Pericardial disease, or pericarditis, is an inflammation of any layer of the pericardium. The pericardium is a clash of thin tissue around the heart and includes:

• Visceral pericardium: the inner layer that covers the entire heart.
• Fluid layer between the visceral pericardium and parietal pericardium to avoid friction
• Parietal pericardium: the outer layer made of fibrous tissue.
  

Causes

Pericardial effusion is caused by inflammation of the pericardium (pericarditis) in response to illness or injury. Pericardial effusion also occurs when the flow of pericardial fluid is blocked or blood collects at the pericardium from a chest injury.

Sometimes the cause cannot be determined (idiopathic pericarditis).
Causes of pericardial effusion:

• Inflammation of the pericardium after heart surgery or a heart attack.
• Autoimmune disorders such as rheumatoid arthritis or lupus
• Cancer (metastasis), especially lung cancer, breast cancer, melanoma, leukemia, non-Hodgkin's lymphoma, or Hodgkin's disease
• Pericardial or heart cancer
• Radiation therapy for cancer if the heart is in the radiation field
• Chemotherapy treatments for cancer include doxorubicin (Doxil) and cyclophosphamide
• Dysfunctional thyroid (hypothyroidism)
• Viral, bacterial, fungal, or parasitic infection
• Trauma or puncture wound near the heart after open-heart surgery
• Some prescription drugs, including hydrolyzing, a drug for high blood pressure; Isoniazid, a drug for tuberculosis; And phenytoin (Dilantin, Fenitech, et al.), and Antiepileptic drug

Risk Factors

Pericarditis affects people of all ages, but men in their 20s and 50s are more likely to develop it.

The cause of pericarditis is unknown in many cases. However, some factors can trigger pericarditis:

• Recovering from a heart attack
• Autoimmune diseases
• Injury or injury from an accident
• Some bacterial, viral, and fungal infections
• Renal insufficiency
• In rare cases, some medicines, such as phenytoin to treat seizures and procainamide to treat irregular heartbeat
  

Types

Idiopathic pericarditis

The cause of acute pericarditis is very difficult to establish, and idiopathic pericarditis remains the most common diagnosis. In most cases, a viral etiology is assumed.

Viral pericarditis

Coxsackievirus B and Echovirus are the most common viruses and diagnosis requires a four-fold increase in antiviral titers. Patients often experience a prodrome of upper respiratory infection. The prognosis for viral pericarditis is generally good, with a self-limited course, and if uncomplicated, patients can be treated on a patient basis.

Pure pericarditis

Before the age of antibiotics, pneumonia was the leading cause of purulent pericarditis. Currently, there are extensions of thoracic surgery, chemotherapy, immunosuppression and hemodialysis, as well as pneumonia and emphysema. The appearance is usually severe with high fever, chills, night sweats, and dyspnea, but the classic findings of chest pain or friction rub are very rare. Cardiac tamponade is common (42–77% of patients in the selected series), and mortality is high.

If purulent pericarditis is suspected, hospitalization, treatment with broad-spectrum intravenous antibiotics, and emergency drainage are recommended. Pericardial fluid analysis findings include a high protein level (> 6 g / dL), a low glucose level (<35 mg / dL), and a very high white blood cell count (6,000 to 240,000 / mm3). .

Tuberculous pericarditis

Tuberculous pericarditis occurs in 1% to 2% of pulmonary tuberculosis cases. It is the leading cause of pericarditis in some developing countries. Human immunodeficiency or immunosuppressed virus (HIV): Patients are at risk.4 Special symptoms such as dyspnea, fever, chills, and night sweats develop slowly, and often there is no rubbing or chest pain. A patient with suspected or diagnosed pericardial tuberculosis should be hospitalized and antituberculous treatment started immediately.

