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SA Cardiology > Pericardial disease > Flashcards

Pericardial disease Flashcards

1
Q

Anatomy of the pericardium

A

Fibrinous pericardium (outer)

Serous pericardium (inner)
- Parietal layer
- Pericardial fluid
- Visceral layer

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2
Q

Fibrinous pericardium (outer)

A

Thin, tough sac that is continuours with the adventitia of the great vessels dorsally and with the sterno-pericardial ligament ventrally

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3
Q

Serous pericardium (inner)

A

Consists of two layers and the pericardial fluid between them.
A thin layer of mesothelial cells is present in the inner aspects of the layers

Parietal layer: inner surface of the fibrinous pericardium, composed of collagenous fibers

Pericardial fluid: between the layers, small volume, serous, thin, clear fluid

Visceral layer: forms the epicardium

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4
Q

Blood supply to the pericardium

A

Via branches of the aorta, internal thoracic artery, and musculophrenic arteries

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5
Q

Lymphatic drainage from the pericardium

A

Cardiac, mediastinal, and pre-sternal lymph nodes

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6
Q

Function of the pericardium

A

Prevention of overdilation
Protection from infection
Maintain the heart in a fixed position within the thorax
Coordinates the left and right ventricular function

NOT VITAL

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7
Q

Congenital pericardial disease

A

Peritoneopericardial diaphragmatic hernia (PPDH)

Pericardial cysts

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8
Q

Peritoneopericardial diaphragmatic hernia (PPDH)

A

Defect in the ventral diaphragm and pericardium during embryonic development

Incomplete sepration of the thoracic and abdominal cavities

Most common congenital defect

Weimeraners and Persian cats

Often asymptomatic
Can be GI signs or less commonly resp signs

Surgical correction can be curative

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9
Q

Pericardial cysts

A

Rare

Result from the entrapment of the omentum or falciform ligament in the pericardium

Often asymptomatic but can cause pericardial effusion and cardiac tamponade

Surgical removal is possible

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10
Q

Acquired pericardial diseases

A

Pericardial effusion

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11
Q

Categories of pericardial effusion

A

Haemorrhagic

Transudate

Exudate

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12
Q

Causes of haemorrhagic pericardial effusion

A

Neoplastic

Idiopathic

Left atrial rupture

Coagulopathy

Trauma

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13
Q

Causes of transudate pericardial effusion

A

Congestive heart failure

Neoplasia

PPDH

(Less common: hypoproteinaemia, uraemia with renal failure)

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14
Q

Causes of exudate pericardial effusion

A

FIP

Infection

Foreign bodies

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15
Q

Neoplastic pericardial effusions

A

Haemangiosarcoma

Chemodectomas (heart base tumour)

Mesothelioma

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16
Q

Pericardial effusion caused by haemangiosarcoma

A

Most common

Predilection site: right atrial appendage and right atrium

GSDs and Golden retrievers

High rate of metastasis (sleen/liver common)

Rapid recurrence following pericardiocentesis

Grave prognosis

Surgical excision rarely feasible, chemotherapy not generally advised

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17
Q

Pericardial effusion caused by chemodectomas (heart base tumour)

A

Second most common

Arise from chemoreceptors in the pulmonary artery and ascending aorta

Predisposed: brachycephalics, older dogs

Benign, typically slow growing with slow metastatic rate - but can be locally invasive

Clinical signs due to compression of the great vessels

Pericardiectomy can prolong survival with good QOL

18
Q

Pericardial effusion caused by mesothelioma

A

Low-grade malignancy originating from mesothelial cells lining coelomic cavities

Malignanacy uncommon in dogs

Predilection site: pleura +/- pericardium

Often large volume pericardial effusion

Pericardiectomy palliative

Intracavity chemo an option

19
Q

Paragangliomas

A

Another form of aortic body tumour

Functional - secrete catecholamines

20
Q

Idiopathic pericardial effusion

A

Diagnosis of exclusion - neoplasia more common in older dog

Second most common cause of pericardial effusion

Unknwon aetiology

Large breeds over-represented

50% recurrence rate - pericardiectomy is indicated

Pericardial fibrosis with a mixed inflammatory response and no vasculitis

21
Q

Left atrial rupture

A

Rare

Typically older, small breed dogs

Secondary to severe myxamatosus mitral valve associated with severe left atrial dilation and jet lesions

