58. Case Report: Constrictive Pericarditis University of Tennessee
Worldwide cardiovascular disease affects the lives of hundreds of millions dedicated cardio nerds everywhere are working hard to fight this global epidemic. These are their stories. Welcome back Carter exhibits. Dan. Thanks for joining us as we tour fellowship programs across the country as part of a Cardi nerds. Series produced in collaboration with the American College of Cardiology fellows in training section, each episode will feature a cardiology fellowship program fellows from that program will present and teach about a fascinating case and share what makes their hearts flutter about their program. Each case discussion is followed by an e CPR segment from a content expert and a message from the program director. Before we dive in, just remember who we are an independent educational platform. This podcast is not meant to be used for medical advice the views expressed you're doing. To reflect the opinions or policies of employers, the case you're about to hear is one hundred. 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Welcome to the show. Would you mind introducing yourselves? Hey Cardio nerds I'm Rachel Goodwin first-year year cardiology fellow here at the University of Tennessee in Knoxville, went to medical school at Lincoln. Memorial did my internal medicine residency at the University of Kentucky and I'm from Nashville Tennessee originally. nerds my name is Emmanuel. East. Saying I'm one of the second year cardiology fellows here on University of Tennessee Rasouli born in Nigeria but have resided in Atlanta Georgia in Knoxville Tennessee for most of my life I went to Ross University, and then completed my internal medicine residency here actually liked it so much that I decided to stick around for fellowship. Hey Cardio. NERD. My Name is William Black. I'm a third year fellow here at ut and the chief cardiology fellow I'm from Birmingham Alabama originally, I went to medical school at the University of South Alabama and then back to Birmingham pre internal medicine residency had Brookwood Baptist, and now here at ut for cardiology fellowship I'm Dan thank you so much for having us. We're really looking forward to this. We've been checking in on the previous episodes of the case report so far and they've been fantastic we really learned. A Lot thank you so much William Amanullah? Rachel. This is music to our years and hearing from you guys meeting you guys has been already a pleasure and we are so excited to dive into a case. I have two things before we get started. One is do people do this could be really annoying question but colleague do the heart sounds like fourth starts on individuals touchy or do people do that they're paying they definitely do that there's the and Kentucky lived in both places and it's a thing. I was GONNA ask Rachel. She's living in Kentucky and Tennessee if she's the particularly good at listening for Gallup's. Perky Kentucky Tennessee. And and do people do it with pride or is it like here we go again and now it's a complete source of confusion for anyone learning murmurs. Limit. Okay. Secondly, I'm closing my eyes I have not been to Knoxville I'm using Google maps a little bit Scott situation but bring the in. I'm so ashamed that I haven't been there and I WANNA come and we'll get there eventually but take us on a journey on a magic carpet ride through. So Tennessee Landau set your favorite place the child could be a high could be restaurant could be anything and discuss the case they're. The best place to start outside Knoxville's in the smoky mountains you really can't beat really taken the day high and really being in the mountains and being next to the river and really just taking a nature. It's just so beautiful up there have in that. So close away from Knoxville and then coming back and then chillan in market square onto a few restaurants and maybe catch a movie is a great day I. Agree with that completely, I may. Add. We could stop on our way to the mountains at the lonesome dove and get some him loves chocolate cake, which was the desert that he used to win the iron chef. So it's fantastic and on the Dan when you guys make it the Knoxville highly recommend it. It's definitely worth the trip but yeah, I agree. With Rachel you can't beat the scenery of the smokey mountain national parks just under an hour away from the heart of downtown. KNOXVILLE. So lots of great hiking and outdoor activities there. It's always a favorite spot. Why don't we go get some topic Mona lives forever in the hips but I'm sure it sounds like it'll be totally worth it and we could chat about our discussion there. Maybe move on later for some hiking sweat off. All right let's start off with our case. So there's no shortage of interesting patients here in East Tennessee this was no exception we have A. Thirty nine year old male who was referred dark cardiology clinic for a violation of recurrent aside Dima he was diagnosed with I j nephrops Athena's early twenties eventually went on to develop in stage renal disease. Fortunately, he received a deceased donor kidney transplant several years later and did quite well after the transplant until he began to have these issues about eight to nine months ago with swelling, and eventually some abdominal swelling as well and suicide he's Trying to clear my mind. So we have our patient who's having worsening lower extremity swelling for several months now, and now that is progressive. The point that he's also having abdominal distension sites as well. The differential is quite broad and it's such a common complaint but anytime, I'm seeing somebody in general cardiology office or clinic swelling in a domino distension I. always worry about heart failure. Would I'm sure that you have more history for us and probably physical exam? Absolutely. So he said he I noticed the swelling in his ankles around eight to ten months ago at first. He didn't really think too much of it because he had dealt with some mild swelling in the past it was annoying but he could control it fairly well with diabetics. But since then it's just continue to worsen to the point where he's gone up on his diuretics and still swelling he started getting concerned when he noticed that abdominal distension especially, the swelling in his legs was so bad. He had weeping shrimp wounds and eventually develop cellulitis that had to be treated with antibiotics when his craton started creeping up, he was concerned that his kidney transplant may be was. Failing I think I'd be concerned as well about my kidneys and get scenario. It sounds like he's