Curs Cardiomiopatii de Prezentat 15 Dec -2015

8/9/2019 Curs Cardiomiopatii de Prezentat 15 Dec -2015

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Universitatea TituUniversitatea TituMaiorescuMaiorescu

C U R S M E D I C I N A

I N T E R N A

B o l i l e m i o

c a r d u l u i

e n d o c a r d u l u i , p e r i c a r d u l u i

P r o f u n i v d r I o n C .Ț i n t

o i u


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Heart Wall♥ PericardumPericardum (outside) – visceral layer(outside) – visceral layer

of the serous pericardium.of the serous pericardium.

♥ MyocardiumMyocardium (muscle) – cardiac(muscle) – cardiacmuscle layer forming the bulk of themuscle layer forming the bulk of theheart.heart.

♥ EndocardiumEndocardium (within) – endothelial(within) – endotheliallayer of the inner myocardial surface.layer of the inner myocardial surface.


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The Anatomy of theThe Anatomy of the

HeartHeart

The Heart Wall and Cardiac Mu cle The Heart Wall and Cardiac Mu cle Ti ue Ti ue

Figure 12-4(


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HE !"

#ericardium

#ericardium♥$embrane sac

♥%urrounds the heart♥#rotection

♥ nchors♥&ontains serous fluid

Pericarditis inflammation of the pericardiumdecreases serous fluid causingpainful adhesions interfering withheart movements


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Cha!ter "#$ Cardiova cular S% te&Cha!ter "#$ Cardiova cular S% te& ''

Heart AnatomyHeart Anatomy

(i)ure "#."


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PE !"A #!UMPE !"A #!UMC*N(INES HEART T*C*N(INES HEART T*

THE MEDIASTINUM THE MEDIASTINUMA++*WS SU((ICIENTA++*WS SU((ICIENT(REED*M *((REED*M *(M*,EMENT.M*,EMENT.C*NSISTS *( TW*C*NSISTS *( TW*

PARTS-THE (I R*USPARTS-THE (I R*USAND SER*US.AND SER*US.


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EPICARDIUMEPICARDIUM - C*MP*SED *(- C*MP*SED *(MES*THE+IUM AND DE+ICATEMES*THE+IUM AND DE+ICATE

C*NNECTI,E TISSUE /IMPARTS AC*NNECTI,E TISSUE /IMPARTS AS+IPPER0 TE1TURE T* THE *UTERS+IPPER0 TE1TURE T* THE *UTERSUR(ACE *( THE HEART2.SUR(ACE *( THE HEART2.


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(I R*US-THIN INE+ASTIC$ DENSE(I R*US-THIN INE+ASTIC$ DENSEIRRE3U+AR C*NNECTI,E TISSUEIRRE3U+AR C*NNECTI,E TISSUE

444HE+PS IN PR*TECTI*N$ ANCH*RS444HE+PS IN PR*TECTI*N$ ANCH*RSHEART T* MEDIASTINUMHEART T* MEDIASTINUM

SER*US- THINNER$ M*RE DE+ICATESER*US- THINNER$ M*RE DE+ICATEDI,IDED INT* PARIETA+ ANDDI,IDED INT* PARIETA+ AND,ISCERA+,ISCERA+


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&ardiac $uscle♥%peciali'ed muscle cells%peciali'ed muscle cells

♥ nvoluntarynvoluntary♥%triated%triated♥&ushioned by endomysium&ushioned by endomysium♥ oined by intercalated discsoined by intercalated discs

♥&ardiac cell metabolism&ardiac cell metabolism♥ eobic eobic♥*arge mitochondria*arge mitochondria♥+rganic fuels, fatty acids - glucose+rganic fuels, fatty acids - glucose♥ atigue resistanceatigue resistance


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& !/+ $ +# "H0


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"567#"567# &ed lide .co&&ed lide .co& """"

#e$nition#e$nition

88A !ri&ar% di order of the heartA !ri&ar% di order of the heart&u cle that cau e&u cle that cau e a9nor&ala9nor&al&%ocardial !erfor&ance&%ocardial !erfor&ance andand iinot the re ult of di ea e ornot the re ult of di ea e ord% function of other cardiacd% function of other cardiac

tructuretructure : &%ocardial: &%ocardialinfarction$ % te&ic h%!erten ion$infarction$ % te&ic h%!erten ion$valvular teno i or re)ur)itation;valvular teno i or re)ur)itation;


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"ar%iomyo&athies"ar%iomyo&athies

#e$nition'#e$nition' di ea e of heart &u cledi ea e of heart &u cle"7#< WH*- un=no>n cau e"7#< WH*- un=no>n cau e? Not clinicall% relevantNot clinicall% relevant"77' WH*- 8"77' WH*- 8 di ea e of thedi ea e of the&%ocardiu& a ociated >ith&%ocardiu& a ociated >ith

cardiac d% function 8cardiac d% function 8? !atho!h% iolo)%!atho!h% iolo)%? each >ith &ulti!le etiolo)ieeach >ith &ulti!le etiolo)ie


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1212

"ar%iomyo&athies"ar%iomyo&athiesDi order of the heart &u cleDi order of the heart &u cleMo t ca e idio!athicMo t ca e idio!athicMan% due to i che&ic heart di ea eMan% due to i che&ic heart di ea e

and h%!erten ion.and h%!erten ion. Three cate)orie - Three cate)orie -

? Dilated / for&erl%$ con)e tive2Dilated / for&erl%$ con)e tive2

? H%!ertro!hicH%!ertro!hic? Re trictiveRe trictive

Heart lo e e@ectivene a a !u&!Heart lo e e@ectivene a a !u&!


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"ar%iomyo&athy"ar%iomyo&athy

WHO Classificationanatomy & physiology of the LV

1. Dilated• Enlarged• Systolic dysfunction

2. Hypertrophic• Thickened• iastolic dysfunction

3. Restrictive• iastolic dysfunction

4. Arrhythmogenic RV dysplasia• !i"rofatty replacement5. Unclassified

• !i"roelastosis• LV noncompaction

Circ 7 -#B"$ "77


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"567#"567# &ed lide .co&&ed lide .co& "'"'

H "*assi$cationH "*assi$cation

Un=no>n cau eUn=no>n cau e/!ri&ar%2/!ri&ar%2

? DilatedDilated? H%!ertro!hicH%!ertro!hic? Re trictiveRe trictive? uncla i eduncla i ed

S!eci c heartS!eci c heart&u cle di ea e&u cle di ea e

/ econdar%2/ econdar%2? InfectiveInfective? Meta9olicMeta9olic? S% te&ic di ea eS% te&ic di ea e

? Heredofa&ilialHeredofa&ilial? Sen itivit%Sen itivit%? To ic To ic

3r Heart 14567 88,9:;


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"567#"567#

&ed lide .co&&ed lide .co&

""

Functiona*Functiona*

"*assi$cation"*assi$cationDilatatedDilatated /con)e tive$ DCM$ IDC2/con)e tive$ DCM$ IDC2? ventricular enlar)e&ent and % tventricular enlar)e&ent and % t

d% functiond% functionH%!ertro!hicH%!ertro!hic /IHSS$ HCM$ H*CM2/IHSS$ HCM$ H*CM2? ina!!ro!riate &%ocardial h%!ertro!h%ina!!ro!riate &%ocardial h%!ertro!h%

in the a9 ence of HTN or aortic teno iin the a9 ence of HTN or aortic teno i

Re trictiveRe trictive /in ltrative2/in ltrative2? a9nor&al llin) and dia tolic functiona9nor&al llin) and dia tolic function


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"M' +&eci$c Etio*ogies"M' +&eci$c Etio*ogies

I che&icI che&ic,alvular,alvular

H%!erten iveH%!erten iveInFa&&ator%InFa&&ator%Meta9olicMeta9olic

InheritedInherited To ic reaction To ic reactionPeri!artu&Peri!artu&

I che&ic- thinned$ carredti ue


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1515

#i*ate% car%iomyo&athy#i*ate% car%iomyo&athy

# C$O$% throm"i formation % G contractility' andmitral (al(e incompetence' arrhythmias T)*relie(e symptoms of heart failure' decrease

+orkload' and anticoagulants% transplants


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1414

Hy&ertro&hicHy&ertro&hic"ar%iomyo&athy"ar%iomyo&athy

C.*. i nor&al$ inFo> re i tance$and &itral valve inco&!etence$arrh%th&ai and udden death.


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;6;6

estrictiveestrictivecar%iomyo&athycar%iomyo&athy

Reduced dia tolic co&!liance of theventricle. C.*. i nor&al or #% for&ationof thro&9i$ dilation of left atriu&$ and&itral valve inco&!etence.


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IDIOPATHIC DILATED CARDIOMYOPATHYIDIOPATHIC DILATED CARDIOMYOPATHY

NEW INSIGHTS INTONEW INSIGHTS INTO

PATHOGENESIS AND TREATMENT PATHOGENESIS AND TREATMENT


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#i*ate% "ar%iomyo&athy#i*ate% "ar%iomyo&athy

•Dilation and impaired contraction of ventricles•,educed systolic function +ith or +ithout heart failure•Characteri-ed "y myocyte damage•.ultiple etiologies +ith similar resultant pathophysiology

•!a"ority of cases are idiopathic•incidence of idiopathic dilated C. /012344'444

•incidence likely higher due to mild' asymptomatic cases•56 more pre(alent among males and 7frican07mericans


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DCM-DCM- Etio*ogyEtio*ogy#schemicValv$larHypertensive%amilial#diopathic#nflammatory

#nfectio$sViral & picornovir$s' (o) *' (!V' H#VRic+etsial , -yme Diseasearasitic , (hagas/ Disease' 0o)oplasmosis

on,infectio$s(ollagen Vasc$lar Disease - ' RAeripart$m

0o)ic Alcohol' Anthracyclins adriamycin ' (ocaine!eta6olic

ndocrine &thyroid d7' pheochromocytoma' D!' acromegaly'$tritional

0hiamine' seleni$m' carnitine

e$rom$sc$lar D$chene/s !$sc$lar Dystrophy,,),lin+ed


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#"M'#"M' !nfectious!nfectious

Acute viral &%ocarditiAcute viral & %ocarditiCo a ac=ie or echoviruCo a ac=ie or echoviru

Self4li&ited infection in %oun) !eo!leSelf4li&ited infection in %oun) !eo!leMechani & -Mechani & -? M%oc%te cell death and 9ro iM%oc%te cell death and 9ro i?

