Pericardial Diseases PDF

PERICARDIAL DISEASES  Content Pericardial Anatomy and Functions. pericarditis. Pericardial effusion and cardiac tamponade. Constrictive pericarditis. Case  Pericardial Anatomy: The pericardium is composed of two distinct layers ✓Fibrous parietal pericardium which...

PERICARDIAL DISEASES  Content Pericardial Anatomy and Functions. pericarditis. Pericardial effusion and cardiac tamponade. Constrictive pericarditis. Case  Pericardial Anatomy: The pericardium is composed of two distinct layers ✓Fibrous parietal pericardium which protects the heart from sudden cardiac dilatation ✓Inner visceral pericardium. These two layers are separated by 10-15 ml of clear fluid that acts as lubricant.  Pericardial Functions: Limits distention and facilitates interaction of the cardiac chambers, Influences ventricular filling Prevents excessive torsion and displacement of the heart, Minimizes friction with surrounding structures Prevents the spread of infection from contiguous structures. The pericardium also has immunologic, vasomotor, fibrinolytic, and metabolic activities. Therapeutically the pericardial space can be used for drug delivery.  Pericarditis ❑ Clinical Classification: Etiological Classification:  Dry ”Fibrinous” Pericarditis Clinical picture of pericarditis: ❖ Symptoms: 1.General manifestations: Fever, sweating & chills. 2.Pain: Site: sternal or parasternal. Radiation: radiate to neck & shoulders commonly to left. Ch.ch: sharp. Increased by: inspiration, recumbency, cough & chest movement. relieved by: sitting up. ❖ Signs: 1-Pericadial friction rub: Def.: transient superficial scratchy to &fro sound. unrelated to heart sounds. maximal over the pulmonary area & lower left sternal edge. increases by pressure é stethoscope. II-Clinical picture of underlying etiology. ❖ Investigations: 1-Blood picture shows leucocytosis in most cases. 2-ESR is elevated. 3-ECG: elevated ST segment (S-T segment is concave upward) & inverted T wave in most cases. 4-Investigations of etiology. The 2015 ESC Guidelines suggest that at least two of four of the following criteria are needed to make the diagnosis: pericardial pain, pericardial rub, ECG changes, and pericardial effusion. Additional supporting findings include elevation in inflammatory markers and evidence of pericardial inflammation by computed tomography (CT) or magnetic resonance imaging (MRI).  Treatment 1.Complete rest in bed. 2.Analgesics for pain. 3.Treatment of etiology. 4.Follow up.  Pericarditis with Effusion: ❖ Haemodynamic: Accumulation of more than 150 mL in the pericardial sac prevents ventricular expansion in diastolic with consequent: 1.Stagnation of blood in systemic and to a lesser extent in pulmonary veins. 2.Diminution of stroke volume. ❖ Clinical picture: Symptoms: 1-Pericardial pain: dull and oppressive due to distension of the pericardium. 2-Dyspnea: due to pulmonary congestion & pressure on lungs by effusion. relieved partly or wholly by leaning forward. 3-Mediastinal compression symptoms e.g: cough&dysphagia due to compression of bronchi& esophagus. 4-Systemic congestive symptoms. 5-Low COP symptoms. ❖ Signs: I-General: 1.Fever,sweating&loss of weight. 2.patient is sitting & leaning forwards. 3.Pulse: -Small volume & rapid. -Pulsus paradoxicus. 4.Neck veins: Kaussmaul's sign: congested neck veins with inspiratory filling due to failure of right side of heart to accept increased venous return during inspiration é consequent accumulation of blood in veins. II-Abdomen: -Enlarged tender liver. -Ascites which may develop before lower limb oedema (ascites praecox).  III-Chest: Ewart's sign: dullness & bronchial breathing over left lung base due to collapse by effusion. IV-Cardiac: 1.Invisible & impalpable apex. 2.Percussion:enlargement of dullness of bare area, dullness outside apex, to right of sternum &in left second intercostal space. The latter may disappear on sitting (shifting dullness). 3. Auscultation: weak heart sounds. ❖ Complications: a) Cardiac tamponade: Def.: accumulation of fluid in the pericardial space in a quantity sufficient to cause serious obstruction to inflow of blood to ventricles results in cardiac tamponade. N.B: quantity of fluid necessary to produce this critical state may be as small as 250 mL when fluid develops rapidly or > 1000 mL in slowly developing effusions when pericardium has had the opportunity to stretch and adapt to an increasing volume. It is manifested clinically by Beck's triad: 1-Rising venous pressure. 2-Falling arterial pressure. 3-Small quiet heart. b) Constrictive pericarditis. ❖ Investigations: 1.ECG: Low voltage ”decreased motility leads to decrease electrical activity”. depressed S-T segment and flat or inverted T wave in all leads. 2.Echocardiography: ((the best investigation)) sensitive, specific, simple, noninvasive and bed side investigation. 3.Chest CT &MRI: These techniques may be superior to echocardiography in detecting loculated pericardial effusions, pericardial thickening & presence of pericardial masses.  4. X-ray: Symmetrical enlargement of cardiac shadow with obliteration of outline of individual chambers (flask shaped cardiac shadow). supracardiac vascular shadow is shortened and widened by engorged svc. cardiac shadow is altered with changing the position of patient. Lung fields are clear.  5.Cardiac catheterization: Elevated RA and RV and diastolic pressure. A space is seen between catheter tip pushed against right atrial wall &right cardiac border. 