been doing well for almost a decade now, and then all of a sudden he just starts having oddest swelling sounds pretty crazy. Now, his name is also climbing what interesting was going on with him keeping my internal medicine hat. We love on the show to say Hashtag, medicine I because we try to keep a broader differential first I all you guys are just tastic jumping into that differential diagnosis away off the bat, which makes medicines so much fun I shouldn't say. Fine because we're dealing with patients but I, it could bring joy out of medicine when you have a problem and you develop at the frontal quickly right off the bat, and then you're sinking your teeth in trying to take patients history physical, really tease out exactly the ideology looking at a patient who is coming in with a diva. We think about neurosis cirrhosis and Cardio says our big three contributing organs can contribute to a diva as repealing the case and I'm going like I'm trying to balance it all together. Obviously, you've got referred to cardiology, but he presented from. And then we also have now renal failure. So sometimes, these cases can be very challenging in that all three can contribute to the Dima or one is the primary. So I'm really looking forward to the future data more history potentially labs to tease out, which is the primary insult here, and then we'll sink our teeth or therapies into that particular organ. Hopefully, make a difference for this patient. Yeah I am too many. Think he just said everything I'm quite interested to see what else is going on especially with his worsening renal function is that such a? Great Point even though we are cardiology fellows and budding cardiologists, we are still internist at heart and board certified internal medicine doctors, and it seems a lot of times when dealing with the heart people very concerned and sometimes they focus in on the primary cardiac complaints and don't always think about the whole picture. So a lot of times we may be seeing someone who's now been appropriately worked for diagnosed and it's not uncommon that the cardiologists service makes diagnoses they're outside the realm of cardiology. So it is important to sometimes get back to your internal medicine. Roots and look at the big picture and think about all of the data that you have available to you. William. I couldn't agree more analysis told my interns that look everyone cardiovascular disease is the most common cause of mobility immortality worldwide, and so everyone has cardiovascular disease and by virtue of that, we see patients with every other disease and so the overlap there is important in all the time have a patient who was consulted for one reason that you end up being a person diagnosed something else such import point. So Rachel, What happened next they? Were quite concerned about his kidney function especially with his Craton and rising and given the picture with his at the transplant service was thinking he looked like maybe have had renal syndrome. In fact, even had a liver biopsy performed and was sent see hepatic Aji for further workup and was worried he might need kidney transplant or maybe even a liver transplant. Thankfully, biopsy of the liver showed relative preservation of the hypnotic architecture and no fibrosis and the hepatic was concerned about a potential cardiac ideology of symptoms said, that's how he ended up in our office. All the things he went through to come to cardiology the end. Up, about his medical history, he has a history of the renal failure due to I J frothy status posts kidney transplants on chronic immunosuppression. He's had recurrent bouts of lurks Germany cellulitis as well as complication of cryptococcal meningitis in the past and severe malnutrition with muscle wasting at past surgical history, he had a colleague the recent liver biopsy in than his renal transplant medications include zone seven point, five milligrams daily fluconazole four, hundred milligrams daily cyclosporin seventy, five milligrams twice daily bureau semi forty milligrams twice daily and sodium bicarbonate thirteen hundred milligrams, three times a day as as his family history, his father's deceased has a history of m. i. And hypertension and alcoholism his mother who's alive had the OPD from tobacco Saniez, two siblings with hypertension and also alcohol use as far as social history. He's never used tobacco never used alcohol and never used recreational drugs and he's works as technical support. Quite thank you so much for going over that Rachel and when you think about the patient, there's so much going on in so much in the history, but you think about what is in the foreground of what's in the background in the foreground we have patients coming in with low seventy Dima societies and thinking, okay. What are the causes has Dan pointed out? We think Asus but with his Past medical history, add another layer to that differential diagnosis for third spacing and that's kwashiorkor right? Because essentially the reason you have Dima in nephrotic syndrome or encierro says because he have low albumin pressure, which is a little bit different from why you have Dima in heart failure, which is elevated hydro static pressure malnutrition with low production consumption of proteins that can give you a similar picture with he's deny and so I think the physical exam will be useful to see if they're actually evidence of elevated filling pressures or hydro static issue or in the to see if there's an issue with the academic pressure, low protein and. The going back to also the other things in the background are that this isn't your typical patient, the suppression, the kidney transplant in the past, these things really broaden the different things that can be going on in terms of predispositions to infectious ideologies, and I'm not sure how to add that into the patient's history right now but it may become relevant later on, and then if this is cardio sus or heart failure risk factor for coordinators at least maybe a family history of CAD. But at least we know the patient is not a smoker and doesn't have other past medical risk factors like diabetes hypertension or hyper liberty that we've diagnosed. So this. Is Really Helpful. Thanks for giving us such a rich past medical history, Rachel. Thank you. This is absolutely tastic, and again we're seeing our teeth into this case as we in other side I've had a patient who basically had no initial comber abilities but several years back also developed Aegean property and we think of idea to frothy is sometimes suffers off and pets. We could treat it ultimately patients requiring renal