MYOPERICARDITIS

Bernardo D. Morantte Jr M.D. Dept. of Medicine College of Medicine Pamantasan Ng Lungsod Ng Maynila

Pericardium
• It is the sac like protective covering of the heart which consist of the visceral and parietal components • It is a collagen like material just like the pleura and the lining of the joints. Hence in collagen vascular diseases the pericardium is frequently affected. • Normally there is a negligible amount of fluid in the pericardial sac.

Congenital Absence of the Pericardium
• Absence of part of the pericardium usually involves the left half but it can also affect the right half. • It results in the herniation of the heart to the left hemi-thorax. • Herniation of the left atrium with strangulation is a fatal complication. Symptoms • Atypical chest pains • Palpitations

Key findings in congenital absence of the left hemipercardium
PE : the PMI or apical impulse is displaced to the left. EKG: left axis deviation and poor R/S progression in the precordial leads. Chest x-ray: the heart is displaced to the left hemithorax. Echocardiogram: • the parietal pericardium is not distinct or is absent. • Herniation of the left atrium with strangulation. THERAPY: Surgical repair

Chest x-ray

Myopericarditis
• It is the inflammation of the pericardium which also frequently involves the myocardium. Abnormal amount of fluid may accumulate in the pericardial sac. It must be distinguished from Acute endocarditis Cardiac tamponade is the accumulation of large amount of fluid in the pericardial sac with compression of the heart.

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Types of Pericarditis 8. Acute 9. Chronic

Causes of Acute Pericarditis
1. Infectious a. Viral _ (most common) ex. Coxsackie B, Echo virus, adenovirus, influenza b. Bacterial (as in pneumonias) c. Fungal in immunosuppressed patients (AIDS, Anti-cancer drugs) d. Parasitic in endemic areas 7. Drug induced a. Hydralazine d. Dilantin b. Procainamide e. Methysergide c. INH 11. Acute MI 12. Post myocardial infarction pericarditis _Dressler’s syndrome. ( Needs to be distinguished from recurrence of angina following an Acute STEMI).

Causes of Acute Pericarditis
• • • • • • Postcardiotomy syndrome Uremia* Collagen vascular diseases_ Lupus, scleroderma, rheumatoid arthritis. Radiation Cardiac transplant rejection Cholesterol and chylomicron induced

Causes of Chronic Pericarditis
a. TB pericarditis b. Neoplastic _ usually from metastatic CA but maybe primary as in mesothelioma. It is frequently recurrent and effusive. c. Myxedema d. Chronic renal failure

Causes of Cardiac tamponade
1. Any of the above causes 2. Anti-coagulants _ ASA, Warferin, Heparin 3. After CABG due to leak in the arterialvenous anastomosis 4. Cardiac rupture post MI 5. Trauma 6. Hematological disorders ex. thrombocytopenia, hemophilia

Pneumopericardium
• It is the presence of air in the pericardial sac. Causes: 3. Trauma 4. Pneumothorax 5. Postcardiotomy as in CABG Key Finding: The presence of mediastinal crunch and subcutaneous emphysema

Symptoms of pericarditis
• • • • • Pleuritic type of chest pain Fever Dyspnea / easifatigability Palpitations due to cardiac arrhythmias Systemic manifestations of collagen vascular disease such as arthralgias and myalgias

PE findings in pericarditis
• • • Vital signs: febrile, tachycardia, hypernea Presence of a pericardial rub Signs of Cardiac tamponade: a. Borderline BP/ hypotension b. Jugular veins are distended and full (Kausmaul sign in chronic pericarditis) c. Pulsus paradoxus Evidence for arthritis such as joint swelling, rashes Petechiae and hemorrhagic spots

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Diagnostic tests
1. EKG: “Hang up” of the ST segment (diffuse) Non specific T wave changes / T wave inversion. A-Fib, SVT, VT 2. Chest x-ray: Globular enlargement of the heart Accompanying pleural effusion and pulmonary infiltrates. Calcification in the pericardium 3. Echocardiogram: Fluid in the anterior and posterior pericardial space Pericardial thickening if chronic. 4. MRI _ thickened pericardium and fluid space

Other diagnostic tests
To determine the etiology 5. CBC, Sed rate, C- reactive protein 6. Serology: ANA and RA titers, cold agglutinins, viral titers 7. Pericardial fluid analysis a. cell count b. protein content to determine whether it is an exudate or transudate* c. AFB smear and culture d. cell culture and cytology To determine hemodynamic status 8. Cardiac catheterization to establish the presence of pericardial constriction.

Treatment of Pericarditis
1. 2. 3. 4. 5. 6. Relief of pain Discontinue causative drugs such as: Hydralazine, Procainamide, ASA, Warferin, Heparin Specific Rx: Anti-viral, antibacterial, anti-fungal and anti-parasitic agents NSAID Steroids for resistant or recurrent pericarditis Anti-arrhythmic agents: a. Digoxin for control of atrial fib. b. Calcium channel blockers such as Deltiazem and Verapamil. c. Betablockers _ be aware of contraindications d. Quinidine for conversion to sinus rhythm Therapy of specific conditions such as: myxedema, collagen vascular disease and hematological or bleeding disorders. Pericardiocentesis for cardiac tamponade Pericardiectomy of chronic constrictive pericarditis.

12. 13. 14.

Pericardiocentesis
• Pericardiocentesis is the removal of pericardial fluid by needle aspiration.

Method: 1. EKG guided 2. Ultrasound guided 3. Blind aspiration in an emergency situation Indications: 9. Relief of cardiac tamponade 10. To obtain fluid sample for analysis if fluid sample is not available anywhere else such as in the pleura.

Technique of pericardiocentesis
Semi-recumbent position
45 0

sternum

EKG

Drainage bag

Syringe and metallic needle

Complications of Pericardiocentesis
1. 2. 3. 4. 5. Sinus bradycardia or AV block Hypotension Cardiac arrest Cardiac tamponade Infection with improper sterile technique

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