correlated). 4. It prevents excessive cardiac dilatation.

Transcription

1 Anatomy of Pericardium Functions of Pericardium Pericardial disease 1. Fibrous layer 2. Serous layer: Filled with ~ 50 ml Epicardium: visceral layer that covers the heart Parietal pericardium: reflection of epicardium that covers the fibrous layer 1. It protects and lubricates the heart. 5. Distribution and equalization of hydrostatic forces on heart. 2. It minimizes friction with surroundings. 6. Diastolic coupling (diastolic pressure in two ventricles is 3. It holds it in a fixed anatomical position. correlated). 4. It prevents excessive cardiac dilatation. 7. It retards spread of infection and malignancy from surroundings. 8. It holds proximal portions of the great vessels. Pericardial Diseases Congenital absence of pericardium. Pericardial cyst. Syndromes of pericarditis Syndromes of pericarditis Etiology of of Pericarditis 7 I s: Idiopathic Infection Infarction Irradiation Immunological Iatrogenic Infiltration Pathology Presentation DD of Pericardial Rub 1. Dry 2. Constrictive 3. Adherent Infectious Post- myocardial infarction (worse prognosis) Malignant Uraemic Myxoedema Chylopericardium Autoimmune Viral (Echo, Mumps, Herpes, HIV) Bacterial (Staphylococcus, Streps) Tuberculous Acute myocardial infarction (early) Dressler s syndrome (late Primary tumours of the heart (mesothelioma) Metastatic pericarditis (breast, leukaemia,) Collagen vascular (rheumatoid arthritis, rheumatic fever, SLE) Drug- induced (hydralazine, isoniazid) Post- radiation Post- surgical Post- pericardiotomy syndrome Post- traumatic Familial Idiopathic The most common cause is Idiopathic ( mostly unrecognized Viral Pathology ( Fibrinous) : bread- and- butter Diagnostic Triad: (SSI) à Chest pain+ Friction rub + ECG changes ± General constitutional symptoms FHMA (Fever, headache, malaise, anorexia) Items Symptom Chest pain (SOCRATES) Sign Friction Rub (hallmark of acute pericarditis) (PQRS) S Site Retrosternal / parasternal O Onset Over hours C Character Soreness/ ache / sharp R Radiation Shoulder / scapula / back A Association Pleuritic pain / SOB T Timing Duration / course / pattern 4. Effusion with or without tamponade. 5. Effusive- constrictive (effusion + constriction). Fungal (Histoplasmosis, Candida) Protozoal (Amoeba) Comment E Exacerbation / Lying flate / inspiration / cough / swallowing / sitting up / leaning forward Alleviating S Severity Moderate Item P Pitch High- pitched ( press with diaphragm), sitting, leaning forward, inspiration increases it Q Quality Superficial, leathery,, transient (fleeting), gallop- like, very loud rubs can be palpable R Radiation No or little radiation S Site Pulmonary area, lower left sternal edge T Timing 3 components (ventricular systole, diastole, atrial systole) nb It sounds like two pieces of sandpaper rubbed against one another. Transient, fleeting. Does not disappear on holding up respiration (DD pleurisy) Scratching Crackling (making a snapping sound) Creaking (squeak, making a harsh sound) Crunchy (making a crackly sound) Grating (making a harsh or abrasive noise) Scraping Squeaky (making short, high sound) ECG PR segment Knuckle- shaped depression & ST segment Saddle- shaped elevation PR- segment depression is virtually pathognomonic for acute pericarditis CXR Associated pleural effusion Echo/Doppler Associated pericardial effusion Echocardiography is neither sensitive nor specific for the diagnosis of acute pericarditis. Pleural rub: Stop breathing ( pleural ceases but pericardial remains). Both are heard in o Viral pleuropericarditis. o Post- myocardial infarction (Dressler's) syndrome Other causes of Lots of Noise: (SYSTOLO- DIASTOLIC MURMUR) o PDA murmur. o To- and- fro murmur of AR o Murmur of combined AS and AR. o VSD with AR. o Severe MR with high- flow diastolic rumble. 1. Symptomatic: Analgesia for pain 2. Specific: o Steroids for rheumatic diseases o Colchicine for recurrent, idiopathic form o Anti- TB with steroids

