Pericardial Diseases


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Pericardial Diseases

  1. 1. Pericardial diseases By Dr. Osman Bukhari
  2. 2. <ul><li>1- The pericardium is a fibrous tissue that </li></ul><ul><li>consist of an inner visceral layer </li></ul><ul><li>attached to the epicardium & outer </li></ul><ul><li>parietal layer . 2- It stabilize the heart in the normal </li></ul><ul><li>position & acts as a barrier to spread of </li></ul><ul><li>infections. </li></ul><ul><li>3- It normally contains 50 ml of serous fluid </li></ul><ul><li>that lubricate the heart . </li></ul>
  3. 3. <ul><li>presentation of pericardial diseases include:- </li></ul><ul><li>1- Pericarditis </li></ul><ul><li>2- Pericardial effusion ( PE) </li></ul><ul><li>3- Constrictive pericarditis (CP) </li></ul>
  4. 4. <ul><li>Pericarditis </li></ul><ul><li>Acute Pericarditis is initially dry & fibrinous, but most causes induce PE . </li></ul><ul><li>Causes:- </li></ul><ul><li>1- Viruses : Coxsackeviruses, echoviruses, others. It lasts few weeks, prognosis is good, but recurrences and sudden death can occur. There may be associated myocarditis. 2 - Rh fever : associated myocarditis and endocarditis. </li></ul><ul><li>3 - Tuberculosis: Sub acute presentation with associated general symptoms. </li></ul>
  5. 5. <ul><li>Pericardial aspiration and biopsy may be required for diagnosis. Effusion is usually serous, but may be blood stained . 4- Post MI or Post pericardiotomy Pericarditis may occur 2-5 days after transmural MI. Dresslers syndrome occurs weeks to months after MI or pericardiotomy. It is autoimmune phenomenon. ESR is high. </li></ul>
  6. 6. <ul><li>5- Uraemia : It is usually terminal, hargic and asymptomatic. It usually resolves with institution of dialysis. Tamponade is fairly common. </li></ul><ul><li>6- Malignant : from invasion of adjacent lung Ca or other Ca. </li></ul><ul><li>7- Pyogenic : purulent pericarditis rarely occur from septicemia, pneumonia, endocarditis and following thoracic trauma & surgery. 8- Radiation </li></ul>
  7. 7. <ul><li>9- Connective tissue diseases . </li></ul><ul><li>10 - Mycoplasma, borrelia, chlamydia, fungal. </li></ul><ul><li>11 - Drugs : INH, procainamide, hydralazine, doxorubicin. </li></ul><ul><li>12- Hypothyroidism 13- Idiopathic . </li></ul>
  8. 8. <ul><li>Clinical presentation : </li></ul><ul><li>1- Chest pain : sharp retrosternal pain increases with deep breathing, change of posture & relieved with leaning forward. It may be referred to the neck & shoulders. </li></ul><ul><li>2- Pericardial friction rub is diagnostic </li></ul><ul><li>3- Fever with viral, bacterial, Rh fever & MI </li></ul><ul><li>4- Symptom & signs of underlying disease. </li></ul><ul><li>5- Sequelae: Cardiac tamponade and constrictive pericarditis (CP) . </li></ul>
  9. 9. <ul><li>Investigations : </li></ul><ul><li>1- ECG : Early ST elevation which is concave upwards. Later ST normalize & T wave become inverted which may persist in chronic pericarditis. No path Q waves or decrease R waves. 2- Leucocytosis in early stages </li></ul><ul><li>3- Raised cardiac enzymes if there is associated myocarditis. </li></ul>
  10. 10. <ul><li>Treatment: </li></ul><ul><li>1 - Bed rest 2- High dose aspirin & NSAIDs </li></ul><ul><li>3- Systemic steroids in severe or recurrent cases. </li></ul><ul><li>4- Azathioprim if resistant to steroids. </li></ul><ul><li>5- Pericardiectomy in refractory cases </li></ul><ul><li>6- Treat za underlying disease e.g. Tb. </li></ul>
