Case-report seminar 3
Case report no. 3,
Department of Pathological Physiology
V. Danzig, MD, PhD,
2nd Dept. Internal Medicine
Cardiology and Angiology Division
1st Med.F CUNI
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Patient history
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Case-report seminar 3
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Female, 57 years old
Family history: father died aged 78, diabetes, prostate cancer
(Ab)usus: “reduced smoking” to 1 cigarette/ day half year ago, it
used to be 10 cigarettes daily before, alcohol drinking denies
Gynecological history: 2 childbirths, 4 months breastfeeding,
menopausis
4 years ago incidental mammographic finding of breast cancer in
upper left quadrant, treated by: excision, then repeated excision,
axillary exenteration, adjuvant chemo-therapy and radio-therapy,
histologically: invasive ductal carcinoma, highly malignant.
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Patient history - questions
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Can you find some risk factors in the patient history at the onset of
carcinoma? (roll back one slide)
What are dangers of possible generalizations of early captured
breast cancer?
Can cancer therapy have adverse effects on heart?
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Patient history – answers
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Can you find some risk factors in the patient history at the onset of
carcinoma? Important is family history (ca mammae in family),
gynecological history, breastfeeding and its duration, smoking.
What is the risk of possible generalizations of early diagnosed
breast cancer? Exceptionally early generalization is possible in case
of invasive and little differentiated tumor.
Can cancer therapy have adverse effects on heart? Yes, cardiotoxic
chemoterapy, radiotherapy.
3b
Current disorder
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Two years ago during oncological checkup, a
generalization of cancer has been found, with
mediastinal lymphatic adenopathy, and affected liver.
One year ago, on PET/ CT scan, besides progression
of the lymphatic adenopathy, also found pericardial and
pleural effusion
Pericardial effusion classified as highly suspected as
malignant, chemotherapy adjusted/ changed
Both clinically and on ECG without signs of cardiac
tamponade
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Pericardial effusion notable especially at right atrium
(between nos. 6 and 9 on the yellow scale on left)
RV
RA
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Effusion
(cca 3 cm)
Apical projection 4AC
Effusion
(cca 0,5 cm)
LV
LA
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Pericardial effusion
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• In area of RA and slightly around LV
enlargement of pericardium is visible, presence
of fluid (effusion)
• RA wall is not yet compressed
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Pericardial effusion shown in M-mode
- before right ventricle and behind back wall of left ventricle,
larger in systole, +++ denoted by blue crosses +++
RV wall
RV
Septum
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LV with mitral
valve *
Back wall of
pericardium
diastole systole
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Pericardial effusion shown in M-mode
- before right ventricle and behind back wall of left ventricle,
larger in systole, +++ denoted by blue crosses +++
Case-report seminar 3
• Behind the back wall of the ventricle
enlargement is visible (effusion – separation of
two pericardium sheets); it changes with heart
action (larger in the systole – „more space“)
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Current disorder – questions
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What are mechanisms of propagation of malignant tumor in organism?
What does the “PET/ CT scan” stand for? What physiological principle
this imaging method uses in detection of malignant and inflammatory
processes?
Under what circumstances can pericardial effusion cause tamponade
and what are conditions of its emergence?
What heart cavities are more prone to compression and why?
What physical phenomena (in palpation and listening) are found in
pericardial effusion?
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Current disorder – answers
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What are mechanisms of propagation of malignant tumor in organism?
Per continuitatem, lymfogenic, hematogenic.
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What does the “PET/ CT scan” stand for? What physiological principle
this imaging method uses in detection of malignant and inflammatory
processes? Positron emission tomography in the combination with CT;
hypermetabolisms of glucose in inflammation and even more in tumorous tissue.
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Under what circumstances can pericardial effusion cause tamponade
and what are conditions of its emergence? Mainly amount of effusion and time
during it developed.
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What heart cavities are more prone to compression and why? Those with
low intracavital pressure, mainly right atrium.
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What physical phenomena (in palpation and listening) are found in
pericardial effusion? Apex non palpable, heart sounds weak or not heard due to the
isolation by the effusion.
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In which moment of heart cycle is the effusion more visible and why? In
the systole, there is more space.
9b
Next development of the disorder
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Last year in summer, clinical signs of cardiac tamponade showed
for the first time, confirmed by the echo-cardiography.
Patient indicated to pericardial puncture. In hemorrhagic effusion,
tumor elements have been found.
