Pathology of pericarditis

2021-01-28 12:00 AM

In clinical practice, when there is a large amount of pericardial effusion, there is fibrin to create a local septum, at that time, the heart can still be heard clearly. There may be a scratching of the pericardium.

Outline

Pericarditis is a disease of the pericardium. Need for emergency treatment. If slow, it will die quickly (pericardial effusion compresses the heart). Or, if delayed, surgical treatment will lead to a poor prognosis (constrictive pericarditis).

Today thanks to ultrasound for accurate, early diagnosis. Timely treatment reduces the rate of bad complications for patients.

Reason

Bacterial infections: Tuberculosis, viruses, other bacteria (common in other infections).

Inflammation: Rheumatoid arthritis, rheumatoid arthritis, lupus erythematosus.

Immune allergic reactions: Allergic reactions after mitral valve dissection, post-myocardial infarction syndrome, surgery related to the pericardium

Cancer: Primary or secondary such as liver cancer, lung cancer, mediastinal cancer.

The adjacent abcès: Liver, lungs, under the diaphragm.

Ischemic heart disease.

Injury to the chest: cause pericardial haemorrhage. Chest tube rupture: pericardial effusion of nourishing fluid.

Metabolic disorders: increased urea causes an inflammatory reaction to the pericardium. Cholesterol deposits in the pericardium.

Due to the consequences of treatment: Anticoagulants, long-term radiation therapy in the chest.

Due to fungus.

Severe heart failure: Patients with heart valve disease, cardiomyopathy with pericardial effusion.

EBSTEIN disease.

Idiopathic.

Typical fluid pericarditis

Clinical

Systemic symptoms:

Depending on the cause: fever, loss of appetite, fatigue, weight loss may occur.

Mechanical symptoms:

Chest pain: Very common, diffuse non-painful pain with a feeling of pressure in the left chest.

Shortness of breath: fast, shallow, restless.

Difficulty swallowing: due to the heart pressing on the back oesophagus, accompanied by coughing and hiccups.

Physical symptoms:

Look, touch: The tip of the heart is beating weakly or the sensation of not having felt a beating. Type: the chiselled area of ​​the heart is large.

Hearing: Tachycardia, distant faint heart sound blocked by a water membrane. If you do not translate, you will hear the pericardial rubbing sound (when holding your breath, this sound is still present).

In clinical practice, when there is a large amount of pericardial effusion, there is fibrin to create a local septum, at that time, the heart can still be heard clearly. There may be a scratching of the pericardium.

Signs of peripheral circulation stasis:

Oedema, hepatomegaly, venous veins, cervical venous hepatic feedback (+) Peripheral venous pressure increased (normal 8-12 cm H2O) Central venous pressure increased (normal 4-7 cm H2O))

Small tachycardia, reduced maximum blood pressure, clamped blood pressure. There may be a Kussmaul paradoxical pulse (when the pulse is lessened). Normally, when inhaled in a vessel is smaller than when exhaled due to increased alveolar pressure (less blood to the left ventricle. In pericarditis due to diastolic insufficiency (less blood to the heart) (thus the lighter the pulse better

A tachycardia of maximum blood pressure at the end of inhalation and exhalation of more than 10 mmHg (normal below 10 mmHg)

Subclinical

ECG:

Due to damage (metabolic and inflammatory disorders) in the subendocardial layer of the myocardium (generating a traumatic current, manifested by a vector directed from the centre of the heart to the centre of the affected area; that is downwards, to the left, and forward and projected onto the lead axis shows ST elevation in the leads (repolarization disorder).

According to Bots, there are 3 phases of ST-T transformation:

Stage 1: Isotropic ST elevation in the peripheral and precordial leads. There is no mirror image on the opposite wall as in myocardial infarction.

Phase 2: After 3 weeks, ST gradually drops to the copper electric line. T flattens down and T (-). But ST is still elevated.

Stage 3: Over 1 month, ST depression and T (-) but not as sharp and asymmetrical as in ischemic cardiomyopathy.

