Pericardial Disease

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By Medifit Education

PERICARDIAL DISEASE

pericardial-effusion

PERICARDIAL DISEASE DEFINITION

Pericardial effusion (per-e-KAHR-dee-ul uh-FU-zhun) occurs when too much fluid builds up around the heart.

The heart is surrounded by a double-layered, sac-like structure called the pericardium. The space between the layers normally contains a very small amount of fluid.

But if the pericardium is diseased or injured, the resulting inflammation can lead to pericardial effusion. Fluid can also build up around the heart without inflammation. Sometimes, pericardial effusion can be caused by the accumulation of blood after a surgical procedure or injury.

When the amount of fluid exceeds the pericardium’s “full” level, pericardial effusion puts pressure on the heart, causing poor heart function. If left untreated, pericardial effusion can cause heart failure or even death.

 

PERICARDIAL DISEASE CAUSES

Most pericardial effusions are caused by inflammation of the pericardium, a condition called pericarditis. As the pericardium becomes inflamed, extra fluid is produced, leading to a pericardial effusion.

Viral infections are one of the main causes of pericarditis and pericardial effusions. Infections causing pericardial effusions include cytomegalovirus, coxsackieviruses, echoviruses, and HIV.

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Other conditions that can cause pericardial effusions include:

  • Most pericardial effusions are caused by inflammation of the pericardium, a condition called pericarditis. As the pericardium becomes inflamed, extra fluid is produced, leading to a pericardial effusion.
  • Viral infections are one of the main causes of pericarditis and pericardial effusions. Infections causing pericardial effusions include cytomegalovirus, coxsackieviruses, echoviruses, and HIV.

Other conditions that can cause pericardial effusions include:

  • Cancer
  • Injury to the pericardium or heart from a medical procedure
  • Heart attack (myocardial infarction)
  • Uremia (severe kidney failure)
  • Autoimmune disease (lupus, rheumatoid arthritis, and others)
  • Bacterial infections, including tuberculosis
  • In a large number of people with pericardial effusion, no cause can be identified. These are called idiopathic pericardial effusions.

In a large number of people with pericardial effusion, no cause can be identified. These are called idiopathic pericardial effusions.

Pericardial_Effusion

PERICARDIAL DISEASE PATHOPHYSIOLOGY

The normal pericardium is composed of 2 layers: the tough fibrous parietal pericardium and the smooth visceral pericardium. Usually, approximately 50 mL of fluid (plasma ultrafiltrate) is present in the intrapericardial space to minimize friction during cardiac motion.

Acute and subacute forms of pericarditis (which may or may not be symptomatic) may deposit fibrin, which, in turn, can evoke a pericardial effusion. This often leads to pericardial organization, chronic fibrotic scarring, and calcification, most often involving the parietal pericardium (see Constrictive-Effusive Pericarditis for visceral pericardial disease).

In constrictive pericarditis, the easily distensible, thin parietal and visceral pericardial linings become inflamed, thickened, and fused. Because of these changes, the potential space between the linings is obliterated, and the ventricle loses distensibility. Venous return to the heart becomes limited, and ventricular filling is reduced, with associated inability to maintain adequate preload. Filling pressures of the heart tend to become equal in both the ventricles and the atria.

Since the myocardium is unaffected, early ventricular filling during the first third of diastole is unimpeded. After early diastole, the stiff pericardium affects flow and hemodynamics. Accordingly, the ventricular pressure initially decreases rapidly (producing a steep y descent on right atrial pressure waveform tracings) and then increases abruptly to a level that is sustained until systole (the “dip-and-plateau waveform” or “square root sign” seen on right or left ventricular pressure waveform tracings).

The preservation of myocardial function in early diastole aids in distinguishing constrictive pericarditis from restrictive cardiomyopathy. Systolic function is rarely affected until late in the course of the disease, presumably secondary to infiltrative processes that affect the myocardium, atrophy, or scarring or fibrosis of the myocardium from the overlying adjacent pericardial disease.

