Pericardium PDF

Pericardial diseases
What is it?
• Pericardium is 2 sacs
• Fibrous sac surrounding heart formed of dense network of
collagen fibres
• Serous membrane formed of two continuous layers
separated by a small amount of fluid lubricant (10-20ml)
• Serous pericardium has 2 layers called visceral and parietal
– Visceral is inner layer (epicardium)
– Parietal is continuous with diaphragm and outer walls of great
arteries
Where is it?
• Surrounds the heart

• Continuous with the great arteries and the
diaphragm
What is its function?
• Stabilises the position of the heart within
the chest
• Prevents friction between the moving
heart and adjacent structures
• Allows for small acute changes in size and
shape with in limits (not the case in
chronic setting)
Pericardial disease
• Acute pericarditis
• Chronic constrictive pericarditis
• Pericardial effusion
• Cardiac tamponade
Acute pericarditis
Causes
▪ Idiopathic – 86%
• Infective (viral or bacterial) – 7%
• Following a myocardial infarction or cardiac surgery
(Dressler’s syndrome)
• Radiation therapy
• Neoplastic disease (commonly lung or breast) – 6%
• Connective tissue disease
Clinical findings
• Retrosternal chest pain – sharp worse on inspiration

and lying flat, improve with sitting and leaning
forward.
• Friction rub (high pitched scratching sound), heard

best at bare area of the heart, increase with stress
with the stethoscope on the chest wall, disappear
with formation of pericardial effusion.
ECG (acute pericarditis)
ECG differential diagnosis - MI
• What leads is the ST elevation in?
• What shape is the elevation?
• Are there Q waves?
• Do the ST –T changes evolve with time?
• History of the patient
• Cardiac markers
• But remember that you can get more than one
pathology at the same time!
Clinical signs differential diagnosis -
pleurisy
• Pleuritic pain has similar sharp quality but
is usually more specific in location
• Pleural rub is heard over the area where
the pain occurs
Treatment
• Search for the underlying disease
• Patients require bed rest
• NSAID (aspirin, indomethacin) are
generally accepted as effective for
relieving symptoms of chest pain
• Colchicine may be a useful adjunct in those
who do not respond to NSAIDs alone
Prognosis
• Pericarditis is usually a benign disorder
• Prognosis relates to underlying cause
• But any cause can lead to an effusion and
tamponade which can lead to death
• Pericarditis can also progress to pericardial
constriction and heart failure
Chronic constrictive pericarditis
Pathology of Constrictive Pericarditis
• Present when a fibrotic, thickened, and adherent
pericardium restricts diastolic filling of the heart.
• An initial episode is acute pericarditis, which may not be
detected clinically.
• Fibrous scarring and thickening of the pericardium
• Obliteration of the pericardial space
• Uniform restriction of filling of all heart chambers.
• Calcium deposition may contribute to stiffening of the
pericardium.
Importance of Constrictive pericarditis
Although uncommon, need substantial

clinical interest because of the perceived
potential for surgical cure.
Causes
• Tuberculous constrictive pericarditis was

common cause of constriction pre 1960 – decline
in incidence.
• Post-radiotherapy constriction features
prominently today along with post-surgical
causes.
• Needs to be differentiated from restrictive
cardiomyopathy when making diagnosis.
Clinical Features - Symptoms and signs
• Reduced cardiac output (fatigue, hypotension,

reflex tachycardia)
• Elevated systemic venous pressure (jugular venous
distension, hepatomegaly with marked ascites and
peripheral edema)
• Pulmonary venous congestion (exertional dyspnea,
cough and orthopnea)
Kussmauls sign
• Normal subjects – inspiration causes a

decrease in chest pressure. Increase in venous
return – JVP falls
• Constrictive pericarditis – Increased venous
return cannot be accommodated in RV
because of high EDP
• So JVP rises on inspiration
Investigations
• ECG: may be normal, sinus tacycardia

