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Hemodynamic Conference

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Right Heart Catheterization Overview. Review of Waveform ... Liver was palpable 3 cm below the costal margin and the spleen tip was palpable. No LE edema ... – PowerPoint PPT presentation

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Title: Hemodynamic Conference


1
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

2
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

3
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

4
Pressure Waveforms
5
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6
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7
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8
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9
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10
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11
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12
Practice Case
13
RA
14
RV
15
PA
16
PCW
17
Diagnosis?
18
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19
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20
M5
21
M12
22
Diagnosis
  • Non-Ischemic Cardiomyopathy

23
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.

24
PMHx None Medications None Family History No
family h/o heart disease Social History Denies
EtOH, Tobacco, Drugs. One lifetime sexual partner
25
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

26
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

27
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

28
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

29
ECG
30
CC
31
CC
32
CC
33
CC
34
CC
35
  • 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.

36
C5
37
C8
38
C2
39
RA
40
RV
41
PA
42
PCW
43
RV/LV
44
Differential Diagnosis
  • Constrictive Pericarditis
  • Restrictive Cardiomyopathy

45
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

46
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

47
Echocardiographic Presentation
  • Holger Salazar, M.D.

48
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49
Chene3-23
50
Chene3-8
51
Chene3-9
52
Chene3-3
53
Chene3-13
54
Chene3-12
55
Chene3-preop,continuing 14
56
Chene3-14
57
Chene3-preop, continuing 5
58
Chene3-preop, continuing 9
59
Chene3-11
60
Chene3-5
61
Chene3-20
62
Chene3-preop, continuing 1
63
Chene3-preop, continuing 4
64
Diagnosis
  • Constrictive Pericarditis

65
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

66
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
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