17 pericardial disease

Pericardial DiseasePericardial Disease

Wutao Zeng Wutao Zeng Department of Cardiology, the First Affiliated HoDepartment of Cardiology, the First Affiliated Ho

spital of Sun Yat-sen Universityspital of Sun Yat-sen University

General characteristicsGeneral characteristics((Normal Pericardial Anatomy and PhysiologyNormal Pericardial Anatomy and Physiology))

1.Pericardium is the membranous sac 1.Pericardium is the membranous sac surrounding the heart. surrounding the heart.

2. The pericardium consists of two layers: 2. The pericardium consists of two layers: visceral layer and parietal layer.visceral layer and parietal layer.

3.There is about 50ml pericardial fluid in the 3.There is about 50ml pericardial fluid in the pericardial cavity. pericardial cavity.

The normal functions of the pericardiumThe normal functions of the pericardium

Maintaining an optimal cardiac shape.Maintaining an optimal cardiac shape.Reducing friction between the beating Reducing friction between the beating

heart and adjacent structures. heart and adjacent structures. Protecting the heart from other diseases Protecting the heart from other diseases

which are caused by the neighboring which are caused by the neighboring organs: inflammation , TB, cancer etc. organs: inflammation , TB, cancer etc.

Preventing the overfilling of the heart.Preventing the overfilling of the heart.

Classification of Pericardial DiseasesClassification of Pericardial Diseases

Congenital defectCongenital defectPericarditisPericarditis

acute pericarditisacute pericarditispericardial effusionpericardial effusion constrictive pericaditisconstrictive pericaditis..

Pericardial neoplasmPericardial neoplasmPericardial cystsPericardial cysts

Acute pericarditisAcute pericarditis

DefinitionDefinition

Acute pericarditisAcute pericarditis is an inflammation is an inflammation

of the pericardium.of the pericardium.

EtiologyEtiology

The disease may be idiopathic or secondary to oThe disease may be idiopathic or secondary to other diseases, for examplether diseases, for example

Viral infection: coxsackievirus B, CMVViral infection: coxsackievirus B, CMV Bacterial infection: Staphylococcus sp, Streptococcus Bacterial infection: Staphylococcus sp, Streptococcus

sp, tubercle bacillussp, tubercle bacillus Post-MI complicationsPost-MI complications DrugsDrugs Malignancy Malignancy Collagen vascular diseaseCollagen vascular disease

Pathology Pathology Early stageEarly stage：：

fibrous protein pericarditisfibrous protein pericarditis

Progressive stageProgressive stage：： Rapid effusive pericarditis → acute cardiac tamponade Rapid effusive pericarditis → acute cardiac tamponade Chronic accumulation is accommodated by the expanding pericaChronic accumulation is accommodated by the expanding perica

rdiumrdium myopericarditismyopericarditis

Final resultFinal result ：： The exudate was completely dissolved and absorbed The exudate was completely dissolved and absorbed Organization Organization →→ calcification of pericardium calcification of pericardium →→ constrictive perica constrictive perica

rditisrditis

pathophysiologypathophysiology

Acute pericardial effusionAcute pericardial effusion↓↓

The pressure of the pericardial cavityThe pressure of the pericardial cavity↑↑↓↓

FV( filling volume) of the ventricular diastoleFV( filling volume) of the ventricular diastole↓↓↓↓

SV( stroke-volume)SV( stroke-volume)↓↓↓↓

BPBP↓↓

Clinical ManifestationsClinical Manifestations --- ---fibrous protein pericarditisfibrous protein pericarditis

Chest pain Chest pain (Symptoms)(Symptoms) Position Position ：：

retrosternal or precordiretrosternal or precordium, midsectionum, midsection

CharacterCharacter ：： sharp pain, dull pain, cosharp pain, dull pain, co

mpressionmpression WorsenWorsen

deep breathing, cough, deep breathing, cough, and lying down.and lying down.

Relieved Relieved sitting and leaning forwsitting and leaning forw

ard.ard.

Pericardial friction rubPericardial friction rub

(Signs)(Signs) Both systole and Both systole and

diastolediastole This finding is This finding is

diagnosticdiagnostic

Clinical Manifestations Clinical Manifestations --- ---Pericardial effusionPericardial effusion

SymptomsSymptoms

DispneaDispnea Pressure symptomsPressure symptoms ：：

dry cough(bronchus)dry cough(bronchus) hoarseness(laryngeal hoarseness(laryngeal

nerve)nerve) dysphagiadysphagia （（ esophagesophag

us)us)

SignsSigns physical sign of the heart physical sign of the heart

tachycardia, tachycardia, indistinct heart sounindistinct heart soundsds

Ewart signEwart sign (consolidation of lower (consolidation of lower lobe of left lung)lobe of left lung)

Hypotension Hypotension SBP↓SBP↓ ，， pulse pressure↓pulse pressure↓ even even paradoxical pulseparadoxical pulse.(there is .(there is

an exaggerated reduction of the an exaggerated reduction of the pulse >10mmHg during inspiratiopulse >10mmHg during inspiration)n)