  11. 11. <ul><li>Pericardial effusion (PE) </li></ul><ul><li>1 - It may follow any cause of pericarditis </li></ul><ul><li>2- Clinical picture depends on the speed of accumulation. </li></ul><ul><li>3 - Large eff & tamponade restrict venous return & ventricular filling </li></ul><ul><li>4- Tachycardia with pulsus paradoxus </li></ul><ul><li>5- Elevated JVP with kussmaul,s sign . </li></ul><ul><li>6- Low CO, apex difficult to locate & HS are faint & heard distantly </li></ul><ul><li>7- Pericardial rub may be abolished . </li></ul>
  12. 12. <ul><li>8- Increased cardiac dullness with large eff </li></ul><ul><li>9- Systemic congestion with hepatomegaly, ascites & LL edema. </li></ul><ul><li>10- With large eff there is dyspnoea and dullness at za lung bases </li></ul><ul><li>11- Symptoms & signs of underlying dis. </li></ul>
  13. 13. <ul><li>Investigations : </li></ul><ul><li>1- CXR Large globular heart shadow. Pulm veins not distended . </li></ul><ul><li>2- ECG : Low voltage, non specific T change and QRS alternans is pathognomonic 3- Echo is diagnostic & sensitive. </li></ul><ul><li>4- Doppler & MRI. </li></ul><ul><li>5- Diagnostic pericardiocentesis & biopsy </li></ul><ul><li>6- Investigation of underlying disease . * Pericardial aspiration may cause coronary and RV injury, arrhythmia and pneumothorax. </li></ul>
  14. 14. Pericardial effusion
  15. 15. Pericardial effusion
  16. 16. <ul><li>Treatment : 1 - Cardiac tamponade is a medical emergency and must be tapped. 2- Pericardiocentesis if malign, Tuberculos or purulent eff is suspected. 3- Pericardial fenestration for re accumulating effusion </li></ul><ul><li>4- Pericardiectomy for recurrent malign eff </li></ul><ul><li>5- Small eff can be followed up clinically by echo </li></ul><ul><li>6- Treat the underlying disease . </li></ul>
  17. 17. <ul><li>Constrictive pericarditis (CP) </li></ul><ul><li>1- It follows viral, bacterial & Tuberculous pericarditis, radiation, cardiac surgery and haemopericardium </li></ul><ul><li>2- Pericardium is thickened, fibrotic and adherent to epicardium encasing the heart and restricting diastolic filling causing elevated venous pressure. </li></ul>
  18. 18. <ul><li>Clinically: </li></ul><ul><li>1- systemic venous congestion without much breathlessness & pulm venous cong 2- Rapid low volume pulse </li></ul><ul><li>3- Atrial fibrillation in 1/3 </li></ul><ul><li>4- Pulsus paradoxus </li></ul><ul><li>5- Kussmaul’s sign </li></ul><ul><li>6- Loud S3 (pericardial knock) due to rapid ventricular filling </li></ul>
  19. 19. <ul><li>Differential diagn osis include - restrictive pericarditis - cardiac tamponade </li></ul><ul><li>Investigations : </li></ul><ul><li>1- CXR : relatively small heart +/- calcifica </li></ul>
  20. 21. <ul><li>Investigations : </li></ul><ul><li>1- CXR : relatively small heart +/- calcification 2- ECG : low voltage & Tw inversion </li></ul><ul><li>3- Echo : thickened pericardium with calcification & small vent chambers and dilated atria. </li></ul><ul><li>4- CT & MRI </li></ul><ul><li>5- Cardiac catheter in difficult cases. Equal diastolic pressure in all chambers </li></ul>
  21. 22. Pericardial calcification
  22. 23. <ul><li>Treatment : </li></ul><ul><li>1- Slow diuresis initially </li></ul><ul><li>2- Pericardiectomy provides cure. In others persistent constriction, AF and myocardial fibrosis prevent full recovery. </li></ul><ul><li>3- Treat the underlying cause </li></ul>