[02.14] SUR - Pericardial Diseases_ Surgical Diseases of the Pericardium & Tumors of the Heart V2.pdf

Protective cover of the heart

What is the primary general role of the pericardium?

Prevents rapid cardiac enlargement

What mechanical function does the pericardium perform to protect the heart against sudden extreme volume changes?

Adapts to slow increase in pericardial volume

How does the pericardium behave when there is a slow, chronic increase in pericardial volume?

Promoting blood clot formation inside the pericardial sac

How does the pericardium prevent rapid exsanguination from penetrating cardiac injuries?

Pericardial fluid

What is the lubricant fluid produced by the pericardium called?

Visceral and parietal pericardium

What are the two anatomical layers that compose the pericardium?

Epicardium

What is another name for the visceral pericardium?

Visceral pericardium

Which pericardial layer is intimately attached to the heart, atrium, and ventricles?

Monocellular

How many cell layers thick is the visceral pericardium?

Parietal pericardium

Which pericardial layer is a tough, fibrous layer?

15 mL to 50 mL

What is the normal volume range of pericardial fluid produced by the parietal pericardium?

Not detectable by physical examination or imaging

What is the clinical and imaging visibility of normal pericardial fluid?

Great vessels and pulmonary veins

Over which structures do the visceral and parietal pericardium fuse?

Acute pericarditis

What is defined as the acute inflammation of both the parietal and visceral pericardium?

Bacterial, viral, tuberculous, or fungal

What are the four main categories of infectious etiologies of acute pericarditis?

Lupus erythematosus

Which specific autoimmune condition is listed as an inflammatory etiology of acute pericarditis?

Scleroderma and rheumatoid arthritis

What are two non-lupus systemic inflammatory conditions that can cause acute pericarditis?

Myocarditis and Post pericardiotomy syndrome

What are the two cardiac-specific etiologies of acute pericarditis?

Opening the pericardium during surgery

What surgical action triggers post pericardiotomy syndrome?

Acute pericarditis and pericardial effusion

What is a common clinical occurrence after opening the pericardium during surgery?

Metastatic, primary cardiac malignancy, or direct tumor invasion

What are three neoplastic etiologies of acute pericarditis?

Uremia and hypothyroidism

What are two metabolic etiologies of acute pericarditis?

Radiation injury

What physical injury class is noted as a cause of acute pericarditis?

Idiopathic

What is the etiology for 80 percent of acute pericarditis cases where the cause is unidentifiable?

80 percent

What percentage of acute pericarditis cases are classified as idiopathic?

Decrease in diastolic volume

What is the primary hemodynamic consequence of the compressive effect of pericardial fluid on the heart?

Right atrium

Which chamber of the heart is compressed first by pericardial fluid?

Right ventricle

Which chamber of the heart is compressed second, after the right atrium, by pericardial fluid?

Left ventricle

Which chamber of the heart is compressed last because it is the thickest?

Decrease in stroke volume

What is caused by the collapse of the right atrium, right ventricle, and left ventricle?

Decreased cardiac output

What direct systemic delivery failure is caused by a decreased stroke volume?

Shock

What is the ultimate clinical state if the cycle of decreased cardiac output remains unabated?

Sympathetic surge

What is the body's physiological compensation mechanism during acute pericardial compression?

Tachycardia and vasoconstriction

What are the two primary components of the body's sympathetic surge compensation?

Increase in heart rate before hypotension

What clinical sign change occurs in the earliest phase of acute pericarditis and tamponade before blood pressure drops?

Right atrium

Which chamber is first affected in moderate pericardial effusion?

Volume of the right and left ventricles

What collapses in more than moderate or large pericardial effusion when the fluid compresses the ventricles?

Chest pain

What is the most characteristic pain symptom of acute pericarditis?

Substernal and inspiratory

What are the two descriptors for the location and respiratory phase of acute pericarditis chest pain?

Supine position

Which body position worsens the chest pain of acute pericarditis?

Leaning forward

Which body position relieves the chest pain of acute pericarditis?

Dyspnea and orthopnea

What are two respiratory symptoms caused by acute pericarditis?

Non-specific

How are the physical examination findings of acute pericarditis generally described?

Pericardial friction rub

What classic auscultatory finding is heard on physical examination in acute pericarditis?

Beck's triad

What is the named clinical triad seen in patients with a significant amount of pericardial fluid who go into tamponade?

Hypotension, distended neck veins, and muffled heart sounds

What are the three components of Beck's triad?

Non-specific

What is the diagnostic utility of standard blood works in acute pericarditis?

Elevated ESR

What inflammatory marker is commonly elevated in the blood of acute pericarditis patients?

Elevated white blood cell count

What hematologic cell count is typically elevated in acute pericarditis?

