Pericarditis (M/A) (Lai)

Pericardial Diseases (MA64)

Anatomy & Physiology

-visceral (epicardial) & parietal layers

-made of elastic fibers + collagen, w n/art/vn/lymphatics beneath visceral and surrounding parietal layer

-Q fr musculophrenic branch of int mam art, and fr desc Ao

-Nervation fr vagus and phrenic n + symp fibers

-L phrenic n crosses the L side of the pericardium, ant to LAA

-encloses GAs till the transverse arch, and the PA just beyond bifurcatoin; and SVC just below azygous

-inf pericardium attaches to IVC, posterior pericardium includes PVns

-Pericardial space- lubricated by lymph, w <30mL fluid in an adult...

-Acute increase in fluid can --> tamponade

-Pulsus Paradoxus= >10mmHg decr in SBP w inspiration seen with tamponade

-Nly, neg intraTx P --> incr syst vn return to RH, but it also incr pulm vasc bed capacitance even more, so that net--> decrease in left sided cardiac output (bc it stays in lungs...)

-W Tamponade, RV filling effect is kept, but LV is more restricted to accommodate the volume to the R heart, so with inspiration as the vol of Q to RH is increased, with it all 'sitting in the lungs' LH filling is reduced (now both bc of decr blood return to LH and bc of restrictive physiology of tamponade due to incr vol on RH)--> net greater decr in systemic output

Sx/Si:

-pericardial friction rub - due to abrading of inflamed pericardial surfaces w cardiac motion

-best heard in 2nd and 4th IS along LSB or at midclavicular line

-loudest in upright position w pt leaning fwd

-Ewart sign- suprascapular dullness to percussion = L lung compression by a massively enlarged heart, might be assoc w abNl BS.

-Tamponade--> low CO, incr CVP, JVD, paradoxical pulse, muffled heart sounds, tachy

ECG:

-xx = effect of the pericardial xx on the underlying myocardium (superficial inflm or pressure effect on the myocardium)

-PR depression, QRS, ST, T wave changes

-dysrhythmias are rare

-Pericarditis --> ST elevation most often

-4 Stages:

-diffuse ST elevation & PR depression (>80% of pts)

-Normalization of ST and PR

-Widespread T wave inversion

-T wave Nl'ization

-ST elevation:Twave amp of >0.24 in v6 - useful to ddx ischemic ST-T elevation fr pericarditis...

-PR depression seen in 1/4 pts w pericardial effusion

-low voltages on ECG w pericardial effusion bc of insulation of fluid/fibrin

-Electrical alternans = cyclic variation in QRS amplitude, occurs w heart motion in the fluid filled pericard.

CXR:

-acute peridarditis--> Nl

-effusion--> enlarged

-water bottle heart, or triangular heart w smoothed out borders if massive effusion, w clear lung fields

-tamponade w Nl heart size on CXR if acute...

Echo:

-see the effusion by echo

-HD xx: 1st see RH compression w RV free wall collapse in early diastole, then RA collapse in late diastole

-w large effusion, see heart swinging in pericardial cavity, abNl septal motion, dilated IVC, loss of respiratory caval motion

-Doppler w tamponade--> inspy decrease in transmitral flow and velocity integrals w greater dependence on atrial systole in late diastole. Tamponade: inspiration--> mitral E wave decreases by >30% compared to expiration.

-Transtricuspid flow and velocity integrals INCREASE with tamponade, so that the TV E wave increases by >70% in insp compared to exp.

