Pericardial Disease - Aortic Surgery by Mike Poullis

1,103 views

Published on

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
1,103
On SlideShare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
41
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

Pericardial Disease - Aortic Surgery by Mike Poullis

  1. 1. Pericardial Effusion Normal: 15-50 ml of thin serous fluid Sudden increase: up to 200 ml: OK between 200 and 300 ml: can be fatal Slow increase: up to 2 liters: OK
  2. 2. Cardiac Tamponade Jugular venous distention, muffled heart sounds, hypotension, pulsus paradoxus Echocardiogram: diastolic collapse of right atrium and right ventricle Swan-Ganz: equalization of pressures
  3. 3. Acute Pericarditis Most commonly idiopathic (viral), self-limited to 1-3 weeks with Sharp substernal pleuritic positional pain Pericardial friction rub Diffuse upward concavity ST elevation
  4. 4. <ul><li>Diseases of the Pericardium </li></ul><ul><li>Pericardial effusion </li></ul><ul><li>A. Hemopericardium </li></ul><ul><li>B. Cardiac tamponade </li></ul><ul><li>2. Pericarditis </li></ul><ul><li>A. Serous D. Hemorrhagic </li></ul><ul><li>B. Fibrinous E. Constrictive </li></ul><ul><li>C. Purulent </li></ul>
  5. 5. Pericardial Effusion Normal: 15-50 ml of thin serous fluid Sudden increase: up to 200 ml: minimal increase in pressure between 200 and 300 ml: sharp rise in pressure Slow increase: up to 2 liters: minimal increase in pressure
  6. 6. Pericardial Effusion: Common Causes Viral myopericarditis Metastatic malignancy Autoimmune disease Drug-induced Renal failure Bleeding (Hemopericardium)
  7. 7. Pericardial Effusion: Symptoms Dull constant left chest ache Dyspnea (shortness of breath) Less common: Hiccups (phrenic nerve) Hoarseness (recurrent laryngeal nerve) Dysphagia (esophageal compression)
  8. 8. Pericardial Effusion: Signs Muffled soft heart sounds Dullness to percussion over lower posterior left lung (Ewart’s sign) Decrease in pericardial friction rub
  9. 9. Pericardial Effusion: Diagnosis Chest x-ray: if >250 ml: enlarged globular cardiac silhouette, maybe EKG: decreased voltage, (alternating large and small QRS “ electrical alternans” as electrical axis changes as heart swings to and fro in a large effusion, cute but rare)
  10. 10. Pericardial Effusion: Diagnosis Echocardiogram: can provide estimate of size and evidence of tamponade Pericardiocentesis: low yield, best reserved for cases with tamponade when simultaneously diagnostic and therapeutic
  11. 11. Hemopericardium Rare, but commonly fatal Causes: cardiac rupture after transmural myocardial infarction (especially day 5), aortic aneurysm rupture, chest trauma, anticoagulation, leukemia
  12. 12. Cardiac Tamponade Pericardial effusion or blood compressing the heart enough to impair filling and pumping Symptoms: If sudden: confusion, agitation, dyspnea, collapse, arrest If slow: fatigue, leg edema, dyspnea
  13. 13. Cardiac Tamponade: Signs Jugular venous distention, muffled heart sounds and hypotension (Beck’s triad) Pulsus paradoxus [misnomer] exaggeration of normal decrease in blood pressure with inspiration >10 mm Hg systolic (not specific, also seen in obstructive airway disease)
  14. 14. Cardiac Tamponade: Diagnosis Echocardiogram: diastolic collapse of right atrium and right ventricle Swan-Ganz right heart catheterization: increased and equalized right atrial and left atrial (surrogate: wedge) pressures Treatment: tap it! (subxiphoid)
  15. 15. Types of Pericarditis Serous: smooth surface, scant neutrophils, lymphocytes and macrophages, usually with effusion of 50-200 ml of thin fluid (protein <50% of serum level) Fibrinous: dry, roughened, shaggy, “ bread and butter” surface, more neutro- phils, lymphocytes and macrophages, serofibrinous if with effusion
  16. 16. More Types of Pericarditis Purulent (synonym: suppurative): red granular surface coated with pus, lots of subsurface neutrophils, up to 500 ml exudate in the pericardium Hemorrhagic: serous, fibrinous or purulent plus hemorrhage, +/- effusion or exudate with blood added Constrictive: [misnomer] rarely any -itis
  17. 17. Acute Pericarditis The most common disease of the pericardium Most common causes 1. Infectious A. Viral (idiopathic) B. Pyogenic bacterial C. Tuberculosis
  18. 18. Acute Pericarditis: Most common causes 2. Non-Infectious A. Post myocardial infarction B. Metastatic malignancy (lung, breast) C. Autoimmune connective tissue disease D. Drug-induced (e.g. procainamide) E. Radiation-induced F. Renal failure
