1 visceral – single layer mesothelial cells parietal- fibrous < 2 mm thick functions –limits...
TRANSCRIPT
![Page 1: 1 Visceral – single layer mesothelial cells Parietal- fibrous < 2 mm thick Functions –Limits motion –Prevents dilatation during volume increase –Barrier](https://reader031.vdocuments.us/reader031/viewer/2022020417/56649ced5503460f949b9f3f/html5/thumbnails/1.jpg)
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
![Page 2: 1 Visceral – single layer mesothelial cells Parietal- fibrous < 2 mm thick Functions –Limits motion –Prevents dilatation during volume increase –Barrier](https://reader031.vdocuments.us/reader031/viewer/2022020417/56649ced5503460f949b9f3f/html5/thumbnails/2.jpg)
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
![Page 3: 1 Visceral – single layer mesothelial cells Parietal- fibrous < 2 mm thick Functions –Limits motion –Prevents dilatation during volume increase –Barrier](https://reader031.vdocuments.us/reader031/viewer/2022020417/56649ced5503460f949b9f3f/html5/thumbnails/3.jpg)
3
Infectious
• Viral (idiopathic)– Echovirus, coxsackie B– Hepatitis B, influenza, IM, Caricella, mumps– HIV, TB– Bacterial (purulent)
• Pneuococcus, staphlococci
• fulminant
![Page 4: 1 Visceral – single layer mesothelial cells Parietal- fibrous < 2 mm thick Functions –Limits motion –Prevents dilatation during volume increase –Barrier](https://reader031.vdocuments.us/reader031/viewer/2022020417/56649ced5503460f949b9f3f/html5/thumbnails/4.jpg)
4
Pericarditis post- MI
• Early <5% patients
• Dressler’s 2 weeks – months– Autoimmune
• Post-pericardiotomy
![Page 5: 1 Visceral – single layer mesothelial cells Parietal- fibrous < 2 mm thick Functions –Limits motion –Prevents dilatation during volume increase –Barrier](https://reader031.vdocuments.us/reader031/viewer/2022020417/56649ced5503460f949b9f3f/html5/thumbnails/5.jpg)
5
Neoplastic
• Breast
• Lung
• Lymphoma
• Primary pericardail tumors rare
• Hemmorrhagic and large
![Page 6: 1 Visceral – single layer mesothelial cells Parietal- fibrous < 2 mm thick Functions –Limits motion –Prevents dilatation during volume increase –Barrier](https://reader031.vdocuments.us/reader031/viewer/2022020417/56649ced5503460f949b9f3f/html5/thumbnails/6.jpg)
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
![Page 7: 1 Visceral – single layer mesothelial cells Parietal- fibrous < 2 mm thick Functions –Limits motion –Prevents dilatation during volume increase –Barrier](https://reader031.vdocuments.us/reader031/viewer/2022020417/56649ced5503460f949b9f3f/html5/thumbnails/7.jpg)
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
![Page 8: 1 Visceral – single layer mesothelial cells Parietal- fibrous < 2 mm thick Functions –Limits motion –Prevents dilatation during volume increase –Barrier](https://reader031.vdocuments.us/reader031/viewer/2022020417/56649ced5503460f949b9f3f/html5/thumbnails/8.jpg)
8
Clinical
• Chest pain– Radiate to back– Sharp and pleuritic– Positional – worse lying back
• Fever
• Dyspnea due to pleuritic pain
![Page 9: 1 Visceral – single layer mesothelial cells Parietal- fibrous < 2 mm thick Functions –Limits motion –Prevents dilatation during volume increase –Barrier](https://reader031.vdocuments.us/reader031/viewer/2022020417/56649ced5503460f949b9f3f/html5/thumbnails/9.jpg)
Chest pain in Pericarditis
• เจ็�บบริ�เวณหลั�งต่�อกริะดู�กsternum
• เจ็�บมากเวลัาหายใจ็ แลัะเวลัานอนหงาย • เจ็�บน�อยลังเวลัาลั�กน��ง แลัะ โน�มต่�วไปดู�านหน�า
![Page 10: 1 Visceral – single layer mesothelial cells Parietal- fibrous < 2 mm thick Functions –Limits motion –Prevents dilatation during volume increase –Barrier](https://reader031.vdocuments.us/reader031/viewer/2022020417/56649ced5503460f949b9f3f/html5/thumbnails/10.jpg)
10
Exam
• Friction rub– Diaphragm leaning forward– 1, 2 or 3 components
• Ventricular contraction, relaxaltion, atrial contraction
– intermittent
![Page 11: 1 Visceral – single layer mesothelial cells Parietal- fibrous < 2 mm thick Functions –Limits motion –Prevents dilatation during volume increase –Barrier](https://reader031.vdocuments.us/reader031/viewer/2022020417/56649ced5503460f949b9f3f/html5/thumbnails/11.jpg)
11
Diagnostic• Clinical history• ECG
– Abn in 90%– Diffuse ST elevation– PR depression
• Echocardiography– Effusion
• PPD• Autoimmune antibodies• Evaluate for malignancy
![Page 12: 1 Visceral – single layer mesothelial cells Parietal- fibrous < 2 mm thick Functions –Limits motion –Prevents dilatation during volume increase –Barrier](https://reader031.vdocuments.us/reader031/viewer/2022020417/56649ced5503460f949b9f3f/html5/thumbnails/12.jpg)
12(Circulation. 2006;113:1622-1632.)