I&&une &ediated inJur%I&&une &ediated inJur%

? UT-UT-No chan)e >ith i&&uno u!!re ive dru)No chan)e >ith i&&uno u!!re ive dru)


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#"M'#"M' to,icto,ic

Alcoholic cardio&%o!ath%Alcoholic cardio &%o!ath%Chronic u eChronic u eRever i9le >ith a9 tinenceRever i9le >ith a9 tinenceMechani & -Mechani & -? M%oc%te cell death and 9ro iM%oc%te cell death and 9ro i

? Directl% inhi9it -Directl% inhi9it - &itochondrial o idative !ho !hor%lation&itochondrial o idative !ho !hor%lation(att% acid o idation(att% acid o idation


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#"M' inherite%#"M' inherite%

(a&ilial cardio&%o!ath%(a&ilial cardio &%o!ath%


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#"M'#"M' Peri&artumPeri&artumDia)no tic CriteriaDia )no tic Criteria

" &o !re$ ' &o !o t" &o !re$ ' &o !o tEcho- +, d% functionEcho- +, d% function

? +,E( B'K+,E( B'K? +,EDD O 5. c&6&5+,EDD O 5. c&6&5

E!ide&iolo)%6Etiolo)%E!ide&iolo)%6Etiolo)%"-B


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PP"M'PP"M' PrognosisPrognosisDeath fro& CM- 7"47Death fro& CM- 7"47? 5B' CM death in US$


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#i*ate%#i*ate%"ar%iomyo&athy"ar%iomyo&athy

ME"HA ! M ! HEA T FA! U E


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ME"HA !+M+ ! HEA T FA!.U EME"HA !+M+ ! HEA T FA!.U E

Hemodynamic erangementClinical Heart !ailure7rrhythmia

8eurohormonesCytokines

O)idati(e stress

9schemic in:ury.yocardial disease

;eneticsAltered &olecular e !re ionAltered &olecular e !re ionUltra tructural chan)eUltra tructural chan)eM%oc%te h%!ertro!h%M%oc%te h%!ertro!h%

M%oc%te contractileM%oc%te contractiled% functiond% function

A!o!to iA!o!to i(i9ro9la t !roliferation(i9ro9la t !roliferation

Colla)en de!o itionColla)en de!o ition,entricular re&odelin),entricular re&odelin)


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Patho!h% iolo)%Patho!h% iolo)%

•9nitial Compensation for impaired myocyte contractility*•!rank0Starling mechanism• 8eurohumoral acti(ation

↑ intra(ascular (olume

•E(entual decompensation•(entricular remodeling

•myocyte death2apoptosis•(al(ular regurgitation


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"*inica* Fin%ings"*inica* Fin%ings

*iventric$lar (ongestive Heart %ail$re

, -o8 for8ard (ardiac 9$tp$t,fatig$e' lightheadedness' hypotension

, $lmonary (ongestion,Dyspnea',orthopnea' : D

, ystemic (ongestion

, dema,Ascites,;eight gain


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Physica* E,amPhysica* E,am

Decreased (.9.Tachycardia↓ (asoconstriction?=ulsus 7lternans >end0stage?

$lmonary veno$s congestion

rales pleural effusions

(ardiaclaterally displaced =.9S5 >acutely?

mitral regurgitation murmur ystemic congestion↑ @Vhepatosplenomegalyascites

peripheral edema


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#iagnostic +tu%ies#iagnostic +tu%ies

( Anormal

tachycardia' atrial and (entricular enlargement' L


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Echo in %i*ate% "MEcho in %i*ate% "M


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Class 1: No limitation of physical activityClass 1: No limitation of physical activityO!"ina!y physical activity #$o fati%&'( palpitation( o! "yspn'aO!"ina!y physical activity #$o fati%&'( palpitation( o! "yspn'a

Class ): *li%ht limitation of physical activity Comfo!ta+l' at !'st( +&tClass ): *li%ht limitation of physical activity Comfo!ta+l' at !'st( +&tsymptoms #$ o!"ina!y physical activitysymptoms #$ o!"ina!y physical activity

Class ,: Ma!-'" limitation of physical activity Comfo!ta+l' at !'st( +&t l'ssClass ,: Ma!-'" limitation of physical activity Comfo!ta+l' at !'st( +&t l'ssthan o!"ina!y activity ca&s's fati%&'( palpitation( o! "yspn'a than o!"ina!y activity ca&s's fati%&'( palpitation( o! "yspn'a

Class .: /na+l' to ca!!y o&t any physical activity #itho&t "iscomfo!tClass .: /na+l' to ca!!y o&t any physical activity #itho&t "iscomfo!t*ymptoms incl&"' ca!"iac ins&ffici'ncy at !'st If any physical*ymptoms incl&"' ca!"iac ins&ffici'ncy at !'st If any physicalactivity is &n"'!ta-'n( "iscomfo!t is inc!'as'"activity is &n"'!ta-'n( "iscomfo!t is inc!'as'"

J Cardiac FailureJ Cardiac Failure 1000 2:,234,5)1000 2:,234,5)

&riteria for =0H unctional &lassification&riteria for =0H unctional &lassification


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Ai& of Treat&entAi& of Treat&ent

• =reload reduction• iuretics• (enodilators

• Vasodilators• 7CE9

• 9notropes• 7cutely• Chronically

• mortality


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,a odilator A)ent in Heart,a odilator A)ent in Heart(ailure(ailure

rug .echanism 7ction Fse 8itroglycerinand long0acting nitratesG

irect (ia nitrico)ide

Veno 2arterioloar

Hemodynamic%anti0ischemic%long term

8itroprusside irect (ia nitrico)ide

7rteriolar (enodilation

Hemodynamic

Hydrala-ineG irect 7rteriolar Ilong termG

7CEinhi"itorsJ

,educed 70999ncr$ "radykinin

Veno 2arterioloar

Long0term

GHydrala-ine and a long0nitrate sho+n to reduce mortality long0termJ Other actions >aside from (asodilation? likely to "e important

Do9uta&ine and MilrinoneDo9uta&ine and Milrinone


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Do9uta&ine and MilrinoneDo9uta&ine and MilrinoneE@ectE@ect

E* i * %E* t i * %


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E*ectrica* an%E*ectrica* an%Mechanica* /entricu*arMechanica* /entricu*ar

#yssynchrony#yssynchronyE !eri&entall%E !eri&entall% induced + ha e@ect on-induced + ha e@ect on-? e !re ione !re ion of re)ional tre =ina eof re)ional tre =ina e

? calciu&4handlin) !rotein .calciu&4handlin) !rotein .E !re ion of ! #4MAP E !re ion of ! #4MAP /a tre =ina e2 i/a tre =ina e2 ielevated in the endocardiu&elevated in the endocardiu& of the late4of the late4activated re)ion$ >herea !ho !hola&9anactivated re)ion$ >herea !ho !hola&9ani decrea ed.i decrea ed.Sarco!la &atic reticulu& CaSarco!la &atic reticulu& Ca 55 4ATPa e4ATPa e iidecrea ed in the re)ion of earl% activation.decrea ed in the re)ion of earl% activation.

D l iD l t i


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DeleteriouDeleteriouHe&od%na&ic E@ect ofHe&od%na&ic E@ect of+, D% %nchron%+, D% %nchron%

.. Di&ini hed S, V C* due-Di&ini hed S, V C* due-

Reduced dia tolic llin)Reduced dia tolic llin)

ti&eti&e""

Wea=ened contractilit%Wea=ened contractilit% 55

Protracted M,Protracted M,re)ur)itationre)ur)itation 55

Po t % tolic re)ionalPo t % tolic re)ionalcontractioncontraction

At!io4v'nt!ic&la!

Int'!46

Int!a46

&a'eau> et al. PACE ;6627 ;9?#t. @, 12:–182

". 3rine C+$ Circulation "7#7 7- #B'4#'

5. 1iao H $ Br Heart J "77" - BB 4BB . S )aard P$ QACC 5


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" T' "ar%iac" T' "ar%iacesynchroni0ationesynchroni0ation

Thera&yThera&y". I&!roved". I&!roved

he&od%na&iche&od%na&ic? Increa ed C*Increa ed C*? Reduced +, llin)Reduced +, llin)

!re ure!re ure? Reduced %&!atheticReduced %&!atheticactivit%activit%

? Increa ed % tolicIncrea ed % tolicfunction >6o M,*5function >6o M,*5

5. Rever e +,5. Rever e +,re&odelin)6architecturere&odelin)6architecture? Decrea ed +,ES6EDDecrea ed +,ES6ED

volu&evolu&e? Increa ed +,E(Increa ed +,E(

? Circ


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Hy&ertro&hic "ar%iomyo&athyHy&ertro&hic "ar%iomyo&athy


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Hy&ertro&hic "MHy&ertro&hic "MMo t co&&on cau e of death in %oun) !eo!le.Mo t co&&on cau e of death in %oun) !eo!le.

The &a)nitude of left ventricular h%!ertro!h% i The &a)nitude of left ventricular h%!ertro!h% i

directl% correlated to the ri = of SCD.directl% correlated to the ri = of SCD.

0oun) !t >ith e tre&e h%!ertro!h% and fe> or no 0oun) !t >ith e tre&e h%!ertro!h% and fe> or no%&!to& are at u9 tantial lon)4ter& ri = of SCD.%&!to& are at u9 tantial lon)4ter& ri = of SCD.

.%pirito #. N Engl J Med. 144:7229,::A


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hH & &hi


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#iasto*ic #ysfunction#iasto*ic #ysfunction

Bo&en

Etiolo)%- HTN V +,HEtiolo)%- HTN V +,HDia)no i -Dia)no i -? M,V P, Do!!lerM,V P, Do!!ler? TDI$ Color &4&ode TDI$ Color &4&ode

Echo #o&&*erEcho #o&&*er


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Xile MR. Circ "


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-eft ventric$lar hypertrophy not d$e to press$re overloadHypertrpohy is varia6le in 6oth severity and location

,asymmetric septal hypertrophy,symmetric non,o6str$ctive,apical hypertrophy

Vigoro$s systolic f$nction ' 6$t impaired diastolic f$nctionimpaired rela)ation of ventricleselevated diastolic press$res

prevalence as high as 1?5@@ in general pop$lationmortality in selected pop$lations 4, B instit$tionalpro6a6ly more favora6le 1B


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Etiolo)%Etiolo)%!amilial in K // of cases +ith autosomal dominant transmission

.utations in one of M genes encoding proteins of cardiacsarcomereaccount for ma:ority of familial cases

β0.HCcardiac troponin Tmyosin "inding protein Cα0tropomyosin

,emainder arespontaneousmutations$

Hy&ertro&hicHy&ertro&hic


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Hy&ertro&hicHy&ertro&hic


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H%!ertro!hiccardio&%o!ath%


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A!icalH%!ertro!hic

Cardio&o!ath%


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Patho!h% iolo)%Patho!h% iolo)%

hH"M i h


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H"M ith out oH"M ith out oo3structiono3structionynamic LVOT o"struction >may not "e present at rest?