Congestion of systemic circulatCongestion of systemic circulationion distended jugular veindistended jugular vein edemaedema

Clinical Manifestations Clinical Manifestations --- ---Cardiac tamponadeCardiac tamponade

Acute Acute ：： Beck’s trilogyBeck’s trilogyHypotension or shockHypotension or shockDistended jugular veinDistended jugular vein Indistinct heart soundsIndistinct heart sounds

Subacute or chronicSubacute or chronic ：： venous pressure↑ ↑venous pressure↑ ↑congestion of systemic circulationcongestion of systemic circulationKussmaul sign( dilation of jugular vein duriKussmaul sign( dilation of jugular vein duri

ng inspiration)ng inspiration)

Laboratory findingsLaboratory findings --- ECG--- ECG

Stage I:Stage I:ST segment elevationST segment elevation (concave upward not (concave upward not convex) in all leads except avR and V1 without reciconvex) in all leads except avR and V1 without reciprocal ST segment depression (which occurs in MI) procal ST segment depression (which occurs in MI) (Several hours later).(Several hours later).

Stage IIStage II: ST segments return to baseline, the initiall: ST segments return to baseline, the initially upright T waves flatten (several days later)y upright T waves flatten (several days later)

Stage III:Stage III:T waves invert (weeks later)T waves invert (weeks later) Stage IV:Stage IV:T waves revert to normal (weeks or monthT waves revert to normal (weeks or month

s later))s later))Other changes: Large effusion can cause both reduceOther changes: Large effusion can cause both reduce

d voltage and electrical alternans. d voltage and electrical alternans.

EKG of Acute pericarditis (Stage I)

Acute inferior myocardial infarctionAcute inferior myocardial infarction

Laboratory findingsLaboratory findings --- Chest x-ray film--- Chest x-ray film

Cardiac shadow has Cardiac shadow has an enlarged an enlarged “water-“water-bottle”bottle” appearance. appearance.

Clear lung field. Clear lung field.

Cardiac shadow Cardiac shadow changes with changes with postures.postures.

Laboratory findingsLaboratory findings ---Echocardiography---Echocardiography

This is the best This is the best noninvasive invnoninvasive investigation for cestigation for confirming diagnonfirming diagnosis of a pericaosis of a pericardial effusionrdial effusion

Laboratory findingsLaboratory findings --- Pericardiocentesis--- Pericardiocentesis

1.Pericardiocentesis can help to make1.Pericardiocentesis can help to make diagnosis diagnosis..Fluid should be sent for culture and assayFluid should be sent for culture and assay

Protein, glucose and LDH assaysProtein, glucose and LDH assays: LDH, glucose and protein : LDH, glucose and protein determine if fluid is a transudate or exudate;determine if fluid is a transudate or exudate;

Cytology and tumor markerCytology and tumor marker: CEA, AFP, CA125 and so on;: CEA, AFP, CA125 and so on; ANA assayANA assay: if collagen vascular disease is suspected.: if collagen vascular disease is suspected.

2. Pericardiocentesis can relieve the pressure of p2. Pericardiocentesis can relieve the pressure of pericardial cavity.ericardial cavity.

Diagnosis of Acute PericarditisDiagnosis of Acute Pericarditis

Chest pain aggravated by coughing, inspiration,or Chest pain aggravated by coughing, inspiration,or recumbencyrecumbency

Pericardial friction rub on auscultationPericardial friction rub on auscultation

Charateristic EKG changesCharateristic EKG changes

Chest X-ray and UCG may find pericardial effusioChest X-ray and UCG may find pericardial effusionn

Differential Diagnosis of Acute PericarditisDifferential Diagnosis of Acute PericarditisAcute idiopAcute idiopathic pericaathic perica

rditisrditis

Tuberculous Tuberculous pericarditispericarditis

Purulent pPurulent pericarditisericarditis MaligancyMaligancy

PostpericarPostpericardiostomy sydiostomy sy

ndromendrome

HistroryHistrory

History of up History of up respiratory trrespiratory tract infectionact infection ，，acute onsetacute onset ，，often recurreoften recurre

ntnt

Accompanied Accompanied with primary with primary

TBTB

AccompaAccompanied with nied with original inoriginal infection lesfection lesion or sepion or sep

temiatemia

Frequently Frequently caused by caused by metastatic metastatic

tumourtumour

History of History of cardiac injury cardiac injury

such as such as operation, operation, myocardial myocardial infarction, infarction, may often may often recurrentrecurrent

FeverFever Constant Constant feverfever seldomseldom High High

feverfever seldomseldom oftenoften

PericardiPericardial friction al friction

rubrub

obviouslyobviously，，occur earlyoccur early oftenoften oftenoften seldomseldom seldomseldom