Experimental models indicated that a change in volume-elasticity curves (see the image below) was the fundamental pathophysiologic change associated with the disease. During development of the constriction, right and left ventricular diastolic pressure increased, and stroke volume decreased. A small increase in volume resulted in a considerable increase in end-diastolic pressure.

pericardium-diagram

PERICARDIAL DISEASE SYMPTOMS

When a pericardial effusion is caused by pericarditis, the main symptom is chest pain. The chest pain may be made worse by deep breathing and lessened by leaning forward. When pericarditis is causing a pericardial effusion, other symptoms may include:

When a pericardial effusion is caused by pericarditis, the main symptom is chest pain. The chest pain may be made worse by deep breathing and lessened by leaning forward. When pericarditis is causing a pericardial effusion, other symptoms may include:

  • Fever
  • Fatigue
  • Muscle aches
  • Shortness of breath
  • Nausea, vomiting, and diarrhea (if viral illness is present)
  • In people with a pericardial effusion that’s not due to pericarditis, there are often no symptoms.
  • Large, serious pericardial effusions may cause symptoms including:
  • Shortness of breath
  • Palpitations (sensation that the heart is pounding or beating fast)
  • Light-headedness or passing out
  • Cool, clammy skin

A pericardial effusion causing these symptoms is a medical emergency and may be life threatening.

 

PERICARDIAL DISEASE DIAGNOSIS

The diagnosis of acute pericarditis remains a clinical one based on history, physical examination, ECG and the echocardiogram. Other imaging studies, including computed tomography (CT) and magnetic resonance imaging (MRI) may be used in selected cases to investigate the pericardium.

pericardium

PERICARDIAL DISEASE TREATMENT

Treatment for pericardial effusion will depend on how much fluid has accumulated, what is causing the effusion, and whether pericardial effusion has caused or is likely to cause decreased heart function due to pressure on the heart (cardiac tamponade). Treating the underlying cause of pericardial effusion often corrects the problem.

 

Medications that reduce inflammation

If you don’t have tamponade or there’s no immediate threat of tamponade, your doctor may prescribe one of the following to treat inflammation of the pericardium that may be contributing to pericardial effusion:

  • Aspirin
  • Nonsteroidal anti-inflammatory drugs (NSAIDs), such as indomethacin (Indocin) or ibuprofen (Advil, Motrin IB, others)
  • Colchicine (Colcrys)

If you don’t respond to medications or you have recurring pericardial effusion after a successful treatment, your doctor may prescribe a corticosteroid, such as prednisone.

Other treatments

If anti-inflammatory treatments don’t correct the problem, if you have tamponade or if you’re at risk of tamponade, your cardiologist will likely recommend one of the following procedures to drain fluids or prevent fluids from accumulating again.

  • Drain the fluid. Your doctor can use a needle to enter the pericardial space and then a small tube (catheter) to drain fluid from the pericardium. This procedure is called pericardiocentesis. The doctor will use imaging devices — either echocardiography or a type of X-ray technology called fluoroscopy — to guide the work. Your heart is monitored during the procedure with an ECG machine. In most cases, the catheter will be left in place to drain the pericardial space for a few days to help prevent the fluid from building up again.
  • Open heart surgery. If there’s bleeding into the pericardium, especially due to recent heart surgery or other complicating factors, you may undergo surgery to drain the pericardium and repair any related damage. Occasionally, a surgeon may drain the pericardium and create a “passage” that allows it to drain as necessary into the abdominal cavity where the fluid can be absorbed.
  • Seal the layers together. During a procedure called intrapericardial sclerosis, a solution is injected into the space between the two layers of the pericardium that essentially seals the layers together. This procedure is usually used if you have recurring pericardial effusion or if the effusion is caused by cancer.
  • Remove the pericardium. Pericardiectomy is the surgical removal of all or a portion of the pericardium. This procedure is usually reserved for treatment of recurring pericardial effusions despite catheter drainage. The heart can function adequately without the pericardium.

By Medifit Education

www.themedifit.in