S7. >systolic anterior motion of mitral (al(e?

LVOT O"struction LVOT gradient ↑+all stress ↑.VO ischemia2angina

↑ LVOT gradient* ↑ H, > !=?' ↓ preload >LVE V?' ↓ afterload>


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Ph% ical E a&Ph% ical E a&

Nspike and dome ?SM gallopCrescendo2 escrescendo systolic e:ection murmur

HOC. (s$ Val(ular 7S 9ntensity of murmur HOC.7S

Valsal(a > ↓ preload' ↓ afterload? ↑ ↓SPuatting > ↑ preload' ↑ afterload? ↓ ↑Standing > ↓ preload' ↓ afterload? ↑ ↓

Holosystolic apical "lo+ing murmur of mitral regurgitation


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Dia)no tic StudieDia)no tic Studie

E 3? NSR? +,H? e!tal Y >ave

5D4Echocardio)ra!h%? +,H e!tu& O".B free

>all? +,*T )radient 9% Do!!ler? S% tolic anterior &otion of

the &itral valere)ur)itationCardiac CatheteriZation

? +,*T )radient and !ull9ac=? !rovocative &aneuver? roc=en9rou)h !hen HCM4ASH u in) contra t


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TreatmentTreatment!or symptomatic "enefit

β0"lockers ↓ m(O ↓ gradient >e)ercise?arrythmias

Calcium Channel "lockers7nti0arrhythmicsafi"

amiodoroneisopyramide

79C for sudden death

anti"iotic prophyla)is for endocarditis 8o therapy has "een sho+n to impro(e mortality

HCM S )i l T t& tHCM Sur)ical Treat&ent


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HCM- Sur)ical Treat&entHCM- Sur)ical Treat&ent

!or se(ere symptoms +ith large outflo+ gradient > /4mmHg? Does not prevent Sudden Cardiac Death

!yomyectomyremo(al of small portion of upper 9V septum

D20 mitral (al(e replacement/ year symptomatic "enefit in K Q4 of patients

D$al (am6er DDD pacema+er pacingdecreases LVOT gradient >"yK / ?

randomi-ed trials ha(e sho+n little longterm "enefit possi"le fa(ora"le morphologic changes

09H septal a6lation

79C to pre(ent sudden death

P g iPrognosis


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PrognosisPrognosisSudden eath 0M 2year in adults

M0R in children2adolescents79C for* sur(i(ors of SC +ith Vfi"

episodes of Sustained VT pts +ith family h) of SC in young family mem"ersHigh risk mutation >TnT' 7rgM45;ln?

=redictors of ad(erse prognosis*early age of diagnosisfamilial form +ith SC in 3st degree relati(ehistory of syncope

ischemia presence of (entricular arrhythmias on Holter >E=S?E=S7miodorone >lo+ dose?=rophylactic 79C I


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H"M vs Ath*etes HeartH"M vs Ath*etes Heart

Endurance trainin)-Endurance trainin)-? Ph% iolo)ic increa e in +, &aPh% iolo)ic increa e in +, &a

Wall thic=ne and cavit% iZeWall thic=ne and cavit% iZe

Earl% HCM v Athlete heartEarl% HCM v Athlete heart? DE(INITI*N- S%&&etric$ " &&DE(INITI*N- S%&&etric$ " &&? 7B elite athlete - " thic=ne [" 4" &&7B elite athlete - " thic=ne [" 4" &&

"' ro>er $ EDD[''4 c6> 5# athlete 655 other"' ro>er $ EDD[''4 c6> 5# athlete 655 otherNEQM"77" 5B-57'NEQM"77" 5B-57'

? 5# c%cli t - 5' thic=ne " 4"'5# c%cli t - 5' thic=ne " 4"''6 "5K reduced +,E('6 "5K reduced +,E(

QACC 5


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estrictiveestrictive"ar%iomyo&athy"ar%iomyo&athy

....

i ii i


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estrictiveestrictive"ar%iomyo&athy"ar%iomyo&athy

(haracteri7ed 6y• impaired (entricular filling due to an a"normally stiff >rigid? (entricle•normal systolic function >early on in disease?•intra(entricular pressure rises precipitously +ith small increases in (olume

=ressure

Volume

Causes * infiltration of myocardium "y a"normal su"stancefi"rosis or scarring of endocardium

normal

restriction


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A&%loid in ltrative CM

A&%l id iA&%l id i


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A&%loido iA&%loido i

=rimary 7myloidosisimmunoglo"ulin light chains 00 multiple myeloma

Secondary 7myloidosisdeposition of protein other than immunoglo"ulin

senilefamilialchronic inflammatory process

restriction caused "y replacement of normal myocardial contractile

elements "y infiltrati(e interstitial deposits


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Amy*oi%osisAmy*oi%osis

A * i%A * i%


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Amy*oi%Amy*oi%"ar%iomyo&athy"ar%iomyo&athy


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+arcoi%osis+arcoi%osis

..


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+arcoi%osis+arcoi%osis

Multi % te& di order of un=no>nMulti % te& di order of un=no>netiolo)% that &o t co&&onl%etiolo)% that &o t co&&onl%

a@ect the lun) $ 9ut can al oa@ect the lun) $ 9ut can al oa@ect other or)an .a@ect other or)an .eethoven i thou)ht to haveeethoven i thou)ht to have

9een the r t !er on de cri9ed9een the r t !er on de cri9ed>ith thi condition.>ith thi condition.


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Erythema o%osumErythema o%osum


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.u&us Pernio.u&us Pernio


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+ystems a ecte% 3y+ystems a ecte% 3y

+arcoi%osis+arcoi%osisNeurolo)iNeurolo)icc

'K'K

Cranial nerve !al %$ eiZure $ 9a alCranial nerve !al %$ eiZure $ 9a al)ranulo&atou &enin)iti $ h%!othala&ic or)ranulo&atou &enin)iti $ h%!othala&ic or!ituitar% le ion $ h%droce!halu $ !eri!heral!ituitar% le ion $ h%droce!halu $ !eri!heralneuro!ath%$ ! %chiatricneuro!ath%$ ! %chiatric

*cular*cular5


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"*inica* Presentation"*inica* Presentation

Mo t !atient have the !ul&onar%Mo t !atient have the !ul&onar%&anife tation $ &o t co&&onl%&anife tation $ &o t co&&onl%

!re entin) >ith incidental ndin)!re entin) >ith incidental ndin)on C1R.on C1R.Inter titial di ea eInter titial di ea e

S%&!to& include dr% cou)h$S%&!to& include dr% cou)h$d% !nea$ and che t di co&fortd% !nea$ and che t di co&fortUn!redicta9le cour eUn!redicta9le cour e

4 +t g f P *4 +tages of Pu*monary


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4 +tages of Pu*monary4 +tages of Pu*monary+arcoi%osis+arcoi%osis

II ilateral hilarilateral hilarl%&!hadeno!ath% andl%&!hadeno!ath% and!aratracheal adeno!ath%!aratracheal adeno!ath%

''47ith!ul&onar% !arench%&al!ul&onar% !arench%&alinvolve&entinvolve&ent

B


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g


78/194

TreatmentTreatment

*9 ervation*9 ervationInitiatin) cortico teroid thera!%Initiatin) cortico teroid thera!%

>hen a!!ro!riate>hen a!!ro!riateMonitorin) re !on e to thera!%Monitorin) re !on e to thera!%Di continuin) cortico teroidDi continuin) cortico teroid>hen clinicall% or !h% iolo)icall%>hen clinicall% or !h% iolo)icall%indicated.indicated.

En%omyocar%ia* Fi3rosisEn%omyocar%ia* Fi3rosis


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En%omyocar%ia Fi3rosisEn%omyocar%ia Fi3rosis

Endemic in parts of 7frica' 9ndia' South and Central 7merica' 7sia3/0 / of cardiac deaths in ePuatorial 7frica

hypereosinophilic syndrome >Loffler s endocarditis?

Thickening of "asal inferior +allendocardial deposition of throm"usapical o"literationmitral regurgitation140 4 die +ithin 30 years

Clinical (indin)Clinical (indin)


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Clinical (indin)Clinical (indin)

,ight Left heart failureyspneaOrthopnea2=8=eripheral edema7scites2Hepatomegaly

!atigue2 ↓e)ercise tolerance

Clinically mimics constricti(e =ericarditis



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0Echo2 oppler0mitral in0flo+ (elocityrapid early diastolic filling

Catheteri-ation A diastolic pressure ePuili"ration restricti(e (s constricti(e

hemodynamics

Endomyocardial "iopsy0 definite ) of restricti(e pathology

T &


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Treat&ent Treat&entTreat underlying cause

r2o constriction +hich is treata"le >restriction poor prognosis?amyloid >melphalan2prednisone2colchicine?Endomyocardial !i"rosis >steroids' cytoto)ic drugs' .V,?Hemochromatosis >chelation' phle"otomy?Sarcoidosis >steroids?

iuretics!or congesti(e symptoms' "ut ↓ LV2,V filling ↓ CO

igo)in >a(oid in amyloidosis?7ntiarrhythmics for afi"

amiodorone=acemaker for conduction system disease7nticoagulation for throm"us >esp in atrial appendages?

A h th g i /Arrhythmogenic /


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Arrhythmogenic /Arrhythmogenic /#ys&*asia#ys&*asia

....

A h th i /A h th g i /


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Arrhythmogenic /Arrhythmogenic /#ys&*asia#ys&*asia

M%ocardiu& of R, free >allM%ocardiu& of R, free >allre!laced-re!laced-

? (i9rofatt% ti ue(i9rofatt% ti ue? Re)ional >all &otion6function iRe)ional >all &otion6function i

reducedreduced

,entricular arrh%th&ia,entricular arrh%th&ia? SCD in %oun)SCD in %oun)

M !' / # &* iM !' / # &* i


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M !' / #ys&*asiaM !' / #ys&*asia


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./ oncom&action./ oncom&action

Dia)no tic CriteriaDia )no tic Criteria Pro&inent tra9eculation $ dee! rece e in +,a!e

Thin co&!act e!icardiu&$ thic=enedendocardiu&

Stoll9er)er C$ QASE L


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Echo' ./ oncom&actionEcho' ./ oncom&action


88/194

Myocar%itisMyocar%itis$$


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"AU+AT!"AU+AT!