transplant and think of that as a distinct clinical entity that we can take care back. But for some patients, this JANA frothy sets off a domino effect of so many health problems down the road that relate to renal dysfunction you. Have a patient that came with primary renal failure Jana from the ultimately become immune suppressed because of transplant and potentially patients renal failure developing a higher risk for coronary arteries and calcification everywhere stenosis valve dysfunction in just reflect sometimes patients ideology could tie down to one being historically and could be healthy. Otherwise, it really developed a host of other risk factors for so many other disease entities. So I'm really glad we went through this deep dive into this patient's history Rachel give a really good and thorough history I'm sure did a pretty good physical examine him also right now me in general he's ill appearing custom temporal muscle wasting his Clara's anecdote. Eric on his neck veins, his Jd was to the angle of his jaw even sitting upright lungs were cleared early heart was regular rate rhythm without murmurs sped. He did have a palpable heave over his left chest as abdomen was distended with the positive fluid wave and normal bowel sounds and his extremities had to plus bilateral lotion with chronic venous stasis changes. His vitals were blood pressure one, thirty, eight over ninety, eight, heart, Ninety, eight, Respiratory Rate Twelve and temperature ninety eight point five degrees, Fahrenheit racial talked about a few things than differential for a site has your exam help you better understand his picture I think with the. Chronicler Shamanee Dima, you know the JD is what really sets it apart seeing JD upright position to the level of his job really made me suspicious for heart failure. Yeah. I'm definitely right there with you I'm getting more and more concerned about what the heart is doing in this context. Thank you. Yeah. Just to be deliberate about that. Gary said Cardio System I is said Cirrhosis surely not the right order but was the roses we expect it's blood flow or plasma leaking out in third spacing, and often the fans could flat even and basically this is really steering us away from that or at least showing is the there's a contribution in versus. League albumin you have low pressure certainly, renal failure could give you a lot of hydro static pressures as well if you're not able to get rid of fluid in the normal way, but usually you're going to also have some underlying cardiac cause to not accommodate for that extra fluids really pointing us towards the heart of the matter. I think the labs hair in the next series of diagnostics really helpful because say the patient have psoriasis there is a link of cardiomyopathy related sources and there's definitely a Puerto Pulmonary hypertension that can you elevated Wti, and so I, think we just need more information but I am definitely more concerned about the heart at this point but to get lapsed to help guide US further we did. So his sodium was one forty. Four point four, chloride one, six by car twenty, five, UN. Seventy-seven Creatine Three Point One one glucose one of five, his Espn Lt were twenty, five and fifteen respectively t billy was one point six albumin of three point five with a total protein of eight point eight and he had a normal and are one point two, three hemoglobin of nine point one platelets of one, sixty four and he had a pro Natura peptide elevated four fourteen Rachel does labs I think help us a lot here as you guys have mentioned, the differential is quite broad the BNP being up nonspecific but point you towards the diagnosis, a part failure but more specifically the fact that albumen is not too bad as our normal. Liver enzymes or normal all of that together for me at least points me away from a primary liver problem. It makes me more concerned at this point about his heart. Yeah I agree William we don't have the urinalysis urine protein craton ratio, but with A. Three point five is just unlikely that there's a underlying severe nephrotic syndrome to be causing the swelling as well. So this is really helpful in trying to focus in to the heart of the problem and usually expect to see some degree of drums side opinion while if the livers dysfunctional again, we're not really getting that liver picture here as much is being expected. So I, have again, heart of the matter guys are there. In addition to labs, we got an ekg and chest x Ray EKG showed Sonesta Cardia with the normal access rate of one nineteen and nonspecific st changes. He had a chest x ray that was also fairly unremarkable, no pulmonary Dima or pleural effusions with all the exams that you've given and also would is history to one thing. I really haven't heard his any shortness of breath or any type of Disney Rachel have any not really he had a little bit of this Nia but that really wasn't his main complaint. We also asked about Ortho NIA or. PROXIMAL NOCTURNAL SNIA but he wasn't having any of that either religious abdominal distension with a Siamese, and then the recurrent lower Shembe Edina rates were most of the symptoms appear to be right sided heart failure symptoms into typically the most common causes from her heart failure. But aside from, let's let heart failure the causes can be broad including any type of lung pathology pulmonary disease that can be causing this moving downwards to right sided valvular issues or any type of right ventricular hypertrophy and always the dreaded constriction versus restrictions that can be causing some of his symptoms. Manual I love how you broke down your approach to isolated ted affiliate without left cited failure and you included essentially you pulmonary hypertension, which is pre capillary pulmonary hypertension, and all of the right sided diseases that we can think about like rights valvular disease isolated RV muscle disease RV. RB. ISCHEMIA as well as an I agree, the dreaded constriction versus restriction paradigm which presents Domino's right sided sometimes rather than left sided sometimes but hopefully, we can demystify some of that going forward. Yet guy this is a fantastic opportunity and our caveat here is that we do know that some patients do have left sided heart failure that drives right there harshly. But the left side has symptoms are less predominant owing to the different loaf attic systems in the lawns that can take care of some of the extra third spacing fluids in the lungs that you don't have necessarily in the periphery while our antenna are definitely up for right side it's things especially. Going, back from potentially