Case report no . 3, Department of P athological Physiology

1. Casereport no. 3,Department of Pathological Physiology V. Danzig, MD, PhD,2nd Dept. Internal MedicineCardiology andAngiologyDivision 1st Med.F CUNI

2. Patient history • 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-therapyand radio-therapy, histologically: invasive ductal carcinoma, highly malignant.

3. Patient history - questions • 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?

4. Currentdisorder • Two years agoduring 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, alsofound pericardial and pleural effusion • Pericardial effusion classified as highly suspected as malignant, chemotherapy adjusted/ changed • Both clinically and on ECGwithout signs of cardiac tamponade

5. Currentdisorder - questions • 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?

6. Pericardial effusion notable especially at right atrium (betweennos. 6 and 9 on the yellow scale on left)

7. Pericardial effusionshown in M-mode- before right ventricle and behind back wall of left ventricle,larger in systole, +++ denoted by blue crosses +++

8. Next development of the disorder • 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

9. Next development of the disorder - questions • 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?

10. Pericardial tamponade

11. Vena cava inferior dilated,with absent respiratory variability

12. Fluctuations of trans-mitralflow

13. Last developments – last hospital admission to date 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

14. Last developments - questions • 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…)?

15. Conclusions • 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.

16. Conclusions II • 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.