Pericardial Diseases
Section snippets
Embryology of the Pericardium
Embryologically, the pericardium derives from thin layers of mesoderm (the pleuropericardial membranes) that divide the primitive thoracic cavity of the intraembryonic coelom into pericardial and pleural compartments.2 The endocardial heart tube invaginates into the developing pericardial cavity, whereby the innermost serosal layer adheres to the myocardium and then folds back onto itself to create visceral and parietal layers.3 This process of invagination eventually results in suspending the
Pericardial Physiology
The adult pericardial cavity is bounded by reflections of the parietal pericardium on those anatomic conduits that must necessarily penetrate the pericardial volume to communicate with the heart chambers—namely, the aorta, pulmonary artery, inferior and superior vena cavae, and pulmonary veins. The parietal pericardium is folded over and exists in a double-layered tube extending over the surface of these vessels and reaching a few centimeters out from the heart. These reflections form
Absence
Congenital absence of pericardial tissue occurs on a spectrum from complete absence of the pericardium to small regional defects, and either in isolation or in association with other congenital heart diseases.7, 8 Patients are generally asymptomatic but some experience recurrent “stabbing” chest pains, which may be positional, “heart shifting,” or dyspnea.7, 8 The etiology of symptoms is speculative, but may result from increased heart mobility and tension on and distortion of other
Pericardial Injury in Systemic and Cardiac Illnesses
The pericardium may be an affected tissue in numerous systemic and cardiac disorders and occasionally is the sole locus of isolated disease.17 The cellular and fibrous layers of pericardium exhibit 2 principal phenotypic responses to a variety of injurious stimuli—fluid exudation and acute inflammation.17 The correlation between the noxious agent and pericardial response remains unclear, and similar injuries can produce either pericardial effusion or acute pericardial inflammation
Hemodynamic Consequences of Pericardial Disease
Changes in pericardial compliance affect the ability of the heart chambers to fill, altering hemodynamics and impairing cardiac performance. In pericardial constriction, pericardial noncompliance results from fibrosis, scarring, or calcification of the parietal and/or visceral pericardium. In cardiac tamponade, the compliance of the pericardial tissue per se may not change, but accumulation of pericardial fluid, at either a volume or rate that raises intrapericardial pressure, effectively
Diagnostic Imaging Evaluation of the Pericardium
Echocardiography remains the primary and initial imaging modality for evaluation of pericardial disease. It is widely available, cost-effective, can be performed portably and quickly, and does not require radiation and intravenous contrast to outline the pericardial space. Importantly, it also provides critical physiological data in patients with hemodynamic compromise. Poor echocardiographic windows in certain patients and the lack of anatomic detail of the pericardium often serve as
Pericardial Procedures
Indications for pericardiocentesis include tamponade and suspected bacterial, pruluent, or neoplastic pericarditis. The general approach is via subcostal, although apical and parasternal access may also be performed depending on effusion location. Major complications include right heart perforation, coronary laceration, or pneumothorax. Pericardial fluid analysis should be tested for red blood cell count, white blood cell count and differential (monocytes in malignant disease and
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2021, American Journal of MedicineCitation Excerpt :Acute aortic dissection usually causing severe pain can also cause both effusions, but whereas the incidence of pleural effusion is similar in Stanford type A and B dissections (∼19%), pericardial effusion is predominantly associated with type A (>33%), an ominous sign of possible tamponade.22 In contrast with these acute presentations, transudative pleural effusion may occur in cirrhosis, nephrosis, and other marked hypoalbuminemia, although pericardial effusions are more unusual.7 Such effusions are generally asymptomatic unless very large, or an additional specific cause is present (such as lupus, tuberculosis).
Competing Interests: David M. Dudzinski has received payment from Lippincott Williams and Wilkins for authorship of a medical review manual unrelated to this topic and has nothing else to disclose. Gary Mak and Judy Hung have no conflicts of interest to disclose.