![Page 13: 1 Visceral – single layer mesothelial cells Parietal- fibrous < 2 mm thick Functions –Limits motion –Prevents dilatation during volume increase –Barrier](https://reader031.vdocuments.us/reader031/viewer/2022020417/56649ced5503460f949b9f3f/html5/thumbnails/13.jpg)
EKG in Pericarditis
![Page 14: 1 Visceral – single layer mesothelial cells Parietal- fibrous < 2 mm thick Functions –Limits motion –Prevents dilatation during volume increase –Barrier](https://reader031.vdocuments.us/reader031/viewer/2022020417/56649ced5503460f949b9f3f/html5/thumbnails/14.jpg)
14(Circulation. 2006;113:1622-1632.)
![Page 15: 1 Visceral – single layer mesothelial cells Parietal- fibrous < 2 mm thick Functions –Limits motion –Prevents dilatation during volume increase –Barrier](https://reader031.vdocuments.us/reader031/viewer/2022020417/56649ced5503460f949b9f3f/html5/thumbnails/15.jpg)
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
![Page 16: 1 Visceral – single layer mesothelial cells Parietal- fibrous < 2 mm thick Functions –Limits motion –Prevents dilatation during volume increase –Barrier](https://reader031.vdocuments.us/reader031/viewer/2022020417/56649ced5503460f949b9f3f/html5/thumbnails/16.jpg)
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
![Page 17: 1 Visceral – single layer mesothelial cells Parietal- fibrous < 2 mm thick Functions –Limits motion –Prevents dilatation during volume increase –Barrier](https://reader031.vdocuments.us/reader031/viewer/2022020417/56649ced5503460f949b9f3f/html5/thumbnails/17.jpg)
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
![Page 18: 1 Visceral – single layer mesothelial cells Parietal- fibrous < 2 mm thick Functions –Limits motion –Prevents dilatation during volume increase –Barrier](https://reader031.vdocuments.us/reader031/viewer/2022020417/56649ced5503460f949b9f3f/html5/thumbnails/18.jpg)
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
![Page 19: 1 Visceral – single layer mesothelial cells Parietal- fibrous < 2 mm thick Functions –Limits motion –Prevents dilatation during volume increase –Barrier](https://reader031.vdocuments.us/reader031/viewer/2022020417/56649ced5503460f949b9f3f/html5/thumbnails/19.jpg)
19
Diagnostic studies
• CXR - > 250 ml fluid globular cardiomegaly
• ECG low voltage and electrical alternans
• Echocardiogram most helpful– Identify hemodynamic compromise
![Page 20: 1 Visceral – single layer mesothelial cells Parietal- fibrous < 2 mm thick Functions –Limits motion –Prevents dilatation during volume increase –Barrier](https://reader031.vdocuments.us/reader031/viewer/2022020417/56649ced5503460f949b9f3f/html5/thumbnails/20.jpg)
ECG low voltage and electrical alternans
20
![Page 21: 1 Visceral – single layer mesothelial cells Parietal- fibrous < 2 mm thick Functions –Limits motion –Prevents dilatation during volume increase –Barrier](https://reader031.vdocuments.us/reader031/viewer/2022020417/56649ced5503460f949b9f3f/html5/thumbnails/21.jpg)
![Page 22: 1 Visceral – single layer mesothelial cells Parietal- fibrous < 2 mm thick Functions –Limits motion –Prevents dilatation during volume increase –Barrier](https://reader031.vdocuments.us/reader031/viewer/2022020417/56649ced5503460f949b9f3f/html5/thumbnails/22.jpg)
22
Treatment
• If known cause- treat that
• If unknown- may need pericardiocentesis or pericardial window
• Cardiac tamponade is emergency- pericardiocentesis drainage or window
![Page 23: 1 Visceral – single layer mesothelial cells Parietal- fibrous < 2 mm thick Functions –Limits motion –Prevents dilatation during volume increase –Barrier](https://reader031.vdocuments.us/reader031/viewer/2022020417/56649ced5503460f949b9f3f/html5/thumbnails/23.jpg)
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
![Page 24: 1 Visceral – single layer mesothelial cells Parietal- fibrous < 2 mm thick Functions –Limits motion –Prevents dilatation during volume increase –Barrier](https://reader031.vdocuments.us/reader031/viewer/2022020417/56649ced5503460f949b9f3f/html5/thumbnails/24.jpg)
