Wake Cv Diseases Of The Pericardium

Front 1

How much fluid is notmally in the pericarium?

Back 1

10-50 cc

Front 2

What is the function of pericardial fluid normally?

Back 2

fluid acts as a lubricant to minimize frictional forces between the heart and other structures

Front 3

What are the layers of the pericardium and their function?

Back 3

1. Fibrous parietal pericardium
- outer layer which provides a protective sac around the heart
- to prevent sudden cardiac dilation and minimize bulk cardiac motion

2. Visceral pericardium
- inner layer
- intimately related to the surface of the heart

Front 4

Congenital Pericardial Abnormalities

Back 4

Pericardial Cysts

Absence of Pericardium: Partial or Total

- Usually diagnosed with CT or MRI

- Associated with atypical chest pain or sudden death

Front 5

Do pericardial cysts require intervention?

Back 5

No.
They are benign.

Front 6

What is the most common clinical pathologic process involving the pericardium?

Back 6

acute pericarditis

Front 7

What are potential etiologies of acute pericarditis?

Back 7

1. infectious
2. non-infectious
3. hypersensitivity pericarditis

Front 8

Causes of Infectious Pericarditis

Back 8

Viral pericarditis is the most common cause of pericarditis

- Viral (coxsackie A & B, echovirus, mumps, adenovirus, HIV)

- Mycobacterium tuberculosis

- Bacterial (Pneumococcus, Streptococcus, Staphylococcus, Legionella)

- Fungal (histoplasmosis, coccidioidomycocis, candidiasis, blastomycosis)

Front 9

Prognosis associated with bacterial pericarditis

Back 9

VERY BAD

Front 10

Causes of Non-infectious Pericarditis

Back 10

Idiopathic
Neoplasm
- Metastatic (lung, breast, melanoma, lymphoma)
- Primary (mesothelioma)
Renal Failure/Uremia associated with hemodialysis
Irradiation
Myocardial Infarction
Hypothyroidism
Aortic Dissection
Chylopericardium (thoracic duct injury)
Trauma
- Post-pericardiotomy
- Chest wall injury/trauma

Front 11

Causes of Hypersensitivity Pericarditis

Back 11

- Collagen Vascular Disease (systemic lupus erythematosus, rheumatoid arthritis, scleroderma, acute rheumatic fever)

- Drug Induced (procainamide, hydralazine, isoniazid)

- Post Myocardial Infarction or Cardiac Surgery - Dressler’s Syndrome(late presentation... more of an autoimmune reactive process)

Front 12

Acute Pericarditis
Physical Exam

Back 12

- resting tachycardia

- low-grade fever (if infectious etiology)

- pericardial friction rub on auscultation (classically triphasic, but may be biphasic or monophasic)

Front 13

Acute Pericarditis
Chest Pain

Back 13

- usually sudden and severe in onset
- with viral pericarditis, usually 1-2 weeks after “viral illness”
- retrosternal or left precordial pain - may refer to back or trapezius
- pain may be preceded by low-grade fever
- may be pleuritic
- may be positional - worse with supine position; relieved with upright posture

Front 14

ECG Findings in Acute Pericarditis

Back 14

* diffuse ST-segment elevation in early stage
* depression of the PR segment
- T wave inversion in late stage
- low voltage in QRS (if large pericardial effusion)
- electrical alternans (if large pericardial effusion)
- atrial fibrillation

*Most Useful diagnostic tool

Front 15

electrical alternans

Back 15

magnitude of QRS varies with every heart beat ... can be seen with swinging heart in pericardial effusion

Front 16

Is laboratory blood work useful in acute pericarditis?

Back 16

NO
- elevated erythrocyte sedimentation rate
- eleveated white blood cell count

Front 17

Is acute pericarditis always visualized with echocardiography?

Back 17

NO
depends on the amount of pericardial effusion

Front 18

What are the epicardial leads on ECG?

Back 18

1
2
aVL
AVF
V3-V6

Front 19

What are the endocardial leads on ECG?

Back 19

aVR
V1
sometimes V2

Front 20

What is the treatment for Acute Pericarditis?

Back 20

- If no significant pericardial effusion, then treatment is targeted toward symptoms - usually with NSAIDs

- If peri-infarct pericarditis, then may prefer high dose aspirin (650 mg BID-QID)

- Steroids for resistant pericarditis (txs sxs, but has dependence problems)

- Colchicine for resistant pericarditis (Dr. Hoyle prefers this over steroids)

Front 21

Pericardial Effusion

Back 21

- All forms of pericardial disease may lead to excess fluid accumulation in the pericardial space.

- Any etiology for pericarditis is a potential cause for a pericardial effusion.

- Large effusions which accumulate slowly (wks - mos) may be asymptomatic; rapidly (days) accumulating smaller effusions may lead to cardiac tamponade.

