the pericardium

THE PERICARDIUMWhat can go wrong with

ANATOMY PRECIS

PERICARDIUM

Fibrous

Serous

Parietal

Visceral

Pericardial sac

ANATOMY ADDL

Parietal and VisceralContinuous at roots of great vessels

FibrousAttached to diaphragm, great vessels

Pericardial sac50mlFrom mesothelial cells

QUANDRIES

Pericarditis Constriction Effusion Tamponade Tumours

PERICARDITIS Pericardial inflammation Causes:-

Infection○ Viral – Coxsackie B, Hep B, HIV, Mumps, Rubella○ Bact – TB, Staph, Strep○ Other – Actinomycosis, Coccidiomycosis, Histoplasmosis

Myocardial infarction○ Immediate – transmural○ Dressler – 3-4 weeks

Autoimmune○ SLE, RA, Systemic sclerosis, Churg Strauss

Other○ Irradiation, CRF, Uraemia, Hypothyroidism

PERICARDITIS 2 Clinical features

Chest pain – at rest, sudden, sharp, continuous, sitting relief, insp increase

Pericardial rub – scratchy, creaky, anywhere, heart beat sync

ECG – gen ST ↑, concave upwardsCXR – Cardiomegaly +/-Tamponade +/-

ManagementNSAIDsUnderlying causeSpecial - steroids

CONSTRICTIVE PERIC

Pathophysiology –Smaller vol, Higher press↑JVP, prominent X&Y descents

Causes –All pericarditis causesInflammation→fibrosis→calcification

CONSTRICTIVE 2

Clinical features –Dyspnoea, abd swelling, pedal edema,

jaundice (Rt side failure)JVP, prominent X&Y, pericardial knock, AFAscites, hepatomegaly

CXR – pericardial calcification ECG – low volt, nonspecific ECHO – Rt atrium press changes CATH – diagnostic press changes

CONSTRICTIVE 3

Rx – DiureticsPericardiectomyNormalizes – days to weeks

PERICARDIAL EFFUSION

>50ml of pericardial fluid Causes :-

Acute –○ Trauma, cardiac surgery, iatrogenic ventric

puncture, aortic dissection, free wall ruptureChronic –

○ viral, bacterial○ uraemia, autoimmune, myxodema, CCF, renal

failure, cirrhosis liver○ MI, malignancy

EFFUSION 2

Clinical features:-Cause, pericardium condition, rate, amount.Fast = tamponadeAsymptomatic – commonNonspecific - ↓ exercise tolerance, dull

chest pain, dyspnoea, hoarse voice, coughExam - ↑ cardiac dull area, muffled S1S2CXR – cardiomegaly (>250ml), globularECG – electrical alternansECHO - >100ml

TAMPONADE

NOT diagnosis but a physiology Haemodynamic instability due to

chamber compression when intrapericardial pressure > filling pressure of ventricles

Chamber filling ↓ Rt atrium/ventricle collapse Causes – All acute peric effusion

TAMPONADE 2 Clinical features –

DyspnoeaCirculatory collapseTachycardia, pulsus paradoxus↑ JVP, Kussmaul’s sign (↑JVP on insp)

CXR – Cardiomeg, globular, pulmonary edema (+/-)

ECG – tachy, low volt QRS, electrical alternans

ECHO – effusion, RA/RV collapse

TREATMENT (Effu/Tamp)

Tamponade -Emergency pericardiocentesis (pigtail cath)Recc/rapid – pericardial window

Effusion –Drain +/-Rx causes

TUMOURS

Secondary –Breast, lung, malig melanoma, lymphoma,

leukaemia Primary –

Mesothelioma, sarcoma