Pericardial Disease Flashcards
Pericardial cysts and diverticula - definition?
Pericardial Cysts: Fluid filled thin walled cavities without communication to the pericardial fluid
Pericardial Diverticula: focal outpouching of the pericard with communication to the pericardial fluid
Pericardial cysts - epidemiology ?
rare - incidence ~ 1:1Mio ~7% of all mediastinal tumors ~13-33% of all mediastinal cysts most common location - right costophrenic angle less frequent - left paracardial border
Pericardial cysts - clinical symptoms ?
~50% asymptomatic
rarely dyspnea, dysphagia, retrosternal pain, fever, cardiac insufficiency
Complications: infection, rupture, RVOT obstruction
Pericardial cysts - therapy
Complete surgical removal in symptomatic patients
Puncture and drainage only with concomitant alcohol instillation or tissue-adhesive successful
Pericardial cysts - MRI findings ?
Alternative to CT for evaluation of size, location, content
characteristically: T1w hypointense, T2w hyperintense
in protein-rich cysts: T1w hyperintense, T2w iso- to hypointense
no contrast enhancement
differentiation of cysts and diverticula with cine images
Pericardial cysts - differential diagnosis (DDx) ?
- peri- or paracardial fat deposits
- thymidine cysts, bronchogenic cysts
- echinococcal cyst
- cystic tumors: teratoma, neurogenic tumors, lymphangioma
Pericardial hypoplasia / aplasia - facts ?
- partial or complete absence of pericardium
- most often congenital, rarely iatrogenic
- very rare
Pericardial hypoplasia / aplasia - clinical symptoms, complications, therapy ?
complete aplasia usually asymptomatic, sometimes unspecific thoracic pain and / or dyspnea
partial aplasia can rarely lead to severe complications because of herniation (mPA or left atrial appendage) with syncope, myocardial infarction, sudden cardiac death
increased risk of aortic dissection
therapy: surgical pericardial plastic in case of herniations
Pericardial hypoplasia / aplasia - MRI findings ?
- interruption of the pericardium with sufficient epicardial fat
- atypical cardiac position
- interposition of lung tissue between inferior cardiac surface and diaphragm or aorta and mPA respectively
- atypical motility of the cardiac apex and intermittent herniations with cine images
Pericardial hypoplasia / aplasia - differential diagnosis ?
- ASD
- pulmonary stenosis
- mitral valve disease
- pulmonary hypertension / embolus
Pericardial tumors - definition and epidemiology ?
- most frequent malignancies: pericardial metastasis
- most frequent primary malignancy: mesothelioma
- most frequent benign tumors: pericardial cyst, lipoma
- other benign tumors: fibroma, teratoma, haemangioma
Pericardial tumors - clinical symptoms, complications and prognosis ?
unspecific
usually as a result of pericardial effusion, pericarditis or infiltration of adjacent structures
arrhythmia, ventricular compromise
mortality ~10-30% also with benign tumors
mortality ~100% within 3 years in malignancies
Pericardial tumors - therapy ?
surgical resection in benign tumors
palliative, symptomatic and conservative drug therapy in most malignancies
Pericardial tumors - MRI findings ?
- localisation
- infiltration of adjacent structures
- differentiation of various tumor entities with signal and contrast pattern
- dynamic information with cine imaging
Pericardial tumors - differential diagnosis (DDx) ?
- pericarditis (infectious, inflammatory, idiopathic)
- post-therapeutic pericarditis (chemotherapy, radiation)
- postoperative seroma / haematoma
- pericardial tamponade
Pericardial tamponade - definition and epidemiology ?
Life-threatening filling of the pericardial sac with increase of pericardial pressure and concomitant cardiac compromise
incidence of small pericardial effusion ~10-15%
incidence of pericardial effusions requiring drainage ~0.02-0.03%
Pericardial tamponade - aetiology ?
Manifold aetiologies: infection/inflammation, trauma, postoperativ, aortic dissection, myocardial infarction, Dressler syndrome, pericardial neoplasia
Content: blood, pus, lymph, gas
filling speed is crucial
Pericardial tamponade - clinical symptoms ?
