PERICARDIAL DISEASE

PROF S. S. DANBAUCHI

OBJECTIVES

• For the student to learn about anatomy/ importance of pericardium
• To learn about symptoms and signs of Pericardial disease
• To learn how to make a diagnosis of Pericardial disease
• How to treat both stable and life threatening conditions related to the pericardial diseases

Heart- Covered by Pericardial sac�

Pericardial disease

Pericarditis

Pericardium - Anatomy

• Normal pericardium is a fibro-serous sac which surrounds the heart and adjoining proximal portions of the great vessels.
• The inner visceral layer, also known as the epicardium, consists of a thin layer of mesothelial cells closely adherent to the surface of the heart.
• The epicardium is reflected onto the surface of the outer fibrous layer with which it forms the parietal pericardium.
• The parietal pericardium consists of collagenous fibrous tissue and elastic fibrils.

Pericardium: Anatomy

Pericardial Layers:

• Visceral layer
• Parietal layer
• Fibrous pericardium

Pericardium - Anatomy

• Between the two layers lies the pericardial space, which contains approximately 10-50ml of fluid, which is an ultra-filtrate of plasma.
• Drainage of pericardial fluid is via right lymphatic duct and thoracic duct.

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Function of the Pericardium

1. Stabilization of the heart within the thoracic cavity by virtue of its ligamentous attachments -- limiting the heart’s motion.

2. Protection of the heart from mechanical trauma and infection from adjoining structures.

3. The pericardial fluid functions as a lubricant and decreases friction of cardiac surface during systole and diastole.

4. Prevention of excessive dilation of heart especially during sudden rise in intra-cardiac volume (e.g. acute aortic or mitral regurgitation).

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Etiologies of Pericarditis – inflammation of the pericardium

I. INFECTIVE

1. VIRAL - Coxsackie A and B, Influenza, adenovirus, HIV, etc.

2. BACTERIAL - Staphylococcus, pneumococcus, tuberculosis, etc.

3. FUNGAL - Candida

4. PARASITIC - Amoeba

II. AUTOIMMUNE DISORDERS

1. Systemic lupus erythematosus (SLE)

2. Drug-Induced lupus (e.g. Hydralazine, Procainamide)

3. Rheumatoid Arthritis

4. Post Cardiac Injury Syndromes i.e. postmyocardial Infarction (Dressler's) Syndrome, postcardiotomy syndrome, etc.

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Etiologies of Pericarditis

• III. NEOPLASM

1. Primary mesothelioma

2. Secondary, metastatic

3. Direct extension from adjoining tumor

• IV. RADIATION PERICARDITIS
• V. RENAL FAILURE (uremia)

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• VI. TRAUMATIC CARDIAC INJURY

1. Penetrating - stab wound, bullet wound

2. Blunt non-penetrating - automobile steering wheel accident

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• VII. IDIOPATHIC

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..�Nwiloh J, Ediagbeni S, Danbauchi S S, Aminu M B, Oyati A I. Arrow injury to the heart. Ann Thorac Surg 2010; 90:287-9

• Arrows once a common cause of penetrating trauma has been replaced over the last century by gunshot and stab wounds, except for certain tribal regions in developing nations where they are still frequently used in conflicts and hunting. Survival with cardiac injuries is possible in most cases if prompt medical attention is sought and there is available surgical expertise close to the rural areas where these injuries occur.
• We report one such case that survived after three days and traveling over 1000 km with a pulsating arrow protruding from the chest to receive expertise care, and reviewed the literature on such injuries.

Causes of Acute Pericarditis

Pathogenesis of Pericarditis

1) Vasodilatation:

🡪 transudation of fluid

2) Increased vascular permeability

🡪 leakage of protein

3) Leukocyte exudation

neutrophils and mononuclear cells

Pathology

depends on underlying cause and severity of inflammation

serous pericarditis

serofibrinous pericarditis

suppurative (purulent) pericarditis

hemorrhagic pericarditis

Gross Pathology

“Bread & Butter” appearance

Fibrinous stranding

Hemodynamics of Pericarditis--Effusion

Cardiac Tamponade -- Pathophysiology

Accumulation of fluid under high pressure:

compresses cardiac chambers & impairs

diastolic filling of both ventricles

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↓ SV ↑ venous pressures

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↓ CO systemic pulmonary congestion

