Author Ольга Кияница
Pericardial effusion (exudate) is an abnormal accumulation of fluid in the pericardial sac. Such a violation leads to the fact that intrapericardial pressure becomes higher or equal to the pressure of the right ventricle, which causes diastolic collapse of the ventricle and right atrium, as well as a decrease in cardiac output with subsequent failure. The amount of pericardial fluid is not a reliable indication of tamponade.
Intrapericardial pressure is determined by pericardial elasticity, the rate of fluid accumulation and the amount of accumulated fluid.
The elasticity of the pericardial sac decreases with age, with chronic inflammation of the pericardium and with pericardial neoplasia, therefore, a small amount of fluid in the pericardium will be enough to create high pressure on the heart chambers. In view of this, the patient should be provided with the fastest possible medical assistance for exudative pericarditis, thus avoiding heart failure and death.
Video: Pericardial Effusion
Description of exudative pericarditis
Normally, the outer (fibrous) layer of the pericardium is elastic and resilient. The inner (serous) membrane forms a second layer around the heart. The outer and inner layers of the pericardium are separated by a lubricating fluid from 15 to 50 ml.
In exudative pericarditis , an excess of fluid (100 ml or more) caused by inflammation in the serous membrane is determined, as a result of which blood circulation may be disturbed.
Pericardium plays a key role in cardiac changes during inspiration. Usually, when the right atrium and ventricle are filled during air inhalation, the pericardium limits the ability of the left chambers to expand. This contributes to the inclination of the interatrial and ventricular partitions to the left, which reduces the filling volume of the left ventricle (LV) and leads to a decrease in cardiac output.
When intrapericardial pressure rises, as occurs with exudative pericarditis, this effect becomes pronounced, which can lead to a clinically significant decrease in stroke volume. Ultimately threatens the development of cardiac tamponade.
The pericardium plays a useful role during hypervolemic conditions, limiting acute dilatation of the heart.
Most patients with acute exudative pericarditis recover without complications. The only predictive conclusions may worsen in the following cases:
- There is a fever above 38 ° C.
- Symptoms develop within a few weeks due to depressed immunity.
- Traumatic pericarditis is determined.
- The patient takes oral anticoagulants.
- There is a large pericardial effusion.
- Acceptance of nonsteroidal anti-inflammatory drugs (NSAIDs) do not provide adequate efficacy.
Morbidity and mortality from exudative pericarditis depends on the etiology and associated diseases. Idiopathic effusions are well tolerated by most patients. It was also found that up to 50% of patients with large chronic exudative pericarditis (lasting more than 6 months) were asymptomatic for a long observation period.
Pericardial exudate is the main or frequent cause of death in 86% of cancer patients with symptomatic manifestations of the disease. The survival rate for patients with HIV and symptomatic exudative pericarditis is 36% after 6 months and 19% after 1 year.
Signs of exudative pericarditis
The clinical manifestations caused by exudative pericarditis can be divided into four groups:
- Signs and symptoms resulting from the underlying disease.
- Manifestations caused by stretching of the pericardial bag with the appearance of oppressive, uninterrupted chest pain.Pain is more common in acute pericardial effusions, in which there is a stretching of the pericardial sac. May be accompanied by vagal hypertension and bradyarrhythmias;
- Manifestations of compression of adjacent structures located extracardiac, including dysphagia (esophagus compression), cough (compression of the respiratory tract), shortness of breath and pulmonary atelectasis (bronchial obstruction), hiccups (compression of the phrenic nerve) and hoarseness (compression of the larynx).
- Manifestations due to increased intrapericardial pressure during cardiac compression and pericardial filling with exudate.
The symptoms of pericardial effusion are largely dependent on the rate of fluid accumulation in the pericardial bag. For example, the rapid accumulation of pericardial fluid can cause an increased intrapericardial pressure of only 80 ml of fluid. At the same time, slowly progressive effusions may contain up to 2 liters with no symptoms.
Large pericardial effusions often develop quickly and can cause the following symptoms:
- Difficult breathing , worsening with the patient lying down and improving with the support with the legs down, such a violation is also called orthopnea.
- Pleural pain - characterized by intense pain in the center of the chest (chest pain), worsening with inspiration, not worsening during physical exertion, which can also spread to the back and last for several days.
- Heartbeat is a sensation in which the heart beats faster than usual.
- Dizziness or fainting.
- Wet and cold skin.
Other, perhaps less common, symptoms are cough, fever, fatigue, anxiety.
Pericardial effusion: causes
Viral infections are the main cause of pericardial inflammation and exudate excretion into the pericardial cavity. The most common pathogens are:
- Cytomegaly virus.
- Coxsackie virus.