-Similar findings at Ao and Pulm vlv

Labs:

-Troponins elevated if myocardial injury; can't reliably DDx fr MI

Tx:

Pericardial Fluid Drainage

-Indication: Decr CO, hypotension, paradoxical pulse >10mmHg

-give IVF rapidly to incr syst CO until you can drain the effusion

-Pericardiocentesis- US guided helps ensure safety

-Complications: myocardial puncture, coronary art/vn laceration, hemopericardium, IMA laceration, PTx, liver lac, Ao injury

-keep a pigtail in for continuous drainage of the effusion

-Surgical drainage w a complete/partial pericardiectomy +/- pericardial window - safe and effective

-via thoracotomy, subxiphoid approach, thoroscopic technique

ACUTE PERICARDITIS

-infection, collagen vasc dz, cardiac surg, Rx, Rh Fever, ch renal failure and dialysis all--> pericarditis

-1/3 w/o known cause, likely viral infection trigguring an immune reaction

-Precordial chest Pain (80% pts)- worse w breathing, cough, motion

-most comfortable when upright

-no resp distress unless tamponade or penumonitis

-fever + in most cases, and cant DDx if it is cause of infection, collagen vasc dz, Rh F

-friction rub common

-murmur if valvulitis (e.g. w rh heart dz); tachycardia out of proportion with fever...

Dx:

-check echo if CP and CXR w CM

-Pericardiocentesis if poss bacterial or ?Dx

-check cell ct, Cx for bact, viral, myocabcterium TB, fungi), gram stain, gluc, prtn

-if ?viral, check PCR for ea virus

-if ?TB, check fluid for adenosine deaminase activity (incr w TB)

-+/- Bx of pericardium if poss TB

-if chylous, check fluid TG levels (increased)

-w myxedema, check fluid cholesterol (increased)

-w neoplasm--< incr carcinoembryonic Ag (>5 --> c/s malignancy)

Infectious Diseases of Pericardium

Purulent Pericarditis

-25-75% mortality!

-often disseminated fr another site - pna, septic arthritis, meningitis, OM

-Staph a in 50-80%! (remainder influ B, s penumo, N mening, pseudo aerug, Salmonella, N gon, etc)

Tx-

-1/2 need emergent drainage of pericardial fluid to Tx tamponade, often the fluid is viscous so needs a pericardial window/pericardiectomy

- +/- intrapericardial strepotkinase to improve cath drainage w/o surgery

-IV abx for S aureus and H influ- so 3rd gen ceph + penicillinase resistant PCN or vanc if high MRSA

-abx for 3-4 weeks

-Acute suppurative pericarditis survival - poor Px at Dx: tamponade, septicemia, staph, poor drainage

-survivors dont usually have long term xx, except rare constrictive pericarditis

Viral Pericarditis

-more common than bacteria

-often w URI/GI illness- coxsackievirus, ECHO virus, adeno, influ, mumps, VZV, EBC, HIV

-Sx- f+CP, less toxic appearing than bacterial often; most + friction rub

-Pericardiocentesis if tamponade, imm suppressed, or poss bacterial

-Serous or serosanguineous fluid, mainly lymphos in fluid but also can have neutros,

-check PCR fr fluid for viruses, or fr NP/Stool Cx or by 4x incr in acute and convalescent serum

-Tx- symptomatic w bed rest/NSAIDs, rarely need steroids

-effusion should improve in days-weeks after anti-infmly initiation

-15% pts get a relapse after stopping Tx

-Constrictive pericarditis a rare xx

TB Pericarditis

-1/4 TB pericarditis is in pts <21yo

-was fatal in 90% pts till TB Rx invented

-fr spread fr mediastinal lymph nds or via heme disseminatoin

--> insidious onset w wt loss, night sweats, dyspnea; +CP or subacute; up to 90% w tamponade (!)

-+PPD test usually

-Pericardiocentesis--> serosanguinous pericardial fluid w mainly lymphos

-acid fast bacilli on auramine-rhodamine fluorescent stain; but may need 6 week incubation for Cx

-check pericardial fluid adenosine deaminase level- incr w T lympho's; if >50 then likely TB

-can check Bx for granulomas

-Tx- INH+Pyrazinamide+Rifampin+Streptomycin x9-15months

-steroids for 1-2months to reduce inflmn and speek pericardial fluid resorption

-35% can get constrictive pericarditis

NONINFECTIOUS ACUTE PERICARDITIS

Rheumatic Disease

-Rh Fever--> pancarditis w inflmy of all layers usually; rare to have isolated pericarditis

-JRA- 10% have pericarditis and may precede the Dx; effusion in 1/2 of these pts; Tx w NSAIDs

