Pericardial disease pptx - D. Tahsin

Pericardial Disease

Normal Pericardium

Composed of two layers: visceral & parietal
Function:
Limits distension of the heart
Barrier to infection
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Ventricular interdependence

During inspiration, the diaphragm descends into the abdominal cavity
This reduces the intrathoracic pressure

Ventricular interdependence

Squeezes the intra-abdominal blood into the thoracic cavity
Venous return to the right side of the heart is augmented

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Ventricular interdependence

Filling of the RV occurs at the expense of the left side of the heart (atrial & ventricular septa move to the left)
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Ventricular interdependence

During expiration, the reverse occurs:
Increased intrathoracic pressure
Reduced venous return to right side
Increased pulmonary venous return to the left side of the heart

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Ventricular interdependence

Accordingly, during inspiration the RV stroke volume rises
While during expiration, the LV stroke volume rises
This physiological effect is exaggerated in cases of pericardial constriction & tamponade
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Diseases of the Pericardium

Acute pericarditis
Pericardial effusion without tamponade
Cardiac tamponade
Chronic constrictive pericarditis
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Acute Pericarditis

Acute Pericarditis: Etiology
Infective: viral, bacterial, mycobacterial, parasitic
Immunologic: rheumatic fever, rheumatoid arthritis, SLE, familial Mediterranean fever
In relation to myocardial infarction: AMI, post infarction syndrome (Dressler’s syndrome)

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Acute Pericarditis: Etiology

Pericarditis in disorders of metabolism: chronic renal failure
Neoplastic: secondary or primary (mesothelioma)
Traumatic: direct trauma, radiation
idiopathic

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Common Causes of Pericarditis

Viral (including COVID-19!)
Tuberculous
Post MI
Uremic
Idiopathic
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Acute Pericarditis: Clinical

Pain:
Retrosternal
Sharp
Radiates to the shoulders & neck
Aggravated by movement, respiration, swallowing, posture, & coughing
Fever: low grade

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Acute Pericarditis: Clinical

Pericardial friction rub:
High-pitched
Scratchy sound
May be monophasic (only during systole), biphasic (systolic & diastolic) or triphasic (systolic, diastolic, & pre-systolic)

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Acute Pericarditis: Investigation

ECG:
ST elevation: with upward concavity (≠ AMI)
Depressed PR interval
Later on: T-inversion

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Echocardiography

Thickening of pericardium

Pericardial effusion

Acute Pericarditis: Investigation

Blood tests:
High ESR
High C-Reactive protein: titre important for the follow-up of disease activity
Neutrophil leucocytosis
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Acute Pericarditis: Investigation

CXR:
Ranges from normal to severe cardiomegaly
May show additional pulmonary/mediastinal pathology

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Acute Pericarditis: Investigation

CT scan & MRI:
Demonstrate effusions
Define the pericardial & epicardial tissue
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Acute Pericarditis: Investigation

Other investigations:
Aspiration of pericardial fluid: if large enough
Cell count
Cytology
Cultures: bacterial infections
PCR: to diagnose TB

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Acute Pericarditis: Management

Exercise restriction
Admission to hospital
Determine etiology
Observe for tamponade
Monitor the response to treatment
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Acute Pericarditis: Management

Drug treatment:
Colchicine
AND
Aspirin
other NSAIDs
? Steroids: only in case of recurrent or resistant pericarditis

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Acute Pericarditis: prognosis

Usually self-limiting
May be recurrent
May progress to pericardial effusion
May progress to constriction
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Pericardial Effusion without Tamponade

Pericardial Effusion without tamponade

Could be an exudate or transudate
The clinical picture depends on:
The amount of fluid
The rate of fluid accumulation
* A rapid rate of accumulation of relatively small amount of fluid in the pericardium leads to pericardial tamponade
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Pericardial Effusion Without Tamponade: Clinical

Chest pain: becomes oppressive rather than sharp
Apex beat becomes impalpable
Distant heart sounds
Pericardial friction rub: not always disappears
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Pericardial Effusion: Investigation

ECG :
Low voltage QRS
Electrical alternans: alternating high and low QRS voltage due to oscillation of the heart in the pericardial fluid
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Pericardial Effusion: Investigation

CXR:
Globular enlargement of the heart
Rapid enlargement of cardiac shadow over days
The lungs are usually clear

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Pericardial Effusion: Investigation

Echocardiography: establishes the diagnosis
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Cardiac Tamponade

Cardiac tamponade

Acute cardiac failure caused by compression of the heart by large or rapidly expanding pericardial effusion
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Cardiac tamponade: Clinical

Dyspnea, tachypnea
Hypotension
Tachycardia
Pulsus paradoxus
Raised JVP
Impalpable apex beat
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Cardiac tamponade: Investigation

ECG:
Sinus tachycardia
May be normal otherwise
Low voltage complexes
Electrical alternans
In the terminal state: electro-mechanical dissociation
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Cardiac tamponade: Investigation

CXR:
Cardiomegaly with normal lungs

Echocardiography & Doppler:

Establish the diagnosis
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Cardiac tamponade: Management

Medical emergency
Should be treated by immediate aspiration of pericardial effusion
Usually symptoms disappear after the first few CCs of aspiration
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Chronic Constrictive Pericarditis

Progressive thickening, fibrosis, and calcification of pericardium
The heart becomes encased in a rigid shell of pericardium, restricting its expansion & filling
May follow viral pericarditis, TB, rheumatoid arthritis or hemopericardium
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Symptoms
Fatigue
Enlarging abdomen
Leg edema
Dyspnea is not common because the lungs are rarely congested
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Physical findings

Pulse: rapid & low volume
Pulsus paradoxus: seen in 1/3rd of cases
Elevated JVP
JAUNDICE
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Physical Findings

Kussmaul’s sign: ↑JVP with inspiration
Pericardial knock: loud early diastolic heart sound (early S3)
Hepatomegaly

Physical findings

Ascites
Peripheral edema
Constrictive pericarditis is an elusive entity & is often missed
Should always be suspected in all patients with edema &/or ascites

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Differential Diagnosis

Restrictive cardiomyopathy: both cause congestive heart failure with small heart
Chronic liver disease: the JVP is normal

Investigations

ECG:
May be normal
May show low voltage complexes
CXR:
Pericardial calcification

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Investigations

Echocardiography & Doppler:
RA & LA enlargement
Normal size ventricles
Pericardial thickening
CT/MRI: demonstrate the thickened pericardium
Cardiac catheterization: equalization of diastolic pressures in all 4 cardiac chambers
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Treatment

Surgical excision of the pericardium
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