- ECHO virus.
Other causes that can cause exudative effusions include:
- Heart neoplasia (myxoma, metastasis, lymphoma, mesothelioma, sarcoma).
- Trauma to the heart or after surgery.
- After a heart attack (Dressler syndrome).
- Renal failure with uremia.
- Autoimmune diseases (lupus, rheumatoid arthritis, hypothyroidism).
In the underdeveloped countries, tuberculosis is the main cause of exudative pericarditis. In some cases, the disease develops with aortic dissection, taking certain medications, including using hydralazine (an antihypertensive drug), isoniazid (an anti-tuberculosis drug), phenytoin (an anticonvulsant drug), warfarin, or heparin (anticoagulants). Also, the side effect in the form of pericardial effusion often occurs during chemotherapy.
However, in a large number of patients, pericardial effusion is collected without concomitant diseases. This condition has been termed primary idiopathic acute pericardial disease . Such a diagnosis is said until the cause is discovered.
Diagnosis of pericardial effusion
Pericardial effusion can be completely asymptomatic or can be detected by routine examinations, such as chest X-ray, echocardiography, or an abdominal ultrasound scan. The most important changes during physical examination are associated with cardiac compression and tamponade.
Pericardial effusion: ECG
Electrocardiographic changes found in patients with pericardial effusion can be of two types:
- Due to pericardial inflammation : in approximately 90% of cases of acute pericarditis, there are electrocardiographic changes indicating inflammation of the pericardium, frequent, but not necessarily accompanied by effusion. At the initial stage, ST elevation appears (concave, diffuse, in leads AVR and V1) with positive T teeth. In 80% of cases leveling of the PR segment is additionally determined.
- Due to the accumulation of fluid in the pericardial sac : manifesting symptoms are directly related to the presence of effusion in the pericardium, with the most common disorder being low QRS voltage.
Pericardial effusion: radiograph
Previously, it was the main method for diagnosing pericardial effusion. The key diagnostic feature is an increase in the area of the heart (more than half of the diaphragm), with changes in silhouette, which often takes the form of a water ball. At the same time, pleuropulmonary fields remain normal. Additionally, the absence or reduction of heart pulsations before fluoroscopy can be determined. Today, more informative and sensitive studies, especially echocardiography, are replacing x-rays.
Echocardiography for pericardial effusion
The diagnostic sensitivity of the echocardiogram is quite high. With its help, pericardial fluid in a volume of up to 20 ml can be detected. Although quantification of pericardial effusion on echocardiography is not accurate, a semi-quantitative assessment (mild, moderate, and large) is usually possible and useful for choosing a treatment strategy. The location of the effusion is another important point, even to indicate the point of needle penetration during pericardiocentesis.
Echocardiographic signs accompanying pericardial effusions (the presence or absence of fibrin trames and adhesions) and pericardial leaflets (infiltrates, thickened, calcified, with adequate slip between them or without them) may be important from etiological and therapeutic points of view.
Video: Pericardial Effusion and Cardiac Tamponade
Pericardial effusion: treatment
A therapeutic approach to the pericardial effusion includes a general treatment strategy and specific interventions.
Specific interventions are determined depending on the cause of the formation of exudate.
The overall treatment strategy includes the hospitalization of all patients with acute pericardial effusion, which makes it possible to alleviate the effect of the etiological factor and quickly recognize the threat of cardiac tamponade.
The basic principles of the treatment of exudative pericarditis:
- Physical activity can aggravate the symptoms, so it is recommended to rest until the fever and pain subside.
- Nonsteroidal anti-inflammatory drugs (acetylsalicylic acid in an anti-inflammatory dose or indomethacin in a dose of 150 mg / day).
- Analgesics can be used to relieve pain.
- Corticosteroids - can be used when the pain is very strong and lasts more than 48 hours. Especially drugs from this group are shown to patients with non-infectious pericarditis, but only if there are no contraindications.
Patients with chronic exudative pericarditis are given mostly controversial clinical guidelines. Since in most cases the etiology of these patients remains unknown, the prescription of specific treatment remains impossible.
In case of asymptomatic exudative pericarditis, patients in a stable condition may be advised to avoid the use of anticoagulants and be observed by a cardiologist.
Surgical intervention allows you to inspect the pericardium and take a piece for histological examination. In the pericardium is installed drainage, which is connected to the suction device.
In the case of recurrent exudative effusion, surgical removal of the pericardium may be recommended, but the usefulness of such an intervention remains controversial. Another option is to create a “pericardial window”, which allows fluid to flow into the pleura or peritoneum, which results in avoiding constriction of the heart.
Video: Pericarditis and pericardial effusions causes, symptoms, diagnosis, treatment, pathology