-SLE- 50-80% get CV xx- 1/4 w +Sx pericarditis, though 1/2 of all of them w effusion

-in pericardial fluid, see decr Complement, +ANA, and +/- +RF

Kawasaki Disease

-w acute illness, 1/3 will have an effusion, but rarely --> tamponade

-acute tamponade if rupture of cor art aneurysm

Drug-Induced Pericarditis

-Lupuslike syndrome w Rx- hydralazine, Isoniazid, Procainamide

-1/3 pts w a Drug induced ANA get it, and it might --> pericarditis or tamponade

-Tx by stopping the Rx

Postpericardiotomy Syndrome

-like Dressler Syndrome p MI, or after heart trauma

-30% incidence post operatively; less if <2yo

-?etiology, but seasonal variation occurs so maybe it's viral (see signif viral Ab inc)

-Sx- f within 1st week postop, malaise, CP, irritable, decr appetite, arthralgias

+friction rub or pleural rub

-tachy, fluid retention, hepatomegaly

-tamponade rare but reported

-must f/o infection as cause of fever

-check CXR, BCx, UCx, +/- fluid Cx

-Tx- NSAID for pain, diuresis, drain effusion if Sx

-ASA a mainstay of Tx at 50-75mg/kg/DAY x4-6 weeks; indomethacin used in adults

-Steroids 2mg/kg/DAY max 60mg/day w taper over 3-4 weeks good to reduce effusions, Sx, etc

-Long term xx rare, but may relapse as you taper Tx

-Constrictive pericarditis can occur but has NOT been attributed to postpericardotomy syndrome

Uremic Pericarditis

-seen w ESRD, espec before dialysis

-but no diff in BUN, Cr, Ca, Urate seen on labs

-Lupus or hyralazine Tx for htn has increased risk for pericarditis

-Tx w pericardiocentesis if possible bact infection, or if life threatening effusion

-if stable, tx w intensive dialysis

-note that full heparinization may --> ppt pericardial hemorrhage and then tamponade

-Pericardial window or pericardiectomy if no change after dialysis

Chronic Pericarditis

= >3months - bc of an inflmy dz or CHF

-most w mild Sx, but pts can get ch tamponade

-Tx w NSAID, steroid, drainage...

Recurrent Pericarditis

-intermittent or incessant pericarditis

-seen w Rh dz and w postpericardiotomy syndrome

-Tx adults w NSAIDs, colchicine, steroids x1month then 1-3mo taper, immune Rx (azathioprine or cyclophosphamide), and pericardiectomy if freq recurrences

Constrictive Pericarditis

-thickened, adherent pericardium that restricts ventric filling

-see thick pericardium and focal areas of inflmn

-see atrophy of underlying myocardium

-Causes- infection, CT dz, neoplasm, radiation, trauma, metab/genetic xx - e.g. mulibrey nanism)

-TB pericarditis is #1 cause worlwide; pneumococc, staph, H influ also --> it

--> HD xx bc of restriction of diastole w impairment of mid to late diastole bc pericardium isn't compliant. see incr CVP and PCWP. Syst fx remains normal

-Sx- DOE, fatigue, JVD, hepatic congestion, pedal edema, ascites.

-Precordial knock = protodiastolic sound - = abrupt cessation of ventric filling (Pathognomonic!)

-ECG- low voltage QRS, interventric conduction delay

-CXR- Nl heart size; 1/2 pericardial calcification or pl effusion seen

-Echo- see periacardial thickening, may see dilated SVC or IVC, paradoxical septal motion, IVS bouncing w inspiration, small ventricles w Nl systolic fx and dilated atria

Constrictive versus Restrictive Disease

-Constrictive dz- doppler show signif resp variation in transmitral, pulm vn and TV inflow w Nl myocardial relaxation indices (e.g. velocity of propagation and early mitral annular velocity)

-hard to DDx the 2 by Sx/Si

-MRI/CT to check pericardial thickness; and can tell if there is an infiltrate causing restrictive xx

-Cath- constrictive --> R and L atrial P, PCWP, and ventric EDP are all increased & usually equalized

-Square Root Sign- Ventric P tracing shows early diastolic dip in P (relaxation of ventricle

--> decr P in ventricle), then plateau phase bc of rapid early diastolic filling and then

a restriction in filling.