Due to recurrences of pericardial effusion with signs of tamponade,
punctures have been indicated repeatedly, one together with
cytostatic application into pericardium
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Pericardial tamponade
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effusion
effusion
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Pericardial tamponade
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• The amount of fluid has substantially increased
• The compression of RA walls is visible
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Vena cava inferior dilated,
with absent respiratory variability
liver
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Vena cava
inf.
RA
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Dilatation of vena cava inferior and the
absence of its respiratory variability
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• The vein is borderline enlarged (cca 20 mm)
• In animation the variantion of its size (width)
would depending on the respiratory cycle would
not be visible (the pressure in the pericardium is
higher than the impact of pressure changes
induced by breathing)
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Fluctuations of trans-mitral flow
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Fluctuations of trans-mitral flow
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• … are evident in larger tamponade even in left
parts of the heart – on the picture it is visible on
ECHO, causing pulsus paradoxus
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Tamponade
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• Collapse of RA
• Dilatation of vena cava inferior and the absence
of the respiration induced change of its size
• Fluctuations of trans-mitral flow
• Depends on
amount of the fluid
velocity of its formation
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Next development of the disorder – questions
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Under what conditions is cardiac tamponade manifested? What are
pressures and pressure relations in pericardium and in the right
heart cavities?
Why the compression of parts of left heart are much more rare
compared to the right heart?
What are clinical signs of cardiac tamponade? Into what two groups
can be these signs divided according to their origin?
What is “pulsus paradoxus”, can you explain its cause?
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Next development of the disorder – answers
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Under what conditions is cardiac tamponade manifested? What are
pressures and pressure relations in pericardium and in the right
heart cavities? The pressure of the increasing amount of fluid
becomes higher than the pressure in the right atrium and later than
the right ventricle.
Why the compression of parts of left heart are much more rare
compared to the right heart? The pressure is about 5x higher.
What are clinical signs of cardiac tamponade? Into what two groups
can be these signs divided according to their origin? 1. From the
accumulation of blood before the right heart 2. from the decreased
cardiac output.
What is “pulsus paradoxus”, can you explain its cause? Fluctuation
of puls wave depending on the respiratory cycle.
18b
Last developments – last hospital admission to date
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Patient admitted to hospital with developed edemas of
lower extremities (symmetrical on both legs under
knees), right side chest pain and with hepatomegalia
As highly suspect cause of right heart insufficiency was
given diagnosis of constrictive pericarditis.
Because of cancer with prognostic pessimism, a
conservative (= pharmacological) treatment was
recommended
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Last developments – questions
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What are the causes of progression of constrictive pericarditis after
its several recurring attacks (and after attacks of pericardial
infiltration by cancer)? What can be other factors involved in this
patient?
What are other manifestations of right heart insufficiency besides
the leg edemas and hepatomegalia?
What other alternative to conservative treatment of recurring
idiopatic pericarditis can can be chosen in case of more optimistic
prognosis (=it is a surgical procedure…)?
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Last developments – answers
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What are the causes of progression of constrictive pericarditis after
its several recurring attacks (and after attacks of pericardial
infiltration by cancer)? What can be other factors involved in this
patient? Adhesion and often calcifications in them; intrapericardial
administration of cytostatics.
What are other manifestations of right heart insufficiency besides
the leg edemas and hepatomegalia? Increased filling of neck veins
and in the area of vena cava superior.
What other alternative to conservative treatment of recurring
idiopatic pericarditis can can be chosen in case of more optimistic
prognosis (=it is a surgical procedure…)? Total perikardectomy.
20b
Conclusions
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There are several conditions, which can cause pericardial effusion.
Amount of fluid in pericardium and the speed of the fluid production
(slower production enables adaptive mechanisms of parietal
pericardium) are factors important for the development of this
condition.
Cardiac tamponade occurs when the pressure in pericardial cavity
is higher than pressure in right heart and subsequently in other
heart partitions.
Signs of tamponade have clear patho-physiological cause and can
be divided into 2 groups : 1- due to low cardiac output,
2- due to congestion of blood before the right heart.
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Conclusions II
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The threat of cardiac tamponade can be detected before its full
development by echo-cardiographic imaging.
Echo-cardiography is crucial in diagnosis of pericardial effusion and
the puncture is performed under ultrasonographic guidance.
Pericardial adhesions and their subsequent calcifications lead to a
fixed constrictive pericarditis picture.
A surgical treatment of choice is pericard-ectomia. This is however
a patient challenging cardiac surgery which is typicaly not possible
in cancer patients.
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