The document discusses various pericardial diseases including pericarditis, pericardial effusion, and constrictive pericarditis. Pericarditis can be caused by viruses, tuberculosis, after a myocardial infarction, or be idiopathic. Pericardial effusion can follow pericarditis and cause cardiac tamponade if large. Constrictive pericarditis occurs when the pericardium thickens and restricts heart filling, causing elevated venous pressures. Investigations include echocardiogram, CT, and cardiac catheterization. Treatment involves drainage of effusions, pericardiectomy, or treating the underlying cause.

1. Pericardial diseases By Dr. Osman Bukhari

2. 1- The pericardium is a fibrous tissue that consist of an inner visceral layer attached to the epicardium & outer parietal layer . 2- It stabilize the heart in the normal position & acts as a barrier to spread of infections. 3- It normally contains 50 ml of serous fluid that lubricate the heart .

3. presentation of pericardial diseases include:- 1- Pericarditis 2- Pericardial effusion ( PE) 3- Constrictive pericarditis (CP)

4. Pericarditis Acute Pericarditis is initially dry & fibrinous, but most causes induce PE . Causes:- 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. 3 - Tuberculosis: Sub acute presentation with associated general symptoms.

5. 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.

6. 5- Uraemia : It is usually terminal, hargic and asymptomatic. It usually resolves with institution of dialysis. Tamponade is fairly common. 6- Malignant : from invasion of adjacent lung Ca or other Ca. 7- Pyogenic : purulent pericarditis rarely occur from septicemia, pneumonia, endocarditis and following thoracic trauma & surgery. 8- Radiation

7. 9- Connective tissue diseases . 10 - Mycoplasma, borrelia, chlamydia, fungal. 11 - Drugs : INH, procainamide, hydralazine, doxorubicin. 12- Hypothyroidism 13- Idiopathic .

8. Clinical presentation : 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. 2- Pericardial friction rub is diagnostic 3- Fever with viral, bacterial, Rh fever & MI 4- Symptom & signs of underlying disease. 5- Sequelae: Cardiac tamponade and constrictive pericarditis (CP) .

9. Investigations : 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 3- Raised cardiac enzymes if there is associated myocarditis.

10. Treatment: 1 - Bed rest 2- High dose aspirin & NSAIDs 3- Systemic steroids in severe or recurrent cases. 4- Azathioprim if resistant to steroids. 5- Pericardiectomy in refractory cases 6- Treat za underlying disease e.g. Tb.

11. Pericardial effusion (PE) 1 - It may follow any cause of pericarditis 2- Clinical picture depends on the speed of accumulation. 3 - Large eff & tamponade restrict venous return & ventricular filling 4- Tachycardia with pulsus paradoxus 5- Elevated JVP with kussmaul,s sign . 6- Low CO, apex difficult to locate & HS are faint & heard distantly 7- Pericardial rub may be abolished .

12. 8- Increased cardiac dullness with large eff 9- Systemic congestion with hepatomegaly, ascites & LL edema. 10- With large eff there is dyspnoea and dullness at za lung bases 11- Symptoms & signs of underlying dis.

13. Investigations : 1- CXR Large globular heart shadow. Pulm veins not distended . 2- ECG : Low voltage, non specific T change and QRS alternans is pathognomonic 3- Echo is diagnostic & sensitive. 4- Doppler & MRI. 5- Diagnostic pericardiocentesis & biopsy 6- Investigation of underlying disease . * Pericardial aspiration may cause coronary and RV injury, arrhythmia and pneumothorax.

14. Pericardial effusion

15. Pericardial effusion

16. 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 4- Pericardiectomy for recurrent malign eff 5- Small eff can be followed up clinically by echo 6- Treat the underlying disease .

17. Constrictive pericarditis (CP) 1- It follows viral, bacterial & Tuberculous pericarditis, radiation, cardiac surgery and haemopericardium 2- Pericardium is thickened, fibrotic and adherent to epicardium encasing the heart and restricting diastolic filling causing elevated venous pressure.

18. Clinically: 1- systemic venous congestion without much breathlessness & pulm venous cong 2- Rapid low volume pulse 3- Atrial fibrillation in 1/3 4- Pulsus paradoxus 5- Kussmaul’s sign 6- Loud S3 (pericardial knock) due to rapid ventricular filling

19. Differential diagn osis include - restrictive pericarditis - cardiac tamponade Investigations : 1- CXR : relatively small heart +/- calcifica

21. Investigations : 1- CXR : relatively small heart +/- calcification 2- ECG : low voltage & Tw inversion 3- Echo : thickened pericardium with calcification & small vent chambers and dilated atria. 4- CT & MRI 5- Cardiac catheter in difficult cases. Equal diastolic pressure in all chambers

22. Pericardial calcification

23. Treatment : 1- Slow diuresis initially 2- Pericardiectomy provides cure. In others persistent constriction, AF and myocardial fibrosis prevent full recovery. 3- Treat the underlying cause