1. Pericardial diseases Dr. Ghazi F
Pericardial diseases Dr .Ghazi F. Haji Senior lecturer of cardiology Al-Kindy College of Medicine

2. introduction
Pericardial diseases is potentially curable In westerian countries – idiopathic In developing countries ---tuberculosis

3. What is Pericardium ?
*fibrous sac suround heart *Serous membrane-two layers covering of the heart and root of great vessels *Two layers : parietal (outer)and visceral (inner)with potential spacing between *parietal layer sensitive to pain

5. Function
1-Stabilize the heart in it is position 2-Lubricate surface of the heart Allows smooth and controlled movement of the heart in the thorax 3-Barrier of the infection

6. Pericardial Diseases
-Acute Pericarditis -Pericardial effusion -Constrictive pericarditis

7. Mr X 55 y old man ,diabetic for 10y ago with regular therapy on metformine and glyberid ;presented with history of fever and tiredness for 4 days duration ,his illness associated with progressive chest pain ,in the left side ,increase with respiration and change in posture, He has family history of treatable tuberculosis. On examination ;Pt .Conscious ,no pallor, not cyanosis.his puls was 66b/m BP 124/80 ,RR 18 ,normal S1S2 no added sound, no murmur ,but there is high pitched-scratching over pericordium . What is the diagnosis ? What are the suspected causes? How confirm your diagnosis? How manage ? What are the prognosis?

8. Pericarditis
Inflammation of pericardium Pericardium ; thick and fibrous exudates in between – bread and butter appearance May develop pericardial effusion later Nature of fluid :serous ,purulent and hemorrhage Sequelae-cardiac tamponada constrictive pericaditis recurrent pericarditis

9. Clinical classification
@Acute pericarditis : less than 6 wk Fibrinous pericaditis : 6wk-6month Effusive / pericarditis :more than 6 month Constrictive Adhesive

10. Causes
#idopathic # following Myocardial infraction or cardiac surgery #Infection :Viral –Coxsacki B,mump-Flue-Epstian – Barr- Hepatitis-HIV-Mycobactruim Tuberculosis Staphylococcus /H. influenza #Connective tissue diseases:Rheumatoid arthritis- Rheumatic fever #Traumatic #Post irradiation #Malignancies- Breast 0 lung 0 lymphoma #Drugs –penicillin –INH-hydralazine #Metabolic :Uremia .Myxoedema

11. Clinical features and diagnosis
Pain – anterior ,sudden -central chest Pain- ,may radiated to in nature ,change with position ,relive with sitting up and leaning pain in- uremia ,tuberculous ,neoplastic ,post irradiation pericarditis Pericardial friction rub Classically triphasic –high to and fro sound ,may confuse with sitting leaning, in expiration –best heard

12. ECG
Differential diagnosis ;Acute myocardial infarction 1-Diffuse ST elevation in all leads except Avr + PR segment depression (80%) with upright T (concave) in all leads except aVR 2-normalization of ST-PR segments 3-Widspread T wav inversion 4- normalization of T wav T inversion starts only after ST becoming iso-electiric

15. Blood
Blood picture-CRP,ESR,LEUKOCYTOSIS Cardiac enzymes Blood culture Virology –serelogy Thyroid function tests ANF,RF

16. CXR – ECHO
CXR: Useful if there is effusion ECHO :can detect even small amount

17. Treatment
-Treat underlying cause -Bed rest -Analgesic –NSAID –indomethacin- ibuprofen – -Colchicines -steroid /immunosuppressant

18. .Mr X during treatment , 10 days later ;He developed progressive SOB and tachypenic but the pluertic pain suddenly subside, on examination ;JVP elevated and kuassmoul signs, pulsus paradoxis ,BP 90/50 ,Puls 100b/m What new event happen? What are useful investigation?

20. Pericardial effusion
Collection of fluid in pericardial space Normally ml Echo :50 ml detected CXR : 250 ml positive Clinically : 500 ml Rapid development of pericardial effusion if called tamponade

21. Diagnosis of pericardial effusion
*Pain – subside when effusion develop *Usual presentation as dyspenea *Pulse –pulsus paradoxis (Normally during inspiration systolic Bp decrease up to 10 mmhg Exaggeration of normal fall in systolic BP during inspiration) *JVP elevation *Apex – fainting not palpaple *Percussion –widening of cardiac borders *Auscultation –muffled heart sound

22. Ecg + CXR + ECHO
-ECG-low voltage -CXR-Increase cardiac sillhoutte Flask shaped enlargement -Echo free zone surround the heart -Fluid aspiration-Pericardial protein /serum protein > o.5 exudate Adenosine deaminases –sensitive and spesefic in TB

27. Treatment
Treated the cause Pericardiocentesis(diagnostic and therapeutic ) Culture . ZN stain . cytology .

28. Temponada
Rapid Accumulation of fluid lead to obstruction of ventricular filling even 200 ml but the heart can accumadate 2000ml if slowly accumulated Physiology : Increase intra cardiac pressure Decrease ventricular filling Decrease cardiac output

29. CAUSES
Any pericarditis Aortic dissection Haemodialysis Warfarin therapy Cardiac surgery Post cardiac cathetrization Uremia Connective tissue diseases –SLE.RA

30. Manifestation
-Dyspnea – orthopenia -Tachycardia , Pulsus paradoxis -Hypotension -Raise JVP and prominent descend of x wave Kussmual s- absent (normaly inspiration cause decrease in chest pressure ,increase in venous return-JVP fall ) In constractive pericadritis –increase venous return cannot accommodate in RV because of end diastolic pressure so JVP rises in inspiration -Wideness of cardiac dullness-percussion Beck s triad (fall BP+raise JVP+ quite heart)

31. INVESTIGATION S
-CXR- cardiomegaly -ECG-small QRS+may be - electric alternant ECHO- Free zone surround heart RT atrial and ventricular collapse Dilated inferior vena cava

32. Treatment
Drainage *pericadrocentesis* and culture Xyphisternum puncture site-large needle with syringe

33. Mr X, After complete his treatment ,His general health became well,vital signs normal ,echo finding normal 5years later ;he suffer from progressively increase SOB ,fatigability ,ascites and leg swelling. On examination JVP elevated What is the cause of these finding? What is the underlying cause? What is the diagnosis ? What is the important tool in diagnosis? What is the differnitional diagnosis?

34. Constrictive pericarditis
Pericardium undergo thickening ,fibrosis and calcification(rigid pericardium) Restrict diastolic filling LV systolic function preserve till late

35. causes @Unknown- Usually secondary to chronic inflammation
Tuberculous pericarditis
Hemopericardium
Pyogenic -uremia -rheumatoid disease –rare
@May be late complication of open heart surgery

36. Manifestation
Typical features of systemic venous congestion Increase JVP and prominent y wave descend Hepatosplenomegaly – AScite –pedal edema Impaired filling of ventricle : Pulsus paradoxus- kussmaul sign Heart sounds muffled

37. Radiological features
ECG –Low voltage –diffuse T wave changes CXR- small heart -Calcification ECHO – impaired diastolic relaxation CT scan,MRI – pericardial thickness /calcification Catheterization – dip and plateau curve

38. Treatment
Surgery

41. THANK YOU