心包疾病PPT课件.ppt

心包疾病心包疾病General characteristics(Normal Pericardial Anatomy and Normal Pericardial Anatomy and PhysiologyPhysiology)1.Pericardium is the membranous sac surrounding the heart.2.The pericardium consists of two layers:visceral layer and parietal layer.3.There is about 50ml pericardial fluid in the pericardial cavity.The normal functions of the pericardiumMaintaining an optimal cardiac shape.Reducing friction between the beating heart and adjacent structures.Protecting the heart from other diseases which are caused by the neighboring organs:inflammation,TB,cancer etc.Preventing the overfilling of the heart.Classification of Pericardial DiseasesCongenital defectPericarditisacute pericarditisacute pericarditispericardial effusionpericardial effusion constrictive pericaditis constrictive pericaditis.Pericardial neoplasmPericardial cystsAcute pericarditisDefinition Acute pericarditis is an inflammation of the pericardium.Etiology The disease may be idiopathic or secondary to The disease may be idiopathic or secondary to other diseases,for exampleother diseases,for exampleViral infection:Viral infection:coxsackieviruscoxsackievirus B,CMV B,CMVBacterial infection:Staphylococcus sp,Bacterial infection:Staphylococcus sp,Streptococcus sp,tubercle bacillusStreptococcus sp,tubercle bacillusPost-MI complicationsPost-MI complicationsDrugsDrugsMalignancy Malignancy Collagen vascular diseaseCollagen vascular diseasePathology Early stageEarly stage：fibrous protein pericarditisfibrous protein pericarditis Progressive stageProgressive stage：Rapid effusive pericarditis acute cardiac tamponade Rapid effusive pericarditis acute cardiac tamponade Chronic accumulation is accommodated by the expanding Chronic accumulation is accommodated by the expanding pericardiumpericardium myopericarditis myopericarditis Final resultFinal result：The exudate was completely dissolved and absorbed The exudate was completely dissolved and absorbed Organization Organization calcification of pericardium constrictive calcification of pericardium constrictive pericarditispericarditispathophysiologyAcute pericardial effusionAcute pericardial effusion The pressure of the pericardial cavityThe pressure of the pericardial cavity FV(filling volume)of the ventricular diastoleFV(filling volume)of the ventricular diastole SV(stroke-volume)SV(stroke-volume)BPBP Clinical Manifestations -fibrous protein pericarditis Chest pain Chest pain(Symptoms)(Symptoms)Position Position：retrosternal or retrosternal or precordium,midsectionprecordium,midsection CharacterCharacter：sharp pain,dull pain,sharp pain,dull pain,compressioncompression WorsenWorsen deep breathing,cough,deep breathing,cough,and lying down.and lying down.Relieved Relieved sitting and leaning sitting and leaning forward.forward.Pericardial friction rub Pericardial friction rub (Signs)(Signs)Both systole and Both systole and diastolediastole This finding is This finding is diagnosticdiagnosticClinical Manifestations -Pericardial effusion Symptoms Symptoms DispneaDispnea Pressure symptomsPressure symptoms：dry cough(bronchus)dry cough(bronchus)hoarseness(laryngeal hoarseness(laryngeal nerve)nerve)dysphagia dysphagia（esophagesophagus)us)Signs Signs physical sign of the heart physical sign of the heart tachycardia,tachycardia,indistinct heart indistinct heart soundssounds Ewart signEwart sign(consolidation of (consolidation of lower lobe of left lung)lower lobe of left lung)Hypotension Hypotension SBPSBP，pulse pressurepulse pressure even even paradoxical pulseparadoxical pulse.Congestion of systemic Congestion of systemic circulationcirculation distended jugular veindistended jugular vein edemaedemaClinical Manifestations -Cardiac tamponadeAcute：Becks trilogyHypotension or shockHypotension or shockDistended jugular veinDistended jugular veinIndistinct heart soundsIndistinct heart soundsSubacute or chronic：venous pressure venous pressure congestion of systemic circulationcongestion of systemic circulationKussmaul sign(dilation of