PERICARDIAL DISEASES

Sadhika Kairamkonda
M.Sc. CCT 2nd yr.
Layers of pericardium
 Pericardial Effusion
Pericardial effusion ("fluid around the heart") is an abnormal
accumulation of fluid in the pericardial cavity.
Because of the limited amount of space in the pericardial
cavity, fluid accumulation leads to an increased intrapericardial
pressure which can negatively affect heart function.
Normal levels of pericardial fluid are from 15 to 50 mL.
 Causes
Infection :- viral, bacterial.
Malignancy :- metastasis
Trauma :- accidental, surgical.
Auto-immune :- rheumatoid arthritis.
Metabolic :- uremia ,myxedema.
Toxic :- drug-induced.
Infarction :- post-MI (Dressler’s syndrome)
 Dressler’s Syndrome
• A secondary form of pericarditis that occurs in the
setting of injury to the heart or the pericardium
which is (the outer lining of the heart, is called
Dressler syndrome.
• It consists of pleuritic pain, fever, pericarditis and/or
a pericardial effusion.
• Dressler syndrome occurs in about seven percent of
myocardial infarctions, and composes of a
pericarditis (usually evidenced by a pericardial
friction rub), constant low-grade fever, and/or a
pericardial effusion.
 Signs and Symptoms
Shortness of breath or difficulty breathing
(dyspnea)
Discomfort when breathing while lying down
(orthopnea)
Chest pain
Cough
Rapid heart rate
Hypotension
 Diagnosis

Chest X- ray can be normal in small

increase in pericardial fluid.
Enlarged cardiac silhouette (money-
bag appearance)
 2D Echo for Pericardial effusion
Pericardial effusion creates an
echo-free space posteriorly
between the LV posterior wall
and the pericardium as well
as anteriorly between the RV
free wall and the anterior
chest wall.
Posterior accumulation of
fluid precedes collection of
fluid in the anterior space.
 Cardiac Tamponade
Cardiac tamponade is a serious clinical situation in which
ventricular filling and cardiac output are impaired.
These hemodynamic changes are due to an external pressure
exerted on the heart by a large pericardial effusion.
Tamponade results from a large effusion or rapid
accumulation of a small effusion.
 Causes
Malignancy
Infection - Viral, bacterial, fungal
Drugs - Hydralazine, procainamide.
Trauma
Cardiovascular surgery (postoperative pericarditis)
Connective tissue diseases - rheumatoid arthritis
Uremia
 Sign and Symptoms
Anxiety
Chest pain that gets worse with deep breathing or coughing.
Discomfort, sometimes relieved by sitting upright or leaning
forward.
Fainting
Palpitations
Rapid breathing
Swelling of the abdomen or other areas
Beck’s triad
 Diagnosis
Chest x-ray
Enlarged cardiac silhouette, water bottle shaped heart.
2D Echo for Cardiac tamponade
• Pericardial effusion,
collapse of the right
ventricular, Swinging of
the heart in its sac.

• The heart swings because

of undulation of chambers
caused by displacement of
fluid .
 M-mode
• The right ventricular free
wall moves towards the
inter-ventricular septum
in diastole, obliterating
the right ventricular
cavity .
M- mode scan of the ventricles showing
diastolic collapse of the RV
 Pericardiocentesis
Pericardiocentesis is a procedure that uses a needle to
remove fluid from the pericardial sac.
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%
Pericardiocentesis process
 Risks
Bleeding
Collapsed lung
Heart attack
Infection (pericarditis)
Irregular heartbeats (arrhythmias)
Pneumopericardium (air in the pericardial sac)
 Constrictive Pericarditis
Constrictive pericarditis is a chronic inflammation of the
sac-like covering of the heart (the pericardium).
In pericardial constriction, the pericardium becomes
fibrotic, thick, rigid and often calcific.
Constrictive pericarditis limits the expansion of the
ventricles and thus impairs diastolic filling.
 Causes
Tuberculosis
Connective tissue disorders
Malignancy
Trauma and post-cardiac surgery
Uraemia
Other infection - bacterial, viral
Idiopathic
 Signs and Symptoms

Chest pain
Breathing difficulty that develops slowly and
becomes worse.
Fatigue
Swollen abdomen
Chronic, severe swelling in the legs and ankles.
Weakness
 Chest X-ray
Pericardial calcification can be seen
2D Echo and M-mode for constrictive pericarditis
Calcified pericardium
Abnormal LV filling pattern
Abnormal septal motion
Dilated IVC due to raised systemic
venous pressure.
On M-mode, the thickened
pericardium appears as a dark thick
echo line or as multiple discrete
parallel lines.
Findings depends upon the gain-
setting of the echo machine.
 On abdominal sonography, there is –
 Hepatomegaly

 Dilatation of hepatic veins

 Splenomegaly and

 Ascites
Mitral inflow velocities examination
Pulsed wave Doppler (PW-Doppler) allows the
measurement of velocities at the level of the
sample volume.
Two flow velocity envelopes can be seen during
diastole in persons with sinus rhythm: the E- PW-Doppler sample volume is placed at
wave, representing the early, passive filling of the the tips of the mitral valve in the left
ventricle.
left ventricle, and the A-wave, that happens late
in diastole, representing the active filling, the
atrial contraction.
Left: pulsed wave (PW) Doppler
spectral display shows an E-wave with
higher velocities, as well as an end-
diastolic A-wave with lower velocities.

Right: an A-wave twice as large as the

E-wave indicates impaired LV
relaxation.
 Doppler Echo
On doppler echo, the MV inflow trace shows of a
restrictive pattern diastolic left ventricular filling.
There is increase in early diastolic velocity with rapid
deceleration resulting in a tall E wave and a very small A
wave.
There is exaggerated respiratory variation of MV and TV
inflow velocity.
MV E wave amplitude decreases by more than 25% in
inspiration and TV E wave decreases by more than 25%
during expiration.
 Acute Pericarditis

Inflammation of pericardium.
Has numerous causes-may be associated
pericardial effusion.
Acute pericarditis may be recurrent.
 Causes
Idiopathic causes
Infectious conditions, such as viral, bacterial
Inflammatory disorders, such as scleroderma, and
rheumatic fever
Metabolic disorders, such as renal failure,
hypothyroidism, and hypercholesterolemia
Cardiovascular disorders, such as acute MI, Dressler’s
syndrome
Trauma
 Signs and Symptoms
Chest pain
Shortness of breath
Heart palpitations
Fatigue or feeling sick
Cough
Abdominal or leg swelling
 Diagnosis
ECG diagnostics showing ST elevation with a saddle shaped
concave upwards ST segment.
 2D Echo for Acute Pericarditis

• There may be a pericardial

effusion.
• Thickened pericardium
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