-Rigid pericardium restricts Nl resp variation in intracardiac P (as oppose to the exaggerated resp variation seen w tamponade in pulses paradoxus)

-LVEDP >5mmHg more than RVEDP in restrictive CM, but NOT in constrictive CM

-Tx- surgery- radical pericardiectomy w dc of both visceral and parietal pericardium

MISCELLANEOUS PERICARDIAL EFFUSION CAUSES

Hypothyroidism

-Myxedematous Pericardial Disease- rarely has inflmy signs

-1/3 of adult pts w myxedema have paricardial effusion

-decr thyroid--> incr capillary permeability to prtn and fluid retention, and abNl lymph drainage--> both ascites and pericard effusion

-pts usually have bradycardia (bc of low thyroid) not tachy like most effusion pts

-Tx w thyroid supp--> decr effusion size

-pericardiocentesiss only if very large/tamponade

-fluid will have incr cholesterol often if concurrent chylous pl effusion

Chylopericardium

-aka lymphatic pericardial effusion

-w congen thoracic cystic hygromas w pericardial involvement, or postop trauma to thoracic duct, or w mediast mass that blocks lymphatic drainage

-Dx w pericardiocentesis- see milky fluid w mainly lymphos, and TG >plasma TG level, adn ptrn >3g/dL

-Tx- reduce central pressures w diuresis, inotropes, AL reduction, surgical repiar

-low fat/mediam chan TG diet

-pericardial window or Tx duct ligation, or pericardiopleural-peritoneal shunt

-Octreotride for chyloTx postop may help

Intrapericardial Tumors

-rare to have a primary malignant neoplasm:

-mesothelioma, angiosarcoma, lymphoma, malignant pericardial teratoma

-most are fr mets

-Congenital Nonmalignent intrapericardial lesions:

-pericardial celomic cyst - unilocular mesothelial linced cyst

-cystic lymphangioma- multilocular cystic tumor fr lymph tissue, assoc w mediastinal cystic hygroma

-bronchogenic cyst- w endoderml and mesodermal elements

-pericardial teratoma- w endodermal/mesodermal/ectodermal elements

-may --> fetal hydrops if compress venous structures

-Pericardiocentesis can be life saving initially...

-Tx w surgery

Pericardial Effusion in Children w Cancer

-may rep mets dz w invasion of lymphatics, or infection, hemorrhage, post radiation effusion

-check fluid cell ct ...

Radiation Pericarditis

-usually p >4000rad to heart +/- acute pericarditis

-can --> ch effusion or constrictive pericarditis

Postcardiac Transplant

-common in all postop pts within 30 days, but for OHT pts it can happen >30 days alter

-may be bc of acute/ch rejection, or bc of ismatch in organ size

-must check for rejection...

Hemopericardium/Traumatic Pericardial Effusion

-post surgery, anticoagulation, blunt/penetrating trauma

-must c/s myocardial or coronary rupture/tear

-also Kawasaki cor aneurysm rupture, Ao dissection in Marfan, cath perf, CV line placement perf...

CONGENITAL PERICARDIAL DEFECTS

-rare

-partial/total absent pericardium

-80% are on the L size

-bc of premature atrophy of L duct of Cuvier

-most are ASx incidental findings

-assoc with syncope, CP, arrhythmias, death fr herniation/incarceration of LAA thru it or GA torsion or cor art constriction at the defect rim

-assoc w PDA, ASD, MS and with pulm sequestration, bronchogenic cyst, diaph defects in 1/3 pts

-CXR shows L'ward displaced cardiac border of completely absent pericardium; posterior bulge of the heart; might see LAA herniation (looks like an enlarged MPA)

-ECG Nl, +/- RBBB

-Dx- hard to dx

-echo- RV dilation, excessive cardiac motion, LAA prominence (but can't see the defect on echo)