jugular vein Kussmaul sign(dilation of jugular vein during inspiration)during inspiration)Laboratory findings -ECGStage I:Stage I:ST segment elevationST segment elevation(concave upward not (concave upward not convex)in all leads except avR and V1 without convex)in all leads except avR and V1 without reciprocal ST segment depression(which occurs in reciprocal ST segment depression(which occurs in MI)(Several hours later).MI)(Several hours later).Stage IIStage II:ST segments return to baseline,the:ST segments return to baseline,the initially upright T waves flatten(several days later)initially upright T waves flatten(several days later)Stage III:Stage III:T waves invert(weeks later)T waves invert(weeks later)Stage IV:Stage IV:T waves revert to normal(weeks or T waves revert to normal(weeks or months later)months later)Other changes:Large effusion can cause both Other changes:Large effusion can cause both reduced voltage and electrical alternans.reduced voltage and electrical alternans.EKG of Acute pericarditis(Stage I)Acute inferior myocardial infarctionLaboratory findings -Chest x-ray filmCardiac shadow has Cardiac shadow has an enlarged an enlarged“water-bottle”“water-bottle”appearance.appearance.Clear lung field.Clear lung field.Cardiac shadow Cardiac shadow changes with changes with postures.postures.Laboratory findings -Echocardiography This is the best This is the best noninvasive noninvasive investigation investigation for confirming for confirming diagnosis of a diagnosis of a pericardial pericardial effusioneffusionLaboratory findings -Pericardiocentesis 1.Pericardiocentesis can help to make1.Pericardiocentesis can help to make diagnosis diagnosis.Fluid should be sent for culture and assayFluid should be sent for culture and assay Protein,glucose and LDH assaysProtein,glucose and LDH assays:LDH,glucose and:LDH,glucose and protein determine if fluid is a transudate or exudate;protein determine if fluid is a transudate or exudate;Cytology and tumor markerCytology and tumor marker:CEA,AFP,CA125 and so on;:CEA,AFP,CA125 and so on;ANA assayANA assay:if collagen vascular disease is suspected.:if collagen vascular disease is suspected.2.Pericardiocentesis can relieve the pressure of 2.Pericardiocentesis can relieve the pressure of pericardial cavity.pericardial cavity.Diagnosis of Acute PericarditisChest pain aggravated by coughing,inspiration,or Chest pain aggravated by coughing,inspiration,or recumbencyrecumbencyPericardial friction rub on auscultationPericardial friction rub on auscultationCharateristic EKG changesCharateristic EKG changesChest X-ray and UCG may find pericardial Chest X-ray and UCG may find pericardial effusioneffusionDifferential Diagnosis of Acute PericarditisAcute Acute idiopathic idiopathic pericarditispericarditisTuberculous Tuberculous pericarditispericarditisPurulent Purulent pericarditispericarditisMaligancyMaligancyPostpericarPostpericardiostomy diostomy syndromesyndromeHistroryHistroryHistory of up History of up respiratory respiratory tract infectiontract infection，acute acute onsetonset，often often recurrentrecurrentAccompanied Accompanied with primary with primary TBTBAccompaAccompanied with nied with original original infection infection lesion or lesion or septemiaseptemiaFrequently Frequently caused by caused by metastatic metastatic tumourtumourHistory of History of cardiac injury cardiac injury such as such as operation,operation,myocardial myocardial infarction,infarction,may often may often recurrentrecurrentFeverFeverConstant Constant feverfeverseldomseldomHigh High feverfeverseldomseldomoftenoftenPericardiPericardial friction al friction rubrubobviouslyobviously，occur earlyoccur earlyoftenoftenoftenoftenseldomseldomseldomseldomChest Chest painpainOften Often severelyseverelyseldomseldomoftenoftenseldomseldomoftenoftenAcute Acute idiopathic idiopathic pericarditispericarditisTuberculous Tuberculous pericarditispericarditisPurulent Purulent pericarditispericarditisMaligancyMaligancyPostpericardiPostpericardiostomy