homeowner hypertension, Bomani valve disease, disease RV dysfunction primarily rbis sunshine or a constriction pattern of Bisley really again, that's where the break is isolate the right side. We could also have a potentially less sided driven process. So again, I am so freaking hungry to see this echo shows because it's going to open up a whole new path it could potentially blow this case open. So really excited to hear about that Echo I, agree completely believe it. or not he had never had an echo despite eight to nine months of Lurk shamny swelling seems every day we have echoes ordered for toe pain or diabetes but you have this guy who's got all kinds of swelling for the better part of a year and hasn't had an echo yet the naturally we sent him for an Echo. I agree completely Rachel the fact that he hadn't had an echo yet is a little bit baffling but we can certainly help. Out with that manual, I like the way you think about the diagnosis of predominantly right sided heart failure there you mentioned primary pulmonary causes such a pulmonary hypertension rhythmic intrigue Cardi mop the Primary Bachelor disease all of which can be answered for the most part with an echo. So Rachel, Tell me a little bit about what the Echo looked like had an echo performed that showed that his LV F was normal fifty five to sixty percents moderate education with our. Forty seven the mild range, and then also noted to have abnormally motion, sickness, tive constrictive physiology and the pair cardiac Jason to the RV Free Wall was highly academic suggestive of possible if you sit pericarditis. are really beautiful I can really see actually the bulk of the ventricular. Septum guys listening right now kimberly see the images, but they'll be included the notes. If you WANNA take a look surely it could be possible constrictive pericarditis overall I may want to get the gold standard with a cardiac catheterization. One thing I didn't mention is he did have a very small pair cardio fusion but didn't have any ra or RV. To suggest nod and clearly have any physical exam findings suggest Tampa on he did have some respiratory variation in his track us but inflow velocities, but he was in Asia during the echo. So it's hard to know what to make of that. You're that's an excellent point Rachel when fortunately atrial fibrillation is quite common with patients with constrictive in restrictive cardiomyopathy. So it can be a little bit more difficult to interpret their echo findings. The variation of our intervals with atrial fibrillation make it a little bit more challenging to interpret the try cuts, but in mitral inflow velocities but it sounds like his ECO fits with the overall picture even though it is suggestive invasive Hema dynamic assessment is still the gold standard as a budding interventional cardiologists. Myers did perk up a little bit when Manual Mitch Decaf even if it is primarily a right heart can. Relax, we did measure simultaneous LV pressures. Real quick. You guys want to talk about the cardinal like echo findings of constriction. The way that I think about one of the things that it's so cool about constrict pair if it can be cool is the physiology and I think to really understand it you have to understand cardiac disease allergy. Normally with inspiration you're gonNA have a drop in your graphic pressures and typically does pressure changes are transferred fairly well to the cardiac chambers as well. What happens with constriction is you have this really stiff and noncompliant pericardial sac that serves to. Insulate the heart from those normal changes. So essentially, what happens is with inspiration, the pulmonary pressures are going to drop and consequently the pulmonary vein pressures but that's stiff. Pair Cardio insulates the LV and the our visa. Pressure changes and the pressure stays relatively constant. So what happens is the driving pressure between what we measure in the Cath lab? The pulmonary capillary wedge pressure in the LV EDP is going to vary with respiration does essentially, which is that with inspiration you see a decrease in your left ventricular filling in an increase in your right ventricular filling and you mentioned the Boeing of the Septum that we see on the echo and that's indicative of the increased RV filling and then. You have the exact opposite with expiration where you have increased left ventricular filling in the Septum bows back into the RV. That's how I think about it and it transpires into the inflow posses where when you inspire, you will have to higher velocities in a husband inflow and lower in the module influence vice versa when you expired and you will have the higher velocities in mitral inflows in lower in the tricuspid inflow. Kinda gives that respiratory rate variation that you typically see. Guys I have very similar properties as you do William and the only thing I add just to my description when I'm talking to the Resin, is that when you inspire basically normally the heart drake's that's basically how I think about it just like when I dropped my diaphragm, Eric comes into my So to blood comes into my threats as well and so normally both the will fill and they are not. Competing against each other because the RV accommodate all that fluid by bowing out into the per Kardashian which is supposed to be soft and accommodating, and so the RV drinks and the album drink can it's a tug of war but when you have this heart locked in this cage, a steel cage if you WanNa think about it or just a really calcified gauge, for example, where the heart is as you said, totally. From, the changes in pressure, the pulmonary vessels are actually outside the park party of and so they are not subjected that and I've seen in the SEC are also outside data cage. They is lear feeling this negative pressure and trying to bring in fluid and has that RV fills up and it doesn't have that free wall to bow out and accommodate all that extra fluid. It actually shoves the Septum over into the LV and causes the LV to suffer while the RV is taking advantage of this increase. Flow and so you end up having discordance between the Kartik outgoing out of the RV in the Karnik outgoing out of the LV when normally it's supposed to equal each other and so that's what ends up giving you this shift in inflow velocity through the tricuspid valve, which again is the fluid coming through the tricuspid valve is going to be different during inspiration than during expiration when there is shift back now now the LV says might turn in a shove stuff the back into the RV at. So now, there'll be more of an increased flow into the mitral valve as that doesn't