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Pericardium

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... and adherent pericardium restricts diastolic filling of the heart Constrictive Pericarditis idiopathic ~75% after acute pericarditic episode ... – PowerPoint PPT presentation

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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

2
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

3
Pericardium Arterial Blood Supply
  • pericardiophrenic arteries
  • internal mammary artery
  • branches of the aorta

4
Pericardium Innervation
  • parasympathetic innervation
  • vagus
  • left recurrent laryngeal nerve
  • oesophageal plexus
  • sympathetic innervation
  • stellate and first dorsal ganglia
  • cardiac, aortic, and diaphragmatic plexuses

5
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

6
Pericardial Space Lymphatic Drainage
  • Parietal pericardium
  • Anterior and posterior mediastinal nodes
  • Thoracic duct
  • Visceral pericardium
  • Tracheal and bronchial mediastinal nodes

7
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

8
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

9
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

10
Pericardial Effusion
11
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.
12
Pericardial Tamponade
  • The pericardium of a healthy individual can
    accommodate 15-20 mL of fluid

13
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

14
Signs of Pericardial Tamponade
  • tachycardia
  • decreased pulse pressure
  • parodoxical pulse
  • distended neck veins

15
Becks Triad(described in 1935)
  • decline in systemic arterial pressure
  • elevation in venous pressure (e.g., distended
    neck veins)
  • a small, quiet heart

16
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

17
Pulsus Paradoxus
  • Pericardial tamponade
  • COPD
  • Right ventricular infarction
  • Pulmonary embolism

18
Echocardiogram is the most sensitive diagnostic
tool for detection of pericardial effusion
19
TOE 2-chamber view
Pericardial tamponade
20
TOE 4-chamber view
Pericardial tamponade
21
Right atrial diastolic collapse tends to occur
earlier than right ventricular collapse
22
TOE 4-chamber view
Diastolic collapse of right atrium Septum bulge
into left ventricle during systole
23
TOE transgastric short axis view
24
TOE transgastric short axis view
25
TOE 2-chamber view
26
Diastolic collapse of right atrium and right
ventricle
27
Acute Pericarditis
28
Acute Pericarditis
  • inflammation of the pericardium
  • chest pain
  • constitutional symptoms (weakness, malaise)
  • fever
  • pericardial friction rub
  • serial electrocardiographic abnormalities

29
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

30
Viral Pericarditis (outpatient setting)
  • Coxsackie A and B (highly cardiotropic)
  • Mumps
  • Varicella-zoster
  • Influenza
  • Ebstein-Barr
  • HIV
  • Hepatitis A, B, C

31
Acute Pericarditis(inpatient setting- TUMOR)
  • Trauma
  • Uraemia
  • Myocardial Infarction, Medications (hydralazine,
    procainamide)
  • Other infections
  • Rheumatoid arthritis, Radiation

32
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
33
Drug-Induced Pericarditis
  • Procainamide
  • Hydralazine
  • Methysergide
  • Emetine
  • Minoxidil

34
Acute PericarditisSymptoms
  • chest pain (pleuritic)
  • dyspnoea
  • cough, sputum production
  • odynophagia
  • weight loss (underlying systemic disease)
  • constitutional symptoms (weakness, malaise)

35
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

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)

37
Acute 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

39
Constrictive Pericarditis
  • fibrotic, thickened, and adherent pericardium
    restricts diastolic filling of the heart

40
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

41
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

42
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.
43
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

44
Constrictive PericarditisDiagnosis
  • right-sided heart failure
  • pericardial knock
  • pericardial calcification
  • small cardiac silhouette

45
TOE 2-chamber view
46
TOE 4-chamber view
47
TOE Right ventricle Inflow-Outflow
48
TOE LVOT
49
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

50
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
51
Surgical Technique for Constrictive Pericarditis
  • Median sternotomy
  • Left anterior thoracotomy
  • Bilateral anterior thoracotomy

52
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

53
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
54
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

55
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56
Pericardiocentesis
  • subxiphoid approach
  • fourth ICS

57
Pericardial Window
  • Aiming to drain fluid into the pleural or
    peritoneal space
  • Thoracoscopy, anterior thoracotomy or subxiphoid
    incision

58
Congenital Pericardial Abnormalities
  • Absence or Defects of the Pericardium
  • Pericardial coelomic cysts
  • Pericardial bands

59
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

60
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

61
  • partial absence of the left-sided pericardium
    70
  • (potentially lethal)
  • total absence 9
  • partial absence of the right-sided pericardium
    17

62
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

63
Absent pericardium Left lower lobe
sequestration
lung
Left atrial appendage
Ligated inferior pulmonary vein
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