patologia pericardului
DESCRIPTION
pericardTRANSCRIPT
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Patologia pericarduluiPatologia pericardului
Prof. Dr. Doina DimulescuProf. Dr. Doina DimulescuClinica de CardiologieClinica de Cardiologie
Spitalul Universitar de Urgenta Elias Spitalul Universitar de Urgenta Elias BucurestiBucuresti
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Relatia intre intindere si tensiune in pericardul normalRel presiune-volum in pericardul normal si dupa 4 Sapt de incarcare de volum
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Pericardita acuta - clinicaPericardita acuta - clinica
Durerea toracica ant iradiata spre Durerea toracica ant iradiata spre marginea trapezuluimarginea trapezului
Dispnee –posibilaDispnee –posibila
Febra, subfebraFebra, subfebra
Tahicardie sinusala, aritmii Tahicardie sinusala, aritmii supraventricularesupraventriculare
Frecatura pericardicaFrecatura pericardica
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Pericardita acuta -ECGPericardita acuta -ECG
Modificari seriate, difuze ale Modificari seriate, difuze ale repolarizariirepolarizarii
- Supradeniv ST - Supradeniv ST
- Normalizarea ST- Normalizarea ST
- Negativarea T- Negativarea T
- Normalizarea ST- Normalizarea ST
- Persistenta T negative difuze- Persistenta T negative difuze
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Pericardita ac -ECG
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Pericardita acuta - explorarePericardita acuta - explorare
Sd inflamator minim sau absent; aemie Sd inflamator minim sau absent; aemie posibila, troponina, CK- MBposibila, troponina, CK- MB
Rx toracic –normal; infiltrate Rx toracic –normal; infiltrate pulmonare, marirea siluetei cardiacepulmonare, marirea siluetei cardiace
Ex ecocardiografic – normal sau Ex ecocardiografic – normal sau colectie pericardica minimacolectie pericardica minima
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Pericardita acuta - tratamentPericardita acuta - tratament
Boala autolimitataBoala autolimitata
Antiinflamatoare nesteroidieneAntiinflamatoare nesteroidiene
AnalgezieAnalgezie
Cura scurta de corticoiziCura scurta de corticoizi
Recurente – 15 -30% din pacientiRecurente – 15 -30% din pacienti
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Pericardita lichidiana si Pericardita lichidiana si tamponadatamponada - etiologie- etiologie
Infectii bacteriene, fungice, tbcInfectii bacteriene, fungice, tbcNeoplaziiNeoplaziiBoli autoimuneBoli autoimuneIradireaIradireaUremiaUremiaAmiloidozaAmiloidozaHemopericardulHemopericardulPost chirurgie cardiacaPost chirurgie cardiaca
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Tamponada - fiziopatologieTamponada - fiziopatologie
↑ ↑ presiunii in sacul pericardic – interactiunea presiunii in sacul pericardic – interactiunea ventricularaventriculara
Compresia VD – egalizarea pres diast din Compresia VD – egalizarea pres diast din cav. Dr si sacul pericardic (15-20 mmHg)cav. Dr si sacul pericardic (15-20 mmHg)
Red pres transmurale de umplereRed pres transmurale de umplere
Red debitului in a. pulm si apoi in Ao Red debitului in a. pulm si apoi in Ao agravata in inspir profund (puls paradoxal)agravata in inspir profund (puls paradoxal)
Red pres in venele sist in inspir -prezentaRed pres in venele sist in inspir -prezenta
Mec adrenergice compensatoriiMec adrenergice compensatorii
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Tamponada – ex clinicTamponada – ex clinic
DurereDurereDispneeDispneeMarirea matitatii cardiaceMarirea matitatii cardiaceZg cardiace asurziteZg cardiace asurziteSemne variabile de red DC si activare Semne variabile de red DC si activare simpatoadrenergicasimpatoadrenergicaHipotensiune artHipotensiune artCongestie venoasa jugularaCongestie venoasa jugularaPuls paradoxalPuls paradoxal
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Tamponada –diagnostic paraclinicTamponada –diagnostic paraclinic
Rx pulmonarRx pulmonar
ECGECG
EcocardiografiaEcocardiografia
CT toracic, MRICT toracic, MRI
Ex de laboratorEx de laborator
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Colectie pericardica mare - Rx
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Colectie pericardica lichidiana mare
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Pericardita lichidiana- colaps Pericardita lichidiana- colaps diastolic de ADdiastolic de AD
Braunwald 2005
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Variatiile volumului sistolic pulmonar art si aortic in tamponada acuta
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Tamponada cardiaca Deplasarea spre stg SIV
