Diseases of the pericardium

1. Diseases of the pericardium

2. Pericarditis • Pericardial inflammation may be due to infection, immunological reaction ,trauma or neoplasm and some time remained un explained. • Pericarditis and Myocarditis often coexist. • Causes : • 1)Common ;Acute myocardial infarction ,viral ( e.g.Coxsacki B) • 2)Less common : Uremia,malignant dis,Trauma & connective tissue dis. • 3)Rare : Bacterial infection ,rheumatic fever & Tuberclosis.

3. Clinical features • Pain is retrosternal with radiation to the shoulders and neck and typically aggrevated by deep breathing ,movement, a change of position ,exercise and swallowing. • Low grade fever is common. • A pericardial rub is a high pitched sound its diagnostic, often heared in systole and may be in diastole.(to –and –fro) quality. • Investigations : The ECG show ST elevation with up ward concavity over the affected area .Later may be T inversion ,particularly if there is associated myocarditis.

5. Management • The pain can be relieved by asprin high dose but a more potent anti-inflammatory agent such as indomethacin may be required . • Corticosteroid may suppress symptoms but not healing. • In viral pericarditis recovery usually occurs within a few days or weeks.but there may be recurrence . • Purulent pericarditis require treatment with antimicrobial therapy, paracentesis and if necessary surgical drainage.

6. Pericardial Effusion • Usually present with retrosternal oppression.its difficult to be detected clinically. • The heart sound become quiter.pericardial rub abolished. • The QRS voltage decreased.chest x-ray show globular cardiomegaly. • Echo.is diagnostic. • Depending on aetilogy may be fibrinous,serous,haemorraghic or purulent.

9. A fibrinous exudates may eventually lead to varying degree of adhesion. • While serous pericarditis lead to a large effusion of turbid, straw-colored fluid with a high protein content. • A haemorraghic effusion is often due to malignancy particularly breast cancer,Carcinoma of the bronchus and lymphoma. • Purulent pericarditis is rare and may occur as a complication of septicaemia.

10. Cardiac tamponade • It refer to acute heart failure due to compression of the heart by a large or rapidly developing effusion .Atypical presentation occur when the effusion is loculated as a result of previous pericarditis or cardiac surgery.

11. Pericardial Aspiration • Its also called pericardiocentesis, may be indicated for diagnostic or therapeutic purposes . • It done by inserting a needle under xiphoid process with direction toward left shoulder. • Complications include Coronary artery damage, bleeding and arrythmias.

13. The most common causes of acute pericarditis: A-Malignant neoplasm B-Viral infection. C-Bacterial.

14. Which one is false regarding treatment of acute viral pericarditis: A-May be self limitted disease and need no treatment. B-NSAID or high dose asprin is effective treatment. C-Steroid improve healing.

15. Regarding pericardial tamponade,which one is not true: A-Usually need no treatment. B-Need urgent treatment. C-May be a complication of car accident.

16. Tuberculosis Pericarditis • May complicate pulmonary TB,but may be the first manifestation of the disease. • In Africa tuberculous effusion is a common manifestation of AIDS. • The condition typically present with chronic malaise ,weight loss and low grade fever. • An effusion usually develops and the pericardium may become thick and unyielding, leading to pericardial constriction or tamponade.,an associated pleural effusion is often present..

17. Management • The diagnosis may be confirmed by aspiration of the fluid and direct examination or culture for tubercle bacilli. • Treatment require specific anti TB,in addition, a 3 month course of prednisolone has been shown to improve out come.

18. Chronic Constrictive Pericarditis • Is due to progressive thickening ,fibrosis & calcification of the pericardium. • In effect the heart encased in a solid shell & can not work properly ,the calcification may extend to the myocardium ,so affect the myocardial function.

19. possible causes 1) Tuberculous pericarditis. 2) Haemopericardium . 3) viral pericarditis. 4) Rheumatoid arthritis. 5) purulent pericarditis.

20. Clinical Features • Fatique. • Rapid low volume pulse. • Pulsus paradoxicus. • Elevated JVP (rapid y descent). • Kussmaul sign. • Loud early third sound(pericardial knock). • Hepatomegaly. • Ascitis & peripheral edema.

21. The condition should be suspected in any patient with un explained right sided failure and a small heart. • CXR show pericardial calcification, echocardiography ,CT & MRI help for diagnosis. • The differentiation of chronic constrictive pericarditis from restrictive cardiomyopathy is difficult and need complex echo-doppler studies and cardiac catheterization.

22. Management • Surgical resection of the diseased pericardium can lead to dramatic improvement in up to 50 % of cases.