Analysis of the pericardial fluid shows a high specific gravity, a very high protein level (often> 6 g / dl), and mainly lymphocytic cells. Pericardial biopsy with acid-fast bacilli polymerase chain reaction test is recommended for all patients with tuberculous pericarditis. However, a simple pericardial biopsy does not rule out the diagnosis.

Uremic and dialysis-associated pericarditis

Uremic pericarditis occurs with moderate renal failure in 6% to 10% of patients before the start of hemodialysis; Blood urea nitrogen levels are usually above 60 mg / dL. Normal ST-segment elevation on ECG is usually absent. Although tamponade is very rare, heavy bleeding can occur, facilitated by impaired platelet function. Alternatively, a serous pericardial effusion related to fluid overload may occur. With both forms, the onset or severity of hemodialysis is indicated, which generally leads to improvement in 1 to 2 weeks5,6.

Pericarditis after myocardial infarction

Pericarditis after myocardial infarction is a common complication (25% to 40% of patients with myocardial infarction) and begins within 3 to 10 days after myocardial infarction. Its development is associated with the extent of necrosis, is more common earlier than malignant infarcts, and is associated with a 1-year mortality rate and an increased risk of circulatory heart failure.

The diagnosis of post-myocardial infarction pericarditis requires symptoms or a new pericardial friction; Pericardial effusion alone is not specified. In addition to the general ST elevation seen with severe pericarditis, which is difficult to distinguish from true MI in this setting, ECG findings show normalization of positive T waves more than 2 days after MI or T waves previously transversal.

Post-cardiac injury syndrome

Dresler syndrome usually occurs 2 to 3 weeks after a heart attack or open heart surgery. The sensitive autoimmune component is believed to be responsible for myocardial infarction during infarction. Fully expressed syndromes include pleurisy chest pain, fever, leukocytosis, and pericardial rubbing. Pleural effusions or pulmonary infiltrates may be observed9.

Malignancy

Malignant pericarditis is caused mainly by metastatic disease. Bronchogenic metastatic pericarditis or breast carcinoma, common in Hodgkin's disease and lymphoma

Diagnosis

Our doctor will do a physical exam and listen to your heart with a stethoscope. If you have signs or symptoms of a pericardial effusion, a series of blood and imaging tests will be done to confirm the diagnosis, identify possible causes, and determine treatment.

Sometimes a pericardial effusion is found when testing is done for other reasons.

Echocardiogram

An echocardiogram uses sound waves to create real-time images of your heart. This test allows your doctor to see how much fluid has accumulated in the space between the two layers of the pericardium. The echocardiogram also shows how well your heart is pumping blood and diagnostic tamponade or shock in one of the heart's chambers.

There are two types of echocardiograms:

Transthoracic echocardiogram. This test uses a sound-emitting device (transducer) that is placed on your chest and your heart.

Transosophageal echocardiogram. A small transducer is placed in a tube in your digestive system that goes from your throat to your stomach (esophagus). Because the esophagus is so close to the heart, placing the transducer there provides a more detailed image of the heart.

Electrocardiogram

An electrocardiogram, also known as an ECG or EKG, records electrical signals as they travel through your heart. Your cardiologist can look for samples that indicate tamponade.

Chest x-ray

If you have too much fluid in the pericardium, a chest X-ray will show an enlarged heart.

Other imaging technologies

Computed tomography (CT) and magnetic resonance imaging (MRI) can detect pericardial effusion, although they are not commonly used to look for it.

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Prevention

In general, acute pericarditis cannot be prevented. You can take steps to reduce the chance of another serious episode, complications, or chronic pericarditis. Getting prompt treatment during these stages, following your treatment plan, and getting ongoing medical care as advised by your doctor.

Signs/symptoms

You may not have symptoms. This occurs most often in the case of a mild spill. You may have symptoms from the causes of pericardial effusion. For example, you may have a fever if you have a pericardial sac infection.

