very basic but detailed presentation on pericardial diseases with the help of animated images..

1. THE PERICARDIAL
DISEASES
DR ARPAN SINGH CHOUHAN

2. ANATOMY

3. LAYERS OF HEART

4. PERICARDIUM

5. CUT SECTION

6. FUNCTIONS
• MECHANICAL:
Effects on chambers
 Limits short-term cardiac distention.
 Facilitates cardiac chamber coupling and interaction.
 Maintains pressure-volume relation of the cardiac
chambers and output from them.
 Maintains geometry of left ventricle.

7. FUNCTIONS
Effects on whole heart
Lubricates, minimizes friction
Equalizes gravitation and inertial
hydrostatic forces.
Mechanical barrier to infection

8. FUNCTIONS
• Immunologic
• Vasomotor
• Fibrinolytic
• Modulation of myocyte structure and
function and gene expression
• Vehicle for drug delivery and gene therapy

9. Protecting the heart from other diseases which are caused by
the neighboring organs: inflammation , TB, cancer etc

11. PHYSIOLOGY
• Chronicity and STRESS RELAXATION.
• Pericardium adapts to creep (increase in
volume with contrast stretch)and cellular
hypertrophy.

12. CLASSIFICATION
• Congenital defect
• Pericarditis
– ACUTE PERICARDITIS.
– PERICARDIAL EFFUSION.
– CONSTRICTIVE PERICARDITIS.
– RESTRICTIVE PERICARDITIS.
• Pericardial neoplasm
• Pericardial cysts

15. COMPARISION

16. ACUTE PERICARDITIS
• ACUTE INFLAMMATION OF THE PERICARDIUM
IN LESS THAN 6 WEEKS.
• Also called ACUTE FIBRINOUS or DRY
PERICARDITIS and is a syndrome
characterised by:
1. Chest pain
2. Pericardial frictional rub
3. Specific ECG changes.

18. Chest pain
• SHARP
• RETROSTERNAL
• RADIATING TO THE TRAPEZIUS RIDGE
• AGGRAVATED BY LYING DOWN
• RELIEVED BY SITTING UP
• ONSENT IS FREQUENTLY HERALDED BY APRODOME
OF FEVER,MALAISE AND MYALGIA.
• WORSENS WITH INSPIRATION.

19. Pericardial frictional rub
• Hallmark finding
• Evanescent
• Superficial
• Creaky
• Scratchy character
• Sounds like walking on dry snow or the squeak of
a leather saddle.
• In uncomplicated pericarditis JVP ususally emains
normal.

20. ECG
• Helps in Confirming the clinical suspicion.
• Use of serial tracing to distinguish from ST elevations
caused by pericarditis than in MI or normal early
repolarisation.
FIRST STAGE:
• ST-T elevation
• Depression of PR segment (except in lead AVR)

21. SECOND STAGE:
The ST segment comes back to baseline ; at this point
T waves may appear normal or exhibit a loss of
amplitude.
THIRD STAGE:
Tracing show T inversion,particularly with
tuberculous,uremic, or neoplastic pericarditis.
ECG normalises in the variably FOURTH STAGE.

22. ECG
Twelve-lead electrocardiogram from a patient with acute pericarditis. Reproduced with permission
from
Hoit BD. Pericardial disease and pericardial heart disease. In: O’Rourke RA, ed. Stein’s Internal
Medicine. 5th ed. St. Louis,
MO: Mosby-Year Book; 1998:273.

23. Labs and Imaging
• CXR-Normal (Uncomplicated)
• However an enlarged cardiac silhoutte can be seen
creating a flask shape dullness due to mod or large
effussion and presents as water bottle sign.
• .

25. • 2decho -given class ! Recommendation by a
2003 task force of the ACC and AHA.
• Helpful in confirming clinical diagnosis and
estimation of volume of pericardial fluid.
• ESR and TLC – increased

26. • Patients with extensive epicarditis
occassionally have increased serum cardiac
isoenzymes suggestive of MI.
• In one series nearly half of all patients
presenting with acute ,idiopathic pericarditis
had Trop I levels increased,half of which were
within the range considered for acute MI(1).

27. PERICARDIAL EFFUSSION
• Causes: Accumulation of
exudates,transudates or blood in pericardial
sac are common complications of pericardial
disease.
• Effussion is reported with following
conditions:
• HEART FAILURE
• VALVULAR DISEASES
• MYOCARDIAL INFARCTION

28. • Pericardial effussion is also caused by
lymphatic obstruction and limited drainage
resulting in heart failure and hypertrophy.
• Common after cardiac surgery.
• A retrospective study was done in which only
48 developed large or moderate effussion out
of 4500.

29. • Prevelance is more common in female
patients,patients undergoing valvular heart
surgery and patients with preoperative
anticoagulants have more prodominance of
tamponade.

30. • Echo guided pericardiocentensis are safe and
effective for detection of pericardial effussion.
• Other conditions causing effussive pericarditis
are:
• Uraemia
• Tuberculosis
• Neoplasia
• Connective tissue disorders.

31. NATURE OF PERICARDIAL FLUID
• Although culture and cytology are not specific
for diagnosis,however in certain situations it
becomes mandatory to determine the nature
of pericardial fluid.(neoplasia)
• In case of bacterial and non viral infection it is
necessary to detect wether it is exudative
particularly in fungal and tubercular
pericarditis.