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Hypotension/shock JVP rales

Reflex tachycardia hepatomegaly

ascites

peripheral edema

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Tamponade-- Clinical Features

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Symptoms:

Acute: (trauma, LV rupture)

profound hypotension

confusion/agitation

Slow/Progressive large effusion (weeks)

Fatigue (↓CO)

Dyspnea

JVD

Signs:

Tachycardia

Hypotension

rales/edema/ascites

muffled heart sounds

pulsus paradoxus

Tamponade

Constrictive Pericarditis

Late complication of pericardial disease

Fibrous scar formation

Fusion of pericardial layers

Calcification further stiffens pericardium

Etiologies:

any cause of pericarditis

idiopathic

post-surgery

tuberculosis

radiation

neoplasm

Pathophysiology- constrictive pericarditis

Rigid, scarred pericardium encircles heart:

Systolic contraction normal

Inhibits diastolic filling of both ventricles

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↓ SV ↑venous pressures

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↓ CO systemic pulmonary congestion

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Hypotension/shock JVD rales

Reflex tachycardia hepatomegaly

ascites

peripheral edema

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Pericardial disease: pathophysiology

Clinical features

Small effusions do not produce hemodynamic abnormalities (can go unnoticed).

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Large effusions, in addition to causing hemodynamic compromise, may lead to compression of adjoining structures and produce symptoms of:

dysphagia (compression of esophagus)

hoarseness (recurrent laryngeal nerve compression)

hiccups (diaphragmatic stimulation)

dyspnea (pleural inflammation/effusion)

History

• Often preceding viral illness 1-2 week prior

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• Chest Pain
• Sudden, sharp, pleuritic, constant
• worse supine/ Left lat decubitus, relief sitting up
• radiation: back, trapezius ridge
• symptoms usually resolve by 2 weeks, ECG abnormalities may persist for months

Clinical Features of Acute Pericarditis

Idiopathic/viral

* Pleuritic Chest pain

* Fever

* Pericardial Friction Rub

3 component:

a) atrial or pre-systolic component

b) ventricular systolic component (loudest)

c) ventricular diastolic component

* EKG: diffuse ST elevation

PR segment depression

CVS exams;Pulsus paradoxus

• Exaggerated (>10mmHg) cyclic decrease in systolic BP during normal inspiration
• Inspiration: increased venous return increased RV volume.
• Interventricular septum shifts left, decreased LV volume decreased stroke volume systolic pressure falls.

Jugular venous pulse

• Distended neck veins (external jugular)
• Raised JVP

Precordial features

• Silent precordium

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• Apex not palpable

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• No heaves (LVH or RVH)

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• No thrills

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• Heart sounds are distant(less audible)

Constriction vs. Tamponade

TAMPONADE

Pulsus paradoxus:

Present

Echo/MRI:

• Normal systolic function
• Large effusion
• RA & RV compression

Treatment:

Pericardiocentesis

CONSTRICTION

Pulsus paradoxus:

Absent

Echo/MRI:

• Normal systolic function
• No effusion
• Pericardial thickening

Treatment:

Pericardial stripping

Investigations

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• Chest X-ray
• Electrocardiogram
• Echocardiogram
• Cardiac catheterization
• Blood tests ESR, C reactive protein levels, etc.
• FBC, differentials
• Immunological screening of some viruses. bacteria

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Constrictive Pericarditis

Diagnostic Tests

Echocardiogram: Pericardial effusion

N.B.: absence does not rule out pericarditis

N.B.: Pericarditis is a clinical diagnosis, not an

Echo diagnosis!

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Blood tests: Mantoux, RF, ANA

Viral titers

Search for malignancy

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Pericardiocentesis:

low diagnostic yield

done therapeutically

Chest X -ray: Normal heart

CXR in Pericardial effusion

CXR PA view in Acute Pericarditis

Pericardial effusion

Pericardial effusion after tap

Calcific Constrictive Pericarditis

PA and Lateral CXR of Calcific Pericarditis

Calcified pericardium, lateral CXR

Pericardial calcification

Pneumopericardium

ECG

• PR depression
• ST elevation
• concave up, ST/T V6 >.25, no reciprocal
• DDx:
• Acute MI
• Early Repolarization
• Myocarditis
• Aneurysm
• other: Brugada, BBB

