Diseases of the pericardium

Pericarditis

• Pericardial inflammation may be due to infection, immunological reaction ,trauma or neoplasm and some time remained un explained.

• 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 &

Tuberclosis.

Clinical features

• Pain is retrosternal with radiation to the shoulders and neck and typically aggrevated 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 heared in systole and may be in diastole.(to –and –fro) quality.

• Investigations : The ECG show ST elevation with up ward concavity over the affected area .Later may be T inversion ,particularly if there is associated myocarditis.

Management

• The pain can be relieved by asprin 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.

Pericardial Effusion

• Usually present with retrosternal oppression.its difficult to be detected clinically.

• The heart sound become quiter.pericardial rub abolished.

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

• Echo.is diagnostic.• Depending on aetilogy may be

fibrinous,serous,haemorraghic or purulent.

• A 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 haemorraghic 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 septicaemia.

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

• Its 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 arrythmias.

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 limitted disease and need no treatment.

B-NSAID or high dose asprin is effective treatment.

C-Steroid improve healing.

Regarding pericardial tamponade,which one is not true:

A-Usually need no treatment.

B-Need urgent treatment.

C-May be a complication of car accident.

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 require specific anti TB,in addition, a 3 month course of prednisolone has been shown to improve out come.

Chronic Constrictive Pericarditis

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

• In effect the heart encased in a solid shell & can not work properly ,the calcification may extend to the myocardium ,so affect the myocardial function.

possible causes

1) Tuberculous pericarditis.

2) Haemopericardium .

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.• Ascitis & peripheral edema.

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

• CXR show pericardial calcification, echocardiography ,CT & 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.