Signs of exchange potential (electrically alternating): Due to the pericardium, many heart fluids move as strongly as swimming in water. After each heart cycle, the heart does not return to its original position. (After each depolarization the heart is at a different position, so the QRS axis changes.

Reduced potential mark: total absolute value of Q, R, S of the three sample leads <15 mm in the precordial leads: in V2 the total amplitude / R + S / <9 mm in V5, V6 / Q + R + S / <7 mm.

X-ray:

Soy: Big heart ball, weak contraction.

X-ray: large heart on two sides in the lower arc, diaphragm angle of the heart-shaped prison. Short heart stem. Hence the heart shape is like a gourd. Can see binaural heart shape (the inner bank is heart ball, the outer edge is pericardium), bright lung: due to diastolic circulation deficiency.

Echocardiography:

What are the amount of fluid and the position of the fluid in the heart wall to decide on pericardial puncture? Is there a lot of fibrin in the fluid and has a wall?

View the thickness of the pericardium for timely directions for medical or surgical treatment. Evaluation of hemodynamic disorders through diastolic pressure imaging. Evaluate the diastolic function. Probe pressure in the right heart. Explore the tension of the heart wall.

Specifically, on ultrasound:

TM measures the size of the fluid interval at the plasma centre and then calculates the pericardial fluid prediction.

Exploration in 2 2D dimensions: General view of the heart's whole heart, to see the volume of the local area or the whole.

With 3 main signs to evaluate:

The Echo void at the back of the heart.

The Echo gap is greatly reduced or completely lost at the left atrial and left ventricular junction.

The pericardium does not move.

Note: Amount of fluid: Pericardial fluid from 30 ml can be detected. A normal healthy person can have 50 ml of DMT. When the volume of fluid covering the whole heart is visible on 2D ultrasound, the volume is about 300 ml.

Determination of the contents of the pericardium (supplementation)

Abnormal movement of the heart in DMT: Paradoxical movement with the ventricular septum.

Pericardial effusion:

Taking the fluid for definitive diagnosis and diagnosing the cause to have the right treatment direction. Pericardial fluid is usually 3 colours or common.

Lemon juice: Tuberculosis, virus, allergies, spontaneous, systemic disease

White-brown condensed pus: Sepsis, ruptured abcès

Red translation: K, tuberculosis, bleeding trauma, caused by anticoagulants.

Differential diagnosis

Big heart: Due to cardiomyopathy, severe heart failure

Angina: Myocardial infarction, pneumonia, etc.

The role of ultrasound is very useful in easy diagnosis and exclusion.

Diagnose the cause

Based on clinical and test pericardial fluid.

The reasons are as mentioned above.

Acute cardiac compression

Define

A condition in which the pressure in the pericardium suddenly increases presses the heart and prevents the ventricular filling of the ventricles during the diastole, causing acute diastolic insufficiency, the acute systolic failure prevents the heart from squeezing.

Increased intracardial pressure also prevents the heart from fully dilating during the diastole. As a result, less blood returns to the heart, blood pressure and cardiac output decrease. The heart rate increases to compensate for these changes when the pressure in the pericardium reaches nearly 15cm water, the cardiac output and blood pressure will drop even more dramatically and the clinical appearance of dizziness. If the pressure in the pericardium is not lowered (by drawing blood or fluid), the patient will die. Just 200ml of fluid or blood can be fatal.

Pathophysiology

Normally, the pressure in the pericardium is zero or slightly negative, thereby helping to increase blood suction to the heart during the diastolic period. When there is a lot of fluid in the pericardium, it changes its pressure (the amount of fluid is too large or the amount of fluid is not much but forms too quickly). Cardiac blockers (very difficult for the heart to draw blood): increased pressure in the neck veins, stuck blood pressure, paradoxical vessels, decreased cardiac output.

Diagnose

Mechanical symptoms:

Onset suddenly with severe shortness of breath, chest pain, struggles, pale skin, sweating.

Physical symptoms:

Tachycardia, blurred heart sound (difficulty hearing) paradoxical pulse (KUSSMAUL). Visible peripheral circulatory stasis. (enlarged liver, prominent cervical vein.).