  19. 19. Acute Pericarditis: Symptoms Pain: substernal, but sharp, pleuritic (increased with inspiration), positional (increased with lying down, decreased with sitting up and leaning forward) Dyspnea: not exertional Fever (Malaise, myalgias, if viral)
  20. 20. Acute Pericarditis: Physical & EKG signs Pericardial friction rub: evanescent, superficial, scratchy, to and fro, best heard with stethoscope diaphragm, with patient leaning forward, exhaling EKG (abnormal in 90%): ST elevation diffuse (except aVR, V1) with concavity upwards, +/-PR depression
  21. 21. Viral (Idiopathic) Pericarditis Self-limited, usually over in 1-3 weeks Most common viruses: Coxsackie (especially group B) or echovirus not routinely cultured, so specific diagnosis requires anti-viral titers, acute and convalescent 4-6 weeks later rarely worth doing, so viral pericarditis = idiopathic (sort of, approximately)
  22. 22. Acute Pericarditis due to Pyogenic Bacteria Rare, purulent, generally fulminant High mortality Most common bugs: Staphylococcus aureus Streptococcus pneumoniae
  23. 23. Acute Pericarditis due to Pyogenic Bacteria Pathogenesis: extension of empyema or myocardial abscess OR seeding of pre-existing effusion OR hematogenous infection Evolution: fibrinous adhesions, organization (fibroblasts), fibrous adhesions, “ constrictive pericarditis”
  24. 24. <ul><li>Post Myocardial Infarction Pericarditis: </li></ul><ul><li>Two Forms </li></ul><ul><li>Extension of visceral pericarditis to </li></ul><ul><li>parietal over large transmural infarct, </li></ul><ul><li>uncommon, <5% of infarctions </li></ul><ul><li>2. Dressler syndrome 2-12 weeks after </li></ul><ul><li>infarction, probably autoimmune, </li></ul><ul><li>has become rare </li></ul>
  25. 25. Autoimmune Pericarditis: occurs in 30% of patients with lupus (as part of a polyserositis with simultaneous pleuritis and peritonitis), and with rheumatoid arthritis Drug-induced Pericarditis: occurs with procainamide (sometimes as part of a polyserositis), and with hydralazine
  26. 26. Hemorrhagic Pericarditis Rare, associated with 1. metastatic carcinoma 2. leukemia (thrombocytopenia) 3. tuberculosis Skin test for tuberculosis (“PPD”) and chest x-ray: important tests for unexplained pericarditis
  27. 27. Constrictive “Pericarditis” Encasement of the heart in a dense fibrous or fibrocalcific scar which prevents cardiac hypertrophy or dilatation Rare, commonly due to previous purulent or tuberculous pericarditis Pathophysiology similar to tamponade
  28. 28. Constrictive Pericarditis Symptoms: fatigue, leg edema, dyspnea Signs: jugular venous distention (increased with inspiration = Kussmaul’s sign), pericardial knock following S2, hepatomegaly, ascites, leg edema
  29. 29. Constrictive Cardiac Pericarditis Tamponade Pulsus paradoxus No Yes Kussmaul’s sign Yes No
  30. 30. Constrictive Pericarditis EKG: atrial fibrillation (50%), low voltage Chest x-ray: calcification (50%) Cardiac catheterization: dip & plateau right and left ventricular tracings, right atrial prominent y descent
  31. 31. Constrictive Pericarditis Differential diagnosis: restrictive cardiomyopathy Echocardiogram, computerized tomo- graphy or magnetic resonance imaging: thickened pericardium Treatment: strip it! (surgically)
  32. 32. Pericardial Effusion Normal: 15-50 ml of thin serous fluid Sudden increase: up to 200 ml: OK between 200 and 300 ml: can be fatal Slow increase: up to 2 liters: OK
  33. 33. Cardiac Tamponade Jugular venous distention, muffled heart sounds, hypotension, pulsus paradoxus Echocardiogram: diastolic collapse of right atrium and right ventricle Swan-Ganz: equalization of pressures
  34. 34. Acute Pericarditis Most commonly idiopathic (viral), self-limited to 1-3 weeks with Sharp substernal pleuritic positional pain Pericardial friction rub Diffuse upward concavity ST elevation
  35. 35. Sample Examination Question 1. The pericardial effusion most likely to be fatal is A. Hemorrhagic slowly increased to 1500 ml B. Hemorrhagic suddenly increased to 150 ml C. Serous slowly increased to 2000 ml D. Serous suddenly increased to 100 ml E. Serous suddenly increased to 300 ml
  36. 36. <ul><li>Sample Examination Question </li></ul><ul><li>2. A red granular pericardial surface is </li></ul><ul><li>characteristic of </li></ul><ul><li>Constrictive pericarditis </li></ul><ul><li>Fibrinous pericarditis </li></ul><ul><li>Hemorrhagic pericarditis </li></ul><ul><li>Purulent pericarditis </li></ul><ul><li>Serous pericarditis </li></ul>

×