1. 1 Visceral – single layer mesothelial cells Parietal- fibrous < 2 mm thick Functions –Limits motion –Prevents dilatation during volume increase –Barrier to infection 15-50 ml serous fluid Well innervated Pericardial Diseases

2. 2 Acute Pericarditis Etiology Infectious –Viral –Bacterial –TB Noninfeccious –Post MI (acute and Dresslers) –Uremia –Neoplastic disease –Post radiation –Drug-induced –Connective tissue diseases/autoimmune –traumatic

3. 3 Infectious Viral (idiopathic) –Echovirus, coxsackie B –Hepatitis B, influenza, IM, Caricella, mumps –HIV, TB –Bacterial (purulent) Pneuococcus, staphlococci fulminant

4. 4 Pericarditis post- MI Early <5% patients Dressler’s 2 weeks – months –Autoimmune Post-pericardiotomy

5. 5 Neoplastic Breast Lung Lymphoma Primary pericardail tumors rare Hemmorrhagic and large

6. 6 Radiation –Dose > 4000rads –Local inflammation Autoimmune –SLE –RA –PSS (40% may develop) Drugs-lupus like –Hydralazine –Procaimamide –Phenytoin –Methyldopa –Isoniazid Drugs- not lupus –Minoxidil –Anthracycline antineoplastic agents

7. 7 Pathogenesis and Pathology Inflammatory –Vasodilation –Increased vascular permeability –Leukocyte exudation Pathology –Serous-little cells –Serofibrinous – rough appearance / scarring common –Purulent – intense inflammation –Hemmorrhagic – TB or malignancy

8. 8 Clinical Chest pain –Radiate to back –Sharp and pleuritic –Positional – worse lying back Fever Dyspnea due to pleuritic pain

9. Chest pain in Pericarditis เจ็บบริเวณหลังต่อกระดูก sternum เจ็บมากเวลาหายใจ และเวลา นอนหงาย เจ็บน้อยลงเวลาลุกนั่ง และ โน้ม ตัวไปด้านหน้า

10. 10 Exam Friction rub –Diaphragm leaning forward –1, 2 or 3 components Ventricular contraction, relaxaltion, atrial contraction –intermittent

11. 11 Diagnostic Clinical history ECG –Abn in 90% –Diffuse ST elevation –PR depression Echocardiography –Effusion PPD Autoimmune antibodies Evaluate for malignancy

12. 12 (Circulation. 2006;113:1622-1632.)

13. EKG in Pericarditis

14. 14 (Circulation. 2006;113:1622-1632.)

15. 15 Treatment ASA or NSAIDs –Avoid NSAID in MI Colchicine Steroids - avoid –May increase reoccurance TB – Rx TB Purulent – drainage of fluid + antibiotics Neoplastic- drainage Uremic - dialysis

16. 16 Pericardial Effusion From any acute pericarditis Hypothyriodism- increased capillary permeability CHF- increased hydrostatic pressure Cirrhosis- decreased plasma oncotic pressure Chylous effusion- lymphatic obstruction Aortic Dissection

17. 17 Effusion Pathophysiology Pericardium is stiff- PV curve not flat Above critical volume – rapid increase in pressure Factors that determine compression –Volume –Rate of accumulation –Pericardial compliance

18. 18 Clinical Asymptomatic Symptoms –CP, dyspnea, dysphagia, hoarseness, hiccups Tamponade Exam –Muffled heart sounds –Absence of rub –Ewarts sign-dullness L lung at scapula atelectasis

19. 19 Diagnostic studies CXR - > 250 ml fluid globular cardiomegaly ECG low voltage and electrical alternans Echocardiogram most helpful –Identify hemodynamic compromise

20. ECG low voltage and electrical alternans 20

22. 22 Treatment If known cause- treat that If unknown- may need pericardiocentesis or pericardial window Cardiac tamponade is emergency- pericardiocentesis drainage or window

23. 23 Tamponade Any cause of effusion may lead to Diastolic pressures elevate and = pericardial pressure Impaired LV/RV filling Increased systemic venous pressure Decreased stroke volume and C.O. Shock

24. 24 Have right side failure with edema and fatigue only if occurs slowly Key physical findings: –JVD –Hypotension –Small quiet heart Sinus tachycardia Pulsus paradoxus- decease in BP > 10 during normal inspiration Tamponade

25. 25 Pulsus Paradoxus Exaggeration of normal Normally septum moves toward LV with inspiration, with decrease in LV filling With compression and fixed volume, there is even greater limitation in LV filling and reduced stroke volume PP also seen in COPD/asthma

26. 26 Echocardiography –Compression of RV and RA in diastole –Can have localized effuison with localized compression of one chamber (RA,LV) Effusion post cardiac surgery –Differentiate other causes of low cardiac output Cardiac catheterization- definitive –Measure pressures- chamber and pericardial equal, and all elevated. Tamponade

27. 27 Tamponade- external compression blunts filling throughout cardiac cycle

28. 28 Lancet 2004; 363: 717–27

29. 29

30. 30

31. 31 Pericardial Fluid Stained and cultured Cytologic exam Cell count Protein level –pp/sp> 0.5 - exudate LDH level –p LDH/ s LDH > 0.6 - exudate Adenosine Deaminase level - sensitive and specific for TB

32. 32 Constrictive Pericarditis Most common etiology is idiopathic (viral) Any cause of pericarditis Post cardiac surgery Pathology –Organization of fluid, scarring, fusion of pericardial layers, calcification

33. 33 Impaired diastolic filling of the chambers Elevated systemic venous pressures Reduced cardiac output Dip and plateau curve on catheterization Constrictive Pericarditis

34. 34 Constrictive Pericarditis Clinical Symptoms –Fatigue, hypotension, tachycardia –JVD, hepatomegaly and ascites, edema Can confuse with cirrhosis- look for JVD Exam –Pericardial knock after S2- sudden cessation of ventricular diastolic filling Kussmaul’s sign- JVD with inspiration No pulsus paradoxus Difficult to separate from restrictive cardiomyopathy- may need myocardial biopsy

35. 35 Am Heart J 1999;138:219-32

36. 36 (Circulation. 2006;113:1622-1632.) Normal pericardium < 2 mm