Transcript Document

Diseases of the Pericardium
David L. Hykes, Jr. DO
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.
Etiologies of Pericardial Disease
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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,
Chaga’s disease, filariasis)
Etiologies of Pericardial Disease
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Neoplastic
Myxedema
Uremia
Trauma (hemopericardium)
Transmural myocardial infarction and Dressler’s
syndrome
Rheumatologic
– Rheumatoid arthritis, SLE, scleroderma, Whipple’s
disease, Ankylosing spondylitis, Wegener’s
granulomatosis, gout, amyloidosis, polymyositis
Etiologies of Pericardial Disease
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Other systemic diseases
– Sarcoidosis, hemochromatosis, Gaucher’s
disease, pulmonary infiltration with
eosinophilia
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Drug induced
– Procainamide, hydralazine, quinidine,
isoniazid, penicillin, streptomycin,
methysergid, daunorubicin
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Radiation
Acute Pericarditis
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Symptoms
– Chest pain
 Develops suddenly and is severe and constant
 Pain worsens with inspiration
– Low-grade fever
– Weakness/fatigue
Acute Pericarditis
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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
Acute Pericarditis
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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)
Acute Pericarditis
Subacute & Chronic Pericarditis
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Acute pericarditis progresses to subacute
and chronic in rare circumstances
 These cases are usually secondary to
bacterial, viral, rheumatoid, radiationinduced, or dialysis-related
 These conditions usually present with some
degree of cardiac tamponade
Pericarditis
Subacute
Chronic
Pericardial Effusion
& Cardiac Tamponade
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Etiology of percardial effusions
– Serous
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CHF, hypoalbuminemia, viral pericarditis, bacterial
pericarditis, tuberculosis pericarditis, irradiation
– Blood
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Neoplasm, trauma, acute MI, cardiac rupture, uremia,
coagulopathy
Iatrogenic – cardiac operation, cardiac catheterization,
anticoagulants, chemotherapeutic agents
– Lymph
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Neoplasm, congenital, idiopathic, thoracic duct obstruction
Cause of Hemopericardial
effusion
Cardiac perforation
Pericardial Effusion
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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
Diagnosis of Effusion
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EKG
 Echocardiography
 CT Scan
 MRI
Diagnosis of Pericardial Tamponade
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Beck’s Triad
– Hypotension
– Small, quiet heart
– Increasing systemic venous pressure
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Four diagnostic steps
– Elevated jugular venous pressure
– Pulsus paradoxicus
– Evidence of pericardial fluid
– Drainage leads to reversal of tamponade
Cardiac Tamponade
Cardiac Tamponade
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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
Pericardial Effusion on
Echocardiogram
Pericardial Tamponade Treatment
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Circulating blood volume expansion
– 500 to 1,000 ml over 10 to 20 minutes
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Positive inotropes
– Dobutamine 3 to 10 mcg/kg/min
– Dopamine 3 to 10 mcg/kg/min
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Vasodilators
– Hydralazine
– Nitroprusside
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Corticosteroids
– For mild cases such as Dressler’s Syndrome
Pericardial Tamponade Treatment
Pericardial drainage
– Needle pericardiocentesis
– Percutaneous balloon pericardiotomy
– Pericardial window
– Pericardial resection
Pericardiocentesis
Questions
References
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Baljepally R, Spodick DH: PR-segment deviation as the initial
electrocardiographic response in acute pericarditis. Am J
Cardiol 81:1505, 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 138:759, 1999
Allen KB, et al: Pericardial effusion: subxiphoid
pericardiostomy versus percutaneous catheter drainage: Ann
Thorac Surg 67:437, 1999
Hancock EW: Cardiology; XIII diseases of the pericardium,
cardiac tumors, and cardiac trauma. Scientific America, 2001
References
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Larose E, et al: Prolonged distress and clinical deterioration
before pericardial drainage in patients with cardiac tamponade.
Can J Cardiol 16:331, 2000
 Palacios I: Current treatment options in cardiovascular
medicine. 1:79-89, 1999
 Roosen J, et al: Comparison of premortem clinical diagnoses in
critically ill patients and subsequent autopsy findings. Mayo
Clin Proc 75:562, 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 21:1, 1993