The three basic signs of acute heart compression are:

Low blood pressure, blood pressure gradually decreases until no measurement. When there are signs of dizziness; anxiety, irritability, pale, cold and moist skin and ultimately loss of consciousness.

Venous pressure increased. Intravenous pressure can increase to 15-20cm of water. Comes with the prominent cervical vein (however, the liver may not enlarge in acute heart compression).

The sound of the heart is small, quiet, the sound of the heart is sounded far away and fuzzy. These foci cannot be seen in the pre-heart area.

Furthermore, there may be paradoxical circuits. The inversion pulse is usually due to an excessive decrease in the pulse pressure upon inhalation (normally less than 10mmHg). Kussmaul markers (cervical vein rising when inhaled) may be present.

Subclinical

X-ray: When acute cardiac compression occurs in the absence of a previous pericardial effusion, an abnormality is usually not detected on a radiograph because pericardial effusion is less than 250ml (but can cause death) not detected on conventional radiographs.

When acute cardiac compression occurs in a patient who already has pericardial effusion, on radiograph a balloon-like, capsule-like or balloon-like heart ball can be seen with a very sharp angle by the lower right margin of the membrane. extra heart with the diaphragm. Although there is no picture on its own to confirm the diagnosis of pericardial effusion, it can be suspected if the balloon is rapidly enlarged and accompanied by a bright lung field.

Electrocardiogram: Total exchange potential (P waves, QRS and T waves) are diagnosed with pericardial effusion or compression of the heart. However, this is not always present. The typical ECG sign of pericardial bleeding is a sharp, sharp T-wave in the anterior thoracic channel. This happens in spite of the downward T wave. Furthermore, acute crushing of the heart due to rupture of the heart can cause sudden bradycardia and electromechanical dissociation. The sudden low potential of the QRS complex on the electrocardiogram has always led to suspicion that effusion is present.

Ultrasound: Ultrasound is a non-invasive method, helping to diagnose the earliest and most accurate pericardial effusion. On the other hand, it also helps to recognize heart pressure.

TM: See the abnormal change in the right and left ventricles according to the breathing cycle: on inhalation: the right ventricle expands, on exhalation: the right ventricle narrows. Conversely, when inhaled in the left ventricle is forced to narrow.

2D: Comprehensive visualization of fluid in the pericardial cavity, ventricular collapse (P), atrial (P), atrial (T), a large posterior localization.

Note: - Ventricular collapse pressure (P) is highly sensitive and highly specific

Ventricular collapse pressure (T): After surgery, the heart septum (P) and atrium (P) often stick close to the retrograde wall. so, there is no ECHO manifestation in cardiac blocking. Furthermore, after surgery, pericardial effusion is usually posterior, thus creating localized heart compression will see a pressure of ventricular collapse (T).

The cardiac blocker may be absent from a ventricular collapse (P) when the ventricular septum (P) is thickened or has pulmonary hypertension.

Cardiac catheterization: The classic mark in cardiac catheterization is increased intracardial pressure, increased and equal atrial (P) and ventricular (P) pressure, a prominent x-slope and loss of they-slope and ventricular pressure (P) atrial end-diastolic increase (P).

Differential diagnosis

Acute right heart failure can be confused with compression of the heart, as acute right heart failure can provide radiographs with enlarged heart balls and bright lungs. Furthermore, there may be increased central venous pressure and decreased blood pressure. However, congestive heart failure rarely causes a paradoxical pulse.

Non-compressive pericardial effusion can be associated with congestive heart failure. In this case, there is also rarely an inverse pulse, and when hearing the heart, there is a murmur due to rheumatic heart disease or another heart disease than hearing the distant heart.

Spasmodic pericarditis

Define

Spasmodic pericarditis is a thick inflammation of the pericardium, sometimes calcium zinc, squeezes the heart, makes the heart not expand, leading to a decrease in diastolic volume, leading to a decrease in systolic volume. together reduce cardiac output.