A lar)e variet% of infection $A lar)e variet% of infection $% te&ic di ea e $ dru) $ and% te&ic di ea e $ dru) $ and

to in have 9een a ociated >ithto in have 9een a ociated >iththe develo!&ent of thi di ea ethe develo!&ent of thi di ea e,iru e $ 9acteria$ !rotoZoa$ and,iru e $ 9acteria$ !rotoZoa$ and

even >or& have 9een i&!licatedeven >or& have 9een i&!licateda infectiou a)ent .a infectiou a)ent .


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Patho&hysio*ogyPatho&hysio*ogy

Several &echani & of &%ocardial da&a)eSeveral &echani & of &%ocardial da&a)e

/"2 Direct inJur% of &%oc%te 9% the/"2 Direct inJur% of &%oc%te 9% the

infectiou a)entinfectiou a)ent/52 M%oc%te inJur% cau ed 9% a to in uch/52 M%oc%te inJur% cau ed 9% a to in ucha thata that fro&fro& Corynebacterium diphtheriaeCorynebacterium diphtheriae

/ 2 M%oc%te inJur% a a re ult of infection4/ 2 M%oc%te inJur% a a re ult of infection4 induced i&&une reaction orinduced i&&une reaction orautoi&&unit%.autoi&&unit%.


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Tri!ha ic di ea e !roce Tri!ha ic di ea e !roce

Phase !' /ira* !nfection an%Phase !' /ira* !nfection an%e&*icatione&*ication

Phase 2' Autoimmunity an% in5uryPhase 2' Autoimmunity an% in5ury

Phase 6' #i*ate% "ar%iomyo&athyPhase 6' #i*ate% "ar%iomyo&athy

Phase !' /ira* !nfectionPhase !' /ira* !nfection


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Phase ! /ira* !nfectionPhase ! /ira* !nfectionan% e&*icationan% e&*ication

Co ac=ieviru cau e anCo ac=ieviru cau e aninfectiou !ha e$ >hich la t 4"hich la t 4"<da% $ and i characteriZed 9% activeda% $ and i characteriZed 9% activeviral re!licationviral re!licationDurin) thi !ha e initial &%oc%teDurin) thi !ha e initial &%oc%teinJur% ta=e !lace$ cau in) the relea einJur% ta=e !lace$ cau in) the relea e

of anti)enic intracellular co&!onentof anti)enic intracellular co&!onentuch a &%o in into the 9lood trea&uch a &%o in into the 9lood trea&

Phase 2' AutoimmunityPhase 2' Autoimmunity


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Phase 2 AutoimmunityPhase 2 Autoimmunityan% in5uryan% in5ury

The local relea e of c%to=ine $ uch a The local relea e of c%to=ine $ uch ainterleu=in4"$ interleu=in45$ interleu=in4interleu=in4"$ interleu=in45$ interleu=in4$ tu&or necro i factor /TN(2$ and nitric$ tu&or necro i factor /TN(2$ and nitric

o ide &a% !la% a role in deter&inin) theo ide &a% !la% a role in deter&inin) the T4cell reaction and the u9 e]uent T4cell reaction and the u9 e]uentde)ree of autoi&&une !er!etuationde)ree of autoi&&une !er!etuation

The e c%to=ine &a% al o cau e The e c%to=ine &a% al o cau e

rever i9le de!re ion of &%ocardialrever i9le de!re ion of &%ocardialcontractilit% >ithout cau in) cell death.contractilit% >ithout cau in) cell death.

Phase 2' AutoimmunityPhase 2' Autoimmunity


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Phase 2 AutoimmunityPhase 2 Autoimmunityan% in5uryan% in5ury

I&&une4&ediated 9% CD#I&&une4&ediated 9% CD#l%&!hoc%te and autoanti9odiel%&!hoc%te and autoanti9odiea)ain t variou &%oc%tea)ain t variou &%oc%teco&!onentco&!onentAnti)enic &i&icr%$ the croAnti)enic &i&icr%$ the croreactivit% of anti9odie to 9oth virureactivit% of anti9odie to 9oth viru

and &%ocardial !roteinand &%ocardial !roteinM%oc%te inJur% &a% 9e a directM%oc%te inJur% &a% 9e a directre ult of CD# l%&!hoc%te in ltrationre ult of CD# l%&!hoc%te in ltration

Phase 6' #i*ate%Phase 6' #i*ate%


95/194

Phase 6 #i ate%Phase 6 #i ate% "ar%iomyo&athy"ar%iomyo&athy,iru e &a% al o directl% cau e &%oc%te a!o!to i .,iru e &a% al o directl% cau e &%oc%te a!o!to i .

Durin) the autoi&&une !ha e$ c%to=ine activateDurin) the autoi&&une !ha e$ c%to=ine activatethe &atri &etallo!roteina e $ uch a )elatina e$the &atri &etallo!roteina e $ uch a )elatina e$colla)ena e $ and ela ta e .colla)ena e $ and ela ta e .In later ta)e of i&&une activation$ c%to=ine !la%In later ta)e of i&&une activation$ c%to=ine !la%a leadin) role in adver e re&odelin) anda leadin) role in adver e re&odelin) and!ro)re ive heart failure.!ro)re ive heart failure.Cardio&%o!ath% develo!ed de !ite the a9 ence ofCardio&%o!ath% develo!ed de !ite the a9 ence ofviralviral

!roliferation 9ut >a correlated >ith elevated!roliferation 9ut >a correlated >ith elevatedlevel of level of

c%to=ine uch a TN(.c%to=ine uch a TN(.


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+ym&toms an% +igns+ ym&toms an% +igns 4 Patient /'7K2 fre]uentl% !re ent da% to >ee=4 Patient /'7K2 fre]uentl% !re ent da% to >ee=after an acute fe9rile illne $ !articularl% a Fu4li=eafter an acute fe9rile illne $ !articularl% a Fu4li=e%ndro&e%ndro&e4 M%ocarditi i &o t co&&onl% a %&!to&atic$4 M%ocarditi i &o t co&&onl% a %&!to&atic$>ith no evidence of left ventricular d% function>ith no evidence of left ventricular d% function4 fever$ &alai e$ fati)ue$ arthral)ia $ &%al)ia $4 fever$ &alai e$ fati)ue$ arthral)ia $ &%al)ia $and =in ra h.and =in ra h.4Cardiac %&!to& &a% re ult fro& % tolic or4Cardiac %&!to& &a% re ult fro& % tolic or

dia tolic left ventricular d% function or fro&dia tolic left ventricular d% function or fro&tach%arrh%th&ia or 9rad%arrh%th&ia /d% !nea$tach%arrh%th&ia or 9rad%arrh%th&ia /d% !nea$fati)ue$ decrea ed e erci e tolerance$fati)ue$ decrea ed e erci e tolerance$!al!itation 2!al!itation 2


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"*inica* Fin%ings"*inica* Fin%ings+ym&toms an% +igns+ ym&toms an% +igns

4 Che t di co&fort/ 'K2 i a co&&on4 Che t di co&fort/ 'K2 i a co&&on%&!to&%&!to& and i t%!icall% !ericardial in natureand i t%!icall% !ericardial in nature4 M%ocarditi &a% !re ent a udden death$4 M%ocarditi &a% !re ent a udden death$a aa a re ult of &ali)nant ventricularre ult of &ali)nant ventriculararrh%th&ia orarrh%th&ia or

co&!lete heart 9loc=co&!lete heart 9loc=4S% te&ic and !ul&onar% thro&9oe&9oli4S% te&ic and !ul&onar% thro&9oe&9olihave al o 9een noted.have al o 9een noted.


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Physica* E,aminationPh ysica* E,amination 4T4Tach%cardia$ h%!oten ionach%cardia$ h%!oten ion $ fever and tach%cardia$ fever and tach%cardia &a% 9e di !ro!ortionate to the de)ree of fever&a% 9e di !ro!ortionate to the de)ree of fever44 rad%cardia i eenrad%cardia i een rarel%$ and a narro> !ul erarel%$ and a narro> !ul e

!re ure i occa ionall% detected!re ure i occa ionall% detected44Mur&ur of &itral or tricu !id re)ur)itationMur&ur of &itral or tricu !id re)ur)itation areareco&&on $ S and SB )allo! &a% al o 9e heard.co&&on $ S and SB )allo! &a% al o 9e heard.

4Di tended nec= vein $ !ul&onar% rale $ >heeZe $4Di tended nec= vein $ !ul&onar% rale $ >heeZe $ )allo! $ and !eri!heral ede&a &a% 9e detected)allo! $ and !eri!heral ede&a &a% 9e detected


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E*ectrocar%iogra&hyE*ectrocar%iogra&hy 4The &o t co&&on a9nor&alit% i4The &o t co&&on a9nor&alit% iinu tach%cardia.inu tach%cardia.4 &a% ho> ventricular arrh%th&ia4 &a% ho> ventricular arrh%th&iaor heart 9loc=$ or it &a% &i&ic theor heart 9loc=$ or it &a% &i&ic thendin) in acute &%ocardialndin) in acute &%ocardial

infarction or !ericarditi .infarction or !ericarditi .4Relation 9et>een the e clinical4Relation 9et>een the e clinicaland la9orator% ndin)and la9orator% ndin)


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"hest ra%iogra&h"hest ra%iogra&h 4Mild to &oderate cardio&e)al% fro&4Mild to &oderate cardio&e)al% fro& dilatation of the left or ri)ht ventriculardilatation of the left or ri)ht ventricular cavit%cavit%4The cardiac ilhouette &a% al o 9e4The cardiac ilhouette &a% al o 9e)lo9ular >hen a !ericardial e@u ion i)lo9ular >hen a !ericardial e@u ion i!re ent!re ent4 ,enou con)e tion and !ul&onar%4 ,enou con)e tion and !ul&onar%ede&a &a% 9e een in &ore evereede&a &a% 9e een in &ore evereca eca e


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Echocar%iogra&hyEchocar%iogra&hy 4&%ocardial contractilit% $ cha&9er iZe $4&%ocardial contractilit% $ cha&9er iZe $ valvular functionvalvular function

4+eft ventricular % tolic d% function$4+eft ventricular % tolic d% function$re)ional >all &otion a9nor&alitie $re)ional >all &otion a9nor&alitie $)lo9al h%!o=ine i)lo9al h%!o=ine i

4 +, &a% 9e nor&al in iZe or &ini&all%4 +, &a% 9e nor&al in iZe or &ini&all%

enlar)edenlar)ed

4Mitral or tricu !id re)ur)itation4Mitral or tricu !id re)ur)itation4Mural thro&9i in "'K of ca e4Mural thro&9i in "'K of ca e


