1	מחלות הפריקרד היבטים המודינמיים ושילוב MDCT ו-MRI באבחנה פרופ, אליו די סגני מרכז רפואי שיבא, תל השומר
2	מחלות הפריקרד פריקרדיטיס קונסטריקטיבית הצגת הכללים המודינמיקה CT MRI מקרים בעיתיים טמפונדה של הלב מקרה בעיתי הגדרת בעיות..ופיתרון?
3	גב' תם סובלת מקוצר נשימה tam-ponade?
4	גב' תם סובלת מקוצר נשימה tam-ponade?
5	Tam…
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13	Right atrial and intrapericardial pressure
14	Right atrial and intrapericardial pressure after pericardiocentesis
15	Echocardiographic Tam-ponade
16	Pericardial tamponade, a problem of definition Accumulation of pericardial fluid causing: Compression of the heart Impaired ventricular diastolic filling Reduction of stroke volume and cardiac output Hemodynamic tamponade Clinical tamponade Echocardiographic tamponade An all or none phenomenon or hemodynamic spectrum?
17	Pericardial pressure-volume curve and cardiac tamponade
18	Spectrum of hemodynamic changes in cardiac tamponade Reddy PS et al. Am J Cardiol 1990;66:1487-91
19	Clinical tamponade: Acute tamponade Iatrogenic Catheterization diagnostic and therapeutic: 9.6% of all pericardiocentesis Pacemaker Trauma Dissecting aneurysm Beck`s triad: Increased venous pressure Hypotension A quiet heart Tachycardia Tachypnea Stupor-agitation Orthopnea
20	Clinical tamponade: subacute and chronic cases Compensated High venous pressure Pulsus paradoxus Normal or high BP De-compensated High venous pressure Pulsus paradoxus Low BP
21	Elevated arterial blood pressure in cardiac tamponade Brown J et al N Engl J Med 1992;327:463-6 18 consecutive patients with cardiac tamponade All with equal right atrial and pericardial pressure In 6 patients with an history of hypertension BP ranged from 150/100 to 210/130 After pericardial tap BP decreased from 176/113 to 139/83 and CO increased In 12 patients with normal or low BP, pericardial tap increased BP and CO
22	Pulsus paradoxus and related Doppler signs False positive: COPD Pulmonary embolism False negative: abolition of ventricular interdependance R /L not competitive: ASD Unequal diastolic pressure: AI, CHF
23	Riva-Rocci sphygmomanometer: an endangered species
24	Compressive pericardial syndromes Pericardial tamponade Constrictive pericarditis Variant form of constrictive pericarditis Elastic form of constrictive pericarditis Effusive-constrictive
25	Cardiac tamponade/constrictive pericarditis: the common mechanism - LA pressure curve
26	Cardiac tamponade/constrictive pericarditis: the difference - RA pressure curve
27	Right atrial diastolic collapse Atrio-ventricular inerdependence End-diastole and early systole
28	מחלות הפריקרד פריקרדיטיס קונסטריקטיבית הצגת הכללים המודינמיקה CT MRI מקרים בעיתיים טמפונדה של הלב מקרה בעיתי הגדרת בעיות..ופיתרון?
29	Constrictive pericarditis hemodynamics Traditional criteria Dynamic respiratory changes
30	Constrictive pericarditis traditional criteria
31	Kussmaul’s sign
32	Constrictive and restrictive heart disease Constriction Restriction Impaired diastolic filling Increased filling pressure
33	The changing profile of constrictive pericarditis Tuberculosis is rare in developed countries Up to 1/3 of the cases are post cardiac surgery or radiation Many acute or subacute cases Variant form of constrictive pericarditis: Effusive-constrictive pericarditis Transient constrictive pericarditis Localised constrictive pericarditis Pericardial calcification dropped from > 50% to 20-30% Hancock WE Heart 2006
34	The changing profile of restrictive cardiomyopathy Amyloid Other infiltrative diseases Endomyocardial fibrosis Idiopathic restrictive cardiomyopathy Diastolic dysfunction Elderly patients Hypertension Increased arterial stiffness Hancock WE Heart 2006
35	Constrictive pericarditis vs restrictive CMP: traditional criteria PREDICTIVE ACCURACY (% pts correctly classified by the test) Criteria PPV-CP Restr. CMP Overall PV Pr. Equalization 92 70 85 RVD/RVS > 1/3 95 32 76 RVSP > 50 90 24 70 All 3 criteria 91 94 CP: 82 pts Restrictive CMP: 37 pts
36	Constrictive pericarditis vs restrictive CMP: traditional signs Criteria Sensitivity Specificity PPV NPV Pr. Equalization 60 38 4 57 RVD/RVS >1/3 93 38 52 89 PAP <55 93 24 47 25 Lack of RAP change 93 48 58 92 CP: 15 pts Restrictive CMP: 21 pts Hurrel et al. Circulation 1996
37	Constrictive pericarditis vs restrictive CMP: dynamic respiratory changes “Characteristic changes were seen with respiration that suggest that differentiation of these disease states may also be possible from hemodynamic data” Differentiation of constrictive pericarditis and restrictive cardiomyopathy by Doppler echocardiography. Hatle LK et al. Circulation1988
