1. Simulation training Curriculum Pericardial Disease

2. Constrictive Pericarditis Etiology Idiopathic Irradiation Post-surgical Infectious Neoplastic Connective tissue disorder Uremia Trauma Sarcoid Methysergide therapy Epicardial implantable defibrillator patches CATHSAP6: Coronary Angiography and Intervention

7. Kussmaul’s Sign CATHSAP6: Coronary Angiography and Intervention

10. Cardiac Tamponade 20 0 40 CATHSAP6: Coronary Angiography and Intervention

11. Balloon Pericardiotomy

12. Case 1: Constrictive Pericarditis 64 year old female 1 Year s/p 3-vessel CABG Presents with 6 months of progressive dyspnea and atypical chest pain At angiography, all grafts are patent Hemodynamics

13. Right atrium 0 20 40

14. LV vs. RV 20 0 40

15. LV vs. RV with Valsalva 20 40 0

16. Constrictive Pericarditis Right Atrial Tracing X-descent y-descent

17. Constrictive Pericarditis – LV vs. RV. Tachycardia Obscures Evaluation PVB

18. Kussmaul sign

19. Case 2: Restrictive Cardiomyopathy 43 year old female presented with predominant right heart failure (peripheral edema, ascites) Hemodynamic tracings suggest constrictive- restrictive physiology Exploratory thoracotomy excluded the presence of constrictive pericarditis

20. CATHSAP6: Coronary Angiography and Intervention

23. Restrictive Cardiomyopathy

24. Ventricular Interdependence During Respirations Differentiates Constrictive Pericarditis from Restrictive Cardiomyopathy Constrictive Pericarditis (LV and RV discordant) Restrictive Cardiomyopathy (LV and RV concordant) Hurrell et al, Circulation 1996; 93:2007

25. Sensitivities, Specificities, Positive Predictive Values, and Negative Predictive Values as a Function of Criteria Hurrell et al, Circulation 1996; 93:2007

26. Constrictive Pericarditis vs. Restrictive Cardiomyopathy Greater ventricular interdependence in constrictive pericarditis Greater separation of diastolic pressure in restrictive cardiomyopathy LV and RV diastolic filling more rapid in constrictive pericarditis Pulmonary pressures higher in restrictive cardiomyopathy Adjunctive tests: evidence of pericardial thickening (normal 1-2 mm; thickening ≥ 3 mm); pericardial calcification, RV biopsy, exploratory thoracotomy

27. Case 3: Pericardial Tamponade 37 year old female 2 day history of dyspnea, fatigue and dizziness Mastectomy for breast cancer 3 years ago Echocardiogram suggests pericardial tamponade Hemodynamics

28. inspirationexpiration Femoral artery 0 100 200 Cardiac Tamponade Pulsus Paradoxus

29. Right atrium 20 0 40

30. Right ventricle 20 0 40

31. Pulmonary artery 20 0 40

32. Pulmonary capillary wedge 20 0 40

33. Before Pericardiocentesis; Pericardium vs. RA 20 0 40

34. After Pericardiocentesis 20 0 40 Right atrium Pericardium

35. After Pericardiocentesis Right ventricle 20 0 40

36. After Pericardiocentesis Pulmonary capillary wedge 20 0 40

37. Long-Term Effectiveness of Pericardiocentesis 2/3 of patients with malignant pericardial effusions redevelop tamponade after a median of 7 days More than 80% of patients with non-malignant pericardial effusion require no further intervention Laham et al, Heart 1996; 75:67

38. Variants on Constrictive-Restrictive Physiology Acute enlargement of the heart with constriction by normal pericardium –right ventricular infarct, tricuspid regurgitation, mitral regurgitation Low pressure tamponade Effusive-constrictive pericarditis Single chamber tamponade Localized constriction Occult constrictive pericarditis

39. Severe, Acute Tricuspid Regurgitation Associated With Constrictive- Restrictive Physiology

40. Severe, Acute Mitral Regurgitation Associated With Constrictive-Restrictive Physiology

41. Variants on Constrictive-Restrictive Physiology Acute enlargement of the heart with constriction by normal pericardium –right ventricular infarct, tricuspid regurgitation, mitral regurgitation Low pressure tamponade Effusive-constrictive pericarditis Single chamber tamponade Localized constriction Occult constrictive pericarditis