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4hel!ful in de&on tratin)4hel!ful in de&on tratin)a9nor&alitie of dia tolic llin) thata9nor&alitie of dia tolic llin) that&i&ic re trictive cardio&%o!ath% and&i&ic re trictive cardio&%o!ath% and

indi tin)ui hin) ventricular dilatationindi tin)ui hin) ventricular dilatationfro& !ericardial e@u ionfro& !ericardial e@u ion4&onitor the cour e of the illne and4&onitor the cour e of the illne andto evaluate thera!%to evaluate thera!%a%ionuc*i%e ventricu*ogra&hya%ionuc*i%e ventricu*ogra&hy 4!rovide accurate e ti&ate of4!rovide accurate e ti&ate ofcha&9er volu&e $ a >ell a left andcha&9er volu&e $ a >ell a left andri)ht ventricular eJection fractionri)ht ventricular eJection fraction


103/194


Myocar%ia* imagingMyocar%ia* imaging 43alliu&4 i&a)in)43alliu&4 i&a)in) 4O active inFa&&ation of the4O active inFa&&ation of the

&%ocardiu&&%ocardiu& and !ericardiu&and !ericardiu&4Indiu&4""" &onoclonal anti&%o in4Indiu&4""" &onoclonal anti&%o in anti9od% i&a)in) anti9od% i&a)in) 4O detectin) &%oc%te inJur% in !atient4O detectin) &%oc%te inJur% in !atient

4Contra t &edia4enhanced MRI4Contra t &edia4enhanced MRI 4Odetectin) &%ocardial inFa&&ation4Odetectin) &%ocardial inFa&&ation


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"ar%iac catheteri0ation"ar%iac catheteri0ation 4elevated left ventricular end4dia tolic4elevated left ventricular end4dia tolic!re ure$ a de!re ed cardiac out!ut$!re ure$ a de!re ed cardiac out!ut$and increa ed ventricular volu&eand increa ed ventricular volu&e4Coronar% an)io)ra& t%!icall%4Coronar% an)io)ra& t%!icall%de&on trate nor&al coronar%de&on trate nor&al coronar%arterie .arterie .


105/194


En%omyocar%ia* 3io&syEn%omyocar%ia* 3io&sy 4 )old tandard for the dia)no i of4 )old tandard for the dia)no i of

&%ocarditi&%ocarditi44#a**as#a**as criteriacriteria

/an inFa&&ator% in ltrate of the /an inFa&&ator% in ltrate of the &%ocardiu& inJur% to the adJacent &%ocardiu& inJur% to the adJacent &%oc%te 2 &%oc%te 2

49orderline &%ocarditi i &ade >hen49orderline &%ocarditi i &ade >henthe in ltrate i not acco&!anied 9%the in ltrate i not acco&!anied 9%&%oc%te inJur%&%oc%te inJur%

orma* Myocar%iumorma* Myocar%ium


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orma Myocar%iumorma Myocar%ium

7or%er*ine Myocar%itis7or%er*ine Myocar%itis


107/194

7or%er ine Myocar%itis7or%er ine Myocar%itis

Active Myocar%itisActive Myocar%itis


108/194

Active Myocar%itisActive Myocar%itis

h


109/194

thers testthers test

elevated er%throc%teelevated er%throc%teedi&entation rate /ESR2 $ &ild toedi&entation rate /ESR2 $ &ild to&oderate leu=oc%to i&oderate leu=oc%to iCP 4M $ Cardiac tro!onin4ICP 4M $ Cardiac tro!onin4I *ther la9orator% anal% e that*ther la9orator% anal% e that&a% 9e u eful include a Mono4 !ot&a% 9e u eful include a Mono4 !ot

te t$ E! tein4 arr viru titer $te t$ E! tein4 arr viru titer $he!atiti erolo)%$ and urine andhe!atiti erolo)%$ and urine anderu& for c%to&e)aloviru /CM,2.eru& for c%to&e)aloviru /CM,2.

Tri&hasic %iseaseTri&hasic %isease


110/194

&rocess8&rocess8


111/194

En%ocar%itisEn%ocar%itis

..

" f" f


112/194

"ontents of .ecture"ontents of .ecture

En%ocar%itisEn%ocar%itis? #e$nitions#e$nitions? E&i%emio*ogyE&i%emio*ogy? PathogenesisPathogenesis? "*inica* Presentations"*inica* Presentations? #iagnosis#iagnosis

? "om&*ications9Morta*ity"om&*ications9Morta*ity+e&tic throm3o&h*e3itis+e&tic throm3o&h*e3itisMycotic aneurysmMycotic aneurysm

En%ocar%itis'En%ocar%itis'


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En%ocar%itis#e$nition#e$nition

!nfective En%ocar%itis!nfective En%ocar%itis ' a micro3ia*' a micro3ia*infection of the en%ocar%ia* surface ofinfection of the en%ocar%ia* surface ofthe heartthe heart

"ommon site"ommon site '' heart valveheart valve : 3ut may occur: 3ut may occurat se&ta* %efect: on chor%ae ten%inae orat se&ta* %efect: on chor%ae ten%inae orin the mura* en%ocar%iumin the mura* en%ocar%ium"*assi$cation'"*assi$cation'? acuteacute oror subacute-chronicsubacute-chronic on tem&ora* 3asis:on tem&ora* 3asis:

severity of &resentation an% &rogressionseverity of &resentation an% &rogression? 7y organism7y organism? ative va*ve or &rosthetic va*veative va*ve or &rosthetic va*ve

E # "A #!T!E # "A #!T!


114/194

E # "A #!T!+E # "A #!T!+

Cha!act'!istic patholo%ical l'sion: vegetation (compos'" of plat'l'ts( fi+!in( mic!oo!%anismsan" inflammato!y c'lls

P h iP th i


115/194

PathogenesisPathogenesis

A*tere% va*ve surfaceA*tere% va*ve surface? Ani&al e !eri&ent u))e t that IE i al&o tAni&al e !eri&ent u))e t that IE i al&o t

i&!o i9le to e ta9li h unle the valve urface ii&!o i9le to e ta9li h unle the valve urface i

da&a)edda&a)ed#e&osition of &*ate*ets an% $3rin ;#e&osition of &*ate*ets an% $3rin ;non3acteria* throm3otic vegetation ( 7TE)non3acteria* throm3otic vegetation ( 7TE)7acteraemia7acteraemia ? attache to !latelet4 9rin de!o it? attache to !latelet4 9rin de!o it? Covered 9% &ore 9rinCovered 9% &ore 9rin? Protected fro& neutro!hilProtected fro& neutro!hil? Divi ion of 9acteriaDivi ion of 9acteria? Mature ve)etationMature ve)etation

P h iP th i


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Hae&od%na&ic (actorHae&od%na&ic (actor? acterial coloni ation &ore li=el% toacterial coloni ation &ore li=el% to

occur around le ion >ith hi)hoccur around le ion >ith hi)hde)ree of tu9ulencede)ree of tu9ulence

e). &all ,SD$ valvular teno ie). &all ,SD$ valvular teno i

? +ar)e urface area $ lo> Fo> and lo>+ar)e urface area $ lo> Fo> and lo>

tur9ulence are le li=el% to cau e IEtur9ulence are le li=el% to cau e IEe) lar)e ,SD$e) lar)e ,SD$

P h iP th i


117/194


acterae&iaacterae&ia? Tran ient 9acterae&ia occur >hen a heavil% Tran ient 9acterae&ia occur >hen a heavil%

coloni ed &uco al urface i trau&ati edcoloni ed &uco al urface i trau&ati ed

Dental e tractionDental e tractionPeriodontal ur)er%Periodontal ur)er%

Tooth 9ru hin) Tooth 9ru hin) Ton illecto&% Ton illecto&%*!eration involvin) the re !irator%$ 3I or 3U tract*!eration involvin) the re !irator%$ 3I or 3U tract&uco a&uco a*e o!ha)eal dilatation*e o!ha)eal dilatationiliar% tract ur)er%iliar% tract ur)er%

+it f ! f ti+it f ! f ti


118/194

+ite of !nfection+ite of !nfection

Aortic valve &ore co&&on than &itralAortic valve &ore co&&on than &itralAortic-Aortic-? ,e)etation u uall% on ventricular a !ect$,e)etation u uall% on ventricular a !ect$

all cu ! u uall% a@ectedall cu ! u uall% a@ected? Perforation or d% function of valvePerforation or d% function of valve? Root a9 ceRoot a9 ceMitral-Mitral-? D% function 9% ru!ture of chordaeD% function 9% ru!ture of chordae

tendinaetendinae

EP!#EM!


119/194

EP!#EM! . uire%en%ocar%itis is 18?-en%ocar%itis is 18?-@82 cases &er@82 cases &er1 : &erson-1 : &erson-years8years8M'F ratio 18?'1M'F ratio 18?'1

Mean age no 4?-@BMean age no 4?-@B(6 -4 &revious*y)(6 -4 &revious*y)

EP!#EM!


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EP!#EM! .


121/194

P +THET! /A./E+P +THET! /A./E+

?-2D of cases of infective en%ocar%itis?-2D of cases of infective en%ocar%itisThe rates of infection are the same at DThe rates of infection are the same at Dyears for 3oth mechanica* an%years for 3oth mechanica* an%

3io&rostheses: 3ut higher for mechanica*3io&rostheses: 3ut higher for mechanica*in $rst 6 monthsin $rst 6 months"u*mu*ative risC' 681 at 12 months an%"u*mu*ative risC' 681 at 12 months an%D8? at @ months &ost surgeryD8? at @ months &ost surgery

nset'nset'? ithin 2 months of surgeryithin 2 months of surgery early earl y an%an%

usua**y hos&ita* ac>uire%usua**y hos&ita* ac>uire%? 12 months &ost surgery12 months &ost surgery latelate onset an%onset an%

usua**y community ac>uire%usua**y community ac>uire%

osocomia* !nfectiveosocomia* !nfectiveE % %i iE % %i i


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En%ocar%itisEn%ocar%itis

457K of alll ca e een in tertiar%457K of alll ca e een in tertiar%referral ho !italreferral ho !italAt lea t half lin=ed to intrava cularAt lea t half lin=ed to intrava culardevicedevice*ther ource 3U and 3IT*ther ource 3U and 3IT!rocedure or ur)ical4>ound!rocedure or ur)ical4>oundinfectioninfection

A ti * gi * Ag tAetio*ogica* Agents


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Aetio*ogica* AgentsAetio*ogica* Agents

".". Stre!tococciStre!tococci? ,iridan tre!tococci6,iridan tre!tococci6 ^4hae&ol%tic^4hae&ol%tic

tre!tococcitre!tococci

S. mitis, S. sanguis, S. oralisS. mitis, S. sanguis, S. oralis? S. bovisS. bovisA ociated >ith colonic carcino&aA ociated >ith colonic carcino&a

5.5. EnterococciEnterococci E. faecalis, E. faeciumE. faecalis, E. faecium

A ociated >ith 3U63I tract !rocedureA ociated >ith 3U63I tract !rocedureA!!ro . "ith enterococcalA!!ro . "ith enterococcal9acterae&ia develo! endocarditi9acterae&ia develo! endocarditi



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68 +ta&hy*ococci68 +ta&hy*ococci+ta&hy*ococcci have sur&asse%+ta&hy*ococcci have sur&asse%viri%ans stre&tococciviri%ans stre&tococci as the mostas the mostcommon cause of infective en%ocar%itiscommon cause of infective en%ocar%itis

? S. aureusS. aureusNative valveNative valveacute endocarditiacute endocarditi

? Coa)ula e4ne)ative ta!h%lococciCoa)ula e4ne)ative ta!h%lococciPro thetic valve endocarditiPro thetic valve endocarditi



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B. 3ra&4ne)ative rodB. 3ra&4ne)ative rod? HACE )rou!HACE )rou!

