drenajul pericardic percutan in pericardita neoplazica

DRENAJUL PERICARDIC DRENAJUL PERICARDIC PERCUTAN GHIDAT PERCUTAN GHIDAT

ECOGRAFIC IN ECOGRAFIC IN PERICARDITA CRONICA PERICARDITA CRONICA

NEOPLAZICANEOPLAZICA

Alexandru AndritoiuAlexandru Andritoiu, Aurelia Resceanu, Cristian Silosi, Paul Demetrian, Corina Drighiciu, Florin Robescu

Sp. Militar CraiovaSp. Militar Craiova

IndicatiiIndicatii

• Pericardita cronica• Tamponada subacuta

Scop

• Diagnostic

• Terapeutic - hemodinamic

• Drenaj evacuator

TehnicaTehnica

• Trusa drenaj• Ecograf• Monitorizare ATI :

TA, AV, ECG, SaO2

1. Caz clinic

• F Ghe, F, 68 yr• Edeme mm infer-perete

abd infiltrat• Dispnee, ortopnee,• Tuse seaca, iritativa• Scadere G• Afebrila • Biol: VSH 34/47 mm• Fibrinogen 944 mg/dl

US

• Doppler venos mm infer: exlude tromboza vv prof.

• Eco cord: revarsat pericardic progresiv• Eco abd: ficat de staza; revarsat pleural

bilater; exclude tromboza VCI

Pericardocenteza(tamponada cardiaca)(tamponada cardiaca)

PericardocentezaGhidaj US

Anestezie locala(xilina 1%)

Pericardita hemoragica !

Ex laborator – lichid pericardic

• R. Rivalta (++)• Proteine 5.4 g/ml• CEA –slab pozitiv !?• Culturi negative (aerobe);• Frotiu: inflamator; fara

atipii celulare!

Drenaj pericardic continuupercutan sub ghidaj US

Control US

Fi.A paroxistica

Rx (control 48 ore)

CT

2. Caz clinic

• CS, F, 80 ani

• Pericardita cronica

• Insuf. Card cls 2/3

Rx C- PRx C- P

CT

ECGECGRS, T neg. D1, D2, aVL, V4-V6

EcocardiografieEcocardiografie

Zoom

Tumora pericardica?

Zoom

CTCT

Examene biologiceExamene biologice

• VSH: 41-99 mm/h

• Proteina C reactiva - pozitiva

Diagnostic de etapaDiagnostic de etapa

• Pericardita cronica-hemoragica

• Mezoteliom pericardic ?

Drenaj pericardic 14 Drenaj pericardic 14 zilezile

Adm. Intra-pericardicaAdm. Intra-pericardica

• Cisplatinum 10mg x 5 z

• Gentamicina 80 mg

Suport ATI

Punctie pericardica

Dilatator pe fir-ghid

Insertie cateter

Monitorizare ECG, TA, SaO2

Control Rx

Contrast intra-pericardic

Reconstructie 3D-CT

Lichid pericardic – z 12

Benzi de fibrina flotante

Benzi de fibrina

Examen lichid pericardic

BIOCHIMIE

Proteine: 5.1 g/dL

LDH 903 UI/L

CRP 0.2 mg/dL

Glucoza 82 mg/Dl

CEA negativ

CITOLOGIEFrotiu hipercelular, hemoragic,

Frecvente celule mezoteliale

dispuse izolat sau in grupuri,

unele de dimensiuni mari, cu

citoplasma bazofila, cu unul sau

mai multi nuclei , cu nucleoli

vizibili, uneori multipli;

Relativ frecvente limfocite;

Rare PMN.

CULTURA - NEGATIVA

Cispatinum

5 x 10 mg/zi - intrapericardic

Caz clinic 3

• ILIE CONSTANTIN, 53 ani, Craiova

Motivele internarii

• Durere intensa-prelungita cervico-brahial stg (de peste 2 luni)-AINS, antialgice

• Sincope repetate-hipoTA• Stare generala alterata• Voce ragusita

• Fumator >35 ani-40 tigarete/zi• AHC-tatal decedat Neo Br Pulm (mare fumator)

Ex. obiectivEx. obiectiv

• Facies suferind

• Formatiune dura-dureroasa la insertia claviculara a muschiului SCM stg

• Torace hipostenic-fara modificari stetacustice

• Echilibrat C-V (TA 110/65 mmHg;AV 80 bpm)

ECG la prezentare

10.10.2013

US/10.10.2013US/10.10.2013

CervicalaCervicala• Bloc adenopatic stg

Eco tiroidaEco tiroida• Noduli benigni bilateral

Eco-cord-relatii normale

Eco Abdmen• Colecist exclus chirurgical• Ficat, pancreas, splina,

RD, RS, vezica urinara, prostate-normale

Diagnostic de etapaDiagnostic de etapa

In obs: Neoplasm bronho-pulmonar

Elemente:Elemente:

• Fumator (+++)

• Ereditate: tatal decedat de neo pulmonar

• Voce ragusita

• Adenopatie tumorala (maligna)

14.10.2013/ CT toracicCT toracic

• Laringe asimetric-formatiune infiltrativa lateral stg+bloc adenopatic latero-cerv stg

• Pulmon, mediastin, pleura-normale

Dr. Demetrian Paul

15.10.2013Laringoscopie endoscopicaLaringoscopie endoscopica

• Paralizie de coarda vocala stg

• Infirma neoplasmul laringian

Dr Cheita Nicolae

Evolutie intraspitaliceasca

• Dureri atroce cervical stg

• Scadere ponderala (facies malign)

• Tuse seaca

• Dispnee progresiva

• Ziua - prabusire TA (TAS 70-80 mmHg)

27.10.2013/Eco cord27.10.2013/Eco cord

• Pericardita (revarsat abundent > 3 cm anterior)

• Semne de tamponada sub.acuta

ECG (pericardita)

Complexe hipovoltate

Atitudine terapeuticaAtitudine terapeutica

• Punctie pericardica• Drenaj pericardic

• Biopsie ganglionara (supra-clavicular stg)

Dr. Andritoiu A, Dr Silosi C, Dr. Resceanu Aurelia

Anestezie generalaAnestezie generala

28.10.2013/Punctie pericardica28.10.2013/Punctie pericardica

Drenaj pericardic percutanDrenaj pericardic percutan(tehnica Seldinger)ghidaj ecografic

Ex. Citologic (lichid pericardic)

• Frecvente hematii

• Frecvente mezotelii (mezoteliom pericardic?)

• Rare leucocite

• Aspect ,,reactiv,,

• Fara celule maligne!

Dr. Drighiciu Corina

30-50% din cazuri-citologie negativa!!!

30.10.2013/ Repeta CT toracic Repeta CT toracic

• Pericardita• Pleurezie bilaterala• Colabare lob inf stg• Adenopatie • Tum hilara

CT – cateter pericardicCT – cateter pericardic

EvolutieEvolutie

• Aspirat continuu• >100 ml/zi• Refacere rapidaRefacere rapida• Aspect hemoragic

• TratamentTratament• AB• HSHC• Etamsilat• Suport inotrop pozitiv• Antialgice• Oxigen

TA 100/65 mmHg, AV 90 bpm, SaO2 85-92%

Chimioterapie localaChimioterapie locala

• CisplatinCisplatin• 3 zile• Fara rezultat favorabil

10 mg+20 ml Na Cl (dilutie)/zi

ToracentezaToracenteza

• 01.11.2013

• Punctie pleurala stg

Lichid sero-citrin

• Drenaj pleural stg

Evacuare > 1000 mL

Dr. Dobrinescu Adrian, Cl Chir Toracica, Sp Jud nr 1 Craiova

• VSH 30-36 mm/hVSH 30-36 mm/h• Le 11.790/mmcLe 11.790/mmc• Hb 15.6-11.4 g/dLHb 15.6-11.4 g/dL• Ht 43-31%Ht 43-31%• Fibrinogen 457-471 mg/dLFibrinogen 457-471 mg/dL• CRP 7.9 mg/dLCRP 7.9 mg/dL• TGO 14-91 UI/LTGO 14-91 UI/L• TGP 14-375 UI/LTGP 14-375 UI/L• Ac. bK negativi• Mb negativ• CPK-MB 23 UI/L• LDH 432 UI/L

Biochimie (lichid pericardic)Biochimie (lichid pericardic)

• Proteine g/dL• Glucoza 62 mg/dL• LDH 2933 UI/L• R. Rivalta Poz (+++)

Oncogene (lichid pericardic)Oncogene (lichid pericardic)

Incidente/Complicatii

• Infectie cutanata

• Blocajul cateterului

• Pneumopericard

• Pneumotorax

• Aritmii

• Deces

CisplatiniumCisplatiniumEfecte adverse

• Gastro-intestinale: greata, varsaturi• Cardiovasculare: aritmii, HTA, cardiotoxicitate• Renale: nefrotoxicitate• SN: polineuropatie senzitiva periferica• Hematologice: anemie, mielosupresie• Oculare: nevrita optica, edem papilar, orbire• Hepatice: TGO, BR>• Dermatologice: rush, alopecie.

Intrapericardial Cisplatin treatment prevents effectively Intrapericardial Cisplatin treatment prevents effectively the recurrence of neoplastic pericardial effusionthe recurrence of neoplastic pericardial effusion

B. Maisch, S.Pankuweit, H. Rupp, A. Ristic,

Conclusion:Conclusion:• Intrapericardial treatment with cisplatin prevents

recurrences of NE effectively. The treatment was more successful in lung than in breast cancer pts. 

Circulation. 2009;120:S885