Diseases of the pericardium

Dr. Akram Beshr

The pericardium:
The normal pericardial sac contains about 50 mL of fluid, similar to
lymph
which lubricates the surface of the heart.
The pericardium limits distension of the heart
Contributes to the hemodynamic interdependence of the ventricles,
and acts as a barrier to infection.
Nevertheless, congenital absence of the pericardium does not result
in significant clinical or functional limitations.
Acute pericarditis
Definition:
This is due to an acute
inflammatory process
affecting the pericardium,
which may coexist with
myocarditis
Clinical features:

 The typical presentation is with chest pain that is retrosternal,

radiates to the shoulders and neck, and is typically aggravated by
deep breathing, movement, a change of position, exercise and
swallowing.
 A low-grade fever is common.
 A pericardial friction rub is a high-pitched, superficial scratching
noise, produced by movement of the inflamed pericardium &
frequently has a ‘to-and-fro’ quality.
Investigations:

 ECG: ST elevation with upward concavity

Investigations:

 Echocardiography: may be
normal or may reveal
pericardial effusion.

 CBC,ESR,CRP
 Pericardiocentesis
Management:
 The pain usually responds to aspirin or indomethacin.
 Colchicine is very effective at relieving symptoms and also prevents
relapsing episodes if taken for 3 months from symptom onset.
 Glucocorticoids are no longer recommended for this condition.only
used if the cause is autoimmune disease or NSAID are contraindicated
or in pregnancy.
 Pericardiocentesis: if large pericardial effusion complicated with
cardiac tamponade or suspected of purulent effusion.
Pericardial effusion
Definition:
Pericardial effusion is a collection of fluid in the pericardial space, often
accompanies pericarditis.
Types of pericarditis effusion:
 A fibrinous exudate effusion: may eventually lead to varying
degrees of adhesion formation
 serous pericarditis effusion: often produces a large effusion of
turbid, with a high protein content.
 A haemorrhagic effusion is often due to malignant disease,
particularly carcinoma of the breast or bronchus, and
lymphoma.
 Purulent pericarditis effusion: is rare and may occur as a
complication of sepsis, by direct spread from an intrathoracic
infection, or from a penetrating injury.
Clinical features:

 With the onset of an effusion the heart sounds may become quieter,
 and a friction rub, if present, may diminish in intensity but is not
always abolished.
 Larger effusions may be accompanied by a sensation of retrosternal
discomfort.
 large or rapidly developing effusions may cause cardiac tamponade.
 Typical physical findings of cardiac tamponade are a markedly raised
JVP, hypotension, pulsus paradoxus
Investigations:

 Echocardiography is the definitive investigation and is helpful in

monitoring the size of the effusion and its effect on cardiac function
 The QRS voltages on the ECG are often reduced in the presence of a
large effusion. The QRS complexes may alternate in amplitude due to
a to-and-fro motion of the heart within the fluid-filled pericardial sac
(electrical alternans).
 The chest X-ray may show an increase in the size of the cardiac
silhouette and, when there is a large effusion
 Aspiration of the effusion may be required for diagnostic purposes
and, if necessary, for treatment of large effusions.
Management:

 Patients with large effusions that are causing haemodynamic

compromise or cardiac tamponade should undergo aspiration of the
effusion.
 Complications of pericardiocentesis include arrhythmias, damage to
a coronary artery and bleeding, with exacerbation of tamponade as a
result of injury to the RV.
 When tamponade is due to cardiac rupture or aortic dissection,
pericardial aspiration may precipitate further potentially fatal
bleeding and, in these situations, emergency surgery is the treatment
of choice.
Tuberculous pericarditis

 May complicate pulmonary tuberculosis but may also be the first

manifestation of the infection.
 The condition typically presents with chronic malaise, weight loss and a low-
grade fever.
 An effusion usually develops and the pericardium may become thick, leading
to pericardial constriction or tamponade.
 An associated pleural effusion is often present.
 The diagnosis may be confirmed by aspiration of the fluid and direct
examination or culture for tubercle bacilli.
 Treatment requires specific antituberculous chemotherapy in addition, a 3-
month course of prednisolone (initial dose 60 mg a day, tapering down
rapidly) improves outcome.
Chronic constrictive pericarditis
Definition:
Constrictive pericarditis is due to progressive thickening, fibrosis and
calcification of the pericardium.
In effect, the heart is encased in a solid shell and cannot fill properly.
The calcification may extend into the myocardium, so there may also be
impaired myocardial contraction.
The condition often follows an attack of tuberculous pericarditis but can also
complicate haemopericardium, viral pericarditis, rheumatoid arthritis and
purulent pericarditis.
Clinical features:

 The symptoms and signs of systemic venous congestion are the

hallmarks of constrictive pericarditis.
 AF is common
 there is often dramatic ascites and hepatomegaly
 Breathlessness is not a prominent symptom because the lungs are
seldom congested.
 The condition should be suspected in any patien with unexplained
right heart failure and apparently normal heart size and function on
echocardiography
Investigations:

 A chest X-ray, which may show

pericardial calcification
 Echocardiography often help to
establish the diagnosis.
 CT scanning is useful for imaging the
pericardial calcification.
Management:

 The resulting diastolic heart failure is treated using loop diuretics and
aldosterone antagonists, such as spironolactone.
 Surgical resection of the diseased pericardium can lead to a dramatic
improvement but carries a high morbidity, especially if performed late
in the disease course, as the pericardium becomes heavily bound to
the myocardium.
Cardiac tamponade
Definition:
This term is used to describe acute heart failure due to compression
of the heart as the result of a large pericardial effusion.
Tamponade may complicate any form of pericarditis but can be
caused by malignant disease, by blood in the pericardial space
following trauma, or by rupture of the free wall of the myocardium
following MI..
Clinical features:

 Patients with tamponade are unwell, with hypotension, tachycardia

and a markedly raised JVP.
Investigations:

 Echocardiography, which can confirm the diagnosis and also helps to

identify the optimum site for aspiration of the fluid.
 The ECG may show features of the underlying disease, such as
pericarditis or acute MI.
 When there is a large pericardial effusion, the ECG complexes are
small and there may be electrical alternans.
 A chest X-ray shows an enlarged globular heart but can look normal.
Management:

 Cardiac tamponade is a medical emergency.

 When the diagnosis is confirmed, percutaneous pericardiocentesis
should be performed as soon as possible, which usually results in a
dramatic improvement.
 In some cases, surgical drainage may be required.
Thank you