2 Hemodynamics of Pericardial Effusion Symptoms & Signs Pericardial Effusion Type Fluid Causes Transudation Water Generalized anasarca as heart failure Exudation Serofibrinous Inflammatory (all causes of pericarditis) Hemorrhagic Serous + blood TB, AMI, uremia, malignancy Suppurative Pus Pyogenic infections Hemopericardium Pure blood Trauma, rupture heart (AMI), rupture dissecting aortic aneurysm Chylopericardium Chylous Thoracic duct obstruction or injury 1. Depends on amount and rate of accumulation 2. Massive, slowly accumulating may cause no effects. 3. Small, rapidly accumulating causes an increase in intrapericardial pressure which interferes with cardiac filling causing cardiac tamponade. 4. It compresses the right side more. 1. Pain: of pericarditis or dull ache due to pericardial distension. 2. Dyspnea & orthopnea: relieved by sitting up and leaning forwards. 3. Compression of surroundings: Symptoms Cough (trachea) Dysphagia (esophagus) Hoarseness of voice (LRLN 1. General: FHMA 2. Local: (Heart) Inspection: precordial bulge in children Palpation: invisible and impalpable apex Percussion: o Increase area of cardiac dullness o Dullness in 2nd left space disappeared by sitting up (shifting dullness) Signs o Dullness outside apex o Dullness to the right of sternum o Stony dullness at lower end of sternum o Wide bare area Auscultation: o Faint and distant heart sounds o Sinus tachycardia 3. Local: (left lung) Ewart,s sign (dullness & bronchial breathing below inferior angle of left scapula) Complications 1. Cardiac tamponade. 2. Constrictive pericarditis. X- ray heart and chest. Globular or flask- shaped heart. ECG (low voltage, ST- T wave changes, electrical alternans). Echocardiography. Chemical & bacteriological study of pericardial fluid. Blood tests: viral markers, autoimmune markers, CRP, etc. X- Ray Heart and Chest Cardiomegaly Flask- shaped heart (narrow base) Acute right costo- phrenic angle Sharply defined, immobile border Normal lung vessels Decreased pulsations of cardiac borders with fluoroscopy Echocardiography Diagnostic Bedside Detect amount Guide aspiration Follow progress

3 Definition Cardiac Tamponade (Compression) Medical emergency caused by accumulation of fluid in an amount sufficient to cause serious obstruction to diastolic ventricular filling. Amount: < 200 ml when collects rapidly > 2000 ml when collects slowly causing pericardial stretching. Cardiac tamponade results in: Low COP & congestion in systemic and pulmonary veins. Pathologic Physiology Symptom and sign Clinical Diagnosis Echocardiography All symptoms of pericardial effusion. Low COP symptoms. Symptoms of systemic venous congestion. Symptom Beck,s triad: Falling arterial pressure + rising venous pressure + small, quiet heart. Seen only with acutely developing tamponade as cardiac trauma or rupture. All signs of pericardial effusion. Low COP signs: small pulse volume, hypotension, tachycardia. Signs of systemic congestion: Marked neck vein congestion Enlarged tender liver Ascites precox Sign Edema of lower limbs Pulsus paradoxus : decrease in SBP > 10 mm Hg with normal inspiration. Kaussmaul s sign = inspiratory filling of neck veins. Prominent X- descent with diminutive or absent y descent. Tetrad 1. Tachycardia 3. Distended neck veins 2. Dyspnea/tachypnea 4. Clear lungs 1. Decrease SBP Beck s triad 2. Distended neck veins 3. Distant heart sounds (Small, quiet heart) 4. Seen only with acutely developing tamponade as cardiac trauma or rupture. Tamponade is a clinical diagnosis. It shows location of effusion. Swinging heart (Like watch pendulum). RV collapse in diastole. RA collapse. It identifies the best access route for drainage. Total electrical alternans (involving P- QRS- T) is pathognomonic of cardiac tamponade. ECG Lead II in Tamponade Pre- and post- pericardiocentesis DDX Marked Cardiomegaly. Constrictive Pericarditis. 1. Specific treatment of underlying etiology. 2. Pericardiocentesis: Diagnostic/Therapeutic ( in cardiac tamponade, it is urgent) 3. Surgical: pericardiectomy or pericardio- pleural window