38	Constrictive pericarditis Dissociation of intrathoracic and intracardiac pressures.
39	Constrictive pericarditis Out of phase pressure changes: Ventricular interdependence
40	Restrictive cardiomyopathy: in phase right and left ventricular changes
41	Constrictive pericarditis vs restrictive CMP: Dynamic respiratory changes Criteria Sensitivity Specificity PPV NPV PCWP/LV 93 81 78 94 LV/RV interdep. 100 95 94 100 CP: 15 pts Restrictive CMP: 21 pts Hurrel et al. Circulation 1996
42	Constrictive pericarditis imaging
43	Constricive pericarditis echo-Doppler
44	Constrictive pericarditis vs. restrictive cardiomyopathy: pathophysiologic and morphologic features Constrictive pericarditis Compression of the whole heart The heart is isolated from the influence of respiratory pressure changes The pericardium is thickened and/or calcified The myocardium is normal Restrictive cardiomyopathy Mainly LV involvement Respiratory pressure changes are transmitted to the heart The pericardium is normal The myocardium is abnormal
45	From hemodynamics to pericardial imaging- MDCT and MRI CT and MR Imaging of Pericardial Disease. Zhen J. Wang et al. RadioGraphics 2003 CT and MRI are not limited by the acoustic window as echocardiography Excellent soft tissue contrast Accurate thickness measurement Complete pericardial visualization Heart chamber morphology Specific myocardial patterns in restrictive cardiomyopathy Mediastinal and lung imaging
46	Pericardial imaging with MDCT
47	MRI Normal pericardium PE with normal pericardium
48	MRI-Constrictive Pericarditis SSFP 4 chamber view
49	MRI-Constrictive Pericarditis SSFP 4 chamber view
50	MRI-Constrictive Pericarditis SSFP short axis oblique
51	MRI-Constrictive Pericarditis SSFP short axis oblique
52	Septal bounce at cine MRI Real-Time Cine MRI of Ventricular Septal Motion: A Novel Approach to Assess Ventricular Coupling. M. Francone et al, JOURNAL OF MAGNETIC RESONANCE IMAGING 2005
53	Septal bounce at MRI: two mechanisms A. Standard cine : breath hold, multiple beats SSFP C. Real time cine imaging: respiration
54	MRI in restrictive cardiomyopaty
55	MDCT and MRI for constrictive pericarditis vs restrictive cardiomyopathy CT and MR Imaging of Pericardial Disease. Zhen J. Wang et al. RadioGraphics 2003 MDCT/MRI Normal pericardium < 2 mm. A thickening>4 mm has 93% accuracy for differentiation between CP and restrictive CMP RV: relative low volume, normal EF, tubular configuration. IVC enlarged, hepatomegaly, ascites MDCT better Pericardial calcification MRI better Abnormal septal motion Myocardial tissue characterization
56	Constrictive versus restrictive disease: is cardiac catheterization still necessary? Pros Atrial fibrillation 20 to 50% in constrictive pericarditis: Temporary pacing for analysis of phasic respiratory changes Coronary disease in CP: median age 1936-1982 1985-1995 45 61 Mayo Clinic data, Ling et al. Circulation 1999
57	Constrictive versus restrictive disease: is cardiac catheterization still necessary?
58	73 old male with shortness of breath had open heart surgery (AVR) 2004 Catheterization 2004 RA 11 RV 35/11 PCW 12 Borderline ventricular interdependence Echo 2004 Normal mitral flow No septal bounce Catheterization 2007 RA19 RV 47/24 PCW 23 Deep and plateau Echo 2004 Normal mitral flow No septal bounce
59	73 old male with shortness of breath had open heart surgery (AVR) 2004
60	73 old male with shortness of breath had open heart surgery (AVR) 2004
61	73 old male with shortness of breath had open heart surgery (AVR) 2004
62	Constrictive versus restrictive disease: is cardiac catheterization replaced by MRI? Constrictive Pericarditis in 26 Patients With Histologically Normal Pericardial Thickness. Deepak R. Talreja et al. Circulation. 2003 The pericardium was of normal (<2 mm) in 26 patients (18%; group 1) and was thickened (>2 mm) in 117(82%; group 2) Causes of constriction in group 1 included previous cardiac surgery, chest irradiation, infarction, and idiopathic disease. “When clinical, echocardiographic, or invasive hemodynamic features indicate constriction pericardiectomy should not be denied on the basis of normal thickness by noninvasive imaging”
63	Constrictive pericarditis versus restrictive cardiomyopathy “Any good pericardiologist has sent to pericardiectomy at least once in his life a patient without constrictive pericarditis”