Capitoril 27

BOLILE PERICARDULUI

Adriana Cavagi,D, Zdrenghea

Diagnosticul colcctiilorpericardice a reprez€ntatuna din- colccliei$i ghidarea

localizarea ecoglaficd a drenajuluiper-
tre primeleaplicalii alcccocardiogafiei,ecografiaconstituind culan;aprccicrcafuncticicardiacc[]1.
procedura deeleolicpcrtrudiagnosdcul colecJicipericardice, Ecocardiografic.
colcclia6parcca un spaliulranssonic
inclusivtamponada cardiactrPcntrurcstulpatologicif,cri- (,,ccho-frcc"),
klcalizalinirc foilclc pcricardicc.Colccliilc
cardice(p€ricardite constrictivc.tumori.ctc.)rolulccogralici mici (50-100mm) sc cvidcntiltzlccl mai binc postcrrcrdc
estemodest.darposrbrlimponantin contextclinic. ventricululsdng (parasternalaxul sourtsauaxul lung)$i la-
Pericardul estealcituitdindoul foifc:pcrioardul visccral tcruldcatriuldr€pt(apicnl4oamcrc). Bxuminarca in modul
sauseros. in contactcu epicrrdulii pcricardul parictalsaufi- M esteutiln$iin depistarcacolccliilormici(1i9.27.1).
bros,io raportcuphmanii 9i diafragmul. Celedoul foilc sunt
scparatc dc aproximativ 20-30rnllichid.In condifiinormul€.
nparccoograliccao sioglrrdfoi6 iniensecogena. constituitii
dc lirpl din nai muhe interiller epicard,pericardvhcerAl
ir pcricrrdpanclal.Ecocafdiogralio clasiciinu evidenliaTa
colccliilc pcricrrdiccllziologice(snb30 mL).dafapamre l€de
iralli roTolu{iclc porvizuolizaii pe oresren. Nu exisli insii
critcriicoogralloc clcdilcrenliere0 uneicolecliiperic0rdice
iaancnricidc o colcclicliziologica.
fulburirilc lirnctiijipcdcardutri,expresra bolilor peri-
cardului.surt rczLrltatLrl acuntrlliriidc liclrid(seros.he ro-
ragic.chilossaufurulcDL)in srcul pcricrrclic.al ingrog i
pericardului (evcntual calciiic i) sdual asocicriicclordoun

Diagnosticulcolectieipcrierrdice
Analizaecocardiogralioarin crzul colccliilorpcricdrdicc
i.rmizeazeurnlatoare
le elenrcnlc di.rgnosticci dclccliacolcc Fi!!,27.1. l.co-l\4. Sccliune tara$nrll, ax Lung.Spaliu ecolree
tiei;esimareacantitaliiiindiciicutrivirc la naruracolccticii postefiorin sisroli (sigearal.
 I.:tlgtulia.nn lri ti \rltclat tu ld hdzdrtinij

Pro b l c nr cdc . lidgnos ti cd i l i rc n (i a lri d i c i r1 )rl cs i tu a ti i l c