Haemophilus aphrophilus, ActinobacillusHaemophilus aphrophilus, Actinobacillusactinomycetemcomitans, Cardiobacteriumactinomycetemcomitans, Cardiobacteriumhominis, Eikenella corrodens, ingella kingaehominis, Eikenella corrodens, ingella kingae ..(a tidiou oro!har%n)eal 3N(a tidiou oro!har%n)eal 3N

? E. coli, lebsiellaE. coli, lebsiella etcetcUnco&&onUnco&&on

? !seudomonas aeruginosa!seudomonas aeruginosaI,DAI,DA

? "eisseria gonorrhoae"eisseria gonorrhoaeRare ince introduction of !enicillinRare ince introduction of !enicillin



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'.'. *ther*ther? (un)i(un)i

CandidaCandida !ecie $!ecie $ Aspergillus Aspergillus !ecie!ecie? Y feverY fever? Chla&%diaChla&%dia? artonellaartonella? +e)ionella+e)ionella

"*inica* Manifestations"*inica* Manifestations


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*inica* Manifestations*inica* ManifestationsFever: most common sym&tom: signFever: most common sym&tom: sign(3ut may 3e a3sent)(3ut may 3e a3sent)Anore,ia: eight-*oss: ma*aise: nightAnore,ia: eight-*oss: ma*aise: nights eatss eatsHeart murmurHeart murmurPetechiae on the sCin: con5unctivae:Petechiae on the sCin: con5unctivae:ora* mucosaora* mucosa+&*enomega*y+&*enomega*yight-si%e% en%ocar%itis is notight-si%e% en%ocar%itis is notassociate% ith &eri&hera*associate% ith &eri&hera*em3o*i9&henomena 3ut &u*monaryem3o*i9&henomena 3ut &u*monary$n%ings &re%ominate$n%ings &re%ominate

Oslers’ nodesTender, s/cnodules


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nodules

Janeway lesionsNontendererythematous,

haemorrhagic,or pustularlesions oftenon palms orsoles.

Prosthetic va*ve-Prosthetic va*ve-


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PresentationPresentation*ften indolent illne >ith lo>*ften indolent illne >ith lo>)rade fever or acute to ic illne)rade fever or acute to ic illne

+ocall% inva ive - ne> &ur&ur+ocall% inva ive - ne> &ur&urand con)e tive cardiac failureand con)e tive cardiac failureIf !ro thetic valve in itu andIf !ro thetic valve in itu and

une !lained fever u !ectune !lained fever u !ectendocarditiendocarditi

osocomia*osocomia*


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En%ocar%itisEn%ocar%itisMay &resent acute*y ithout signs ofMay &resent acute*y ithout signs ofen%ocar%itisen%ocar%itis+uggeste% 3y+u ggeste% 3y ' 7acteremia &ersisting for' 7acteremia &ersisting for%ays 3efore treatment or for ?2 hours or%ays 3efore treatment or for ?2 hours ormore after the remova* of an infecte%more after the remova* of an infecte%catheter an% initiation of treatment (es& incatheter an% initiation of treatment (es& inthose ith a3norma* or &rosthetic va*ves)those ith a3norma* or &rosthetic va*ves)isC if &rosthetic va*ve an% 3acteremia'isC if &rosthetic va*ve an% 3acteremia'1111isC if &rosthetic va*ve an% can%i%aemia'isC if &rosthetic va*ve an% can%i%aemia'1@1@

!nvestigations!nvestigations


131/194

!nvestigations!nvestigations

".". lood culturelood culture5.5. EchoEcho

? TTE TTE? T*E T*E

.. ( C6ESR6CRP( C6ESR6CRP

B.B. Rheu&atoid (actorRheu&atoid (actor'.'. MSUMSU

#uCe "riteria#uCe "riteria


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#uCe riteria#uCe riteria

De niteDe nite - 5 &aJor criteria- 5 &aJor criteria - " &aJor and &inor criteria- " &aJor and &inor criteria

- ' &inor criteria- ' &inor criteria - !atholo)%6hi tolo)% ndin)- !atholo)%6hi tolo)% ndin)

Po i9lePo i9le - " &aJor and " &inor criteria- " &aJor and " &inor criteria - &inor criteria- &inor criteria

ReJectedRe Jected - r& alternate dia)no i- r& alternate dia)no i- re olution of &anife tation of IE >ith- re olution of &anife tation of IE >ithB da% anti&icro9ial thera!% or leB da% anti&icro9ial thera!% or le

Echocar%iogra&hyEchocar%iogra&hy


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Echocar%iogra&hyEchocar%iogra&hy

Trans Thoracic Echocar%iogra&yTrans Thoracic Echocar%io gra&y (TTE)(TTE)? ra&i%: non-invasive ; e,ce**entra&i%: non-invasive ; e,ce**ent

s&eci$city (B ) 3ut &oor sensitivitys&eci$city (B ) 3ut &oor sensitivity

? o3esity: chronic o3structive &u*monaryo3esity: chronic o3structive &u*monary%isease an% chest a** %eformities%isease an% chest a** %eformitiesTranseso&hagea* EchoTranseso &hagea* Echo (T E)(T E)? more invasive: sensitivity u& to BD :more invasive: sensitivity u& to BD :

usefu* for &rosthetic va*ves an% tousefu* for &rosthetic va*ves an% toeva*uate myocar%ia* invasioneva*uate myocar%ia* invasion

? egative &re%ictive va*ve of B2egative &re%ictive va*ve of B2? T E more cost e ective in those ithT E more cost e ective in those ith S.S.

aureusaureus catheter-associate% 3acteremiacatheter-associate% 3acteremia

an% 3acteremia9fever an% recent !/#Aan% 3acteremia9fever an% recent !/#A

"u*ture egative"u*ture egative


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En%ocar%itisEn%ocar%itisD-? of &atients ith en%ocar%itis i** haveD-? of &atients ith en%ocar%itis i** havesteri*e 3*oo% cu*turessteri*e 3*oo% cu*tures1 =ear stu%y from France1 =ear stu%y from France? 44 of cases of " E: negative cu*tures44 of cases of " E: negative cu*tures

ere associate% ith &rior a%ministrationere associate% ith &rior a%ministrationof anti3ioticsof anti3iotics

Fasi%ious or non-cu*tura3*e organismFasi%ious or non-cu*tura3*e organismon-infective en%ocar%itison-infective en%ocar%itis

ithho*% em&irica* thera&y unti* cu*turesithho*% em&irica* thera&y unti* cu*tures%ra n%ra n

" MP.!"AT! + F" MP.!"AT! + FE # "A #!T!+E # "A #!T!+


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E # "A #!T!+E # A #!T!+

"ar%iac"ar%iac ''? congestive car%iac fai*ure-va*vu*ar %amage:congestive car%iac fai*ure-va*vu*ar %amage:

more common ith aortic va*vemore common ith aortic va*veen%ocar%itis: infection 3eyon% va*veen%ocar%itis: infection 3eyon% va*ve G ""F:G ""F:higher morta*ity: nee% for surgery: A-/:higher morta*ity: nee% for surgery: A-/:fascicu*ar or 3un%*e 3ranch 3*ocC:fascicu*ar or 3un%*e 3ranch 3*ocC:&ericar%itis: tam&ona%e or $stu*ae&ericar%itis: tam&ona%e or $stu*ae

S% te&ic e&9oliS% te&ic e&9oli?

isC %e&en%s on va*ve (mitra* aortic): si0eisC %e&en%s on va*ve (mitra* aortic): si0eof vegetation: (high risC if 1 mm)of vegetation: (high risC if 1 mm)? 2 -4 of &atients ith en%ocar%itis:2 -4 of &atients ith en%ocar%itis:? risC %ecreases once a&&ro&riaterisC %ecreases once a&&ro&riate

antimicro3ia* thera&y starte%8antimicro3ia* thera&y starte%8


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Prolon)ed (everProlon )ed (ever - u uall% fever a ociated- u uall% fever a ociated>ith endocarditi re olve in 54 da% after>ith endocarditi re olve in 54 da% afterco&&encin) a!!ro!riate anti&icro9ialco&&encin) a!!ro!riate anti&icro9ial

thera!% >ith le virulent or)ani & andthera!% >ith le virulent or)ani & and7ee=7ee=Recurrent fever-Recurrent fever-? infection 9e%ond the valveinfection 9e%ond the valve

? focal &eta tatic di ea efocal &eta tatic di ea e? dru) h%!er entivit%dru) h%!er entivit%? no oco&ial infection or other e.). Pul&onar%no oco&ial infection or other e.). Pul&onar%

e&9olue&9olu

Thera&yThera&y


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Thera&yThera&y

Anti&icro9ial thera!%Anti&icro9ial thera!%? U e a 9actericidal re)i&enU e a 9actericidal re)i&en? U e a reco&&ended re)i&en for theU e a reco&&ended re)i&en for the

or)ani & i olatedor)ani & i olatedE.). A&erican Heart A ociation QAMA "77' 5 B-E.). A&erican Heart A ociation QAMA "77' 5 B-" < 4" .$ riti h Societ% for Anti&icro9ial" < 4" .$ riti h Societ% for Anti&icro9ialChe&othera!%Che&othera!%

? Re!eat 9lood culture until 9lood iRe!eat 9lood culture until 9lood i

de&on trated to 9e terilede&on trated to 9e terileSur)er%Sur)er%? 3et cardiothoracic tea& involved earl%3et cardiothoracic tea& involved earl%