ostomy syndromesyndromeLeukocyte Leukocyte countcountNormal or Normal or increaseincreaseNormal or Normal or slightly slightly increaseincreaseSignificantlSignificantly increasey increaseNormal Normal or or slightly slightly increaseincreaseNormal or Normal or slightly slightly increaseincreaseBlood Blood cultureculture+Volume of Volume of pericardial pericardial effusioneffusionLittleLittleLargeLargeLargeLargeLarge Large MediumMediumCharacterisCharacteristicticGrass Grass yellow or yellow or hematichematicOften Often hematichematicPurulentPurulentOften Often hematichematicOften Often serosityserosityDifferential Diagnosis of Acute PericarditisDifferential Diagnosis of Acute PericarditisAcute Acute idiopathic idiopathic pericarditispericarditisTuberculouTuberculous s pericarditispericarditisPurulenPurulent t pericardpericarditisitisMaligaMaligancyncyPostpericaPostpericardiostomy rdiostomy syndromesyndromeClassificatiClassification of on of leukocyteleukocyteMore More lymphocytelymphocyteMore More lymphocytelymphocyteMore More neutrophilneutrophilMore More lymphocytlymphocyte eMore More lymphocytelymphocyteBacteriaBacteriaNoneNoneTubercle Tubercle bacillus may bacillus may be found be found Purulent Purulent bacteriabacteriaNoneNoneNoneNoneTreatmentTreatmentNSAIDsNSAIDsAnti-tubercle Anti-tubercle bacillusbacillusAntibiotic Antibiotic or or pericardipericardiotomyotomyTreat Treat original original diseases,diseases,PerecardioPerecardiocentesis centesis SteroidSteroidTreatment 1.Etiology treatment1.Etiology treatment Bacterial infectionBacterial infection Viral infectionViral infection TBTB MalignancyMalignancy Collagen vascular diseaseCollagen vascular disease2.2.Relieving pain and inflammation:Relieving pain and inflammation:NSAIDs and steroidsNSAIDs and steroids3.If symptoms are severe,3.If symptoms are severe,pericardiocentesispericardiocentesis is is indicated to remove fluid.indicated to remove fluid.Constrictive pericarditisDefinition Constrictive pericarditis is a thickening and fibrosis of the pericardium that occurs long after an acute episode of pericarditis.It produces decreased diastolic filling.Etiology TBTB is a leading cause in underdeveloped countries is a leading cause in underdeveloped countries including China,about 40%.including China,about 40%.Others:Purulent inflammation,Pericardial injury,Others:Purulent inflammation,Pericardial injury,Radiation therapy etc.Radiation therapy etc.Clinical ManifestationsSymptoms:Symptoms:DyspneaDyspnea on exertion and orthopnea on exertion and orthopneaOther symptomsOther symptoms HypodynamiaHypodynamia Big bellyBig bellyPhysical Signs:Physical Signs:Distended jugular veinDistended jugular veinKussmaul signKussmaul signEdema,ascitesEdema,ascitesHeart sounds are distant and a pericardial knock Heart sounds are distant and a pericardial knock is detected after Sis detected after S2 2SBPSBP、DBPDBP、pulse pressurepulse pressureLaboratory findingsRadiography/CT/MRIRadiography/CT/MRI Pericardial calcificationPericardial calcificationECGECG Low voltage in limb leadsLow voltage in limb leads T wave is low or upside downT wave is low or upside down Atrial arrhythmias.Atrial arrhythmias.EchocardiographyEchocardiography Pericardial thickening in most cases can be Pericardial thickening in most cases can be demonstrateddemonstratedDiagnosis of Constrictive pericarditis 1.Congestion of systemic circulation:distended 1.Congestion of systemic circulation:distended jugular vein,edema jugular vein,edema 2.Pericardial knock on auscultation 2.Pericardial knock on auscultation 3.X-ray,Magnetic resonance,computed 3.X-ray,Magnetic resonance,computed tomography,or echocardiographic imaging tomography,or echocardiographic imaging showing a thickened or calcified pericardium showing a thickened or calcified pericardiumTreatment 1.Pericardiectomy as early as possible.2.Antituberculous therapy may be required if the underlying cause is tuberculosis and should be continued for 1 year.Thank you!