happen normally enroll cases because again woah cases LVN RV getting along. So that's how I think of that. Damn. That's such a great explanation building on what Williams said. One of the things I love about cardiology is that it's very redundant, right? The core principle and the reasons why we see things are pretty straightforward and once you understand that then everything else is just a redundant extra way of looking at it and. So. We talked about how when you expire you increase the pressures in the thorax, but that doesn't transmit to the LVN. So you have increased dry from the pulmonary veins can go into and fill the left side and so in expiration your mattress locals up. But because the ventricular interdependence tricuspid inflow goes down. So you have respiratory phase variation in mitral inflow going up with expiration tricuspid inflow going down with expiration and vice versa inspiration. But for the same exact reason, you get respirate phasing shifts in the Septum. Mo through the personal access few you'll see the septum globally shifting towards the right side because Elvis feeling during expiration, and then shift back towards the left side because the preferentially feeling better during inspiration, and then conversely another helpful tool that's more useful atrial fibrillation right because the in flight patterns can be challenging with HR fibrillation he paddock vein Doppler is very helpful in Asia fibrillation impatience with constrictive pericarditis to French, eat them from restrictive physiology and. So. If you think about how patrick inflow, the paddock veins should be draining into the IDC and into the right atrium and so if a patient has constrictive pericarditis what happens with expiration acceptance bowling towards the right side, and that pressure is being transmitted from the RV to the A to the IVC backup to the paddock means so that you have diastolic flow reversal in a paddock veins predominantly during expiration if the patient is constrictive pericarditis, it's all along. The same track from the LV to rb to the IRA ABC Paddock mates conversely, if a patient has restricted physique polity, what happens is the majority of the inflow to the right side just like a normal healthy hearts will happen during inspiration however, the restrictive stiff noncompliant, right ventricle. It's not able to fully accept all that blood during inspiration and so during inspiration when you get that huge fullest going into the RV, it's not gonna be able to accept. It, and so you get the pressure referred all the way backwards into the paddock means and so with the restrictive physiology get diastolic flow reversal in the paddock baynes predominantly an inspiration. So that can be one way of differentiating it. A couple of other helpful signs for restriction versus construction on echography are looking at your shoe velocities on Doppler, and so you're a prime essentially is the tissue velocity of the Mitral anyalysts and you can look at the medial. And lateral prime and by definition restrictive heart disease there's a deafening of the muscle and it doesn't as well and so the movement of the muscle is low and so you'll have a patient with heart failure preserved ejection fraction predominant right sided symptoms into aprons will be low as you suspect because there's dystopic dysfunction however with constriction, he's not a muscle disease, and so you may have normal or elevated prime philosophies into same clinical context preserve the F. Right sided symptoms with filling pressures and so normal or elevated e prime. Tissue. Doppler. Velocities. With the Mitral Angeles can help promote that constriction and not restriction, and alternatively with the city's, you can compare the media prime velocity to the ladder leading apprentice and the normal healthy heart. The septum is a little bit restricted because it's headed to the cardiac skeleton, and so normally, the laterally prime has a greater velocity. The lateral. Michael Angelus moves faster than the medial Michael Angelus putting constriction because of the tethering of the lateral wall to the constricted inflamed fibrous pericardium you'll have Angeles reverses whereby the medial prime philosophy will be greater than laterally. Prime. Philosophy there's so many nuances to this that I had read more about but this is so much richness in the echocardiogram to better understand what the causes are symptoms whether it's restriction construction for something else going on. Yeah. That's awesome and it really again, it always comes down to that fundamental pathophysiology what is the anatomical problem and that will generate all of what we're seeing in cardiology like you said, cardiology is a lot of it is redundant because a lot of it is looking at the same physiology through a different lens of physical. Hamlin's echo leads emery lands at a Catholic and seeing the same phenomenon and since you brought up restriction again, if you WANNA anchor yourself because this is very complicated discussion restriction construction. It's baffled people for decades. Everybody always forgets about even though they mastered at one time or another, you always have to remember. But if you contact physiology again locked box, that's what constriction is and there's interdependence because of that lock box that is the key fundamental principles that will explain all of the findings that we're describing here, and then for restriction is stiff. Nana lock box. It's a stiff heart, the vegetables new work in concert together they are just terrible feeling no matter what inspiration expiration they just don't feel well, and so there is not going to be that discordance. It's not gonNA be a fight between the LVN RV they're both crying out together. They're both in the same boat. That's GONNA. Be a fundamental difference between constriction and restriction, and basically that is what we're doing by all these studies. He's out what's going on with both of them. They share a lot of common things but that interested dependents is really what sets them apart. Quite Dan fiv begun to unlock that box with the window to the heart use Neko Cardiogram, and we certainly could have taken a patient to that donut of truth with Cardiac Mariah, but the renal function is compromised. So it sounds like we're gonNA take a patient to the table of truth with a cardiac catheterization. What did we find? So, we found that his reinhard pressures were up a bit mean are a pressure was twenty RV systolic pressure was forty and RV industry pressure was twenty five. He had a mean peer pressure of thirty two and a Pulmonary Kepler