4 Definition Postpericardial Injury Syndrome (PPIS) Recurrent pericarditis or pericardial effusion that results from injury of the pericardium or underlying myocardium. Synonyms and causes 1. Post- pericardiotomy 2. Post- myocardial infarction syndrome (Dressler's Syndrome) 3. Traumatic (blunt, sharp, or iatrogenic) pericarditis 1. Following myocardial injury or AMI, myocardial antigens are exposed and/or released, and, in some cases, an immune complex can form. Mechanism 2. This immune activation triggers a local inflammatory reaction, and may involve remote organs such the pleura and synovia, due to molecular mimicry and immune cross- reactions. 3. The time needed for the immune reaction to develop may account for the observed latency period of 2 to 3 weeks between the AMI and the onset of DS. Clinical features Post- Infarction Pericarditis 1. Prior injury of the pericardium, myocardium, or both 2. A latent period (2-10 weeks) between the injury and the development of pericarditis or pericardial effusion 3. A tendency for recurrence 4. Responsiveness to NSAIDs and corticosteroids Usual early form Within a week. 20% of transmural myocardial infarction. Pericardial irritation by adjacent infarcted myocardium. NSAIDs: ibuprofen (increase coronary blood flow) / ASA. Steroids 5. Fever, leukocytosis, and ESR (and other markers of inflammation) 6. Pericardial and sometimes pleural effusion, with or without a pulmonary infiltrate 7. Alterations in the populations of lymphocytes in peripheral blood Late (delayed) autoimmune rxn (Dressler's Syndrome): 2 weeks- few months after infarction. Similar to postcardiotomy syndrome. Definition Etiology Pathologic Physiology Symptoms General Signs Cardiac Signs Constrictive pericarditis Thickening, fibrosis, fusion of visceral with the parietal pericardium and finally calcification which constricts the heart. It imprisons the heart. Most cases are idiopathic. Recurrent viral, bacterial, uremic. Post- cardiac surgery. Radiation. Connective tissue diseases Healing TB pericarditis ( a common cause in the past). 1. Rigid pericardium interferes with filling in late but not in early diastole. 2. Filling is reduced abruptly when the elastic limit of the pericardium is reached. 3. Nb: in cardiac tamponade, the filling is impeded throughout diastole. Resembles CHF, but not due to heart failure. Low COP symptoms. Symptoms of systemic venous congestion. Pulmonary congestive symptoms are not prominent. Acute pulmonary edema never occurs. Pulse Small volume Pulsus paradoxus Atrial fibrillation Neck veins /Abdomen Marked congestion Kussmaul,s sign Marked X- descent Deep Y- descent (Friedreich s sign) 1. Systolic retraction of apex beat and parasternal area. 2. Pericardial Knock 3. Weak heart sounds. 4. Small, quiet heart Enlarged tender liver Ascites precox Edema lower limbs Pericardial Knock Definition Sharp, loud, high- pitched, early diastolic sound. Sudden distension of ventricles against thick, rigid pericardium. Genesis It coincides with early diastolic filling. It is considered as loud S3. Causes Constrictive pericarditis. Complications Cardiac cirrhosis Atrial fibrillation Protein loosing enteropathy Marked proteinuria/ nephrotic syndrome 1. ECG: low- voltage, negative or flat T- waves, P mitrale. 2. CXR: normal or small- sized heart, calcified pericardium best seen in lateral view, clear lungs. 3. Echocardiography: 2D and Doppler (restrictive pattern). 4. MRI & CTS :pericardial thickening > 5 mm thickness. 5. Cardiac catheterization: equal pressure in all cardiac chambers, deep Y descent, square- root sign) 6. Angiography Pericardiectomy is the only definitive treatment. Medical: Salt restriction Diuretics Digitalis for AF and heart failure Anti- TB + steroids for TB

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