-MRI and CT useful

-may need thorascopy to confirm the Dx

-Tx- d/o size

-small- if h/o herniation than --> patch closure

-if completely absent, then no Tx and minimal long term xx

Lai Textbook Ch 35:

RCM

Goals:

[ ] LA & RA size

[ ] LV wall thickness

[ ] LV Function

[ ] RVP by TR (note that RA P may be much increased)

[ ] AV valve function

[ ] IVC dilation and plethora (failure to decrease in size with inspiration)

[ ] Diastolic function by TDI

[ ] DDx from constrictive pericarditis

[ ] check for thrombi (appendages especially)

[ ] check for pulmonary hypertension- septal flattening, TR velocity

[ ] check for myocardial deposits - increased reflectivity

MV- see large E wave, small A wave --> E/A >2

-short DT (<150msec), short IVRT

-no signif change with respiration (unlike CP & Tamponade)

TV- similar to MV...

PVn- see S & D reversal- small S, big D, with A wave reversal - because it is harder for blood to exit atria, so less filling during the S phase (early atrial diastole) and more remaining during D phase, and A reversal because with atrial systole blood goes backward instead of into a stiff ventricle

HVn- similar to PVn, see S/D ratio <=0.5 because D waves are enlarged, see A wave reversal

-note w RCM P's can be very elevated to >50mmHg and RV doesn't equal LV

CP

Goals:

[ ] check for PC effusion

[ ] check for IVC dilation and plethora (failure to decrease in size with inspiration)

[ ] check for septal bounce (sudden shift in IVS to LV with inspiration because LV very underfilled, and RV more filled with inspiration

[ ] check in MM for septal notching during early diastole (IVS goes ant'ly then sharply posteriorly, corresponds to septal bounce and pericardial knock bn 2nd and 3rd hrt sound

[ ] Check Nl fx

[ ] check for changes in Doppler patterns with respiration (unlike w RCM)

[ ] check for diastolic dysfx by Doppler

[ ] check for adhesions to pericardium and myocardium

Doppler:

-MV Inspiration --> Smaller E wave, longer IVRT, shorter DT

-Expiration --> larger E wave, shorter IVRT, longer DT

-TV Inspiration --> larger E wave, shorter IVRT, longer DT

-Expiration--> smaller E wave, longer IVRT, shorter DT

-PVns- Inspiration--> S = D wave; Expiration--> enlarge S & D waves

-HVns - Inspiration--> S >D, with small amount of A reversal; Expiration--> S >>D with a small or absent D wave and signif A wave reversal

-TR jet velocity may also increase with inspiration

-unlike w RCM, there are more pronoucned respiratory variation in filling phases

-E' is high in CP

PC Effusion & Tamponade

Goals

[ ] size of effusion, location

[ ] RA collapse, then RV collapse

[ ] IVC dilation & plethora

[ ] resp variation at AV vlv inflow Doppler

Small = see at length of posterior wall, but not anteriorly, or <10mm in adult heart

Moderate = circumferential usually, or 10-20mm in diastole (Weitzman criteria)

Large = circumferential, >20mm

-first see RV free wall collapse - less Sn if phtn or TOF

-then, see RA collapse with expiration, in late diastole - low Sn, high Sp, but if look for it over longer part of cardiac cycle, then Sn increases from 55% to 90%

-reduced RA & RV size

-IVC >20mm diam in adults, with +plethora- no inspiratory collapse - 97%Sn, 66%Sp

-Then, decr LA, LV size bc reduced filling (rare to have LV collapse bc it is thick)

-see heart swing back and forth, counterclockwise cardiac rotation on short axis

-if tense effusion, see fluid posterior to LA

-c/s tamponade if RV diam on MM is <1cm during expiration

Flows

-MV & TV resp variation

-Nl is <10% variation

-Tamponade = >30% var

-MV- Insp Decr E, longer IVRT, >30% compared to expiration

-TV Insp--> Incr E, by >50% compared to expn

-PVns- Insp --> D wave decreases compared to exp

-HVns- Insp --> S>D and limited/absent D wave, prominant A reversal