Wedge pressure of Twenty Six, we did simultaneous LV pressures, which showed exactly what we are expecting the elderly. ADP was twenty six as well as RV ADP was also twenty six, the left and right ventricular stock pressures were discordant with rest bro phase variation and the pattern feeling during gas both the right and left and dribbles was consistent with rapid early filling in constant light pressure one of the typical findings. Of constrictive pericarditis is the ratio of RB EDP TO RV SP being more than one third and our patient had Arbi Edp of twenty five and RV, stock pressure of forty ratio of nearly two-thirds while and Rachel. It sounds like you gave a very nice description of typical dip in Plateau or square root sign that we normally see that very rapid early diastolic filling that then tapers off with constant pressure during later Diaz Dewey, and again same thing the going back to the redundancy right such a simple concept You can break down to three phase early rapid isolate failing give dice states and then have the atrial kick the early filling. In. Constrictive pericarditis, you have very high rapid velocities because your backup of pressure is so high you're elevated. You're here you're right. Atrial pressure is twentieth massive yet the huge Dr to fill that right ventricle or are you strive to fill from? La to the left ventricle in so that early rapid filling is extremely fast. However, the heart can only feel so much right because it's constrained by that thick fibrous inflamed pericardium may or may not be inflamed, but the thick pericardium and so just as blood very quickly enters the ventricle during early filling or early it just as abruptly stops in. So you think about the different correlates on the physical. Exam that's her mock. You've gotta Gush of blood that goes into LV. It stops abruptly because it's constrained by the Cardio on the Echocardiogram, you have a tall he philosophy or e the mitral influence bossy with very short diesel time because it stops very abruptly and then on the right heart cath, it's the right atrial pressure is that essentially dips very quickly and then all of a sudden it goes back up and plateaus because they're atrial emptying happens very quickly and then the Arby's constraints got backup of pressure than it stops. So it's just Nice Corlett of a very simple concept, but you see across multi modality redundancy is very helpful. Almost almost like textbook, but have to remember the the human dynamics intervention, independence, restaurant variations. All of this sounds looks like it's constrictive pericarditis guessing he was probably sent to see one of the surgeons Rachel we did CD surgery saw him and recommended pericardial stripping or period product me has it sometimes referred to he had a successful surgery and filling so much better. He just had a follow up echo and RV pressures are pretty much back to normal and no longer has intervention dependence. His swelling has improved. His CRATON is improving and he says, he feels like a brand new man one of the things I love about cardiology is really how we can help people. This guy was miserable for nearly a year since the hepatic. Even during liver transplant and being able to diagnose him and getting him the appropriate treatment it just never gets old not to Brag but cardiologists the best I'm sure everybody else here agrees. One hundred percent couldn't agree more with you and I just he had such a profound course and he was treated and managed. So effectively, I just couldn't help but wonder what we think the ideology could have been granted that a majority of the cases of Paradise in general are idiopathic, but there are so many ideologies to consider. So thinking back to his own personal risk factors if we dissect this one, he's had kidney disease, and so there is repaired I'd it's another thing to consider is that he's been immuno-compromised. He's infections, recurrent cellulitis and cryptococcal meningitis. So not only was immunised oppressing medication is actually functionally immuno-compromised, and so you can have a whole host of different infectious pericarditis ideologies. HISTORY PLASMA TV record is probably one of the most common causes of Paradise Infectious, and then there's inflammatory status related to a systemic disorder, for instance, rheumatoid arthritis, systemic lupus. erythematosus. And there's a lot of actress genetic causes. Epidemiology is really shifted especially with all the work that we're doing in medicine in general but postponed cardiology syndrome if patient. Has had heart surgery. This patient hasn't there are reports Paradise's following EP procedures like ablation pacemaker devices even sensing there is post radiation pericarditis is drug induced pericarditis. There is going along the lines of pedal injury. There's acute coronary. Syndrome Associated Initial Paradise Number Dressler Center down the road. But really again by idiopathic credits is probably the most common recalled this patient probably after the damage had been done because his patient had a thick and calcified fibrous pericardium. But in this setting, we had to do the right thing. And take out the pair Kardashian but there are situations patients earlier in the course of their having recurrent bouts of pericarditis of constrictor disease who are diagnosing underling inflammation and underlying ideology can really help figure out how to best manage that patients. So tremendous job figuring out what was going on using multi-modality diagnostics and doing the right thing for the patient in taking care of him. It's amazing how well he's doing right I couldn't agree more Rachel, Absolutely. Wonderful. So fascinating and really fulfilling absolutely it is while we're here. Anybody, have any other thoughts on the case one of the things that really struck out was to make it was mentioned before was a case of anger and bias by Sylvia's on topic but typically we get locked down into a particular diagnosis. That is is really easy to forget all the causes I. Think when we first discussed where medicine doctors I, those always good for us to try to get abroad differential in Cedar patients and get the history for ourselves and. Not Be stuck with a or not believe the first diagnosis that were given from a primary servers or even to Er. That's right. Emmanuel we have buddy dean of the Graduate Medical Education here at the University of Tennessee. Is actually a heart failure cardiologists, which is wonderful because you know he's always looking out for our cardiology fellowship here but he always says trust but verify and what he means