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Tamponada cardiaca –variatiile fluxului transmitral si transtricuspidian cu respiratia
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Tamponada cardiaca- alternanta electrica a QRS pe ECG
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Tamponada cardiaca – colaps diastolic de VD
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Tamponada cardiaca -tratamentTamponada cardiaca -tratament
Antiinflamatoare nester, corticoizi, colchicinaAntiinflamatoare nester, corticoizi, colchicina
Pericardiocenteza –diagn etiol, decompresiePericardiocenteza –diagn etiol, decompresie
In urgenta – hidratare IV, suport inotropIn urgenta – hidratare IV, suport inotrop
Monitorizare hemodinamicaMonitorizare hemodinamica
Decompresie – pericardiocenteza Decompresie – pericardiocenteza
- decompresie chir. - decompresie chir. miniinvaziva,biopsie, fereastra miniinvaziva,biopsie, fereastra pleuropericardica (etiol neoplazica)pleuropericardica (etiol neoplazica)
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Pericardita constrictivaPericardita constrictiva
Stadiu final al proceselor inflamatorii Stadiu final al proceselor inflamatorii ale pericarduluiale pericardului
Necesita evolutie indelungata (ani) Necesita evolutie indelungata (ani) pana la aparitia semnelor clinicepana la aparitia semnelor clinice
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Braunwald 2005
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Pericardita constrictiva -Pericardita constrictiva -fiziopatologiefiziopatologie
Restrictia marcata la umplerea tuturor Restrictia marcata la umplerea tuturor cavitatilor cardiacecavitatilor cardiace
Consecinta – cresterea si echilibrarea Consecinta – cresterea si echilibrarea presiunilor de umplere in cele 4 cavitati si in presiunilor de umplere in cele 4 cavitati si in circulatia venoasa sistemica si pulmonaracirculatia venoasa sistemica si pulmonara
Umplerea rapida ventriculara in protodiastola Umplerea rapida ventriculara in protodiastola (pres.mari atriale) urmata de oprirea fluxului (pres.mari atriale) urmata de oprirea fluxului dupa mezodiastoladupa mezodiastola
Functie contracila miocardica prezervataFunctie contracila miocardica prezervata
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Pericardita constrictiva –ex. Pericardita constrictiva –ex. clinicclinic
Semne si simptome de ins. cardiaca drSemne si simptome de ins. cardiaca dr
Debit cardiac redusDebit cardiac redus
FAFA
Semn Kussmaul -Semn Kussmaul -↑ presiunii venoase in ↑ presiunii venoase in inspirinspir
Puls paradoxal – 1/3 din pacientiPuls paradoxal – 1/3 din pacienti
Zg pericardic (knock)Zg pericardic (knock)
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Pericardita constrictiva -Pericardita constrictiva -explorareexplorare
ECG – nespecificECG – nespecificRX pulmonar – calcificari pericardice, revarsate RX pulmonar – calcificari pericardice, revarsate pleurale bilateralepleurale bilateraleEcocardiografia – ingrosare de pericard, dans Ecocardiografia – ingrosare de pericard, dans septal, dilatare si imobilitate a venei caveseptal, dilatare si imobilitate a venei caveEx Doppler –variatii respiratorii exagerate (VE Ex Doppler –variatii respiratorii exagerate (VE >25% flux mitral) ale fluxurilor mitrale si tric., >25% flux mitral) ale fluxurilor mitrale si tric., aspect restrictiv al f.diastoliceaspect restrictiv al f.diastoliceCateterism – egalizarea presiunilor (20 mmHg), Cateterism – egalizarea presiunilor (20 mmHg), “dip and plateau”“dip and plateau”CT, MRI - calcificariCT, MRI - calcificari
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Pericardita constriciva –egalizarea simultana a presiunilor diastolice in AD si VS
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Pericardita constrictiva – egalizarea simultana a presiunilor diastolice in VD si VS cu aspectul “dip and plateau”
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Rx – calcificari pericardice in pericardita constrictiva
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Pericardita constrictiva –fluxurile transvalvulare si venoase
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Pericardita constrictiva
CT cu minim revarsatpericardic si calcificari
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Pericardita constrictiva - Pericardita constrictiva - tratamenttratament
Diuretice, digoxin in FADiuretice, digoxin in FA
Pericardiectomia 5-15% mortalitate Pericardiectomia 5-15% mortalitate perioperatorieperioperatorie
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Diagn dif hemodinamic intre peric constr si Cardiomiopatia restrict
Braunwald 2005