1. Pericardial Diseases  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 1

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 2

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

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

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

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 6

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 7

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

9. Exam  Friction rub Diaphragm leaning forward 1, 2 or 3 components ○ Ventricular contraction, relaxaltion, atrial contraction intermittent 9

10. Diagnostic  Clinical history  ECG Abn in 90% Diffuse ST elevation PR depression  Echocardiography Effusion  PPD  Autoimmune antibodies  Evaluate for malignancy 10

11. 11 (Circulation. 2006;113:1622-1632.)

12. EKG in Pericarditis

13. 13 (Circulation. 2006;113:1622-1632.)

14. Treatment  ASA or NSAIDs Avoid NSAID in MI  Colchicine  Steroids - avoid May increase reoccurance  TB – Rx TB+steroids  Purulent – drainage of fluid + antibiotics  Neoplastic- drainage  Uremic - dialysis 14

15. Pericardial Effusion  From any acute pericarditis  Hypothyriodism- increased capillary permeability  CHF- increased hydrostatic pressure  Cirrhosis- decreased plasma oncotic pressure  Chylous effusion- lymphatic obstruction 15

16. 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 16

17. Clinical  Asymptomatic  Symptoms CP, dyspnea, dysphagia, hoarseness, hiccups  Tamponade  Exam Muffled heart sounds Absence of rub 17

18. Diagnostic studies  CXR - > 250 ml fluid globular cardiomegaly  ECG low voltage and electrical alternans  Echocardiogram most helpful Identify hemodynamic compromise 18

19. ECG low voltage and electrical alternans 19

21. Treatment  If known cause- treat that  If unknown- may need pericardiocentesis or pericardial window  Cardiac tamponade is emergency- pericardiocentesis drainage or window 21

22. 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 22

23. Tamponade  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 23

24. 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 24

25. Tamponade  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. 25

26. 26 Lancet 2004; 363: 717–27

27. 27

28. 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 28

29. 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 29

30. Constrictive Pericarditis  Impaired diastolic filling of the chambers  Elevated systemic venous pressures  Reduced cardiac output  Dip and plateau curve on catheterization 30

31. 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 31

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

33. 33 (Circulation. 2006;113:1622-1632.) Normal pericardium < 2 mm