by that of course is we certainly want to trust what others have. Said about patients when we see them whether it's in consultation in the hospital or as a referral office but we should also try their best to verify the information that they're telling us see that information first hand in an attempt to try to avoid anchoring in some of these other biopsies that we all victim to trust the verify. Those are words that we should all live by anticipation is a prime example and this has been such a great discussion and really. Highlights so much of what's great about cardiology that it's it's broad. You'd still have to be an internist I and to that than you really are a master of sub specialty have to use advanced diagnostic and management to take care of patients. I'd love to hear from you what Y'all love about cardiology and how your experience has been training at the University of Tennessee beyond honest chocolate cake chocolate by the way is just amazing. I highly recommend recommended for everyone else. Oliver Meister 'cause I can't even talk. Cake is, is certainly a benefit, one of the things that I love about, of course, the decision. Is Very fascinating to me, but I love the variety. Every day is a little something different. You get to the best of the inpatient world outpatient world you get some imaging, you get some procedural time in the Cath. Lab. So there's just always something interesting and no days exactly the same, and that's really what drew me to cardiology in the first place and dancer. The second part of your question training at Tennessee is has been awesome. I really can't say enough good things about our not only our cardiology staff here but the entire hospital we're constantly growing it's a relatively new fellowship program I. Think this is. Our. Thirteenth the year but we've hired three or four new cardiologists within the last year we've got an imaging specialists has just joined us. We've got a heart failure interventionalist starting in a couple of mine and the hospital itself is so supportive of everything we do. In fact, we have a quarterly meeting with all of the residents and fellows with the CEO of the hospital to discuss issues pertaining to the residency programs, and they actually listen and make changes, and it's amazing and I know that kind of thing doesn't happen everywhere. So we're very fortunate to have that kind of relationship with our hospital here at ut. That's really incredible a to to see how dedicated leadership in your opinions on your well being. That's awesome. Your William I I agree with just variety cardiology provides was actually I trained as a hospital this for a few years in one of the things that I missed was outpatient medicine being able to speak with the patient in that setting in cardiology provides just a breadth of different types of experiences. Weather's inpatient outpatient in some procedures for me. The best thing I like about Knoxville is that it's home for me but also close to everything we have to mountains I have a little one year old kid so i. Frequently take him out to parks from time to time and think it's just an amazing place to to raise a family. Yes. I'll follow that up one of the reasons I love cardiology is he dot Amex just can't get enough of the physiology and like you said, there's a lot of redundancy but the redundancy is just going back to the physiology makes you feel like you can really figure things out and just talk through it just knowing how everything works and then really that instant gratification we know we've spent most of our lives in training all delayed gratification but now we actually get to treat our patients in see. Them do better and feel better, and that's really gratifying. Also, the variety is a plus being able to do some imaging and do some procedures inpatient and outpatient, and then really the breadth of cardiology is still growing in everybody's still learning and everything is fresh and we're constantly learning new things. It's just can't say enough good things about cardiology as far as program goes neom odd husband Elliot actually couples matched into cardiology here, and this was one of the programs we felt was so welcoming and just the nicest most supportive group of cardiologists we've come across this home for us and so we had the opportunity to get to. Know some of these cardiologists previously, but the people is just so important who you work within your alongside faculty staff everybody has just been amazing so far and it's been great. Yeah. I couldn't agree more with everything you said, but you know what better way to enjoy a discussion on dynamics than at beautiful case of constriction versus restriction especially when the patient such a great outcome. So congratulations on taking terrific care if your patient thank you so much for your time for taking us on a hike at least. Thank you so much for the chocolate cake. But now let's go on hikes. I didn't feel so bad about the calories. Thanks. Thanks everyone. Thank you for elevating us. Lately we yeah. Thank you for having us. We've enjoyed the case series podcast so far they've been fantastic very informative, and we look forward to hearing what our colleagues at other fellowship programs have to present in the upcoming cases. And now for the East, CPR and message to applicants by Dr Tawana overly our program director of interventional cardiology and APD of our general cardiology fellowship. This is twenty overly at one of the interventional cardiologists here at the University of Tennessee Center in Knoxville I'm the program director of interventional, cardiology first of all, wanted to congratulate all of the fellows on wonderful discussion i. Thought it was I take you later explained and done in a logical appropriate manner to allow the large thinking to come and do more deductive processing to figure out this case. So I really appreciated that really from my perspective I think there's big picture things. There's probably two things that I would focus on. In this case, I can't really say a lot more with regard to. The discussion because it was so excellent. So there's not a lot to add there. But for me, it's too big pictures in first big picture has to do with a Dima. We get a lot of consultations and you get a lot of evaluation for the causes of Dima. So it's important to understand it as a very common complaint is as you all know, Scott along differential. Diagnosis as again as you guys detailed in the discussion, but one of the things that you'll learn in practice is that you'll get a lot of consultation for this and not all swelling his heart