Hemodynamic Conference

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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

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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

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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

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Pressure Waveforms
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Practice Case
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RA
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RV
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PA
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PCW
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Diagnosis?
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M5
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M12
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Diagnosis

• Non-Ischemic Cardiomyopathy

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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.

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PMHx None Medications None Family History No
family h/o heart disease Social History Denies
EtOH, Tobacco, Drugs. One lifetime sexual partner
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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

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Labs

• 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 lt0.05
• TSH 3.17

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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

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Ascites Fluid

• Clear and Yellow
• WBCs 21
• RBCs 453
• Albumin 2.6
• TP 4.8
• LDH 74
• Glucose 104
• Cholesterol 20
• Gram Stain and cultures sent
• Cytology sent

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ECG
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CC
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CC
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CC
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CC
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CC
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• 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.

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C5
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C8
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C2
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RA
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RV
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PA
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PCW
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RV/LV
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Differential Diagnosis

• Constrictive Pericarditis
• Restrictive Cardiomyopathy

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Etiologies of Constrictive Pericarditis

• Common Causes
• -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

• 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

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Restrictive Cardiomyopathy

• Primary RCM
• -Loefflers cardiomyopathy
• -Idiopathic RCM
• -Endomyocardial Fibrosis

• Secondary RCM
• Infiltrative Noninfiltrative
• -Sarcoidosis -Fabrys
  Disease
• -Amyloidosis
  -Hemochromatosis
• -Post Radiation -Glycogen
  Storage
• Therapy Disease
• -Gauchers Disease -Scleroderma
• -Hurlers Disease -Pseudoxanthoma
  
• 
  Elasticum
• 
  -Storage Disease

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Echocardiographic Presentation

• Holger Salazar, M.D.

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Chene3-23
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Chene3-8
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Chene3-9
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Chene3-3
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Chene3-13
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Chene3-12
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Chene3-preop,continuing 14
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Chene3-14
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Chene3-preop, continuing 5
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Chene3-preop, continuing 9
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Chene3-11
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Chene3-5
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Chene3-20
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Chene3-preop, continuing 1
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Chene3-preop, continuing 4
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Diagnosis

• Constrictive Pericarditis

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Follow Up

• 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

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Follow Up (cont)

• 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