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1) Diseases of the Pericardium - Dr. Jawad

Pericarditis

• Pericardial inflammation may be due to infection, immunological reaction, trauma or neoplasm and sometime

remained unexplained.

• Pericarditis and Myocarditis often coexist.

• Causes :

1. Common: Acute myocardial infarction ,viral ( e.g.Coxsacki B)

2. Less common: Uremia, malignant dis, Trauma & connective tissue dis.

3. Rare: Bacterial infection, rheumatic fever & Tuberculosis.

Clinical features

• Pain is retrosternal with radiation to the shoulders and neck and typically aggravated by deep breathing,

movement, a change of position, exercise and swallowing.

• Low grade fever is common.

• A pericardial rub is a high pitched sound its diagnostic, often heard in systole and may be in diastole. (To –and –

fro) quality.

• Investigations: The ECG show ST elevation with upward concavity over the affected area .Later may be T

inversion, particularly if there is associated myocarditis.

Management

• The pain can be relieved by aspirin high dose but a more potent anti-inflammatory agent such as indomethacin

may be required.

• Corticosteroid may suppress symptoms but not healing.

• In viral pericarditis recovery usually occurs within a few days or weeks. But there may be recurrence.

• Purulent pericarditis require treatment with antimicrobial therapy, paracentesis and if necessary surgical

drainage.

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Pericardial Effusion

• Usually present with retrosternal oppression. It’s difficult to be detected clinically.

• The heart sound become quieter, pericardial rub abolished.

• The QRS voltage decreased. Chest x-ray show globular cardiomegaly.

• Echo.is diagnostic.

• Depending on etiology may be fibrinous, serous, hemorrhagic or purulent.

• Fibrinous exudates may eventually lead to varying degree of adhesion.

• While serous pericarditis lead to a large effusion of turbid, straw-colored fluid with a high protein content.

• A hemorrhagic effusion is often due to malignancy particularly breast cancer, carcinoma of the bronchus and

lymphoma.

• Purulent pericarditis is rare and may occur as a complication of septicemia.

Cardiac tamponade

• It refer to acute heart failure due to compression of the heart by a large or rapidly developing effusion .Atypical

presentation occur when the effusion is loculated as a result of previous pericarditis or cardiac surgery.

Pericardial Aspiration

• It is also called pericardiocentesis, may be indicated for diagnostic or therapeutic purposes.

• It done by inserting a needle under xiphoid process with direction toward left shoulder.

• Complications include Coronary artery damage, bleeding and arrhythmias.

The most common causes of acute pericarditis:

A. Malignant neoplasm

B. Viral infection.

C. Bacterial.

Which one is false regarding treatment of acute viral pericarditis:

A. May be self-limited disease and need no treatment.

B. NSAID or high dose aspirin is effective treatment.

C. Steroid improves healing.

Regarding pericardial tamponade, which one is not true:

A. Usually need no treatment.

B. Need urgent treatment.

C. Maybe a complication of car accident.

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Tuberculosis Pericarditis

• May complicate pulmonary TB, but may be the first manifestation of the disease.

• In Africa tuberculous effusion is a common manifestation of AIDS.

• The condition typically present with chronic malaise, weight loss and low grade fever.

• An effusion usually develops and the pericardium may become thick and unyielding, leading to pericardial

constriction or tamponade, an associated pleural effusion is often present.

Management

• The diagnosis may be confirmed by aspiration of the fluid and direct examination or culture for tubercle bacilli.

• Treatment requires specific anti TB, in addition, a 3 month course of prednisolone has been shown to improve

outcome.

Chronic Constrictive Pericarditis

• Is due to progressive thickening, fibrosis & calcification of the pericardium.

• In effect the heart encased in a solid shell & cannot work properly; the calcification may extend to the

myocardium, so affect the myocardial function.

Possible Causes

1) Tuberculous pericarditis

2) Hemopericardium

3) Viral pericarditis

4) Rheumatoid arthritis

5) Purulent pericarditis

Clinical Features

• Fatique.

• Rapid low volume pulse.

• Pulsus paradoxicus.

• Elevated JVP (rapid y descent).

• Kussmaul sign.

• Loud early third sound (pericardial knock).

• Hepatomegaly.

• Ascites & peripheral edema.

• The condition should be suspected in any patient with unexplained right sided failure and a small heart.

• CXR show pericardial calcification, echocardiography, CT and MRI help for diagnosis.

• The differentiation of chronic constrictive pericarditis from restrictive cardiomyopathy is difficult and need

complex echo-doppler studies and cardiac catheterization.

Management

• Surgical resection of the diseased pericardium can lead to dramatic improvement in up to 50 % of cases.