• CXR: may see paricardial calcification and helps
to rule out coexisting effusion
• Echo: paricardial thickening and or calcification,
can identify haemodynamic effects on heart
and coexisting effusion
• MRI/CT scan – thickness of the pericardium.
Cine CT is a technique which gives information
about the heamodynamic effects
Chest x-ray
• Occasionally calcification
noted
• More useful to determine
whether there is a
coexisting effusion (fluid
accumulation)
CXR
Treatment
• The only effective treatment for chronic
constrictive pericarditis is complete
surgical resection of the pericardium.
• Mortality for procedure ranges from 5-16%
• Symptomatic improvement in ~90%
• 5 year survival rate is 74-87% depending
on co-morbidities pre-op
Pericardial effusion
• Spectrum of causes of effusion is similar to

acute pericarditis
• More likely than constriction following MI
and cardiac surgery
• Can coexist with acute pericarditis and
chronic constrictive disease
Causes
• Major causes are post cardiac surgery, infections
(TB) and neoplastic disease
• Gradual accumulation of fluid (chronic) permits
progressive stretching of pericardium
• Patient may develop a large amount of fluid
without significant increase in intrapericardial
pressure
• Rapid accumulation of fluid (acute) leads
to critical elevation of intrapericardial
pressure
Pericardial fluid
According to the cause of pericardial
effusion, may be:
• Transudate
• Exudate
• Pus
• Blood
• Bloody
Manifestations
• Symptoms vary according to cause, amount and

rate of accumulation.
• May be asymptomatic.
• Symptoms of HF
• Auscultation: muffled heart sounds
Investigations
• ECG may show low amplitude QRS complexes
and alternating axis
• CXR – (bottle glass appearance) globular

appearance of heart and therefore increased
cardiothoracic ratio
• Echo – size of effusion and haemodynamic

effect of it
Pericardial fluid aspirate:
3 specimens for:
Chemical, cytological and microbiological
analysis
CX ray
Echocardiography
Treatment
• Depends on the cause and nature

• If no hemodynamic compromise the cause is
treated and the patient monitored
• If persistent problem or life threatening
pericardiocentesis is done
Cardiac tamponade
Cardiac tamponade
(complication of pericardial effusion)
• This is a clinical diagnosis

- It is based upon the patient’s symptoms
• Investigations may be performed to
confirm the suspected cause of the
symptoms (pericardial effusion).
• Occurs when the fluid accumulation around the
heart impairs filling to such an extent that there
is haemodynamic compromise.
• It is a medical emergency and must be treated
promptly.
• Risk of death depends upon speed of diagnosis,
treatment and underlying cause of the
tamponade.
How much fluid is a problem?
• Depends on rate of accumulation and
compliance of the pericardium
• 150 ml that accumulated quickly could
cause a problem
• 1000 ml that accumulates very slowly may
be tolerated fairly well
Signs and symptoms
• Acutely unwell
– Significant SOB, rapid breathing
– Tachycardia
– Orthopnoea
– Cold, clammy extremities because of poor
perfusion
– Kussmauls sign
Investigations (used to confirm presence of effusion
not diagnosis of tamponade)
• CXR – ‘globular’ heart

• ECG (findings are suggestive not diagnostic)
- Sinus tachycardia
- Low voltage QRS complexes
- Electrical alternans (not always)
• Echo
- Size and location of effusion
- Any evidence of diastolic collapse
- ‘Swinging’ of the heart
- Decrease of insp. flow across MV
Treatment
• Medical emergency – intensive care

• Oxygen
• Volume expansion
• Bed rest with leg elevation
• Inotropic drugs if necessary
Pericardiocentesis
• Pericardiocentesis is the definitive therapy

to remove the excessive fluid
• Commonly performed in the cath lab but
may be done ‘blind’ in an intensive care
environment
Pericardiocentesis

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Pericardial diseases

• Surrounds the heart

• Retrosternal chest pain – sharp worse on inspiration

• Friction rub (high pitched scratching sound), heard

Although uncommon, need substantial

• Tuberculous constrictive pericarditis was

• Reduced cardiac output (fatigue, hypotension,

• Normal subjects – inspiration causes a

• ECG: may be normal, sinus tacycardia

• Spectrum of causes of effusion is similar to

• Symptoms vary according to cause, amount and

• CXR – (bottle glass appearance) globular

• Echo – size of effusion and haemodynamic

• Depends on the cause and nature

• This is a clinical diagnosis

• CXR – ‘globular’ heart

• Medical emergency – intensive care

• Pericardiocentesis is the definitive therapy

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