1. Diseases of the Pericardium David L. Hykes, Jr. DO

2. Pericardium and Pericardial Diseases 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.

3. Etiologies 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)

4. Etiologies 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

5. Etiologies 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

6. Acute Pericarditis Symptoms – Chest pain Develops suddenly and is severe and constant Pain worsens with inspiration – Low-grade fever – Weakness/fatigue

7. Acute Pericarditis 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

8. Acute Pericarditis 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)

9. Acute Pericarditis

10. Subacute & 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

11. Pericarditis Subacute Chronic

12. Pericardial Effusion & 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

13. Cause of Hemopericardial effusion Cardiac perforation

14. Pericardial Effusion The 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

16. Diagnosis of Effusion EKG Echocardiography CT Scan MRI

17. Diagnosis of Pericardial Tamponade Beck’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

18. Cardiac Tamponade

19. 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

20. Pericardial Effusion on Echocardiogram

21. Pericardial 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

22. Pericardial Tamponade Treatment Pericardial drainage – Needle pericardiocentesis – Percutaneous balloon pericardiotomy – Pericardial window – Pericardial resection

23. Pericardiocentesis

26. Questions

27. References 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

28. References 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