failure. In fact, most of it isn't, and so it's important to go through that differential that you guys discussed to figure out what the problem is, what the problem isn't because it. Can Be detrimental. If you choose the wrong strategy, obviously, there are some situations in patients with Dima Williams definitely wanna give him diuretics. But if you've got the wrong process von cause of Dima and you him diuretics, it can really be deleterious particularly in patients who are sick or otherwise relatively unstable. So I felt that discussion was excellent. The other thing that we sometimes don't think. About is Venus disease as being calls of some issues and problems, and sometimes you need diuretic. Sometimes, you need aggressive cardiac evaluation but sometimes, you just need an ultrasound maybe the patient has Venus reflex maybe they will do well with compression therapy and basically noninvasive type A treatment strategy. So I think that's really important but again, de detail, the diagnosis was detailed expertly by guy so. I don't think I have a lot of comments on that other than that. The other big picture item of knowing in discussing Dima is knowing and understanding the echocardiogram findings I thought that was really important. The way you guys were able to link the physiology in Echocardiogram because you figure it out essentially, if you understand one of them, you understand the other so being able to. Understand the physiology and echocardiogram important because they help you understand it and has one of the other things that you guys discuss which I thought was critical as a lot of times. When you first learned this, you have to learn it three or four times, and then it sticks but again, understanding the physiology, the echocardiogram makes it really easy to understand. So with that, I'll stop there. So. Briefly, our program here is that the University of Tennessee medical centers in Knoxville, it's a relatively new program the. Thirteenth Year it's a small program. We actually think that's one of the benefits because it makes it really easy to respond to any clinical educational needs of our fellows. We started out with two year and we've actually increased to three fellows a year. One of the problems we've had is just a tremendous amount of growth in a hospital in our program. In the last ten years, we've gone from twelve faculty now up to. Twenty six and we've increased our complement of general cardiology fellows in four years ago we started interventional cardiology fellowship. So there's tremendous amount of growth that's correlating corresponding with the growth of our medical center I think the other unique thing particularly about a program is the cultural. Most of us here had traditionally come from academic large medical centers, and ours is a little bit different. It's doesn't have the traditional hierarchy that A. Lot of traditional academic institutions have we treat our fellows really like colleagues in junior faculty in fact, one of the benefits of having the program here at we've been able to select around seven of our graduates to in our practice. We've got some from EP from interventional cardiology as well as general cardiology I. Think one of the other benefits as a fellow is that it's a very flexible program really other than call our. Fellows aren't critical to any of our clinical services and what that means is since they don't have all these service obligations, they have more time for education or they can spend more time focusing on specific areas of their interest. So if they're interested in EP or interventional imaging and they can spend more time to focus on that in addition to our large hospital service in the inpatient services are outpatient services are phenomenal. Obviously you've. Your general cardiology clinic, which everyone will have. We also have a congenital heart disease clinic. We have a pediatric cardiologists WHO's who? Than sees patients with our fellows. In addition, we have a cardio oncologist. So that's a rotation within our training program, and of course, we have an interventional cardiology fellowship, and because of that general cardiology fellows will have a tremendous exposure to all the upcoming in new technology. With structural heart disease, we have a tavern program Mitra clip in watchmen alcohol, Septa locations, and PF OS as. The whole nine. So there's a lot of exposure to a lot of the newer innovative techniques and procedures that's going on, and we're in the process of starting our program, which will probably start in the first quarter of next year. So it's a really exciting time for a program and our fellows are very happy and enjoy being here as far as Knoxville. It's a wonderful city. On the Tennessee, river's close to the smoky mountains. So you get all the benefits of having a major college town, but it's not just a college town. There's also a lot of several industries in this area that contribute to not only the employment, but also to the academic reputation of the area because we've got oak. Ridge national. Laboratories, and why twelve. So that brings in A. Lot of intellectual talent wealth as well but it's really a great place to live. It's got a very low cost living and active lifestyle. So we've enjoyed living here been here for twelve years now and it's integrate decision. So I look forward to meeting some of you in the future and I appreciate this time and opportunity not only discussed his case but also program. Thank you. What an amazing episode a huge thanks to the fellows and faculty for enriching with another terrific discussion and an incredible edition two Cardi nerds case report series. Be sure to check out the show notes for all the case media available for review key take points and special points and links to the program. If you like the educational takeaways graphics delivered directly to your email silent for the heartbeat cardiac newsletter by clicking on the link in the episode show notes. Thank the ACC and training section chaired by Dr. notion reasons for their incredible support and collaboration and a very special. Thanks to our phenomenal production team for elevating the platform column. Tommy. Rick Ferraro Evelyn Song and billion Verghese internal medicine senior residents as the Johns Hopkins Hospital as well as the team men had mentor and University of Maryland Cardiology fellow current decide if you love the show as much as we do be sure to spread the word reading reviews or your favorite podcast platform and consider becoming a patron of the show on Patriots. All right. That's wrath times make like in s youth and Split.