be found at the heart base?

A
  • Chemodectoma (most common) - chemoreceptor cells at base of aorta
  • Thyroid neoplasm
  • Parathyroid neoplasm
  • Lymphoid neoplasm
  • Connective tissue neoplasm
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6
Q

What characterizes transudative pericardial effusion?

A
  • cell count <1000 cells/µl
  • spec. Gravity <1.012
  • TP <2.5g/dl

Modified transudate has different characteristics.

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7
Q

What are common causes of transudative pericardial effusion?

A
  • CHF
  • Hypoalbuminemia
  • Congenital pericardial malformations
  • Lymphoma
  • SIRS (increased vascular permeability)
  • Toxemia (increased vascular permeability)

SIRS increases vascular permeability.

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8
Q

What indicates exudative pericardial effusion?

A
  • > 3000 cells/µl
  • spec. Gravity >1.015
  • TP > 3g/dl

Cytology is related to the etiology.

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9
Q

Name 3 common causes of exudative pericardial effusion?

A
  • FB migration
  • Extension of pleural or mediastinal infection
  • Bite or penetrating wounds
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10
Q

List 9 infections that can be identified in exudative pericardial effusion?

A
  1. Aerobic + anaerobic bacteria
  2. Actinomycosis
  3. Coccidioidomycosis
  4. Aspergillosis
  5. Disseminated tuberculosis
  6. Systemic protozoal infections
  7. Leptospirosis
  8. Canine distemper
  9. FIP

Others: chronic uremia, idiopathic

FIP stands for feline infectious peritonitis.

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11
Q

Describe the pathophysiology of cardiac tamponade.

A

intrapericardial pressure > cardiac diastolic pressures –> impedes RV filling –> decreased LV filling –> systemic venous pressure increases (=systemic venous congestion= + CO drops –> activation of neurohormonal mechanisms –> fluid retention –> eventually, diastolic pressures in all chambers + great veins equilibrate

Eventually, diastolic pressures in all chambers and great veins equilibrate.

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12
Q

What factors determine the development of cardiac tamponade?

A
  • Rate of fluid accumulation
  • distensibility of pericardium

Large volume implies a gradual process.

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13
Q

How does cardiac tamponade affect coronary perfusion?

A

causes a reduction of coronary perfusion –> impairs systolic and diastolic function

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14
Q

What are the three components of cardiogenic shock due to cardiac tamponade?

A
  • Low CO
  • Hypotension
  • Poor perfusion
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15
Q

Explain pulsus paradoxus and the pathophysiological mechanism behind it during cardiac tamponade?

A

Inspiration:
intrathoracic pressure decreases –> intrapericardial + RA pressures fall –> increased filling of RH –> increases pulmonary flow + shifts IV septum to the left –> LV output + systemic arterial pressure decreases slightly (due to decreased LV diastolic filling)

Simultaneously: LH filling dimininshes because more blood is withheld in the expanded pulmonary vasculator

Expiration:
increased venous return to LH from pulmonary vasculature –> increased LV filling

Cardiac tamponade:
impaired RH filling even during inspiration –> exaggeration of the normal respiratory pressure fluctuation –> inspiratory fall in arterial pressure of ≥ 10 mm Hg

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16
Q

What defines pulsus paradoxus in the context of cardiac tamponade?

A

Inspiratory fall in arterial pressure of ≥ 10 mm Hg

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17
Q

What are clinical signs of pericardial effusion?

A

inappetence, cough, pain (pericardial stretch, inflammation, neoplasia), vomiting, arrhythmias (tumors), labored breathing, palpable weak precordial impulses

high sympathetic tone: pale MM, prolonged CRT, sinus tachycardia

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18
Q

What are the underlying pathomechanisms of vomiting as a clinical sign in pericardial effusion?

A
  • decreased perfusion to GIT
  • direct irritation of the phrenic nerve as it crosses the pericardium
  • irritation of the vagus nerve
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19
Q

Describe the hepatojugular reflex

A

applying firm pressure to cranial labdomen while animal stands quietly with head in normal position –> increases venous return –> normally no change in jugular vein appearance

positive results: Jugular distention persists while abdominal pressure is applied

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20
Q

Name possible findings on thoracic radiographs with pericardial effusion

A
  • globoid-shaped cardiac shadow
  • pleural effusion
  • caudal vena cava distension
  • hepatomegaly
  • ascites
  • pulmonary edema
  • disteneded pulmonary veins
  • deviation or elevation of trachea (heart base mass
  • pulmonary metastasis
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21
Q

Which echocardiographic view ist most sensitive for detection of pericardial effusion?