6.Angiocardiography: A fluid shadow is seen outside the opacified cardiac chambers. 7.Aspiration& analysis of pericardial fluid: ((the most specific investigation.)) fluid is examined physically, chemically, bacteriologically & cytologically. ❖Differential Diagnosis: Other causes of pericardial effusion: a.Hydropericardium (fluid is transudate and not an exudates): Occur with congestive HF, nephrotic syndrome, liver cirrhosis, myoxoedema & hypoproteinemia. b.Haemopericardium: (Blood and not a hemorrhagic effusion in the pericardial sac). Occurs with rupture of cardiac chamber, coronary artery,pulmonary artery or aorta or é haemorrhagic diseases. c. Chylopericardium (lymph in the pericardial sac). Occurs with obstruction or rupture of the thoracic duct. ❖ Treatment: 1-Treatment of the etiology. 2-Pericardial aspiration: a-Value: -Relive symptoms of cardiac compression. -Put cytotoxic drugs in malignant, or antibiotics in infective cases. b-Sites of aspiration: -The angle between the xiphoid process and the left costal margin. -Just outside the apex. -The base of the heart. -Below the angle of left scapula in cases with + Ve Ewart's sign. 3-Pericardial drainage is used for suppurative conditions. 4-Pericardectomy or pericardial window for massive and recurrent pericardial effusion not responding to medical treatment and aspiration.  Constrictive pericarditis ❖ Etiology: 1.Tuberculous (the commonest). 2.Idiopathic. 3.Suppurative and viral pericarditis. ❖ Pathology: dense fibrous tissue resulting from pericarditis adheres both layers of pericardium together and constricts the heart. Frequently it undergoes calcification. ❖ Haemodynamics thickned fibrous pericardium interferes with diastolic expansion of heart leads to haemodynamic effects similar to those of pericardial effusion. ❖ Diagnosis: clinical picture is similar to effusion: The following indicate constrictive pericarditis rather than effusion: 1.Symptoms: only symptoms of systemic congestion and low COP. Dyspnea is usually absent (because the pulmonary artery is constricted). 2.Signs: a. AF (1/3 of cases). b. Cardiac examination: -Disappearance of characteristic dullness of pericardial effusion. -Small quiet heart. -Pericardial knock: an early diastolic sharp sound due to rapid filling of indistensible ventricle. ❖Investigations: 1.X-ray: -Heart size is usually small -Calcification of the pericardium in half of the cases. -Lung fields are clear. 2.Echocardiography. 3.Cardiac catheterization: Reveals equal elevation of the end diastolic pressures in all cardiac chambers. 4.CT or MRI of heart ❖ Differential diagnosis: 1.Liver cirrhosis: Constrictive pericarditis presents é prominent ascites & hepatomegaly that precedes LL edema. Moreover, the patient may not complain from any symptoms that point to a cardiac problem e.g. dyspnea, cough, haemoptysis etc... So, diagnosis can be easily mistaken as liver cirrhosis. However, the following point to diagnosis of constrictive pericarditis: -Special signs in neck veins. -Pulsus paradoxicus. -Pericardial knock. -X-ray and Echocardiography.  2.Restrictive cardiomyopathy: -It shares constrictive pericarditis the same pathophysiology in which heart is stiff with decreased compliance & resists filling. So, both conditions are called stiff heart syndrome. -Both conditions produce the same signs in neck veins, and pulsus paradoxicus. -Differentiation clinically is difficult and may be reached by X-ray, echocardiography, catheter, CT, MRI or even cardiac biopsy. 3.Tricuspid valve diseases: TS and TR produce severely congested neck veins, hepatomegaly, ascites out of proportion to oedema of LL also, cough and dyspnea are absent. -Differention is easy due to presence of characteristic murmurs and absence of pulpus paradoxicus and characteristic signs in neck veins. ❖Treatment: Pericardectomy is the only satisfactory treatment. Preoperative management: Salt restriction and diuretics to reduce the systemic venous pressure. Antituberculous drugs for cases with active TB infection. This should be given for several weeks before operation and continued for at least one year after operation.  Case ❖ A 61-year-old man with hypertension and paroxysmal atrial fibrillation presented for shortness of breath and generalized fatigue. ❖ The patient was recently admitted to a hospital for shortness of breath and found to have bilateral pulmonary embolism, a right sided pleural effusion,. He was diagnosed with lung adenocarcinoma based on his pleural cytology ❖ After discharge he developed progressive shortness of breath over 24 h and presented to the emergency department. Upon presentation the patient was hypotensive with blood pressure of 86/63 and in moderate distress. ❖ Initial laboratory studies were significant for a white blood cell count of 12.5 × 103/mm3, troponin of 146 pg/ml, and BNP of 401 pg/ml.  Case ❖ A chest x-ray done on arrival showed right sided pleural effusion with right sided reticular pattern. ❖ Bedside echocardiography was performed to assess hemodynamics, which demonstrated a loculated pericardial effusion ❖ The patient's loculated pericardial effusion demonstrated right ventricular collapse concerning for pericardial tamponade ❖ What is the expected cause of pericardial effusion? ❖ Lung adenocarcinoma ❖ What is the best line of treatment? ❖ Pericardial drainage by pericardiocentesis or pericardial window THANK YOU