Thera&yThera&y


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Thera&yThera&y

+tre&tococci9Enterococci+tre&tococci9Enterococci? #etermine#etermine M!"M!" of Penici**inof Penici**in? Penici**in I9- aminog*ycosi%ePenici**in I9- aminog*ycosi%e? "eftria,one a*one"eftria,one a*one? /ancomycin I9- aminog*ycosi%e/ancomycin I9- aminog*ycosi%e

? "efota,ime9ceftria,one"efota,ime9ceftria,one

HACE7 %!o&p

Thera&yThera&y


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Thera&yThera&y

+ta&hy*ococci+ta&hy*ococci? ative va*veative va*ve

F*uc*o,aci**in I9- aminog*ycosi%eF*uc*o,aci**in I9- aminog*ycosi%e

/ancomycin I9- aminog*ycosi%e9/ancomycin I9- aminog*ycosi%e9rifam&icinrifam&icin

? Prosthetic va*veProsthetic va*veF*uc*o,aci**in I aminog*ycosi%e IF*uc*o,aci**in I aminog*ycosi%e Irifam&icinrifam&icin/ancomycin I aminog*ycosi%e I/ancomycin I aminog*ycosi%e Irifam&icinrifam&icin

i h &


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+urgica* Thera&y+urgica* Thera&y!n%ications!n%ications ''? "ongestive car%iac fai*ure"ongestive car%iac fai*ure? &eriva*vu*ar invasive %isease&eriva*vu*ar invasive %isease? uncontro**e% infection %es&ite ma,ima* antimicro3ia*uncontro**e% infection %es&ite ma,ima* antimicro3ia*

thera&ythera&y

Pseudomonas aeruginosaPseudomonas aeruginosa :: rucellarucella s&eciess&ecies ! Co"iella burnetti! ! Co"iella burnetti! CandidaCandida an% fungian% fungi? Presence of &rosthetic va*ve en%ocar%itis un*ess *atePresence of &rosthetic va*ve en%ocar%itis un*ess *ate

infectioninfection? .arge vegetation.arge vegetation? Ma5or em3o*usMa5or em3o*us

? Heart 3*ocC Heart 3*ocC

+urgica* Thera&y+urgica* Thera&y


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+urgica Thera&y+urgica Thera&y

The hemo%ynamic status atThe hemo%ynamic status at

the time %eterminesthe time %etermines&rinci&a**y o&erative morta*ity&rinci&a**y o&erative morta*ity

M TA !T=M TA !T=


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M TA.!T M TA.!T

De!end on *R3ANISMDe!end on *R3ANISMPre ence of co&!licationPre ence of co&!lication

Pree i tin) conditionPree i tin) conditionDevelo!&ent of !erivalvular orDevelo!&ent of !erivalvular or&%ocardial a9 ce&%ocardial a9 ce

U e of co&9ined anti&icro9ialU e of co&9ined anti&icro9ialand ur)ical thera!%and ur)ical thera!%

M TA !T=M TA !T=


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M TA.!T M TA.!T

#iridans Stre$tococci #iridans Stre$tococci an%an% S. bovisS. bovis ' 4-' 4-1@1@Enterococci Enterococci '1D-2D'1D-2D

S. aureusS. aureus '' 2D-4?2D-4?% &ever % &ever ' D-6? (1? in !re*an%)' D-6? (1? in !re*an%)P. aeruginosa!P. aeruginosa! fungifungi ! !EnterobacteriaceaeEnterobacteriaceae D Dvera** morta*ity 2 -2D an% for right-vera** morta*ity 2 -2D an% for right-si%e% en%ocar%itis in !/#A is 1si%e% en%ocar%itis in !/#A is 1

PreventionPrevention


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PreventionPrevention

Anti&icro9ial !ro!h%la i i )iven to atAnti&icro9ial !ro!h%la i i )iven to atri = !atient >hen 9acterae&ia4inducin)ri = !atient >hen 9acterae&ia4inducin)!rocedure are !erfor&ed!rocedure are !erfor&ed

+oo= u! and follo> )uideline+oo= u! and follo> )uideline? A&erican Heart A ociation.A&erican Heart A ociation. CirculationCirculation "77"77

B@B@- '#4- '#4? riti h Societ% for Anti&icro9ial Che&othera!%.riti h Societ% for Anti&icro9ial Che&othera!%.

Journal of Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy "77"776161 - B 4B #- B 4B #

? N(N(


145/194

Pericarditi Pericarditi ss

Pericar%ia* AnatomyPericar%ia* Anatomy


146/194

,i ceral ? tran !arent

Parietal ? tran lucent

Tran ver e inu ? curved !ro9e

#ericardium


147/194

HE !"

#ericardium

e ca d u♥$embrane sac♥%urrounds the heart

♥#rotection♥ nchors♥&ontains serous fluid

Pericarditis inflammation of the pericardiumdecreases serous fluid causingpainful adhesions interfering withheart movements

Pericar%ium' AnatomyPericar%ium' Anatomy


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Pericar%ium AnatomyPericar%ium Anatomy

Pericardial +a%er -

_ ,i ceral la%er

_ Parietal la%er_ (i9rou !ericardiu&

Function of theFunction of the


149/194

Pericar%iumPericar%ium". Sta9iliZation of the heart >ithin the thoracic cavit% 9% virtue of itli)a&entou attach&ent 44 li&itin) the heart &otion.

5. Protection of the heart fro& &echanical trau&a and infection fro&adJoinin) tructure .

. The !ericardial Fuid function a a lu9ricant and decrea e friction ofcardiac urface durin) % tole and dia tole.

B. Prevention of e ce ive dilation of heart e !eciall% durin) udden ri e inintra4cardiac volu&e /e.). acute aortic or &itral re)ur)itation2.

Etio*ogies ofEtio*ogies ofPericar%itisPericar%itis

I. IN(ECTI,E". ,IRA+ 4 Co ac=ie A and $ InFuenZa$ adenoviru $ HI,$ etc.


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Pericar%itisPericar%itis5. ACTERIA+ 4 Sta!h%lococcu $ !neu&ococcu $ tu9erculo i $etc.

. (UN3A+ 4 CandidaB. PARASITIC 4 A&oe9a$ candida$ etc.

II. AUT*IMMUNE DIS*RDERS". S% te&ic lu!u er%the&ato u /S+E25. Dru)4Induced lu!u /e.). H%dralaZine$ Procaina&ide2. Rheu&atoid ArthritiB. Po t Cardiac InJur% S%ndro&e i.e. !o t&%ocardial Infarction

/Dre ler` 2 S%ndro&e$ !o tcardioto&% %ndro&e$etc.III. NE*P+ASM

". Pri&ar% &e othelio&a5. Secondar%$ &eta tatic. Direct e ten ion fro& adJoinin) tu&or

I,. RADIATI*N PERICARDITIS,. RENA+ (AI+URE /ure&ia2,I. TRAUMATIC CARDIAC INQUR0

". Penetratin) 4 ta9 >ound$ 9ullet >ound5. lunt non4!enetratin) 4 auto&o9ile teerin) >heel accident

Pericar%ia* E usionPericar%ia* E usionNor&al "'4'< &l of Fuid

ETI* *30


151/194

ETI*+*30". InFa&&ation fro& infection$ i&&unolo)ic !roce .

5. Trau&a cau in) 9leedin) in !ericardial !ace.. Noninfectiou condition uch a -

a. increa e in !ul&onar% h%dro tatic !re ure e.). con)e tiveheart failure.9. increa e in ca!illar% !er&ea9ilit% e.). h%!oth%roidi &c. decrea e in !la &a oncotic !re ure e.). cirrho i .

B. Decrea ed draina)e of !ericardial Fuid due to o9 truction of thoracicduct a a re ult of &ali)nanc% or da&a)e durin) ur)er%.

_ E@u ion &a% 9e erou $ ero 9rinou $ u!!urative$ ch%lou $ orhe&orrha)ic de!endin) on the etiolo)%._ ,iral e@u ion are u uall% erou or ero 9rinou_ Mali)nant e@u ion are u uall% he&orrha)ic.

Patho&hysio*ogyPatho&hysio*ogyPericardiu& relativel% ti@


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Pericardiu& relativel% ti@ S%&!to& of cardiac co&!re ion de!endant on-

". ,olu&e of Fuid5. Rate of Fuid accu&ulation. Co&!liance characteri tic of the !ericardiu&

A. Sudden increa e of&all a&ount of Fuid/e.). trau&a2. Slo> accu&ulation oflar)e a&ount of Fuid/e.). CH(2

PathogenesisPathogenesis"2 a odilation-


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2 ,a odilation- tran udation of Fuid

52 Increa ed va cular !er&ea9ilit% lea=a)e of !rotein2 +eu=oc%te e udation

neutro!hil and &ononuclear cell

Patholo)%de!end on underl%in) cau e and everit% of inFa&&ation

serous &ericar%itissero$3rinous &ericar%itissu&&urative (&uru*ent) &ericar%itishemorrhagic &ericar%itis

"*inica* Features of Acute"*inica* Features of AcutePericar%itisPericar%itis


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Pericar%itis

Idio!athic6viral Pleuritic Che t !ain (ever Pericardial (riction Ru9

co&!onent-a2 atrial or !re4 % tolic co&!onent

92 ventricular % tolic co&!onent /loude t2c2 ventricular dia tolic co&!onent E 3- di@u e ST elevation

PR e)&ent de!re ion

"*inica* features"*inica* features


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S&all e@u ion do not !roduce he&od%na&ic a9nor&alitie .

