diseases of the pericardium david l. hykes, jr. do

Diseases of the PericardiumDiseases of the Pericardium

David L. Hykes, Jr. DO

Pericardium and Pericardial Pericardium and Pericardial DiseasesDiseases

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 DiseaseEtiologies 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, Chaga’s disease, filariasis)

Etiologies of Pericardial DiseaseEtiologies of Pericardial Disease 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 DiseaseEtiologies of Pericardial Disease

Other systemic diseases– Sarcoidosis, hemochromatosis, Gaucher’s

disease, pulmonary infiltration with eosinophilia

Drug induced– Procainamide, hydralazine, quinidine,

isoniazid, penicillin, streptomycin, methysergid, daunorubicin

Radiation

Acute PericarditisAcute Pericarditis

Symptoms– Chest pain

Develops suddenly and is severe and constant Pain worsens with inspiration

– Low-grade fever– Weakness/fatigue


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


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)

Subacute & Chronic PericarditisSubacute & 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

PericarditisPericarditisSubacute ChronicSubacute Chronic

Pericardial EffusionPericardial Effusion& Cardiac Tamponade& 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

Cause of Hemopericardial Cause of Hemopericardial effusioneffusion

Cardiac perforation

Pericardial EffusionPericardial EffusionThe 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 EffusionDiagnosis of Effusion

EKG EchocardiographyCT ScanMRI

Diagnosis of Pericardial TamponadeDiagnosis of Pericardial TamponadeBeck’s 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

Cardiac TamponadeCardiac Tamponade

Cardiac TamponadeCardiac 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

Pericardial Effusion on Pericardial Effusion on EchocardiogramEchocardiogram

Pericardial Tamponade TreatmentPericardial 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 Dressler’s Syndrome

Pericardial Tamponade TreatmentPericardial Tamponade Treatment

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

PericardiocentesisPericardiocentesis

QuestionsQuestions

ReferencesReferences 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

ReferencesReferences 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

diseases of the pericardium david l. hykes, jr. do

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