Diseases of the Pericardium

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Diseases of the Pericardium

• David L. Hykes, Jr. DO

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Pericardium and Pericardial Diseases

• The pericardium is a protective sac around the
  heart which contains a thin layer of fluid that
  reduces friction during heart function.
• Pericardial diseases result from a variety of
  etiologies which manifest themselves as
  pericarditis and pericardial fusion.

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Etiologies of Pericardial Disease

• Infectious
• Viral (coxsackievirus A and B, echovirus, mumps,
  adenovirus, hepatitis, HIV, influenza, varicella,
  infectious mononucleosis)
• Bacterial (pneumococcus, streptococcus,
  staphylococcus, gonococcus, legionella, shigella,
  salmonella, hemophilus, meningococcus, tularemia,
  mycoplasma)
• Fungal (histoplasmosis, coccidoidymycosis,
  candida, blastomycosis, nocardia, aspergillosis)
• Other (tuberculosis, toxoplasmosis, amebiasis,
  syphilis, Chagas disease, filariasis)

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Etiologies of Pericardial Disease

• Neoplastic
• Myxedema
• Uremia
• Trauma (hemopericardium)
• Transmural myocardial infarction and Dresslers
  syndrome
• Rheumatologic
• Rheumatoid arthritis, SLE, scleroderma, Whipples
  disease, Ankylosing spondylitis, Wegeners
  granulomatosis, gout, amyloidosis, polymyositis

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Etiologies of Pericardial Disease

• Other systemic diseases
• Sarcoidosis, hemochromatosis, Gauchers disease,
  pulmonary infiltration with eosinophilia
• Drug induced
• Procainamide, hydralazine, quinidine, isoniazid,
  penicillin, streptomycin, methysergid,
  daunorubicin
• Radiation

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Acute Pericarditis

• Symptoms
• Chest pain
• Develops suddenly and is severe and constant
• Pain worsens with inspiration
• Low-grade fever
• Weakness/fatigue

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Acute Pericarditis

• Findings
• Pericardial friction rub (usually triphasic
  systolic and early diastolic components and a
  later third component associated with atrial
  contraction)
• Electrocardiogram shows diffuse ST segment
  elevation, depression of the PR segment (usually
  the earliest manifestation), sinus tachycardia

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Acute Pericarditis

• Treatment
• Salicylates (aspirin dose 4 g to 6 g)
• NSAIDS (usually indomethacin 25 mg QID)
• Corticosteroids (usually reserved for severe
  cases unresponsive to therapy, typically
  prednisone at a 40 mg to 60 mg dose)

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Acute Pericarditis
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Subacute Chronic Pericarditis

• Acute pericarditis progresses to subacute and
  chronic in rare circumstances
• These cases are usually secondary to bacterial,
  viral, rheumatoid, radiation-induced, or
  dialysis-related
• These conditions usually present with some degree
  of cardiac tamponade

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PericarditisSubacute Chronic
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Pericardial Effusion Cardiac Tamponade

• Etiology of percardial effusions
• Serous
• CHF, hypoalbuminemia, viral pericarditis,
  bacterial pericarditis, tuberculosis
  pericarditis, irradiation
• Blood
• Neoplasm, trauma, acute MI, cardiac rupture,
  uremia, coagulopathy
• Iatrogenic cardiac operation, cardiac
  catheterization, anticoagulants, chemotherapeutic
  agents
• Lymph
• Neoplasm, congenital, idiopathic, thoracic duct
  obstruction

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Cause of Hemopericardial effusion

• Cardiac perforation

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Pericardial Effusion

• The pericardium has the capacity to accommodate
  volumes exceeding 2,000 ml when develops
  gradually
• Effusions developing acutely may cause cardiac
  tamponade with as little as 200 ml of fluid
• As pericardial pressure rises, right atrial and
  central venous pressure increase. Thus, central
  venous pressure reflects the intrapericardial
  pressure

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Diagnosis of Effusion

• EKG
• Echocardiography
• CT Scan
• MRI

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Diagnosis of Pericardial Tamponade

• Becks Triad
• Hypotension
• Small, quiet heart
• Increasing systemic venous pressure
• Four diagnostic steps
• Elevated jugular venous pressure
• Pulsus paradoxicus
• Evidence of pericardial fluid
• Drainage leads to reversal of tamponade

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Cardiac Tamponade
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Cardiac Tamponade

• Echocardiogram findings
• Right atrial collapse
• Right ventrical early diastolic collapse
• Increase in right ventrical dimensions with
  inspiration and decrease in left ventrical
  dimensions with inspiration
• Increase in blood flow velocity through the
  tricuspid and pulmonic valves and decrease in
  mitral and aortic valve flow velocity with
  inspiration
• Respiratory variations in pulmonary and hepatic
  venous flow

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Pericardial Effusion on Echocardiogram
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Pericardial Tamponade Treatment

• Circulating blood volume expansion
• 500 to 1,000 ml over 10 to 20 minutes
• Positive inotropes
• Dobutamine 3 to 10 mcg/kg/min
• Dopamine 3 to 10 mcg/kg/min
• Vasodilators
• Hydralazine
• Nitroprusside
• Corticosteroids
• For mild cases such as Dresslers Syndrome

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Pericardial Tamponade Treatment

• Pericardial drainage
• Needle pericardiocentesis
• Percutaneous balloon pericardiotomy
• Pericardial window
• Pericardial resection

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Pericardiocentesis
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Questions
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References

• Baljepally R, Spodick DH PR-segment deviation as
  the initial electrocardiographic response in
  acute pericarditis. Am J Cardiol 811505, 1998
• Spodick DH Pathophysiology of cardiac tamponade.
  Chest 113 1372, 1998
• Merce J, et al Correlation between clinical and
  Doppler echocardiographic findings in patients
  with moderate and large pericardial effusion
  implications for the diagnosis of cardiac
  tamponade. Am Heart J 138759, 1999
• Allen KB, et al Pericardial effusion subxiphoid
  pericardiostomy versus percutaneous catheter
  drainage Ann Thorac Surg 67437, 1999
• Hancock EW Cardiology XIII diseases of the
  pericardium, cardiac tumors, and cardiac trauma.
  Scientific America, 2001

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References

• Larose E, et al Prolonged distress and clinical
  deterioration before pericardial drainage in
  patients with cardiac tamponade. Can J Cardiol
  16331, 2000
• Palacios I Current treatment options in
  cardiovascular medicine. 179-89, 1999
• Roosen J, et al Comparison of premortem clinical
  diagnoses in critically ill patients and
  subsequent autopsy findings. Mayo Clin Proc
  75562, 2000
• Ziskind AA, et al Percutaneous balloon
  pericardiotomy for the treatment of cardiac
  tamponade and large pericardial effusions
  description of technique and report of the first
  50 cases. J Am Coll Cardiol 211, 1993