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What is pulsus paradoxus

abnormally excessive fall in systolic blood pressure on inspiration > 10 mmHg

Normally on inspiration there is a slight fall in systolic blood pressure (< 5mmHg).
In cardiac tamponade, the increased venous return that occurs on inspiration causes filling of the right heart, thereby displacing the interventricular septum to the left (rigid box with tamponade) resulting in less filling possible in the left heart producing a reduced cardiac output and systemic blood pressure

Other causes of PP include constrictive pericarditis and status asthmaticus


What are the typical findings on investigations with pericardial tamponade

1) ECG--low voltage QRS complexes, electric alternans (due to the heart moving within a fluid-filled sac)
2) CXR--symmetrical globular enlargement of the heart
3) Echocardiography
a) large pericardial collection
b) heart swinging freely within the pericardial sac
c) early diastolic collapse of the right ventricle
d) late diastolic collapse of the right atrium
e) marked respiratory tricuspid valve (>40%) and and mitral valve (>25%) inflow variation


What are the causes of constrictive pericarditis

Idiopathic, which is the major cause in the developed world
Infection---tuberculosis, viral (coxsackie), fungal (hisotplasma)
Mediastinal radiotherapy, which is dose-dependent (lymphoma)
Post Cardiac surgery
tumor, drugs (procainamide),
Sarcoidosis, amyloidosis,
carcinoid syndrome,
myocardial infarction,


Clinical features of constrictive pericarditis

symptoms of left and right heart failure (anorexia, ascites, peripheral edma, fatigue, weakness
Raised jugular venous pressure
Peripheral edema
displaced apex beat
muffled heart sounds
Narrowed pulse pressure
Kussmaul's sign
palsus paradoxus


what are features of cxr and echo of constrictive pericarditis

CXR- pericardial calcification and bilateral pleural effusions
impaired diastolic ventricularfilling, thickened echo bright pericardiaum,and dilated right atrium, inferior vena cava and hepatic veins
Doppler echocardiography
increased E:A ratio (rapid early filling and diastasis) and decreased inspiratory flow reduction in the hepatic veins.


Role of Cardiac Cath in constrictive cardiac cath

Cardiac Catheterisation (important for differentiation of constrictive pericarditis from restrictive cardiomyopathy)
a) equalisation (within 5mmHg) of raised left and right ventricular end-diastolic pressures at any phase of respiration
b) Equalisation of raised (>10mmHg) left and right atrial pressures with prominent x and y descents
c) square root sign---dip and plateau pattern of ventricular pressure with most of the diastolic filling occurring in early diastole, due to raised venous pressure, which then halts abruptly in mid-diastole.
d) left ventricular systolic function is usually normal but may be impaired in severe cases
e) pulmonary artery systolic pressure <50mmHg
f) right ventricular end-diastolic pressure ratio >1:3


How is constrictive pericarditis differentiated from restrictive cardiomyopathy(RCM)

Features for RCM and CP
1) increased EA ratio on the mitral valve inflow pattern
2) dip and plateau ventricular waveform
3) Prominent x and y descents on the atrial waveform
Patients with RCM more likely to have
1) Pulmonary hypertension (PASP > 50mmHg)
2) Reduced left ventricular function
3) endomocardial biopsy evidence of an infiltrative process
Patients with CP are more likely to have
1) Equalization of left and right ventricular end-diastolic pressure (<5mmH)
2) Kussmaul's sign
3) Right ventricular end-diastolic to systolic ressure > 1:3
4) CT or echocardiographic evidence of a thickened pericardium


What are the principles of pericardiectomy

Aim to achieve complete removal of all thickened pericardium and epicardium from the left and right ventricle and diaphragm whilst preserving both phrenic nerves

CPB and cardioplegia arrest is usually required for posterior pericardium

Operative mortality is 10- 15% with a 5 year survival of 70% following pericardiectomy


What are the causes of restrictive cardiomyopathy

Iron storage disease
Loeffler's eosinophilic/endomyocaridal fibrosis


List 5 cardiac catheterization findings of a patient with constrictive pericarditis

Equalization of filling pressure
Elevation of mean atrial pressure
square root sign
prominent Y decent on the right atrial pressure tracing
elevated RV end diastolic pressure
LV ejection fraction must be > 40%


List 5 criteria for distinguishing restrictive cardiomyopathy from constrictive pericarditis

1. Early diastolic filling--decreased in restrictive--normal in CP

2. Left and right ventricular end-diastolic pressures after fluid challenge--diverge in restrictive cardiomyopathy, parallel in CP

3. endomyocardial biopsy--may show fibrosis in restrictive cardiomyopathy (normal in CP)

4. systolic contraction velocity--may be slow in restrictive cardiomyopathy (normal in CP)

5. CT Scan/MRT/Echocardiography---may demonstrate thickened pericardium with pericarditis


Name 5 important issues with surgery for constrictive pericarditis

1. Median sternotomy with full cardiopulmonary bypass
2. pericardium needs to be removed from phrenic to phrenic and posterior to left phrenic nerve (best done on CPB)
3. Areas of grafts have to be protected
4. likley to be bloody
5. in general a high risk procedure
6. Usually want to remove the pericardium from the left ventricle first, then the right ventricle and then both atria
strip it off the vena cavae


How is diagnosis of Cardiac Tamponade

Intrapericardial fluid causing hemodynamic compromise
Echo Hallmark: RA and RV compression
Equalization of RA, LA, LVEDP, RVEDP, wedge pressures


What is Becks triad

Distended neck veins
reduced heart sounds


List common causes of pericarditis

Post MI, surgical traum
Drug induced
Collagen vascular disease


List common drug causes for pericarditis



List features of infectious pericarditis

occurs from contiguous spread or septicemia
Staph, Pneumoccus, Haemophilis, fungal, and TB
percutaneous drainage and antibiotic treatment of choice
surgical drainage and 9 months of triple therapy
6 months treatment after negative culture


List features of uremic pericarditis

usually treat with NSAID and aggressive dialysis
Pericardiocentesis if persists > 2 weeks after medical treatment
Surgical drainage only if hemodynamic instability


List surgical approach to pericariectomy

Median sternotomy
Decorticate as completely as possible(visceral and parietal)
Left Ventricle first!!!
Mortality 5-10% long term survival is good
Most stay in NHYA I or II


List features of radiation pericarditis

Dose response for pericarditis, carditis
May cause accelerate CAD, myocardial fibrosis
20% eventually develop constriction


What are clinical features of pericardial tamponade

Hemodynamic compromise with acute dyspnea and tachypnea
low pulse volume with pulsus paradoxus
Low and undetectable blood pressure
Raised jugular venous pulse (JVP) with a prominent x descent but no y descent
Muffled heart sounds
Oilguria or anuria

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