Diagnose

Clinical:

Outstanding peripheral circulatory stasis syndrome with:

Oedema, enlarged liver, sharp veins, enlarged veins.

There may be an ascites.

Mild skin tanning, especially in the limbs for a long time, resembles cirrhosis, but the other is that there is no collateral circulation above the navel (door - master).

Hear the heart: - The sound of the heart is often blurred a little.

Pericardial rubbing sound.

There may be a "hammering sound" because during the tricuspid valve diastole and opening up, a large amount of blood stagnated in the right atrium has collapsed into a hardened ventricular wall unable to expand (in diastolic period is about 0.10s - 0.13s apart from the second language).

Subclinical:

X-ray: The heart is small or not big, the bank is clear, there may be calcification.

ECG: Decreased ST, flat or negative T wave, atrial fibrillation may be present.

Echocardiography: The lining of the heart is thick and unevenly contracted. The left ventricular posterior wall may have a plateau form. The left atrium is larger than usual.

IV (venous) and hepatic dilatation. Decreased diastolic function. Decreased systolic function the velocity curve of the PP (pulmonary artery) is biphasic, due to the decreased velocity in the mid-ejection period. Classic pulse Doppler and tissue Doppler help recognize spasmodic pericarditis as well as differentiate restrictive cardiomyopathy.

Cardiac catheterization: The ventricular pressure curve (P) had a dip-plateau. Ventricular pressure (P) increases in particular end diastolic pressure, because the hardened pericardium prevents the ventricular muscle from dilating (differential diagnosis with endocardial fibrosis-restricted cardiomyopathy).

Treatment

Surgical treatment

Point:

Long-term blood, pus fluid.

Thick pericardium.

For spasmodic pericarditis depending on the degree of adhesion, calcification of the pericardium that can surgically remove the entire pericardium or open the window.

Postoperative monitoring:

Infection.

Rhythm disturbances.

The most affected neighbouring organs are the mediastinum, the pleura.

Internally medical treatment

General treatment:

Pericarditis pain can be alleviated by giving non-steroidal anti-inflammatory drugs such as Aspirin 500 mg / 4 hours. If pain lasts more than 48 hours, corticoid dose of 1 mg/kg can be used. After 5-7 days, if the pain is reduced, the dose can be reduced and the drug stopped.

Treat the cause of the disease:

Tuberculous pericarditis:

Use early, strong anti-TB drugs, combine at least 3 types of anti-TB. Treatment regimens vary according to progression and antibiotic regimen. Duration of treatment lasts 12-18 months. In the case of progression to pericardial spasm, strengthening anti-tuberculosis drugs and consideration should be given to corticosteroids. Corticoids can reduce fluid quickly, but they can only be used when anti-TB drugs are effective. Many studies show that the combination of anti-tuberculosis and corticosteroids in the case of pericardial effusion improves clinically in non-surgical cases. However, the best method when there is thickening phenomenon is still the removal of the pericardium.

Pericarditis caused by exponential bacteria:

Use systemic antibiotics based on antibiotic mapping of pericardial cap implantation combined with injectable antibiotics in the pericardium. If the pericardium is thick, the cap is thick and requires surgical drainage.

Pericarditis due to rheumatism:

Corticoids and penicillin.

Benign acute pericarditis:

Sometimes no treatment is needed. May use aspirin 1-3 g / day.

Haemorrhage of the pericardium:

After the injury requires surgery.

Pericarditis caused by cancer:

Use chemotherapy, radiation therapy, if you need to drain the surgery or create a pleural-pericardial window if the discharge recurs.

Pericarditis after infarction:

In general, less dangerous, aspirin or corticosteroids can be used.

Pericarditis due to high blood urea:

Dialysis or hemodialysis.

Acute cardiac compression:

Pericardial effusion.

Spasmodic pericarditis:

You can use diuretics to reduce fluid retention. Digital is used only when there is atrial fibrillation at a rapid ventricular rate. If it is caused by tuberculosis, it is necessary to coordinate treatment.

Pericardial removal is a radical measure but needs to be done early.