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
![Page 25: 1 Visceral – single layer mesothelial cells Parietal- fibrous < 2 mm thick Functions –Limits motion –Prevents dilatation during volume increase –Barrier](https://reader031.vdocuments.us/reader031/viewer/2022020417/56649ced5503460f949b9f3f/html5/thumbnails/25.jpg)
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
![Page 26: 1 Visceral – single layer mesothelial cells Parietal- fibrous < 2 mm thick Functions –Limits motion –Prevents dilatation during volume increase –Barrier](https://reader031.vdocuments.us/reader031/viewer/2022020417/56649ced5503460f949b9f3f/html5/thumbnails/26.jpg)
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
![Page 27: 1 Visceral – single layer mesothelial cells Parietal- fibrous < 2 mm thick Functions –Limits motion –Prevents dilatation during volume increase –Barrier](https://reader031.vdocuments.us/reader031/viewer/2022020417/56649ced5503460f949b9f3f/html5/thumbnails/27.jpg)
27
Tamponade- external compression blunts filling throughout cardiac cycle
![Page 28: 1 Visceral – single layer mesothelial cells Parietal- fibrous < 2 mm thick Functions –Limits motion –Prevents dilatation during volume increase –Barrier](https://reader031.vdocuments.us/reader031/viewer/2022020417/56649ced5503460f949b9f3f/html5/thumbnails/28.jpg)
28Lancet 2004; 363: 717–27
![Page 29: 1 Visceral – single layer mesothelial cells Parietal- fibrous < 2 mm thick Functions –Limits motion –Prevents dilatation during volume increase –Barrier](https://reader031.vdocuments.us/reader031/viewer/2022020417/56649ced5503460f949b9f3f/html5/thumbnails/29.jpg)
29
![Page 30: 1 Visceral – single layer mesothelial cells Parietal- fibrous < 2 mm thick Functions –Limits motion –Prevents dilatation during volume increase –Barrier](https://reader031.vdocuments.us/reader031/viewer/2022020417/56649ced5503460f949b9f3f/html5/thumbnails/30.jpg)
30
![Page 31: 1 Visceral – single layer mesothelial cells Parietal- fibrous < 2 mm thick Functions –Limits motion –Prevents dilatation during volume increase –Barrier](https://reader031.vdocuments.us/reader031/viewer/2022020417/56649ced5503460f949b9f3f/html5/thumbnails/31.jpg)
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
![Page 32: 1 Visceral – single layer mesothelial cells Parietal- fibrous < 2 mm thick Functions –Limits motion –Prevents dilatation during volume increase –Barrier](https://reader031.vdocuments.us/reader031/viewer/2022020417/56649ced5503460f949b9f3f/html5/thumbnails/32.jpg)
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
![Page 33: 1 Visceral – single layer mesothelial cells Parietal- fibrous < 2 mm thick Functions –Limits motion –Prevents dilatation during volume increase –Barrier](https://reader031.vdocuments.us/reader031/viewer/2022020417/56649ced5503460f949b9f3f/html5/thumbnails/33.jpg)
33
• Impaired diastolic filling of the chambers
• Elevated systemic venous pressures
• Reduced cardiac output
• Dip and plateau curve on catheterization
Constrictive Pericarditis
![Page 34: 1 Visceral – single layer mesothelial cells Parietal- fibrous < 2 mm thick Functions –Limits motion –Prevents dilatation during volume increase –Barrier](https://reader031.vdocuments.us/reader031/viewer/2022020417/56649ced5503460f949b9f3f/html5/thumbnails/34.jpg)
34
Constrictive PericarditisClinical
• 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
![Page 35: 1 Visceral – single layer mesothelial cells Parietal- fibrous < 2 mm thick Functions –Limits motion –Prevents dilatation during volume increase –Barrier](https://reader031.vdocuments.us/reader031/viewer/2022020417/56649ced5503460f949b9f3f/html5/thumbnails/35.jpg)
35Am Heart J 1999;138:219-32
![Page 36: 1 Visceral – single layer mesothelial cells Parietal- fibrous < 2 mm thick Functions –Limits motion –Prevents dilatation during volume increase –Barrier](https://reader031.vdocuments.us/reader031/viewer/2022020417/56649ced5503460f949b9f3f/html5/thumbnails/36.jpg)
36
(Circulation. 2006;113:1622-1632.)
Normal pericardium < 2 mm