32. HAMEMORRHAGIC EXUDATIVE TRANSUDATIVE
INTRAPERICARDIAL
BLEEDING
INFECTION HEART FAILURE
SANGINOUS EFFUSSIONS SALT RETENTION
SERO SANGINOUS
EFFUSSIONS.
WATER RETENTION
PREGNANCY
CHYLOUS PERICARDITIS IS SEEN IN OBSTRUCTION TO THORACIC DUCT.
CHOLESTEROL PERICARDITIS IS SEEN IN HYPOTHYROIDISM,RHEAUMATOID ARTHRITIS
AND TUBERCULOSIS.

33. DIAGNOSIS
• 2decho-on M MODE is persistance of a echo
free space between parietal and visceral
pericardium throughout the cardiac cycle.
• Fluid adjacent to right atrium is early sign of
pericardial effussion
• As the amount of pericardial fluid increases
fluid distributes over posterobasilar LV apically
and anteriorly than laterally and posterior to
left atrium.

34. • Pericardial fluid resembles epicardial fat.
• How to differentiate?
• Epicardial fat is more prominent anteriorly but
appear circumferentially,fat is echolucent and
motionless.
• Pericardial fluid is echogenic and moving.
• CT SCAN is useful in detecting pericardial fluid and
obtaining geometry,size and distribution of
pericardial fluid.and also helpful to estimate
haematocrit of pericardial effussion.
• MRI detects effussion with high sensitivity and
provides volume.

36. TREATMENT
• Pericardial effussion drainage has a very less
importance unless the effussion cause is
uncertain and warrants pericardiocentensis.
• Anticoagulants should be discontinued
temporarily to reduce the risk of cardiac
tamponade.
• Heparin should be used because of its effect and
reverses rapidly.
• Unexplained effussion should be evaluated
thoroughly to exclude haemorrhage.large
effussion responds to NSAIDS,corticosteroids and
colchicines.

37. Cardiac tamponade
• “Compression of all cardiac chambers
• due to excessive accumulation of
• pericardial fluid leading to
• compromised cardiac output”

38. • It is a haemodynamic condition characterised
by equal elevation of atrial and pericardial
pressures, an exaggerated inspiratory
decrease in atrial systolic pressures(pulsus
paradoxus),and arterial hypotension.
• As intrapericardial pressure rises, venous
pressure increase to maintain cardiac filling
and prevent collapse of cardiac chambers.

39. CAUSES
• Malignancy
• Infection - Viral, bacterial (tuberculosis), fungal
• Drugs - Hydralazine, procainamide, isoniazid, minoxidil
• Postcoronary intervention (ie, coronary dissection and
perforation)
• Trauma
• Cardiovascular surgery (postoperative pericarditis)
• Postmyocardial infarction (free wall ventricular rupture,
Dressler syndrome)
• Connective tissue diseases - Systemic lupus
erythematosus, rheumatoid arthritis, dermatomyositis
• Iatrogenic - After sternal biopsy, transvenous pacemaker
lead implantation, pericardiocentesis, or central line
insertion
• Uremia

40. • Should always be suspected in a patient of
recent chest trauma who appears to be in
shock ,specially when the venous pressure is
elevated.
• Other causes of acute tamponade are cardiac
rupture complicating acute mi and rupture of
a dissecting haematoma of the proximal aorta.

41. PATHOPHYSIOLOGY
 Pericardial fluid > increase intrapericardial
pressure
Intrapericardial pressure equalizes RV diastolic
Pressure
Then equalizes LV diastoilic pressure
Drop in cardiac output

43. TYPES
• Depending upon duration
• Acute
• Subacute
• Chronic
• Depending upon volume of effusion
• Mild
• Severe
• (severe cardiac tamponade produces symptoms)

44. SYMPTOMS
• Dyspnea, Chest pain, Abdominal pain, Fatigue,
Fever, Cough, Weakness, Palpitation.
• Tamponade may be so sudden that the
patient does not complain of symptoms : in
less drastic circumstances,patients with acute
cardiac tamponade may complain of severe
shortness of breath accompanied by chest
tightness and dizziness.

45. SIGNS

46. • PULSUS PARADOXUS-

49. • JVP-
• Loss of y descent and persistence of x descent.

51. • Kussmaul sign- a failure of venous
pressure to decrease during inspiration, is a
sign of constriction and is generally not seen
in pure cardic tamponade.

52. DIAGNOSIS
• Ecg-low voltage ecg or electrical alternans
suggest cardiac tamponade.
• However,electrical alternans is insensitive,
occurring in approximately 20% of
instances.when effusion is massive the heart
swings freely within the pericardial sac and
acquires a pendular,rotary motion that is
associated with electrical alternans.

54. • When cardiac tamponade complicates a
procedure,vague discomfort, generalised
uneasiness and precordial pain are common.
• Fluoroscopy shows an enlarged cardiac
silhouette and diminished pulsations.

56. 2DECHO

57. Emergency subxiphoid percutaneous drainage
A 16- or 18-gauge needle,
angle of
30-45° to the skin, near
the left xiphocostal angle,
aiming
towards the left shoulder
Mortality rate of
approximately 4%,
complication rate of 17%