1. MR
Cardiology
2/18/14
Jon
Halevy

2. Causes
of
Pericardial
disease
• Idiopathic
• Infec.ous
(viral,
bacterial,
fungal,
parasiAc,
IE
with
abscess)
• Radia.on
• Neoplas.c
/
paraneoplasAc
• Cardiac
–
early/late
post-­‐MI.
MyocardiAs,
dissecAon,
post-­‐
cardiac
surgery
• Trauma
• Autoimmune
–
rheumaAc,
IBD,
sarcoid,
vasculiAs,
whipples,
behcet’s
• Drugs
–
drug-­‐induced
lupus,
others
(incl
penicillins
• Metabolic
–
hypothyroid,
uremia,
ovarian
oversAm)

3. Sagrista,
2000
(N=322)
• Mod-­‐large
pericardial
effusion
(>10
mm)
• 37%
with
tamponade
• Idiopathic
–
29%;
Iatrogenic
–
16%;
Malignancy
13%;
uremia
–
6%;
post
acute
MI
8%;
infecAon
6%;
Collagen
Vascular
5%;
Hypothyroid
2%,
other
15%

4. hp://www.cardiothoracicsurgery.org/
content/2/1/30/figure/F2?highres=y

5. • Large/acute
Pericardial
effusion
• CompeAAon
with
heart
and
pericardial
volume
for
space
à
constrained
cardiac
filling
• Normally
venous
return
bimodal
peaking
in
ventricular
systole
and
early
diastole,
heart
volume
minimal
during
systole/ejecAon.
Lose
early
diastole
filling
peak.
Relying
on
systole
to
fill.
•
Tamponade
when
this
impairs
filling
of
ventricles
à
can
cause
shock
• Volume
DepleAon
=
BAD
(avoid
diuresis!)

6. Pericardial
FricAon
Rub
hp://www.youtube.com/watch?
v=fI4XXFRotNE
-­‐
Actual
sounds
are
only
last
20
seconds

7. Pulsus
alternans
(q2
beats,
LV
systolic
faiure)
versus
Pulsus
paradoxus
(lower
during
inspiraAon)

8. Electrical
alternans

9. Respiratory
VariaAon
• Normally
about
10
pt
drop
in
SBP
during
inspira.on
• Inspiratory
decline
in
thoracic
pressure
is
transmied
through
the
pericardium
to
the
right
side
of
the
heart
and
the
pulmonary
vasculature.
As
a
result,
systemic
venous
return
to
the
right
heart
increases
with
inspiraAon,
and
pulmonary
venous
return
to
the
lej
heart
decreases
with
inspiraAon.
•
In
cardiac
tamponade,
the
rigid
pericardium
prevents
the
free
wall
from
expanding.
The
ensuing
distension
of
the
right
ventricle
is
limited
to
the
interventricular
septum,
which
along
with
relaAve
underfilling
of
the
lej
ventricle
causes
the
septum
to
bulge
to
the
lej,
reducing
lej
ventricular
compliance
and
contribuAng
to
further
decreased
filling
of
the
lej
ventricle
during
inspiraAon.
This
concept
is
referred
to
as
"ventricular
interacAon"
or
"ventricular
interdependence".
• RA
Pressure
=
RVEDP
and
LVEDP
=
PA
Diastolic
Pressure

10. Acuity
Maers
• Hyperacute
Coronary
laceraAon
(acute
-­‐
red)
versus
presumed
viral
pericardiAs
(chronic
–
blue)
Data
from
pericardiocentesis