Visceral

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Pericardial Diseases

• Visceral single layer mesothelial cells
• Parietal- fibrous lt 2 mm thick
• Functions
• Limits motion
• Prevents dilatation during volume increase
• Barrier to infection
• 15-50 ml serous fluid
• Well innervated

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Acute Pericarditis Etiology

• Infectious
• Viral
• Bacterial
• TB
• Noninfeccious
• Post MI (acute and Dresslers)
• Uremia
• Neoplastic disease
• Post radiation
• Drug-induced
• Connective tissue diseases/autoimmune
• traumatic

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Infectious

• Viral (idiopathic)
• Echovirus, coxsackie B
• Hepatitis B, influenza, IM, Caricella, mumps
• HIV, TB
• Bacterial (purulent)
• Pneuococcus, staphlococci
• fulminant

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Pericarditis post- MI

• Early lt5 patients
• Dresslers 2 weeks months
• Autoimmune
• Post-pericardiotomy

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Neoplastic

• Breast
• Lung
• Lymphoma
• Primary pericardail tumors rare
• Hemmorrhagic and large

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• Radiation
• Dose gt 4000rads
• Local inflammation
• Autoimmune
• SLE
• RA
• PSS (40 may develop)
• Drugs-lupus like
• Hydralazine
• Procaimamide
• Phenytoin
• Methyldopa
• Isoniazid
• Drugs- not lupus
• Minoxidil
• Anthracycline antineoplastic agents

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Pathogenesis and Pathology

• Inflammatory
• Vasodilation
• Increased vascular permeability
• Leukocyte exudation
• Pathology
• Serous-little cells
• Serofibrinous rough appearance / scarring
• common
• Purulent intense inflammation
• Hemmorrhagic TB or malignancy

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Clinical

• Chest pain
• Radiate to back
• Sharp and pleuritic
• Positional worse lying back
• Fever
• Dyspnea due to pleuritic pain

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Chest pain in Pericarditis

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Exam

• Friction rub
• Diaphragm leaning forward
• 1, 2 or 3 components
• Ventricular contraction, relaxaltion, atrial
  contraction
• intermittent

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Diagnostic

• Clinical history
• ECG
• Abn in 90
• Diffuse ST elevation
• PR depression
• Echocardiography
• Effusion
• PPD
• Autoimmune antibodies
• Evaluate for malignancy

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(Circulation. 20061131622-1632.)
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EKG in Pericarditis
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(Circulation. 20061131622-1632.)
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Treatment

• ASA or NSAIDs
• Avoid NSAID in MI
• Colchicine
• Steroids - avoid
• May increase reoccurance
• TB Rx TB
• Purulent drainage of fluid antibiotics
• Neoplastic- drainage
• Uremic - dialysis

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Pericardial Effusion

• From any acute pericarditis
• Hypothyriodism- increased capillary permeability
• CHF- increased hydrostatic pressure
• Cirrhosis- decreased plasma oncotic pressure
• Chylous effusion- lymphatic obstruction
• Aortic Dissection

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Effusion Pathophysiology

• Pericardium is stiff- PV curve not flat
• Above critical volume rapid increase in
  pressure
• Factors that determine compression
• Volume
• Rate of accumulation
• Pericardial compliance

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Clinical

• Asymptomatic
• Symptoms
• CP, dyspnea, dysphagia, hoarseness, hiccups
• Tamponade
• Exam
• Muffled heart sounds
• Absence of rub
• Ewarts sign-dullness L lung at scapula
• atelectasis

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Diagnostic studies

• CXR - gt 250 ml fluid globular cardiomegaly
• ECG low voltage and electrical alternans
• Echocardiogram most helpful
• Identify hemodynamic compromise

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ECG low voltage and electrical alternans
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Treatment

• If known cause- treat that
• If unknown- may need pericardiocentesis or
  pericardial window
• Cardiac tamponade is emergency-
  pericardiocentesis drainage or window

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Tamponade

• Any cause of effusion may lead to
• Diastolic pressures elevate and pericardial
  pressure
• Impaired LV/RV filling
• Increased systemic venous pressure
• Decreased stroke volume and C.O.
• Shock

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Tamponade

• Have right side failure with edema and fatigue
  only if occurs slowly
• Key physical findings
• JVD
• Hypotension
• Small quiet heart
• Sinus tachycardia
• Pulsus paradoxus- decease in BP gt 10 during
  normal inspiration

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Pulsus Paradoxus

• Exaggeration of normal
• Normally septum moves toward LV with inspiration,
  with decrease in LV filling
• With compression and fixed volume, there is even
  greater limitation in LV filling and reduced
  stroke volume
• PP also seen in COPD/asthma

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Tamponade

• Echocardiography
• Compression of RV and RA in diastole
• Can have localized effuison with localized
  compression of one chamber (RA,LV)
• Effusion post cardiac surgery
• Differentiate other causes of low cardiac output
• Cardiac catheterization- definitive
• Measure pressures- chamber and pericardial equal,
  and all elevated.

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Tamponade- external compression blunts filling
throughout cardiac cycle
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Lancet 2004 363 71727
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Pericardial Fluid

• Stained and cultured
• Cytologic exam
• Cell count
• Protein level
• pp/spgt 0.5 - exudate
• LDH level
• p LDH/ s LDH gt 0.6 - exudate
• Adenosine Deaminase level - sensitive and
  specific for TB

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Constrictive Pericarditis

• Most common etiology is idiopathic (viral)
• Any cause of pericarditis
• Post cardiac surgery
• Pathology
• Organization of fluid, scarring, fusion of
  pericardial layers, calcification

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Constrictive Pericarditis

• Impaired diastolic filling of the chambers
• Elevated systemic venous pressures
• Reduced cardiac output
• Dip and plateau curve on catheterization

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Constrictive PericarditisClinical

• Symptoms
• Fatigue, hypotension, tachycardia
• JVD, hepatomegaly and ascites, edema
• Can confuse with cirrhosis- look for JVD
• Exam
• Pericardial knock after S2- sudden cessation of
  ventricular diastolic filling
• Kussmauls sign- JVD with inspiration
• No pulsus paradoxus
• Difficult to separate from restrictive
  cardiomyopathy- may need myocardial biopsy

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Am Heart J 1999138219-32
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Normal pericardium lt 2 mm
(Circulation. 20061131622-1632.)