Pericardium

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Pericardium

• A. Rüçhan Akar
• Ankara University School of Medicine
• Department of Cardiovascular Surgery
• January-2004
• Contributions to Rakar_at_medicine.ankara.edu.tr

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Pericardium

• two mesothelial layers
• visceral epicardium (monocellular serosal layer)
• parietal tough fibrous structure
• 15-50 ml plasma ultrafiltrate
• two major recesses
• transverse pericardial sinus
• oblique pericardial sinus

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Pericardium Arterial Blood Supply

• pericardiophrenic arteries
• internal mammary artery
• branches of the aorta

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Pericardium Innervation

• parasympathetic innervation
• vagus
• left recurrent laryngeal nerve
• oesophageal plexus
• sympathetic innervation
• stellate and first dorsal ganglia
• cardiac, aortic, and diaphragmatic plexuses

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Pericardium Innervation

• afferent nerves-pain perception transmitted via
  the phrenic nerve (C4C5)
• peripheral sensory fibers that enter the dorsal
  root ganglia at C8T2 supply both the brachial
  plexus and the pericardium

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Pericardial Space Lymphatic Drainage

• Parietal pericardium
• Anterior and posterior mediastinal nodes
• Thoracic duct
• Visceral pericardium
• Tracheal and bronchial mediastinal nodes

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Functions of the Pericardium

• anatomic fixation
• prevention of excessive motion of the heart
• to prevent cardiac distension by sudden volume
  overload
• ligamentous attachments
• anteriorly to the sternum and xiphoid process
• posteriorly to the vertebral column
• inferiorly to the central tendon of diaphragm

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Functions of the Pericardium

• reduces friction between the heart and
  surrounding organs
• provides a barrier against the extension of
  infection and malignancy from contiguous organs
  to the heart

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Pericardial Physiolgy

• normal intrapericardial pressure is zero or
  negative
• pericardial pressure is nearly equal to
  intrapleural pressure
• varies from 5 to 5 cm H2O during the
  respiratory cycle

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Pericardial Effusion
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Malignant Pericardial Effusions

• metastatic
• lung carcinoma
• breast carcinoma

• primary (or contiguous)
• lymphoma
• leukemias
• malignant mesothelioma
• teratoma
• angiosarcoma
• rhabdomyosarcomas

Life expectancy after malignant pericardial
involvement is less than 4 months.
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Pericardial Tamponade

• The pericardium of a healthy individual can
  accommodate 15-20 mL of fluid

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Pericardial Tamponadephysiologic diagnosis

• State of cardiac decompensation due to increased
  intrapericardial pressure
• Cardiac filling is limited from the beginning of
  diastole
• increased intrapericardial pressure diminishes
• diastolic filling of the heart
• stroke volume
• cardiac output

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Signs of Pericardial Tamponade

• tachycardia
• decreased pulse pressure
• parodoxical pulse
• distended neck veins

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Becks Triad(described in 1935)

• decline in systemic arterial pressure
• elevation in venous pressure (e.g., distended
  neck veins)
• a small, quiet heart

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Pulsus Paradoxus

• exaggerated response
• normal physiologic drop in BP (lt 10 mmHg) that
  occurs with inspiration
• inspiratory decrease in the amplitude of the
  palpated pulse in the femoral or carotid arteries
• interventricular septum bulge into left ventricle
  due to augmented right ventricular filling

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Pulsus Paradoxus

• Pericardial tamponade
• COPD
• Right ventricular infarction
• Pulmonary embolism

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Echocardiogram is the most sensitive diagnostic
tool for detection of pericardial effusion
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TOE 2-chamber view
Pericardial tamponade
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TOE 4-chamber view
Pericardial tamponade
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Right atrial diastolic collapse tends to occur
earlier than right ventricular collapse
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TOE 4-chamber view
Diastolic collapse of right atrium Septum bulge
into left ventricle during systole
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TOE transgastric short axis view
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TOE transgastric short axis view
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TOE 2-chamber view
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Diastolic collapse of right atrium and right
ventricle
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Acute Pericarditis
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Acute Pericarditis

• inflammation of the pericardium
• chest pain
• constitutional symptoms (weakness, malaise)
• fever
• pericardial friction rub
• serial electrocardiographic abnormalities

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Acute pericarditis

• Idiopathic (nonspecific)
• Viral Infections
• Tuberculosis
• Acute Bacterial Infection
• Fungal Infections
• Acute Myocardial Infarction
• Uraemia
• Neoplastic Disease

• Radiation
• Autoimmune Disorders
• Drugs
• Trauma
• Delayed Post myocardial-Pericardial Injury
  Syndromes
• Dissecting Aortic Aneurysm
• Myxedema
• Chylopericardium

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Viral Pericarditis (outpatient setting)

• Coxsackie A and B (highly cardiotropic)
• Mumps
• Varicella-zoster
• Influenza
• Ebstein-Barr
• HIV
• Hepatitis A, B, C

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Acute Pericarditis(inpatient setting- TUMOR)

• Trauma
• Uraemia
• Myocardial Infarction, Medications (hydralazine,
  procainamide)
• Other infections
• Rheumatoid arthritis, Radiation

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Dresslers SyndromePost Myocardial Infarction
Syndromedescribed in 1956

• Fever
• Pericarditis
• Pleuritis

few days to several weeks following MI
Incidence 6-25 (50 after transmural
infarction) high dose aspirin usually relieve the
pain within 48 hours
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Drug-Induced Pericarditis

• Procainamide
• Hydralazine
• Methysergide
• Emetine
• Minoxidil

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Acute PericarditisSymptoms

• chest pain (pleuritic)
• dyspnoea
• cough, sputum production
• odynophagia
• weight loss (underlying systemic disease)
• constitutional symptoms (weakness, malaise)