When the stroke is more severe, you may have symptoms similar to:

• Chest pain or discomfort
• Dilation of the neck veins.
• Epilepsy
• Breathe faster
• Increase of cardiac frequency
• Nausea
• Pain in the upper right abdomen
• Difficulty breathing
• Swelling of the hands and feet
  

If the stroke is too severe, it can even lead to very low blood pressure. It causes symptoms of shock. In addition to:

• Mild headache or dizziness
• Cold hands and feet
• Clammy skin
• Weakness
• Fast breathing
• Nausea or vomiting
• Pale skin
• Less urination
• Shock is a medical emergency.
  

The symptoms of pericardial effusion are similar to other health problems. See your healthcare provider for a diagnosis.

Complications

Pericarditis can be one of two serious problems: cardiac tamponade and chronic gastric pericarditis.

Cardiac tamponade is a medical emergency and, if left untreated, can quickly become fatal.

It develops when there is excess fluid between the heart muscle (myocardium) and the pericardium, putting obstructive pressure on the heart to prevent it from working properly.

Cardiac tamponade causes several symptoms, including:

• Anxiety
• Breathing problems and chest pain.
• Dizziness and epilepsy
• Swelling of the abdomen
• Drowsiness
• Weak pulse
• Rare, even chronic, chronic constrictive pericarditis can be fatal if left untreated.
  

Pericarditis develops slowly when scar (fibrous) tissue forms on the pericardium, causing the sac to become thicker, harder, and firmer.

Scar tissue shrinks over time, preventing the heart from fully expanding and filling with blood.

Chronic constrictive pericarditis can lead to weakness and fatigue, shortness of breath, and swelling in the abdomen and extremities.

Treatments

Treatment of pericardial effusion depends on the underlying condition causing it and whether the effusion produces severe symptoms, such as shortness of breath or shortness of breath.

Medical history, the examination of the patient, diagnosis, examination of the pericardial fluid, and the physician will help determine the cause and treatment. Depending on the cause, excess fluid may be high in protein (exudate) or water (translate). Both categories help doctors determine the best course of treatment for pericardial effusion.

Medical administration

The goal of medical treatment for pericardial effusions is to treat the underlying cause. Medical treatments for pericardial effusions:

Nonsteroidal anti-inflammatory drugs (NSAIDs) can be used to treat pericardial effusions caused by inflammation. These medications include ibuprofen or aspirin.

Diuretics can be used to treat pericardial effusions caused by heart failure.

Antibiotics are used to treat pericardial effusions caused by infection.

However, if the pericardial effusion is related to the presence of cancer, treatment may include chemotherapy, radiation therapy, or intramuscular injection.

Procedures for the treatment of pericardial effusion.

Regardless of whether the pericardial effusion is transudative (watery fluid) or exudative (made from a protein-rich fluid), the large pericardial effusion is caused by respiratory symptoms or cardiac tamponade may be the main cause of the elimination of excess fluid, to avoid its return or to increase the liquid.

Large pericardial effusions can be drained through:

Ultrasound-guided pericardiocentesis

It is a safe and effective procedure to remove excess fluid from the pericardium. This is more common after fluoroscopy.

Video-assisted thoracoscopic surgery

(VATS)

Also known as thoracoscopy, is the least invasive technique performed under general anesthesia. VATS allows visual evaluation of the pericardium and is used when the diagnosis of pericardial effusion has not yet been made despite previous less invasive tests. It is also used to drain excess fluid and prevent relapse.

Pericardial effusions that may not be treated with medical maintenance or drainage of excess fluid may require surgical treatment.

The pericardial window

(subluxated pericardiotomy)

It is a minimally invasive procedure in which an opening is made in the pericardium to drain fluid that has accumulated around the heart. The pericardial window can be completed with a small incision under the end of the breastbone or with a small incision between the ribs on the left side of the chest.

Percutaneous balloon pericardiotomy 

It is a nonsurgical procedure performed with an x-ray guide to view the pericardium and place the balloon dilator catheter. This approach is not common.