Acute Pericarditis: Electrocardiogram

Acute Pericarditis – Stages- ECG

• Stage I
• first few days 🡪 2 weeks
• ST elev, PR depression
• up to 50% of pt with sxs/rub do NOT have/evolve stage I¹

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• Stage II
• last days 🡪 weeks
• ST returns to baseline, flat T

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• Stage III
• after 2-3 weeks, lasts several weeks
• T wave inversion

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• Stage IV
• lasts up to several months
• gradual resolution of T wave changes

¹ Spodick DH, Pericardial Disease. Braunwauld 6^th

Acute PCARD – Stage I, II

60 y/o man with acute PCARD on presentation and after 1 mo resolution of sxs,

* Marriott’s Practical ECG 10^th ed, p 208

Acute PCARD – Stage III

19 y/o Female after 1 wk in hospital with Acute Pericarditis

Pericardial effusion showing global low voltages

Pericardial effusion -ECG

ECG diffential diagnosis

Acute Ant MI

Echo- Pericardial Effusion

Pericardial effusion - Echo

Pericardial Effusion

RV Diastolic Collapse

Large Pericardial effusion

Global Pericardial effusion

Global low voltages/electrical alternans

Video of PE with tamponade

Purulent Pericarditis

• Common seen in patients with empyema,�mediastinitis, endocarditis, burn, and post-pericardioectomy

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• Primary purulent pericarditis is rare, even in immunocompromised host

Diagnosis

CXR: calcified cardiac silhouette

EKG: non-specific

CT or MRI: pericardial thickening

MRI Image of constrictive calcific Pericarditis

MRI Image of constrictive pericarditis

MRI Image of constrictive calcific Pericarditis

Effusion in Renal Disease

• Up to 40% of patients with renal failure�will develop pericardial effusion
• Not limited to predialysis but also occurrs�after hemodyalysis
• Pericardial effusion has no evident relation-�ship with heparin use
• Intensive hemodialysis has highest chance �to clear pericardial effusion noted before�hemodialysis or early in the course after �treatment ( several weeks)
• Pericardial effusion more than 200 to 250 ml�(> 1cm in M mode) should be drained

Pericardial Disease after Cardiac Surgery

• First few hours after surgery : hemopericardium or hemomediastinum leads to cardiac tamponade (> 60%)
• Several weeks after operation: post pericardiectomy syndrome with fever, chest pain, and friction rub (10-20%)
• 6 weeks to years after op: constrictive �pericarditis ( 1%)

Acute Pericarditis or ischemia ?- both present with precordial pain

• Pericarditis: fever, CPK and ESR elevation,�pluritic pain and friction rub, concave ST�elevation in all leads except V1 and aVR,�PR segment depression

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• AMI or Prizmental’s angina: Convex ST�elevation in regional leads, series evolutional change in ECG, Q wave noted finally, CPK, Troponin elevation

Treatment Options

• Medical treatment: fluid administration

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• Pericardiocentesis (pericardial effusion)

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• Subxiphoid pericardiotomy

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• Complete pericardium removal – post.�Effusion

Treatment for Pericarditis�

• The treatment depends on the cause of pericarditis. Viral pericarditis is treated with the help of aspirin or NSAIDs. Other treatments include:

• Antibiotics for bacterial infection
• Pericardiocentesis for pericardial effusion
• Use of colchicine drug that helps reduce inflammation ·  
• Pericardiectomy in case of constrictive pericarditis

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Treatment

Pain relief analgesics and anti-inflammatory

ASA/NSAID’s

Steroids for recurring pericarditis

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Antibiotics/drainage for purulent pericarditis

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Dialysis for uremic pericarditis

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Neoplastic: XRT, chemotherapy

Non hemodynamic considerations

• Anticoagulation

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• Management of effusion in renal failure

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• Purulent pericarditis

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• Pericardial effusion following cardiac surgery

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• Acute pericarditis and ischemia

Summary

• Pericardial disease is a common cardiovascular disorder

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• There are many etiologies- infective, autoimmune, physical, chemical etc.

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• It can produce hemodynamic instability, leading to tamponade

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• Investigations spans ECG, CXR, Echo
• Treatment is medical or surgical

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• Thanks