Chest Chest painpain

Often Often severelyseverely seldomseldom oftenoften seldomseldom oftenoften

Acute idioAcute idiopathic peripathic peri

carditiscarditis

Tuberculous Tuberculous pericarditispericarditis

Purulent pPurulent pericarditisericarditis

MaligancyMaligancyPostpericardiPostpericardiostomy syndostomy synd

romerome

Leukocyte Leukocyte countcount

Normal or Normal or increaseincrease

Normal or Normal or slightly slightly

increaseincrease

SignificantlSignificantly increasey increase

Normal Normal or slightly or slightly increaseincrease

Normal or Normal or slightly slightly

increaseincrease

Blood Blood cultureculture —— —— ++ —— ——

Volume of Volume of pericardial pericardial effusioneffusion

LittleLittle LargeLarge LargeLarge Large Large MediumMedium

CharacterisCharacteristictic

Grass yellGrass yellow or hemow or hem

aticatic

Often hematiOften hematicc

PurulentPurulent Often heOften hematicmatic

Often serositOften serosityy

Differential Diagnosis of Acute PericarditisDifferential Diagnosis of Acute Pericarditis

Differential Diagnosis of Acute PericarditisDifferential Diagnosis of Acute Pericarditis

Acute idiopAcute idiopathic pericathic peric

arditisarditis

Tuberculous Tuberculous pericarditispericarditis

Purulent Purulent pericardpericard

itisitis

MaligaMaligancyncy

PostpericaPostpericardiostomy rdiostomy syndromesyndrome

ClassificatiClassification of on of

leukocyteleukocyte

More More lymphocytelymphocyte

More More lymphocytelymphocyte

More neutMore neutrophilrophil

More lympMore lymphocytehocyte

More More lymphocytelymphocyte

BacteriaBacteria NoneNoneTubercle Tubercle

bacillus may bacillus may be found be found

Purulent Purulent bacteriabacteria

NoneNone NoneNone

TreatmentTreatment NSAIDsNSAIDs Anti-tubercle Anti-tubercle bacillusbacillus

Antibiotic Antibiotic or perica or pericardiotomyrdiotomy

Treat originTreat original diseases,al diseases, Perecardio Perecardio

centesis centesis

SteroidSteroid

Treatment Treatment

1.Etiology treatment1.Etiology treatment Bacterial infectionBacterial infection Viral infectionViral infection TBTB MalignancyMalignancy Collagen vascular diseaseCollagen vascular disease

2. 2. Relieving pain and inflammation:Relieving pain and inflammation: NSAIDs and steroidsNSAIDs and steroids

3.If symptoms are severe, 3.If symptoms are severe, pericardiocentesispericardiocentesis is i is indicated to remove fluid.ndicated to remove fluid.

Constrictive pericarditisConstrictive pericarditis

Definition Definition

Constrictive pericarditisConstrictive pericarditis is a thickening a is a thickening a

nd fibrosis of the pericardium that occurs lnd fibrosis of the pericardium that occurs l

ong after an acute episode of pericarditis. Iong after an acute episode of pericarditis. I

t produces t produces decreased diastolic fillingdecreased diastolic filling..

EtiologyEtiology

TBTB is a leading cause in underdeveloped countries is a leading cause in underdeveloped countries including China, about 40%.including China, about 40%.

Others: Purulent inflammation, Pericardial injury, Others: Purulent inflammation, Pericardial injury, Radiation therapy etc.Radiation therapy etc.

Clinical ManifestationsClinical ManifestationsSymptoms:Symptoms: DyspneaDyspnea on exertion and orthopnea on exertion and orthopnea Other symptomsOther symptoms

HypodynamiaHypodynamia Big bellyBig belly

Physical Signs:Physical Signs: Distended jugular veinDistended jugular vein Kussmaul signKussmaul sign Edema, ascitesEdema, ascites Heart sounds are distant and a pericardial knock Heart sounds are distant and a pericardial knock

is detected after Sis detected after S22 SBP↓SBP↓、、 DBP↑DBP↑、、 pulse pressure↓pulse pressure↓

Laboratory findingsLaboratory findings

Radiography/CT/MRIRadiography/CT/MRIPericardial calcificationPericardial calcification

ECGECGLow voltage in limb leadsLow voltage in limb leadsT wave is low or upside downT wave is low or upside downAtrial arrhythmias.Atrial arrhythmias.

EchocardiographyEchocardiographyPericardial thickening in most cases can be dPericardial thickening in most cases can be d

emonstratedemonstrated

Diagnosis of Constrictive pericarditisDiagnosis of Constrictive pericarditis

1.Congestion of systemic circulation: distended 1.Congestion of systemic circulation: distended

jugular vein, edemajugular vein, edema

2.Pericardial knock on auscultation2.Pericardial knock on auscultation

3.X-ray,Magnetic resonance, computed 3.X-ray,Magnetic resonance, computed

tomography, or echocardiographic imaging tomography, or echocardiographic imaging

showing a thickened or calcified pericardiumshowing a thickened or calcified pericardium

TreatmentTreatment

1.Pericardiectomy 1.Pericardiectomy as early as possible.as early as possible.

2.Antituberculous therapy may be required if 2.Antituberculous therapy may be required if the underlying cause is tuberculosis and the underlying cause is tuberculosis and should be continued for 1 year.should be continued for 1 year.

Thank you!Thank you!

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Email:zwtlxy@tom.comEmail:zwtlxy@tom.com

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