Pericardial Diseases

PERICARDIAL DISEASES

Nusrum Iqbal MD

NORMAL FUNCTIONS OF THE PERICARDIUM

•Visceral(serous) and parietal (fibrous)pericardium

•seperated by a small amount of fluid (15-50ml)

•prevents sudden dilatation of cardiac chambers during exercise and with hypervolemia

•facilitates atrial filling during systole

•restricts anatomic position of the heart

•minimize friction between heart and surrounding structure

•prevents displacement of the heart and kinking of great vessels

PERICARDIAL DISEASES

ACUTE PERICARDITIS

PERICARDIAL EFFUSION

CARDIAC TEMPONADE

CHRONIC CONSTRICTIVE PERICARDITIS

OTHERS

•Pericardial cyst

•tumors

ACUTE PERICARDITIS

•Most common pathologic process involving the pericardium

•may be classified clinically or etiologically

•Clinically, Effusive (serous or sanguineous) and Fibrinous

•Duration less than 6 weeks

ETIOLOGY

•COMMON

•acute myocardial infarction

•viral (coxackie B, but often not identified)

•LESS COMMON

•bacterial infection (staphyllococcus/H.influenzae)

•uremia

•malignant disease

•trauma

•connective tissue disease (e.g.SLE)

•RARE

•rheumatic fever

•tuberculosis

CLINICAL FEATURES

•Chest pain (substernal and sharp)

•history of upper respiratory tract infection

•pericardial friction rub

•fever

INVESTIGATIONS

ECG

•ST segment elevation, concave upwards, in all leads facing epicardial surface

•later, T wave inversion

•changes persist for sometime

CARDIAC ENZYMES

•may be elevated if there is associated myocarditis

ECHOCARDIOGRAPHY

Treatment

•Anti-inflammatory drugs such as ASPIRIN, naproxen or indomethacine

•Complete Bed rest

•Corticosteroid if severe or recurrent

PERICARDIAL EFFUSION

•Acute pericarditis is initially dry and fibrinous

•Almost all etiologies of Acute pericarditis also induce the formation of pericardial effusion

•It is important if it collects in a short period of time

•Effusion collects in the closed pericardial sac and can lead to cardiac tamponade

CLINICAL FEATURES

•Chest pain

•obscures the apex beat

•heart sounds are soft and distant

•friction rub can be heard initially but disappear once fluid accumulates

INVESTIGATIONS

ECG

•low voltages

CHEST X-RAY

•large globular heart with sharp outline

ECHOCARDIOGRAPHY

•gold standard test and most effective

CARDIAC TAMPONADE

•Cardiac temponade is a medical emergency

•accumulation of fluid in the pericardium sufficient to cause serious obstruction to the inflow of blood to the ventricles

•this condition is fatal if not recognized and treated promptly

Causes

neoplasia, idiopathic pericarditis, uremia

tuberculosis, hemopericardium, trauma

CLINICAL FEATURES

•Dyspnea, orthopnea, hepatic engorgement

•Hypotension

•Raised jugular venous pressure with sharp diastolic collapse, y descent (Friedrich’s sign)

•paradoxical pulse (fall of systolic blood pressure with inpiration)

•increased neck vein distension with inspiration (kussmaul’s sign) rare

•widening of the area of cardiac dullness

Investigations

ECG

•low voltage

•electrical alternans of the P, QRS, and T waves

CHEST X-RAY

•enlagement of the cardiac silhoutte

•relatively clear lung fields

ECHOCARDIOGRAPHY

RIGHT HEART CATHETERIZATION

•equalization of pressures in all the chambers

Treatment

Observation if the effusion is small and free of signs and symptoms

Pericardiocentesis

•immediately if tamponade

•it is also indicated if malignant, tuberculous or a purulent pericarditis is suspected

pericardial fenestration (pericardial window)

•for reaccumulation of the effusion

CONSTRICTIVE PERICARDITIS

•A slowly progressive fibrosis of the pericardium develops and constricts the movement of the heart, so that it cannot expand in diastole

•fibrous tissue is dense and inelastic

•calcification is common

•inflow to the heart is impeded, so that the cardiac out is diminished and systemic venous pressure is raised

ETIOLOGY

•Tuberculosis is the most important cause

•hemopericardium

•bacterial infection

•rheumatic heart disease

•following acute pericarditis

CLINICAL FEATURES

•Fatigue

•exsercise intolerance

•Typical signs of systemic venous congestion

•ascites

•dependent edema

•hepatosplenomegaly

•jugular venous distension

•kussmaul’s sign

•friedrich’s sign

•pulsus paradoxus

•atrial fibrillation

•pericardial knock (an early loud third heart sound)

INVESTIGATIONS

CHEST X-RAY

•relative small heart with obvious calcification

ECG

•low voltage and T wave inversion

ECHOCARDIOGRAM

•Thickened pericardium with relatively immobility of the heart

•ventricular cavaties are small with normal wall thickness

CT SCAN

CARDIAC CATHETERIZATION AND MRI

•for difficult cases

TREATMENT

Surgical removal is the treatment of choice

Thanks