Guarded prognosis

22
Q

Right-sided congestive heart failure

A

CHF is most common cause of pericardial effusion in cats

Effusion occurs due to passive congestion and decreased drainage

It rarely results in a volume large enough to cause tamponade

Treatment: CHF therapy

Guarded prognosis

23
Q

Septic pericardial effusions

A

Rare

May be associated with penetrating or migrating foreign bodies

Cytology and culture and sensitivity

Aggressive antibiosis, exploratory thoracotomy often required

FIP in cats

Clinical signs usually associated with cardiac tamponade

24
Q

Constrictive pericarditis

A

Uncommon

Thickened, fibrotic pericardium

Can be idiopathic, neoplastic or occur secondary to recurrent pericardial effusions

Signs of right sided heart failure

Pericardiectomy required

Guarded prognosis

25
Q

Cardiac tamponade

A

Once intrapericardial pressures exceed right atrial, and subsequently right ventricular, pressures, this results in diastolic collapse of the right atrium +/- ventricle

Impedes ventricular filling and so reduced stroke volume and cardiac output

26
Q

Pulsus paradox

A

During pericardial effusion

Increase in right ventricular filling on inspiration causing the interventricular septum to shift toward left ventricle (reducing stroke volume)

Variation in pulses quality with the respiratory cycle

27
Q

Signalment and history of a patient with pericardial effusion

A

Often large breed, older dogs

Collapse

Exercise intolerance

Lethargy

Abdominal distension

Cough

Polydipsia

Hyporexia

Acute pericardial effusion is more likely to result in signs of reduced cardiac output while chronic effusions are more likely to present with signs of right sided congestive heart failure (ascites)

28
Q

Clinical examination of pericardial effusion

A

Muffled heart sounds

Weak femoral pulse, pulses paradoxus

Tachycardia

Ascites

Jugular distension

Positive hepatojugular reflux

Hepatomegaly/splenomegaly

+/- respiratory signs

29
Q

Diagnostics of pericardial effusion

A

Echocardiography

Blood pressure

ECG

Radiography

Clinical pathology

Pericardial fluid analysis

30
Q

Echocardiography of pericardial effusion

A

Best non-invasive method

Easy to identify (hypoechoic fluid, contained within bright hyperechoic pericardium)

Also look for pleural effusion and ascites

Ideally do a thorough search for a cardiac or heart base mass

31
Q

Blood pressure - pericardial effusion

A

Assess degree of haemodynamic compromise.

Hypotension with forward failure

32
Q

ECG - pericardial effusion

A

Often sinus tachycardia

Electrical alternans a common finding

33
Q

Radiography of pericardial effusion

A

Inferior to thoracic ultrasound

Globoid, enlarged cardiac silhouette with very distinct margins

Dilated CdVC

Abdominal effusion

Small pulmonary vessels

Clear lung fields

34
Q

Clin path of pericardial effusion

A

Pre-renal azotaemia common finding

Mildly elevated liver enzymes

Albumin may be low

Anaemia

Cardiac troponin I often elevated

35
Q

Pericardial fluid analysis

A

Assess volume, gross appearance

PCV

Cytology - low diagnostic yield for neoplastic effusions, useful for diagnosis of septic pericarditis

C&S if suspicion of septic pericarditis

36
Q

Key treatment points for pericardial effusion

A

If tamponade is present, pericardiocentesis should be performed (unless left atrial tear)

If haemodynamically unstable patients - high rate IV fluids

DO NOT give furosemide

37
Q

Pericardiocentesis

A

Essential if cardiac tamponade

Often palliative rather than curative

Owner must know that the effusion may recur

38
Q

Patient prep for pericardiocentesis

A

Mild sedation

Sternal or left lateral recumbency

Pericardiocentesis performed via the right side to avoid the large coronary artery

Place IV catheter and give IVFT if required

Connect ECG

Aseptic preparation 3rd-8th ICS, ventral half of the right chest

39
Q

Technique for pericardiocentesis

A

Use US to find best point of entry, or 5-6th ICS at level of costochondral junction

Local anaesthetic infiltration

Small stab incision through skin

Over-needle catheter (14G) approach:
- advance catheter over needle and remove needle once in pericardium

Modified Seldinger technique:
- Advance introducer catherter into pericardium over the needle, withdraw needle, then thread the guidewire through and remove introducer catheter

Attach 3-way tap

Aspirate fluid, maintain some for analysis

Ensure it does not clot

Monitor ECG

Once fully drained, remove catheter

40
Q

Complications of pericardiocentesis

A

Haemorrhage and catastrophic bleeding

Arrhythmias

Pneumothorax

Pulmonary oedema

41
Q

Pericardiectomy

A

If more than 3 pericardiocentesis are required

Pericardium should be sent for histopathology

Subtotal pericardiectomy preferred to a pericardial window

May be curative in cases in cases of idiopathic pericardial effusion but in most cases palliative

SA Cardiology (12 decks)

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