A

Diaphragmatico-hepatic view (pericardial view or serial examinations increases sensitivity)

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22
Q

What can be seen on echocardiography when cardiac tamponade is present?

A

*Diastolic (and early systolic) compression or collapse of RA + sometimes RV
* Severe tamponade: small LV chamber + pseudohypertrophy ov LV (due to poor cardiac filling)

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23
Q

In what view do you best visualize the right auricle?

Study These Flashcards
A

angled left cranial long-axic view

24
Q

Describe ECG findings with cardiac tamponade

Study These Flashcards
A
  • Reduced QRS amplitude (<1mV in dogs)
  • Electrical alternan
  • ST segment elevation (epicardial injury)
  • Sinus tachycardia
  • Atrial + ventricular tachyarrhythmias
25
What is electrical alternans?
= every-other-beat alteration in the size or configuration of QRS complex (or sometimes T wave) --> results from heart swinging back and forth within the pericardium - More evident at HR 90-140bpm or in certain body positions (e.g. standing)
26
What is a normal CVP and how is it changed in cardiac tamponade?
normal: 0-8 cmH2O cardiac tamponade: 10-12 cmH2O
27
What role das cTnI play in the diagnosis of pericardial effusion?
* Differentiating HSA from other etiologies (serum or pericardial efffusion) --> >25ng/ml: 81% sensitive + 100& specific for HSA BUT: cardiac ischemia or myocardial invasion could also incrase cTnI
28
Why is NT-proBNP not changed in pericardial effusion?
heart is compressed not stretched
29
How can the pH of the pericardial fluid help in differentiating causes?
<7: inflammatory > 7: neopasia, idiopathic --> BUT too much overlap to be reliable
30
What neoplasm can be identified on pericardial fluid analysis?
lymphoma
31
What further diagnostics should be done if fluid is suggestive of an exsudate?
culture fungul titers in endemic areas: coccidioidomycosis Serology in endemic areas
32
Why are diuretics and vasodilatators contraindicated in pericardial effusion?
Ventricules require high venous pressure to fill --> diuretics/vaodilatators reduce cardiac filling pressure --> decrease CO --> exacerbate hypotension
33
Why do positive inotrops not improve CO in presence of cardiac tamponade?
cardiac filling is impaired, but not contractility
34
Why is the right side preferred for pericardicentesis?
* uses cardiac notch --> minimizes trauma to lung * less risk of damaging major coronary vessels, that are located on left side
35
What equipment is needed for pericardiocentesis?
- Sterile extension tubing (or butterfly needle) - Three-way stopcock - 20-60ml collection syringe - 3ml syringe - Small gauge needle + lidocaine for local block - Small surgical blade (stab incision for large catheter) - Sterile gloves - Surgical scrub - EDTA + clot tubes for fluid samples - Large fluid collection receptacle - Personell
36
Name 4 methods for pericardiocentesis
- Over the needle catheter system (12 to 18 gauge, 1.5-6 inches) - over-the-wire pericardial drainage catheter system - Long hypodermic or spinal needle attached to extension tubing - Butterfly needle (tiny dogs/cats)
37
Name 4 techniques to differentiate pericardial effusion from intracardiac blood sampling
1. place drops on the table or into a clot tube --> pericardial effusion does not clot (unless very recent haemorrhage) 2. spin sample in a hematocrit tube --> PCV < peripheral --> Supernatant appears yellow-tinged (xanthochromic) 3. US to visualize catheter location --> Inject small bolus of sterile, agitated saline --> creation of echocontrast ("bubble" study) 4. Change in ECG with pericardial drainage: --> Increase in QRS amplitude --> Improvement of tachycardia
38
Name 8 complications of pericardial drainage
1. VPCs 2. Atrial fibrillation 3. Coronary artery laceration (--> myocardial infarction, bleeding) 4. continued intrapericardial hemorrhage 5. cardiac perforation 6. lung laceration (--> pneumothorax, pulmonary hemorrhage) 7. dissiminiation of neoplastic cells or infection into pleural space (does not affect SVT in HSA or mesothelioma) 8. death
39
What is an ancillary treatment in idiopathic pericardial effusion after drainage?
- glucocorticoid (prednisone 1mg/kg/d tapered over 2-4w) - efficacy unknown - subtotal pericardiectomy - thoracoscopic partial pericardiectomy + pericardiotomy (pericardial window) - resection of small right auricular mass - biopsy + treatment