Bacterial cultures and viral titers

What two microbiological/virological tests can help establish the specific infectious cause of pericarditis?

Troponin I

Which specific cardiac enzyme may be elevated in viral or idiopathic acute pericarditis, though it is often normal?

Can be diagnostic

What is the diagnostic utility of an ECG in acute pericarditis?

4 stages

Over how many stages does the ECG typically evolve in acute pericarditis?

50 percent

What percentage of patients with pericarditis experience all four stages of ECG evolution?

Stage I

Which ECG stage is characterized by ST-segment elevation with concave upward ST segments?

All leads except V1

In which leads is the Stage I ST-segment elevation noted?

Stage II

Which ECG stage is characterized by ST segments returning to baseline and T-wave flattening?

Stage III

Which ECG stage features T-wave inversion without Q-wave formation?

Stage IV

Which ECG stage is characterized by ECG normalization?

Can be normal

What is the cardiac size finding on chest radiograph in acute/rapid effusion with tamponade?

Acute and rapid accumulation

What type of fluid accumulation rate can cause tamponade without an apparent increase in cardiac shadow on CXR?

Enlarged cardiac shadow

What is the chest radiograph finding when pericardial effusion increases to moderate or massive?

Water-bottle cardiac appearance

What classic cardiac shape is seen on chest radiograph in massive pericardial effusion?

Slow accumulation of fluid

What type of fluid accumulation rate is required to show a water-bottle cardiac appearance on CXR?

At least 200 to 250 mL

What is the minimum volume of fluid required to enlarge the cardiac shadow on chest radiograph?

2D Echo

What is the most important imaging modality for acute pericarditis and effusion?

Presence and degree of effusion

What does 2D Echo detect regarding the fluid itself in acute pericarditis?

Thickness of pericardium

What does 2D Echo indicate about the pericardial tissue wall?

Presence of tamponade

What physiological compromise does 2D Echo help establish?

RA wall diastolic collapse

What is the earliest echocardiographic sign of cardiac tamponade?

RV wall diastolic collapse

What echocardiographic collapse sign follows RA collapse in tamponade?

Dilated inferior vena cava without inspiratory collapse

What IVC abnormality is seen on 2D Echo in tamponade?

Collapses because of high pericardial pressure

Why do the right-sided chambers collapse during diastole in tamponade?

Fluid

What is the dark shadow surrounding the heart on the echocardiogram in Figure 5?

Chest CT scan and MRI

What other imaging modalities can show fluid density around the heart?

Cannot tell if going into tamponade

What is the main limitation of CT and MRI in acute pericardial effusion?

Establish the etiology

What is a highly critical step in managing acute pericarditis to direct treatment?

Cytology, cell count, protein, LDH, and glucose

What five parameters are evaluated on pericardial fluid examination?

Pericardial biopsy

What invasive tissue procedure can help establish the etiology of pericarditis?

Treating the underlying cause

What is the primary concern in the management and treatment of acute pericarditis?

Antibiotics

What is the specific management for bacterial or purulent pericarditis?

Anti-TB/Anti-Koch's regimen

What is the management for TB pericarditis?

Short course NSAIDs

What is the treatment for post-pericardiotomy, viral, post-MI, or idiopathic pericarditis?

5 to 7 days

What is the typical duration of short course NSAID therapy for pericarditis?

Tamponade, suppurative pericarditis, and medical unresponsiveness

What are the three main surgical indications to drain pericardial fluid?

Bacteria or tuberculosis

What are the two suspected pathogens that warrant immediate drainage of suppurative pericarditis?

Patient is not responding to therapy

When is drainage indicated to establish the etiology of pericarditis?

Pericardiocentesis and tube pericardiostomy

What are the two primary methods used to drain pericardial fluid?

Needle

What instrument is used to perform a pericardiocentesis?

Ultrasound guidance

What imaging guidance makes pericardiocentesis significantly safer?

Tube pericardiostomy

Which draining method involves placing a larger tube through a small incision?

Fr 14 and below

What size needle or tube is used in pericardiocentesis?

Fr 28-36

What tube size range is used in tube pericardiostomy?

Percutaneous

What is the insertion path style for pericardiocentesis?

Echo-guidance and sedation

Under what two conditions is pericardiocentesis most favorably performed?

Less invasive and repeated drainage

What are the two main advantages of pericardiocentesis?

Cannot obtain biopsy, prone to myocardial injury

What are two major disadvantages of pericardiocentesis?

Right ventricle

Which cardiac chamber is most prone to needle injury during pericardiocentesis because of the moving heart?

Repeated drainage, less clogs, biopsy access, less myocardial injury

What are four advantages of tube pericardiostomy?

Invasive subxiphoid incision down to pericardium

What is the primary disadvantage of tube pericardiostomy?