Pericardial effusion

Purpose:

Is the most important procedure for definitive diagnosis and cause (even with little translation).

Drain the fluid to avoid squeezing the heart during acute cardiac compression to avoid hemodynamic disorders affecting heart function, or, more severely, death.

Pericardial puncture sites:

Patients must be examined to determine the cloudiness of the heart, determine the heart ballon

Depending on the specific case that chooses the location.

The anterior left V-rib, outside the lower left margin of the perforated heart at 2 cm, also known as the Dieulafoy line, is the common sugar and less dangerous.

Marfan Road:

The angle between the breastbone and the left flank, on the middle white line, is 3-5 cm from the sternum and 1 cm to the left.

This area does not have a lung covering the heart, is well used when combined left pleural effusion when there is a combined left pleural effusion, the pleural effusion is not certain here is pleural or pericardial fluid.

The safe triangle area in the left V or VI intercostal area is the junction between the lung, pleura and left shoulder of the sternum tongue when poked, the needle points back gently, avoiding the left inner breast artery (lying 1,25 - 2.5cm away from the left sternum at IV and V inter ribs).

The right intercostal region of the IV, the right bank edge, belongs to the cloudy region of the heart 1 cm. Applied when the pericardial fluid is concentrated to the right, no matter how much fluid or little, even a few millilitres of rheumatic pericarditis can see fluid.

The right intercostal V or VI region next to the right sternum, the needle goes posteriorly into the mediastinum, avoiding the upper hepatic margin.

Intercostal VII or VIII left behind on the midline of the left shoulder blade when the left-arm puncture is raised, this position is used when a large-scale pericardial effusion is pressed into the lungs (Ewart's mark) without difficulty get translated under other locations.

If the puncture is through ultrasound, the line between the screen is the line between the probe and the probe position is the position of the needle, the direction of the probe is the direction of the needle.

How to puncture the pericardium:

First, you must see the images of the cross-sections on ultrasound, locate the largest volume of fluid and then decide on the puncture

Prepare the patient for the puncture: Explain the patient's mental reassurance. The patient lies upright or 45 degrees posture. - Give the patient oxygen. Measure BP, heart rate, pulse, liver examination (to compare with fluid aspiration)

Prepare medications and equipment, monitoring and emergency equipment when needed: electric shock machine, ECG monitor, Morphine, Valium, Novocain and other antiarrhythmic drugs, etc.

Mark the puncture site.

During the procedure: Disinfect at the puncture site, and around the puncture site. Cover the hole with a towel after the disinfection is complete.

For sedation with drugs: Morphine (if there is no respiratory failure) or intravenous seduxen. Use a small needle to localize the puncture site (with xylocaine or Novocain) both numb and probe to drain fluid (puncture on the upper bank of the lower rib X.)

Note: The amount of fluid taken out slowly avoids sudden pressure changes that change the position of the heart. If the heart is pressed, give fluid quickly. After aspirating fluid, need to pump a little air into the pericardial cavity, the amount equal to 2/3 or 1/2 of the volume extracted.

After puncture:

Sampling for test fluids: biochemistry, cells, bacteria and culture and at the same time as antibiotics for treatment.

Re-measure BP, pulse, heart rate, a re-examination of the liver: the amount of fluid removed immediately improved muscle symptoms. HA is no longer stuck. Smaller liver, slower heart rate.

Re-measure Đ.T.D: The amplitude of the voltage of the electrocardiogram waves is higher than the image of the exchange potential (if there is a voltage before puncture).

For patients to be monitored for complications such as mediastinal fluid leakage, pneumothorax, arrhythmia, etc.

The patient should have heart X-ray again and again: See the heart ball shrink, see if the pericardium is thick enough to have timely directions for internal or surgical treatment for the patient.

There are conditions for echocardiography to give the patient a more accurate assessment of fluid volume and pericardial thickness after a pericardial puncture. S. does not distinguish the pericardial fluid due to inflammation, pressure overflow or nourishment, but can distinguish: There is feline, blood clot or K pericardium metastasis see metastatic masses in the pericardium with fluid.