+ar)e e@u ion $ in addition to cau in) he&od%na&ic co&!ro&i e$&a% lead to co&!re ion of adJoinin) tructure and !roduce%&!to& of-

d% !ha)ia /co&!re ion of e o!ha)u 2hoar ene /recurrent lar%n)eal nerve co&!re ion2

hiccu! /dia!hra)&atic ti&ulation2d% !nea /!leural inFa&&ation6e@u ion2

Physica* Fin%ingsPhysica* Fin%ings


156/194

y gy g

Ph% ical (indin)Ph% ical (indin) --Mubed heart oundMubed heart oundParado icall%Parado icall% reducedreduced inten it% ofinten it% ofru9ru9E>art` i)n-E>art` i)n-

Co&!re ion of lun) leadin) to an areaCo&!re ion of lun) leadin) to an area

of con olidation in the left infra ca!ularof con olidation in the left infra ca!ularre)ion /atalecta i $ detected a dullnere)ion /atalecta i $ detected a dullneto !ercu ion and 9ronchial 9reathin)2to !ercu ion and 9ronchial 9reathin)2

EJ< $n%ings inEJ< $n%ings inP i %itiP i %iti


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Pericar%itisPericar%itis

#iagnostic Tests#iagnostic Tests


158/194

Echocardio)ra&- Pericardial e@u ion

N. .- a9 ence doe not rule out !ericarditi N. .- Pericar%itis is a c*inica* %iagnosis: not an Echo %iagnosisK

lood te t - PPD$ R($ ANA ,iral titer

Search for &ali)nanc%

Pericar%iocentesis'lo> dia)no tic %ielddone thera!euticall%

#iagnostic stu%ies#iagnostic stu%ies


159/194

C1R- 8>ater 9ottle; ha!ed heart

E 3- lo> volta)e 8electrical alternan ;

Echocardio)ra&

Tam&ona%e --Tam&ona%e --#i g i#iagnosis


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#iagnosis#iagnosisE 3- lo> volta)e$ inu tach%cardia$

electrical alternan

Echocardio)ra!h%

!ericardial e@u ion/r6o other etiolo)ie in dif d 2RA and R, dia tolic colla! e

"ar%iac Tam&ona%e"ar%iac Tam&ona%e


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(luid under hi)h !re ure co&!re e the cardiac cha&9er -acute- trau&a$ +, ru!ture ? &a% not 9e ver% lar)e)radual- lar)e e@u ion$ due to an% etiolo)% of acute

!ericarditi

Tam&ona%e-- "*inica*Tam&ona%e-- "*inica*FeaturesFeatures


162/194

FeaturesFeaturesS%&!to& -

Acute- /trau&a$ +, ru!ture2!rofound h%!oten ionconfu ion6a)itation

Slo>6Pro)re ive lar)e e@u ion />ee= 2(ati)ue / ↓C*2D% !nea

Q,D

Si)n - Tach%cardiaH%!oten ionrale 6ede&a6a cite&ubed heart ound!ul u !arado u

Lugu*ar venousLugu*ar venous&ressure aves&ressure aves


163/194

&ressure aves&ressure avesNo!mal 86P conto&!sNo!mal 86P conto&!s 91 A4#av'91 A4#av'

1 !'s&lts f!om ATRIAL cont!action1 !'s&lts f!om ATRIAL cont!action) Timin% 4 PRE*Y*TOLIC) Timin% 4 PRE*Y*TOLIC, P'a- of th' a4#av' n'a! *1, P'a- of th' a4#av' n'a! *1

9) 64#av'9) 64#av'1 !'s&lts f!om PA**I6E fillin% of th' !i%ht at!i&m #hil' th'1 !'s&lts f!om PA**I6E fillin% of th' !i%ht at!i&m #hil' th't!ic&spi" valv' is clos'" "&!in% v'nt!ic&la! systol' 9R'm'm+'! th't!ic&spi" valv' is clos'" "&!in% v'nt!ic&la! systol' 9R'm'm+'! th'64#av' is a ;6;ILLIN< =A6E64#av' is a ;6;ILLIN< =A6E) La!%' 64#av's on th' l'ft si"' of th' h'a!t may +' s''n #ith) La!%' 64#av's on th' l'ft si"' of th' h'a!t may +' s''n #ithmit!al !'%&!%itation( at!ial s'ptal "'f'ct( v'nt!ic&la! s'ptal "'f'ctmit!al !'%&!%itation( at!ial s'ptal "'f'ct( v'nt!ic&la! s'ptal "'f'ctTh' v4#av' in th' >&%&la! v'no&s p&ls' !'fl'cts !i%ht at!ial 'v'ntsTh' v4#av' in th' >&%&la! v'no&s p&ls' !'fl'cts !i%ht at!ial 'v'ntsTo s'' th' v4#av' on th' l'ft si"' of th' h'a!t *#an4


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Intra!ericardial !re ure /IPP2 trac= intrathoracic!re ure.In !iration-

ne)ative intrathoracic !re ure i tran &ittedto the !ericardial !ace↓ IPP

↑ 9lood return to the ri)ht ventricle↓ Ju)ular venou and ri)ht atrial !re ure ↑ ri)ht ventricular volu&e interventriculare!tu& hift to>ard the leftventricle↓ left ventricular volu&e↓ +, tro=e volu&e

↓ 9lood !re ure / "


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E a))eration of nor&al !h% iolo)%

O "< && H) dro! in P>ith in !iration

"ar%iacTam&ona%e --"ar%iacTam&ona%e --Patho&hysio*ogyPatho&hysio*ogy


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Patho&hysio ogyPatho&hysio ogyAccu&ulation of Fuid under hi)h !re ure- co&!re e cardiac cha&9er V i&!air

dia tolic llin) of 3oth ventricle

↓ S, ↑venou !re ure

↓ C* % te&ic !ul&onar% con)e tion

H%!oten ion6 hoc= Q,D raleReFe tach%cardia he!ato&e)al%

a cite!eri!heral ede&a

TreatmentTreatment


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Pain re*ief ana*gesics an% anti-in ammatoryA+A9 +A!# s

+teroi%s for recurring &ericar%itis

Anti3iotics9%rainage for &uru*ent &ericar%itis

#ia*ysis for uremic &ericar%itis

eo&*astic' N T: chemothera&y

Tam&ona%e --Tam&ona%e --TreatmentTreatmentPericardiocente i


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TreatmentTreatmentPericardiocente iPericardial Windo>

alloon Pericardioto&%

Pre4!ericardiocenti i

Po t4!ericardiocente i

"onstrictive"onstrictivePericar%itisPericar%itis


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Pericar%itisPericar%itis+ate co&!lication of !ericardial di ea e

Fi3rous scar formation(u ion of !ericardial la%erCalci cation further ti@en !ericardiu&Etiolo)ie -

an% cau e of !ericarditi

idio!athic!o t4 ur)er%tu9erculo iradiationneo!la &



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Ri)id$ carred !ericardiu& encircle heart- S% tolic contraction nor&al

Inhi9it dia tolic llin) of 3oth ventricle

↓ S, ↑venou !re ure

↓ C* % te&ic !ul&onar% con)e tion

H%!oten ion6 hoc= Q,D raleReFe tach%cardia he!ato&e)al%

a cite!eri!heral ede&a

Physica* e,amPhysica* e,am


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↑HR$ ↓ P

a cite $ ede&a$ he!ato&e)al%

earl% dia tolic 8=noc=;after S5udden ce ation of ventricular dia tolic llin) i&!o ed

9% ri)id !ericardial ac

u &aul i)n

Jussmau* s +ignJussmau* s +ignin !iration- ↓intrathoracic !re ure$ ↑ venou return to thora


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↓intrathoracic !re ure not tran &itted thou)h to R, no !ul u !arado u

no in !irator% au)&entation of R, llin) /ri)id !ericardiu&2 intrathoracic % te&ic vein 9eco&e di tended Q,P ri e >ith in !iration /nor&all% fall 2

#iagnosis#iagnosisC1R- calci ed cardiac ilhouette


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E 3- non4 !eci c

CT or MRI- !ericardial thic=enin)

"ar%iac "atheteri0ation"ar%iac "atheteri0ationElevated and e]ualiZed dia tolic !re ure /RA[R,EDP[PAD[PCW2


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Pro&inent % de cent- 8di! and !lateau;-ra!id atrial e&!t%in) ra!id ventricular llin)

then a9ru!t ce ation of 9loodFo> due to ri)id !ericardiu&

"onstriction vs8"onstriction vs8estrictionestriction


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estrictionestriction

Si&ilar !re entation and !h% iolo)%$ i&!ortant to di@erentiatecon triction i treata9le 9% !ericardiecto&%

MaJorit% of di ea e cau in) re triction are not treata9le

"onstrictive"onstrictivePericar%itisPericar%itis

Tach%cardia$ lo> volta)e


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u &aul

R,[+,$di! V !lateau

E]ualiZed dia tolic !re ure

Thic=ened !ericardiu&

Thic=ened !ericardiu&

Const!iction vs Tampona"'Const!iction vs Tampona"'*&mma!y*&mma!y


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TAMP*NADE TAMP*NADE+o> cardiac out!ut tate+o> cardiac out!ut tate

Q,D !re ent Q,D !re entN* u &aul i)nN* u &aul i)nE]ualiZed dia tolicE]ualiZed dia tolic!re ure!re ure

RA- 9lunted % de centRA- 9lunted % de centDecrea ed heart oundDecrea ed heart ound

C*NSTRICTI*NC*NSTRICTI*N+o> cardiac out!ut+o> cardiac out!uttatetate

Q,D !re ent Q,D !re entu &aul i)nu &aul i)nE]ualiZed dia tolicE]ualiZed dia tolic!re ure!re ureRA- ra!id % de centRA- ra!id % de centPericardial 8=noc=;Pericardial 8=noc=;

&mma!y&mma!y

Const!iction vs Tampona"'Const!iction vs Tampona"'*&mma!y*&mma!y


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&mma!y&mma!y

TAMP*NADE TAMP*NADEPul u !arado u -Pul u !arado u -

Pre entPre ent

Echo6MRI-Echo6MRI-Nor&al % tolicNor&al % tolicfunctionfunction+ar)e e@u ion+ar)e e@u ionRA V R, co&!re ionRA V R, co&!re ion

Treat&ent- Treat&ent- Pericardiocente iPericardiocente i

C*NSTRICTI*NC*NSTRICTI*NPul u !arado uPul u !arado u --

A9 entA9 ent

Echo6MRI-Echo6MRI-Nor&al % tolicNor&al % tolicfunctionfunctionNo e@u ionNo e@u ionPericardial thic=enin)Pericardial thic=enin)

Treat&ent- Treat&ent-Pericardial tri!!in)Pericardial tri!!in)

"a*ci$e% Pericar%ium"a*ci$e% Pericar%ium


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Pericar%ia*Pericar%ia*ca*ci$cations "Tca*ci$cations "T


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ca ci$cations Tca ci$cations T

Pericar%ia*Pericar%ia*ca*ci$cation on echoca*ci$cation on echo


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ca ci$cation on echoca ci$cation on echo

Nor&alNor&al!ericardiu& i!ericardiu& i

hi)hl% reFectivehi)hl% reFectiveri)ht !ericardialri)ht !ericardialecho cannot aloneecho cannot alonedia)no edia)no e

con trictivecon trictive!ericarditi!ericarditi


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Acute Pericar%itis9Acute Pericar%itis9E"< conferenceE"< conference

$$

Pericar%iumPericar%ium


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,i ceral 6 erou,i ceral 6 erou? Direct contact >ith e!icardiu& /STDirect contact >ith e!icardiu& /ST

elev2elev2? in)le la%er &e othelial cellin)le la%er &e othelial cell

Parietal 6 9rouPa

Curs Cardiomiopatii de Prezentat 15 Dec -2015

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