Title: Pericardium
1 Pericardium
- A. Rüçhan Akar
- Ankara University School of Medicine
- Department of Cardiovascular Surgery
- January-2004
- Contributions to Rakar_at_medicine.ankara.edu.tr
2Pericardium
- 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
3Pericardium Arterial Blood Supply
- pericardiophrenic arteries
- internal mammary artery
- branches of the aorta
4Pericardium Innervation
- parasympathetic innervation
- vagus
- left recurrent laryngeal nerve
- oesophageal plexus
- sympathetic innervation
- stellate and first dorsal ganglia
- cardiac, aortic, and diaphragmatic plexuses
5Pericardium 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
6Pericardial Space Lymphatic Drainage
- Parietal pericardium
- Anterior and posterior mediastinal nodes
- Thoracic duct
- Visceral pericardium
- Tracheal and bronchial mediastinal nodes
7Functions 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
8Functions 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
9Pericardial 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
10Pericardial Effusion
11Malignant 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.
12Pericardial Tamponade
- The pericardium of a healthy individual can
accommodate 15-20 mL of fluid
13Pericardial 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
14Signs of Pericardial Tamponade
- tachycardia
- decreased pulse pressure
- parodoxical pulse
- distended neck veins
15Becks Triad(described in 1935)
- decline in systemic arterial pressure
- elevation in venous pressure (e.g., distended
neck veins) - a small, quiet heart
16Pulsus 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
17Pulsus Paradoxus
- Pericardial tamponade
- COPD
- Right ventricular infarction
- Pulmonary embolism
18Echocardiogram is the most sensitive diagnostic
tool for detection of pericardial effusion
19TOE 2-chamber view
Pericardial tamponade
20TOE 4-chamber view
Pericardial tamponade
21Right atrial diastolic collapse tends to occur
earlier than right ventricular collapse
22TOE 4-chamber view
Diastolic collapse of right atrium Septum bulge
into left ventricle during systole
23TOE transgastric short axis view
24TOE transgastric short axis view
25TOE 2-chamber view
26Diastolic collapse of right atrium and right
ventricle
27Acute Pericarditis
28Acute Pericarditis
- inflammation of the pericardium
- chest pain
- constitutional symptoms (weakness, malaise)
- fever
- pericardial friction rub
- serial electrocardiographic abnormalities
29Acute 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
-
-
-
30Viral Pericarditis (outpatient setting)
- Coxsackie A and B (highly cardiotropic)
- Mumps
- Varicella-zoster
- Influenza
- Ebstein-Barr
- HIV
- Hepatitis A, B, C
31Acute Pericarditis(inpatient setting- TUMOR)
- Trauma
- Uraemia
- Myocardial Infarction, Medications (hydralazine,
procainamide) - Other infections
- Rheumatoid arthritis, Radiation
32Dresslers 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
33Drug-Induced Pericarditis
- Procainamide
- Hydralazine
- Methysergide
- Emetine
- Minoxidil
34Acute PericarditisSymptoms
- chest pain (pleuritic)
- dyspnoea
- cough, sputum production
- odynophagia
- weight loss (underlying systemic disease)
- constitutional symptoms (weakness, malaise)
35Chest 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
36 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)
37Acute Pericarditis ECG
- ST-segment elevation in most ECG leads
- Diffuse ST-segment elevation, concave upward
- No reciprocal depressions
38 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
39Constrictive Pericarditis
- fibrotic, thickened, and adherent pericardium
restricts diastolic filling of the heart
40Constrictive 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
41Tuberculous 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
42Constrictive 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.
43Constrictive 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
44Constrictive PericarditisDiagnosis
- right-sided heart failure
- pericardial knock
- pericardial calcification
- small cardiac silhouette
45TOE 2-chamber view
46TOE 4-chamber view
47TOE Right ventricle Inflow-Outflow
48TOE LVOT
49Constrictive 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
50square 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
51Surgical Technique for Constrictive Pericarditis
- Median sternotomy
- Left anterior thoracotomy
- Bilateral anterior thoracotomy
52Surgical 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
53Pericardiectomy
- 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
54Pericardiectomy
- 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
55(No Transcript)
56Pericardiocentesis
- subxiphoid approach
- fourth ICS
57Pericardial Window
- Aiming to drain fluid into the pleural or
peritoneal space - Thoracoscopy, anterior thoracotomy or subxiphoid
incision
58Congenital Pericardial Abnormalities
- Absence or Defects of the Pericardium
- Pericardial coelomic cysts
- Pericardial bands
59Pericardial 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
60Congenital 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
61- partial absence of the left-sided pericardium
70 - (potentially lethal)
- total absence 9
- partial absence of the right-sided pericardium
17
62Total 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
63Absent pericardium Left lower lobe
sequestration
lung
Left atrial appendage
Ligated inferior pulmonary vein