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 neoplasmB-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.