Pericardial Diseases

https://doi.org/10.1016/j.cpcardiol.2011.10.002Get rights and content

Abstract

The pericardium provides an enclosed lubricated space for the beating heart and functions to fix the heart in the chest cavity relative to adjacent organs. Pericardial pathophysiology is often manifested in a spectrum of distinct cardiac and systemic disease states. The pericardial response to injury typically involves a spectrum of inflammation with both acute and chronic features and/or fluid accumulation. Recent advances in imaging methods have refined the diagnosis and therapy of pericardial disease. This article presents the anatomy and physiology of pericardial disease and the clinical approach for diagnosis and treatment.

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

References (82)

  • J. Sagristà-Sauleda et al.

    Clinical clues to the causes of large pericardial effusions

    Am J Med

    (2000)
  • S. Niho et al.

    Clinical outcome of small cell lung cancer with pericardial effusion but without distant metastasis

    J Thorac Oncol

    (2011)
  • K.R. Bainey et al.

    Acute pericarditis: appendicitis of the heart?

    Mayo Clin Proc

    (2009)
  • D.H. Spodick

    Pericardial rubProspective, Multiple observer investigation of pericardial friction in 100 patients

    Am J Cardiol

    (1975)
  • M. Imazio et al.

    Day-hospital treatment of acute pericarditis: A management program for outpatient therapy

    J Am Coll Cardiol

    (2004)
  • D.H. Spodick

    Electrocardiogram in acute pericarditisDistributions of morphologic and axial changes by stages

    Am J Cardiol

    (1974)
  • R. Baljepally et al.

    PR-segment deviation as the initial electrocardiographic response in acute pericarditis

    Am J Cardiol

    (1998)
  • M.A. Bruce et al.

    Atypical electrocardiogram in acute pericarditis: characteristics and prevalence

    J Electrocardiol

    (1980)
  • A.C. Salisbury et al.

    Frequency and predictors of urgent coronary angiography in patients with acute pericarditis

    Mayo Clin Proc

    (2009)
  • R. Zayas et al.

    Incidence of specific etiology and role of methods for specific etiologic diagnosis of primary acute pericarditis

    Am J Cardiol

    (1995)
  • G. Permanyer-Miralda et al.

    Primary acute pericardial disease: a prospective series of 231 consecutive patients

    Am J Cardiol

    (1985)
  • E.I. Curtiss et al.

    Pulsus paradoxus: definition and relation to the severity of cardiac tamponade

    Am Heart J

    (1988)
  • M.S. Gonzalez et al.

    Experimental cardiac tamponade: a hemodynamic and Doppler echocardiographic reexamination of the relation of right and left heart ejection dynamics to the phase of respiration

    J Am Coll Cardiol

    (1991)
  • M.H. Picard et al.

    Quantitative relation between increased intrapericardial pressure and Doppler flow velocities during experimental cardiac tamponade

    J Am Coll Cardiol

    (1991)
  • P. Schulman et al.

    Left ventricular outflow obstruction induced by tamponade in hypertrophic cardiomyopathy

    Chest

    (1981)
  • M.J. Levine et al.

    Implications of echocardiographically assisted diagnosis of pericardial tamponade in contemporary medical patients: detection before hemodynamic embarrassment

    J Am Coll Cardiol

    (1991)
  • D.E. Leeman et al.

    Doppler echocardiography in cardiac tamponade: exaggerated respiratory variation in transvalvular blood flow velocity integrals

    J Am Coll Cardiol

    (1988)
  • B. Reydel et al.

    Frequency and significance of chamber collapses during cardiac tamponade

    Am Heart J

    (1990)
  • D.R. Talreja et al.

    Constrictive pericarditis in the modern era: novel criteria for diagnosis in the cardiac catheterization laboratory

    J Am Coll Cardiol

    (2008)
  • W.J. Nicholson et al.

    Early diastolic sound of constrictive pericarditis

    Am J Cardiol

    (1980)
  • S.C. Bertog et al.

    Constrictive pericarditis: etiology and cause-specific survival after pericardiectomy

    J Am Coll Cardiol

    (2004)
  • D.G. Meyers et al.

    The usefulness of diagnostic tests on pericardial fluid

    Chest

    (1997)
  • N.O. Fowler et al.

    Recurrent acute pericarditis: follow-up study of 31 patients

    J Am Coll Cardiol

    (1986)
  • I.C. Tuna et al.

    Surgical management of pericardial diseases

    Cardiol Clin

    (1990)
  • H.G. Burkitt et al.

    Wheater's Functional Histology: A Text and Colour Atlas

    (1993)
  • T.W. Sadler

    Langman's Medical Embryology

    (1995)
  • J. Männer et al.

    The origin, formation and developmental significance of the epicardium: a review

    Cells Tissues Organs

    (2001)
  • P. Hutchin et al.

    Electrolyte and acid–base composition of pericardial fluid in man

    Arch Surg

    (1971)
  • F. Mantovani et al.

    Congenital complete absence of the pericardium: a multimodality imaging diagnostic approach

    Echocardiography

    (2011)
  • J. Kodde et al.

    Congenital absence of the pericardium

    Neth Heart J

    (2001)
  • Y. Topilsky et al.

    Images in cardiovascular medicinePendulum heart in congenital absence of the pericardium

    Circulation

    (2010)
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      Citation 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).

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    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.

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