Pericardial dz

What are the layers of the pericardium?

• Outer – fibrous

• Inner – serous

  • Parietal layer

  • Visceral layer - epicardium

How much pericardial fluid is normal?

0.25 mL/kg

What is the function of the pericardium?

• Prevents over dilation

• Systolic function (torsion)

• Co-ordinates LV-RV interaction

• Protects heart

• Maintains position

What are the different acquired pericardial diseases you can get?

• Pericardial effusion (dog) - Haemorrhagic (trans-/exudate)

  • Idiopathic

  • Neoplasia

  • CHF (LA rupture, cats) - if a dog is in R-CHF then do not forget pericardial effusion as a differential but more common cause in cats (NOT due to L-CHF in dogs as doesn’t cause pericardial effusion)

  • Coagulopathy (rat bait)

  • Hypoproteinaemia (effusions in lots of places)

  • PPDH - peritoneopericardeal diaphragmatic hernia

  • FIP, FB?

  • Renal failure

• Constrictive pericardial dz

  • effusive-constrictive Pericarditis

What are the congential pericardial diseases you can get?

• Peritoneal pericardial diaphragmatic hernia (can predispose to pericardial effusion)

• Pericardial cyst

• Pericardial defect/absence

What are the main causes of pericardial effusion and how does this differ between dogs and cats?

DOGS:

• Idiopathic

• Neoplasia

• Older, large breed dogs

CATS:

• Congestive heart failure

• FIP

• Infectious, lymphoma, mesothelioma, rhabdomyosarcoma, coagulation, uraemia

How do you diagnose Idiopathic PE Dogs?

• Exclusion diagnosis

  • No mass on echo

  • Cytology negative for neoplasia

    (warn the owner they might still have neo you just haven't found it)

Pericardial fibrosis + mixed inflammatory response result in hypersecretion of fluid

How do you treat Idiopathic PE Dogs?

What would you do if it recurs more than 3 times?

• Drain it

• Can recur

• Pericardectomy if recurrence more than 3 times

What are the neoplasias that can cause pericardial effusion?

• Haemangiosarcoma - Likes Right atrium, spleen and liver

• Chemodectoma - Aortic body tumour

• Mesothelioma - can cause multicavity effusions (hard to diagnose, this is on differentials if there is no mass found)

RARE —> Ectopic thyroid carcinoma, Lymphoma, Rhabdomyosarcoma

What breeds are predisposed to Haemangiosarcoma?

GSD, GR, Setters

How do you treat PE due to Haemangiosarcoma in Dogs?

• Grave prognosis (malignant)

• Pericardiocentesis - will be draining blood from the mass

• Pericardectomy (not recommended as will bleed into thorax)

• Balloon pericardiotomy

• Chemotherapy +/- surgery

• Often palliative - elective euthanasia

present with very acute haemorrhagic shock

What is being shown here?

• Black above the heart is the pericardial effusion

• There is a mass on the right atrium

likely haemangiosarc.

Where are chemodectomas located?

What is the treatment of a chemodectoma pe?

• Generally reasonable prognosis (slow growing and low met rate)

• Drain PE

• Palliative pericardiectomy

mesothelioma

What is the treatment for mesothelioma?

• Poor prognosis

• Palliative - drain

What is the impact of a pericardial effusion?

• Reduced right ventricular filling (lower pressure system so easier to squash)

• Red SV - collapse, tachycardia, RAAS

• Venous congestion - right sided heart failure - organomegaly (bowel signs), ascities and pos pleural effusion

• During inspiration normally right heart fills better - with PE you will get pulses paradoxus (pulse weaker on inspiration)

  (with these signs it will be a chronic effusion)

How would a patient present with an acute effusion and what would you suspect?

• Will present with shock - haemorrhaging into pericardium and cant pump blood properly

• Would suspect malignant process - hemangiosarcoma

How are cats likely to present?

Congestive heart failure

What are the signs of Chronic PE in Dogs?

• R-CHF

  • Organomegaly

  • Abdominal effusion

  • Postive hepatojugular reflux

  • Jugular distension/pulsation

  • Tachycardia

• Femoral pulses

  • Weak

  • Pulsus paradoxus

• Muffled heart sounds

What are the signs of Acute PE in Dogs?

• Weak

• Collapsed

• Tachycardic

• Pale MM

• Arrhythmic potentially

• Signs of haemorrhagic shock

• Signs of forward failure

• Weak pulses

• Very poor prognosis

What do you need to do for diagnostics before pericardiocentesis?

• Patient PCV (checking to see if its haemorrhage)

• Haem, biochem, CTnI

• Coags

• BP

• ECG

• Radiography (looks like football)

• Abdominal ultrasound to check for fluid

• FLUID ANALYSIS

What will you see on ECG?

• Sinus tachycardia HR 180bpm

• Small QRS - because heart is smaller

• Electrical alternans - because heart is swinging (QRS alternate in height)

• Will see improvements once it has been drained

What is an important take home message about treatment of PE in dogs?

• Do NOT use Furosemide in dogs with PE

• Do not want to reduce blood volume because the filling is reduced anyway

  (not the same for cats because they come in with CHF)

How do you carry out pericardiocentesis?

• Mild sedation - Opiates ideal

• Left lateral recumbency (3rd-8th ICS)

• Echo to check incision point

• LA

• 14G over the needle catheter, extension, 3 way tap

• Check the PCV of the fluid - if it is 35 then may be haemangiosarcoma and you don't want to keep draining this and euthanasia will have to be considered

What could be the reason if the paramotors aren't improving after draining?

• Iatrogenic cardiac puncture - get to correct place

• Bleeding cardiac neoplasia causing hemorrhagic effusion - STOP

What do you do after pericardiocentesis?

• Hospitalise for 12-24 hours to check for atrial fibrillation or ventricular arrhythmias

• Weigh twice per day to see if its lost fluid

• If recurrence suspect neoplasia (poor prognosis)

How will constrictive pericarditis present?

How is this treated and what is the prognosis?

• R-CHF, cardiac tamponade with little fluid

• Pericardectomy, pericardial stripping

• Guarded prognosis without pericardiectomy

• Difficult to diagnose

• Specialist Cardiology needed

Which animals are predisposed to PPDH?

Weimaraners and Persian cats

What is PPDH?

• Defect of closure

  • Ventral diaphragm

  • Pericardium

When would you get left atrial rupture?

• Advanced MDVD - jet lesions

• Severe LA enlargement

If there is left atrial rupture what do you do?

• Pericardiocentesis

• Blood transfusion

• Thoracotomy

• Guarded prognosis

What would you do with infectious pericarditis?

• Aggressive antibiosis

• Fluid Culture

• Exploratory thoracotomy

• Pericardiectomy