Front 22

Types of Fluid in Pericardial Effusion

Back 22

Serosanguinous effusions (blood-tinged fluid)
- neoplasm, Tb, uremia, idiopathic, non-infectious cause

Hemopericardium (blood)
- trauma, myocardial rupture, aortic dissection, coronary artery rupture

Purulent effusion (pus)
- secondary to direct invasion of the pericardial space by infectious organisms

Front 23

Pericardial Effusion
Diagnosis

Back 23

ECHOCARDIOGRAPHY - imaging procedure of choice
- size and location
- characteristics of effusion - e.g. presence of fibrin, clot, tumor, calcium

Chest Radiograph - cardiomegaly or “water-bottle” shape

ECG - low voltage, if large effusion

Front 24

Cardiac Tamponade

Back 24

Cardiac tamponade is a clinical spectrum ranging from mild increases in pericardial pressure to profound hemodynamic collapse.

accumulation of fluid in pericardial space
--> increase in pericardial pressure
--> cardiac compression resulting in IMPAIRED DIASTOLIC VENTRICULAR FILLING (throughout diastole) of RV
--> decrease RV output = decrease LV preload
---> depresses CO
--> Cardiogenic Shock

Front 25

Cardiac Tamponade
Slinical Presentation

Back 25

Presentation may mimic heart failure: Dyspnea on exertion and orthopnea

- Tachycardia and tachypnea
- Jugular venous distention
- Hypotension and poor peripheral perfusion
- Shock and profound hemodynamic collapse
- Pulsus Paradoxus

Front 26

Cardiac Tamponade
Diagnosis

Back 26

- Clinical Presentation
- ECG - sinus tachycardia, electrical alternans
- Echocardiography - signs of increased pericardial pressure
- Cardiac Catheterization (not needed for dx)

Front 27

Cardiac Tamponade
Treatment

Back 27

Supportive Measures:
- Keep BP high to avoid shock... IV fluids, pressors (NE, Epi, dopamine)

Remove the fluid
- pericardiocentesis
-surgical pericardectomy

Front 28

Pulsus Paradoxus

Back 28

Big variation (greater than 10 mmHg) in systolic pressure between inspiration and respiration

Front 29

What are the common causes of Constrictive Pericarditis

*Important to know

Back 29

- neoplasm
- tuberculosis
- histoplasmosis
- MEDIASTINAL RADIATION
- purulent or RECURRENT PERICARDITIS
- rheumatoid arthritis
- uremia
- CARDIAC SURGERY

- anything that can cause pericarditis... can take days to years to develop

Front 30

Constrictive Pericarditis

Back 30

- Results from dense fibrosis and adhesion of the parietal and visceral layers

- Creates a rigid “case” around the heart

- EARLY ventricular filling is UNIMPEDED, but diastolic filling is subsequently abruptly reduced as a result of the inability of the ventricles to fill secondary to the restraints imposed by a rigid, thickened, and calcified pericardium (DECREASED LATE DIASTOLIC FILLING).

Front 31

Constrictive Pericarditis
Presentation

Back 31

- Right heart failure
- weakness, dyspnea, orthopnea, anorexia
- peripheral edema, hepatomegaly, splenomegaly, ascites, prominently descent with jugular venous pressures
- “Kussmaul’s sign”
- “pericardial knock”

Front 32

Kussmaul's Sign

Back 32

JVD filling with inspiration

Front 33

Pericardial Knock

Back 33

characteristic abnormal heart sound in diastole (after S2) for Constrictive Pericarditis

Front 34

Constrictive Pericarditis
Diagnosis

Back 34

Chest X-ray
- pericardial calcification

Echocardiography
- signs of ventricular interdependence
- respiratory variation in left and right ventricular filling

Chest CT or MRI
- pericardial thickening

CT
- pericardial calcification

Cardiac catheterization

Front 35

Constrictive Pericarditis
Treatment

Back 35

surgical stripping of the pericardium

Front 36

What can constrictive pericarditis be confused with?

Back 36

restrictive cardiomyopathy

Front 37

Constrictive Pericarditis
Prognosis

Back 37

Poor Prognosis

Natural history:
- slow decline of cardiac output
- progressive renal and hepatic failure.

Front 38

What is the main difference between cardiac tamponade and constrictive pericarditis?

Back 38

- Constrictive pericarditis does not have early diastolic filling dysfunction ... only late

- whereas Cardiac Tamponade has diastolic dysfunction for the whole of diastole

Front 39

What is the preferred method of pericardiocentesis?

Back 39

ECHO-GUIDED (only 10% relapse)

Others:
- surgical
- cardiac cath lab

Front 40

What are the types of cardiac trauma?

Back 40

Penetrating injury - usually bullet or stab injury

Non-penetrating injury - usually deceleration injuries

Front 41

Cardiac Trauma

Penetrating Injury

Back 41

- usually result in hemopericardium with tamponade or exsanguination.

- May have associated cardiac damage such as traumatic valvular regurgitation, intracardiac shunts, and coronary artery injuries.

Treatment: immediate thoracotomy for life-threatening hemorrhage or tamponade

Front 42

What is the most common cardiac manifestation of blunt trauma?

THIS IS A QUESTION!!!

Back 42

CARDIAC CONTUSION

leads to:
- new arrhythmias or ECG changes
- LV wall motion abnormality on echo

Front 43

What are less common manifestation of blunt trauma?

Back 43

- traumatic ventricular septal rupture
- myocardial rupture and/or pseudoaneurysm formation
- coronary artery trauma
- valvular regurgitation
- pulmonary artery rupture

Front 44

What happens in Traumatic Transection of the Descending Thoracic Aorta?

Back 44

Descending aorta remains fixed b/c of ligamentum arteriosum

But heart and ascending aorta move… result in transection of aorta