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Chest painretrosternal, precordial radiating to
the neck, back, left shoulder, or left arm

• Acute Pericarditis
• sharp
• pleuritic
• worsened by
• coughing or inspiration
• lying supine
• swallowing

• Myocardial Infarction
• thoracic motion does not change the intensity

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Acute Pericarditis Physical Examination

• pericardial friction rub
• (biphasic to-and-fro rub)
• three components
• atrial systole
• ventricular systole (loudest)
• rapid ventricular filling in early diastole
  (difficult to detect)

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Acute Pericarditis ECG

• ST-segment elevation in most ECG leads
• Diffuse ST-segment elevation, concave upward
• No reciprocal depressions

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Acute Pericarditis Management

• bed rest
• nonsteroidal anti-inflammatory agents
• aspirin
• indomethicin (25 to 50 mg QDS)
• corticosteroids
• prednisone (60 to 80 mg daily)
• ? ketorolac tromethamine

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Constrictive Pericarditis

• fibrotic, thickened, and adherent pericardium
  restricts diastolic filling of the heart

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Constrictive Pericarditis

• idiopathic 75
• after acute pericarditic episode (viral) 10-15
• tuberculous pericarditis 3
• cardiac surgery 1-4
• mediastinal irradiation common in US
• rheumatoid disease rare
• trauma/haemopericardium rare
• breast carcinoma, lymphoma rare

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Tuberculous Pericarditis

• still seen in patients from developing countries
• Rising in immunocompromised patients (HIV)
• incidence 1-8 of patients with pulmonary
  tuberculosis
• fever, pericardial rub, hepatomegaly
• pericardial biopsy in addition to
  pericardiosentesis provides higher probability of
  definitive diagnosis

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Constrictive Pericarditisafter Open Heart Surgery

• retained haematoma in the pericardial space
  (mesothelial fibrinolytic activity)
• post-pericardiectomy syndrome
• low-grade infection
• irrigation with irritant solutions

Bowman FO Jr. Current Therapy in Cardiothoracic
Surgery, 1989. 296-98.
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Constrictive PericarditisPhysical Findings

• examine the neck!
• jugular veins
• Distended
• Prominent X and Y descents
• Increase in the height of JVP with inspiration
  (Kussmauls sign)
• heart sounds may be decreased in intensity
• ascitis, pulsatile hepatomegaly, enlarged spleen

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Constrictive PericarditisDiagnosis

• right-sided heart failure
• pericardial knock
• pericardial calcification
• small cardiac silhouette

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TOE 2-chamber view
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TOE 4-chamber view
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TOE Right ventricle Inflow-Outflow
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TOE LVOT
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Constrictive PericarditisCardiac Catheterization

• simultaneous left and right heart pressure
  measurements
• equalization of mean RA, RVEDP, PCWP, LVEDP
• elevated mean atrial pressures
• Classic square root sign
• (Early diastolic dip followed by a plateau)
• Prominent atrial X and Y descents
• Elevated RVEDP

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square root sign dip and plateau Constriction
does not restrict cardiac filling in the
earliest stages of diastole 70-80 of diastolic
filling is forced to occur in the first 25-30 of
diastole Early diastolic filling pressures are
normal, later diastolic filling pressures are
higher
The prominent X and Y descents give the right
atrial waveform its characteristic M- or
W-shaped appearance
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Surgical Technique for Constrictive Pericarditis

• Median sternotomy
• Left anterior thoracotomy
• Bilateral anterior thoracotomy

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Surgical Technique for Constrictive Pericarditis

• left ventricle freed first
• anterolateral and diaphragmatic surfaces of both
  ventricles
• excision from phrenic nerve to phrenic nerve
• excision around the enterance of vena cava,
  pulmonary veins and atria

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Pericardiectomy

• Mortality 4-14
• mortality
• RVEDP16 mmHg 5
• RVEDP 20 mmHg 10
• RVEDP 30 mmHg 30

Seifert FC, Miller DC, Oesterle SN Circulation
1985 72 (Suppl II) II-264-273
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Pericardiectomy

• Mortality 4-14
• mortality
• NYHA I or II 1
• NYHA III 10
• NYHA IV 46

• McCauhan BC, Schaff HV, Piehler JM et al.
• J Thorac Cardiovasc Surg 1985 89 340-50

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Pericardiocentesis

• subxiphoid approach
• fourth ICS

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Pericardial Window

• Aiming to drain fluid into the pleural or
  peritoneal space
• Thoracoscopy, anterior thoracotomy or subxiphoid
  incision

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Congenital Pericardial Abnormalities

• Absence or Defects of the Pericardium
• Pericardial coelomic cysts
• Pericardial bands

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Pericardial Cysts

• Most often in the right costophrenic angle
• Contain a clear yellow fluid
• Typically unilocular
• Less than 3 cm in diameter
• Chest pain, dyspnea, cough, arrhytmias
• Can become infected

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Congenital Absence and Defects of the Pericardium

• first described anatomically by Realdus Columbus
  (1559)
• Ante-mortem detection did not occur until 1959
• 31 male/female predominance
• associated congenital anomalies (30)
• atrial septal defect
• bicuspid aortic valve
• bronchogenic cysts, or pulmonic sequestration
• Skeletal anomalies

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• partial absence of the left-sided pericardium
  70
• (potentially lethal)
• total absence 9
• partial absence of the right-sided pericardium
  17

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Total Absence of the Left Pericardium

• widened splitting of the second heart sound
• hyperdynamic precordial impulse
• leftward displacement of the apical impulse
• systolic murmur at the upper left sternal border
  that may be related to turbulent blood flow in an
  unusually mobile heart

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Absent pericardium Left lower lobe
sequestration
lung
Left atrial appendage
Ligated inferior pulmonary vein