40
What are possible treatment options for cardiac HSA?
* resection or biopsy * chemotherapy: doxorubicin or carboplatin * radiation therapy (might reduce frequency of pericariocentesis) * pericardial patch graft (for longer masses) * partial pericardiectomy
41
What is a possible sequelae of epicardial and pericardial fibrosis?
constrictive pericardial disease
42
What is the typical signalment for constrictive pericardial disease in dogs?
* Middle-aged * medium- to large-breed dogs, * males > females * signs develop within weeks to months ## Footnote Occasionally seen in cats; history of pericardial effusion may be present
43
What are the most common clinical findings in constrictive pericardial disease?
Aszites and jugular venous distension ## Footnote Signs develop within weeks to months
44
What is the pathophysiology of constrictive pericardial disease?
Scarring and thickening of the pericardium restricts ventricular diastolic expansion, preventing normal cardiac filling * increases ventricular interdependence * filling is limited to early or possible mid-diastole * increased CVP * CO reduction * compensatory neurohormonal mechanisms --> R-CHF, tachycardia, vasoconstriction ## Footnote Creates a stiff 'shell' around the heart, increasing ventricular interdependence
45
What echocardiographic findings can indicate constrictive pericardial disease?
* Abnormal diastolic septal motion ("septal bounce") * mid- and late diastolic flattening of LV free wall * thickened pericardium * mild pericardial effusion (no diastolic RA collaps) * pleural effusion * vena cava dilation (+ blunted respiratory variation) ## Footnote May also include diminished cardiac chamber dimensions and mild pericardial effusion
46
What is the significance of CVP in diagnosing constrictive pericardial disease?
* CVP > 15 cmH2O * high mean atrial and diastolic ventricular pressures * prominent y descent in atrial pressure waveform (low ventricular filling pressure in early diastole) --> CAVE cardiac tamponade: diminished y descent ## Footnote Early diastolic dip in ventricular pressure followed by a mid-diastolic plateau is also noted
47
Name 6 causes of constrictive pericardial disease?
1. Recurrent idiopathic hemorrhagic effusion 2. infectious pericarditis 3. pericardial foreign body 4. tumors 5. prior surgery 6. idiopathic osseous metaplasia or fibrosis of the pericardium ## Footnote Coccidioidomycosis is a notable infectious cause
48
Name 2 treatment options for constrictive pericardial disease?
* Surgical pericardiectomy (!) * epicardial stripping ## Footnote Epicardial stripping is indicated if the visceral pericardium is involved
49
Name 2 complications of constrictive pericardial disease?
1. Pulmonary thrombosis 2. tachyarrhythmias ## Footnote These complications can occur due to the disease's impact on cardiac function
50
What causes Peritoneopericardial diaphragmatic hernia (PPDH)?
Abnormal embryonic development (of septum transversum) allowing persistent communication between pericardial and peritoneal cavities at the ventral midline
51
What are other possible malformations associated with PPDH?
* Umbilical hernia * Sternal malformations * Cardiac anomalies
52
What are clinical signs might be present with PPDH?
Gastrointestinal: * Vomiting * Diarrhea * Anorexia * Weight loss * Abdominal pain Respiratory: * Cough * Dyspnea * Wheezing
53
What physical exam findings are associated with PPDH?
* Muffled heart sounds (uni- or bilateral) * Weak or displaced cardiac precordial impulse * Empty feel on abdominal palpation * Signs of cardiac tamponade (rare)
54
What are the diagnostic methods for PPDH?
* Thoracic radiographs * Echocardiography * Abdominal ultrasound * CT * Barium series
55
What findings on thoracic radiographs indicate PPDH?
* Enlarged cardiac silhouette * Dorsal tracheal displacement * Overlap of diaphragmatic and caudal heart borders * Abnormal fat or gas densities within cardiac silhouette
56
What is the treatment for PPDH?
Surgical closure of peritoneal-pericardial defect after returning viable abdominal structures to normal position
57
What factors influence the decision to operate on PPDH?
* Presence of other congenital abnormalities * clinical signs

Cardiovascular (21 decks)

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