Clinical diagnosis - Beck’s triad
- decreased arterial pressure
- distended neck veins without known cardiac insufficiency
- faint/muffled heart sounds
Pericardial tamponade - therapy ?
- puncture and drainage
- surgical thoracotomy
Pericardial tamponade - imaging (TEE) ?
- method of choice
- early diastolic collapse of the right ventricle
- late diastolic / early systolic collapse of the right atrium
- early diastolic left atrial collapse (in pulmonary hypertension - specific but rare)
- paradoxical movement of the interventricular septum
- swinging heart
- reduced E-wave
- reduced / increased diastolic transmitral forward flow during inspiration / exspiration
Pericardial tamponade - imaging (CT and MRI) ?
- usually not indicated
- differentiation, characterisation of pericardial fluid
- in case of suspected tumor
- therapy planning
Pericardial tamponade - differential diagnosis (DDx) ?
- constrictive pericarditis
- tension pneumothorax
- restrictive cardiomyopathy
- acute right heart insufficiency in pulmonary embolism
- myocardial infarction
- cardiac insufficiency
Constrictive pericarditis - definition ?
- possible consequence of acute pericarditis with scarred/calcific transformation and reduced elasticity
- impairment of diastolic filling with preservation of systolic function
Constrictive pericarditis - aetiology ?
most common viral or idiopathic
consequence of cardiac surgery or radiation therapy
rarely postinfectious, immunologic, trauma, sarcoidosis, uraemia etc.
pathophysiologic characteristic: diastolic pressure equalisation of all 4 chambers
Constrictive pericarditis - epidemiology ?
~ 0.5% after acute pericarditis of viral or idiopathic origin
~ 2-5% after pericarditis immunologic and neoplastic origin
~ 20-30% after pericarditis of bacterial origin
incidence of effusive pericarditis ~3.6%
Constrictive pericarditis - clinical symptoms ?
- elevated systemic venous pressures
- decreased cardiac output
- typical for right heart insufficiency
Constrictive pericarditis - therapy and prognosis ?
- pericardectomy (mortality up to ~9%)
- antibiotic therapy in tuberculous pericarditis
- non-steroidal antiphlogistic therapy in transient pericarditis
Constrictive pericarditis - imaging (TEE) ?
- septal bounce: early diastolic movement of the interventricular septum towards the left ventricle during inspiration and inverse pattern during exspiration
- dilated SVC / IVC and atria
- small or absent A-wave in Doppler
Constrictive pericarditis - imaging (CT) ?
- focal calcifications
- pericardial thickening > 4mm
- enlarged atria
- tubular form of the right ventricle
Constrictive pericarditis - imaging (MRI) ?
- thickened pericard
- late enhancement
- differentiation of small pericardial effusion from pericardial thickening
- paradoxical septal movement during inspiration
Constrictive pericarditis - differential diagnosis (DDx)
- restrictive cardiomyopathy
- COPD
- pulmonary hypertension
- shunts
- ARVC/ARVD
- right ventricular infarct
Dressler-Syndrome - definition and facts ?
- occurs usually 2-3 weeks up to months after MI
- prevalence ~ 1% and ~ 3-5% after MI
- apparently associated with pericardial bleeding
- possible autoimmune
Dressler-syndrome - clinical symptoms ?
- fatigue, fever, pleuritic pain worse with inspiration
- pericardial effusion
- elevated inflammatory parameters
- ECG: low voltage, ST-elevation (~60%)
Dressler-syndrome - therapy and prognosis ?
- Aspirin / NSAIDs worse prognosis: - high fever - subacute course - large pericardial effusion
Dressler-syndrome - imaging ?
TTE: pericardial effusion
CT: pericardial thickening and localisation / complications
MRI: LGE, monitoring therapy
Dressler-syndrome - differential diagnosis (DDx) ?
- post-infarction pericarditis
- post-traumatic pericarditis
- post-interventional pericarditis
- acute pericarditis (idiopathic, viral, bacterial, neoplastic, uraemic)
- pleuropneumonia
- CAD
- pulmonary embolus
- aortic dissection