ce pol rnilrrao coleciie:grasine epicaldici. colecliepleLrra-
" n. 1 r,{ .i .:, J ..' rh j . ,r.,. (a ,i .,l
clc rncri coronxra,clilxhrca arriului sleng. rurxrri chrstrcc
f r e d i rst n a le s au per ic ad i c e .rs c i ti . p s e u d o a n e v rs mudie
! c n l ri cu l s r r lnsl: 1.
Gri \i m c a nor nr aldpe ri c a rd i c n .o | l s ri .r i e ' r,r,, L (.,| L r i
liccl cn ta dc s pr liu pc r ic . rd i cn o n l i c h i d i rnSc . c \i d c n ti rzn
un spallu ..ccho-licc crclusi\ anlcrlor dc cord. lipsind nl
f , rri L rr<,,t. ^r eI c . , r ' . i r c e i i c i .,c e r.:.rri ,rl .r d r< p r i n
consccin(aitrn sprliu ccho licc locrlizlr slricl rnlcrior nu sc
acccpri ca !i coLec(lcpericardici. cu exceptiasilrLaliilorin
careexlsti sirrfi zc poslerloare( colecliepcricaldici cunoscutar
xnrcrior.ir cvolullc) lll.
In ve rs,Lr ndiagnos t ice c o c a rd i o g ra l ifa c l s n e g a ti vd e
colcclic pcric.rdicn lprrc ii ir trnnalorrclc situa!ii: fixrrc .rk.27.?Lco B.Abod$rbcostrl nncatcc nrcont,)rr.i
Clol.clic codll
madcclata a gairului ccogralirlui. colcclic tuchlslala sau
in co l e cti i c u ec ogenit a tes l rn i l a fi n ri o c !d u l u i a d i a c e nt
(hc i('pclicrrd. p()pcricard). In piopcricard sc li'nncvi o
..pojghjli ' purrlenti pe sLrpmialacorduhri.coreesleecoge|a
iic n o Drl ev a s c nr nc lct i d i n rc n s i u n i lcco l c c l i c if1 .5 1 .
Di{snoslicuIdilcrc lirl dirilrco colccLicpcric.rdicari u a
plcul..lliipirirncdinslinali poslcrioflrislringasc lhcc in lirirclic
de mp o rl Lr lc r lolh des c e n d e n tltoi ln c i c i l n i n c i d e | l a p a m s-
tcmalir. sccliunc lorgih(lir1r ar.colcctir pcricafdicn sctdrai
rLnu l \d n gdc { o ! dc s c cn d c n rih. s c h i n rlcr o l c c l i rip l c u M l i
s c si (u o {7i1pos lor lol il hlcrrl d c l o fl i . l n c z u l c o o x i s L c nl cl
co l o cl i cip lc um lcc u c c r pcri c l i c i . c c l c d o u i c o l c o l i is u nt
sepanrede tbitu ecoSenllr fleufei ti tr peficutdului
l i co g rr f ir l) ot ' plc fnu c s tcu ti l l i n d i rg n o s ti c ucl o l c c tici
pcficrftlicc. cs dc al(lcl nici irr diagnosticullrmponrdci car-
( lia ccf6 l .
Ap ro cier r { m nr im ii co l e c ti e i , l \4 rj o ri t.rtc amc to d c l or
ccoc rdiogruliocclccstnn{rc{ oolccliik)rpcricardiccporncso /rk ? 71 Scclnncpr.sic ldlll!xlLitr8f(!Nl. SccriutrosLheosl^lir
dc l a p rc/unr { isunc idis t r i b u tisi i ' n c l ri c c .rl i c h i d u l ui rrj L rr ul sc c!idcnlia/trrruliu e()fice fosrcri(rri unrerior.
codului. cccs cc nu corcspundcrc'ilitltii [7].
ftl e ctiilc m inim c( 50- 1 5 0m l ) s c v i z rH l i z c a /in u n r i lu
n ivclul pcrclclui postcrioral vcnlriculului stiing.iar scp r rca freei i canti ral cadc l i chi dpcri catul i c. dci i hri i ftl oi al i cxi st i
intre pcficardul \'isccr.rlfi ccl tarictal cslc oviclcnti nunrai o propolionalitalcinlrc ccslcn.irl cco D imrgnrcd!sLcdcccN
ln si sro l i(f g. 27. 2) . r Lrnci..i ni mii nco uftrc dc dpc (l i g.2l .4).
(o l ccl i ilc lllic i ( 150- 1 0 0m l ) s u n l l o c a l i z < rlpco l tc ror hr cazulrl unrul l ri l or l i chi di cncnnprtrnl c. sp.tl i ulfos
.lc vcntriculul sling. cirr scp.rrarcadnrlrc cclc doui li)ilc alc tcr()r ccho-fi ccnu sc l i mi tcazil r j oncl i unc.dnrtr. vcnl fi .ul
t r'r(.,rJL l Li. , t : r r . , r ir ' n. r { ' r.,.r;r r i r{ l r{ r.J .i i .1 ' 1 ..l i I ri atriul sting. ci sc cxtindc ii posLcr!tr dc rriul sLing. in
mcdii (100-500 rnll sDrliul llrnssonic este vizibil ii in litx si nusulobl i c i i nr ccl l rans\crs.rl i 8l .
p( r<r(r i i n < - iur . , \ enr Lrh rl I d re p r.( ,.1 e (l Il em 3 i .L J f e l ' c nri suf.rcrci l cfi i canl i ti l i i d. l i chi drpN rcl cndnr(a sprc
depi$esc500 rnl. inconjurarcofdul ill totalitatc(6g.17.1).i,rf o nl (ni l rtatcc\agcrata.ri rrl rcgul uicord (..\$i ngi nghcr " ) .
seporafeafi)ilclor pcric.rf(luluidctaricirc l0 mm. (rcftcrcr A cersti hi pcrki ncTi egl obal , estc rcsponsrbi l .r.l cLrn.lc
in co n ti n ur r cr c r nLililii c o l c c l i c ifc ri c rrd i .c d c tc rn i n, anefactevi /ual i zrte i n nrdl ul M: pscudoffohps.l !.1\ci
. rci l crd d i am c r r uluia. c s l tri \| .rl i u .,c c b o -l i e ch, rn rc x rs l a rnitmlesaurricL$pide.nriicririprftdo\,rle alc scplLrlui. fscudr)
o rrh ric canrird i!ri absolula nnredimensilnrersp.rliuhriecho' sAMLn.9l.
 t,l5
\enlriculrrcd.epte:cr$lereaprcsiuniilclcdirslolicea Vf)
ri scidcrcad.bituluipul onarsr lolumuluitelediasrolic
lentdcularslingtin orno|rte.
prcsrurcrcstccfesculiinanii.
lcnclc pulmonare ;i cave.
in schinib.dchit l sistolicVS ii
dc'bilulcardiacestescazutpina ld linritaiocuhricaidioge
dc$iIIVS eslenlult crescurlat.
Scrnncleecocardiogralicc dc trmponadicardiacisrLnl

.Col.rIsuldiastolicalpererclui libdal ventricululuidrepl.

conscc inti a presiunii
intrapericardicc crcscute. careegaleazi
saudcpn$eite presixnea de umplcrcvcntriculaddreapli.Sc
cvidc liaTi bineatit in sccliunilc:parasternal axalungi ti
scnttir.cdtSiinapicalpalrucancrc.Pcreteleventriculardrcpr
iri normalizeazi pozlliala sllr$ituldiastolei.xmplercaVD
rcrlizandu-se exclusivin sistola(fis.27.5).
ri&?Zl, Sccliun€
4 caDrere
subcostnl.
F.co-R.
Spitiucdroiiee
care

N aturacolecfi€i,Aprccicrca naturiilichiduluipcricardic
esledificih $ u ilnposibih,dcorrece trallsslrdalclc.cxsudAtclc
$i sAngclc nu ccoslructr.riiidcnlicn.
Ilgrolinrcspcricrr&rl i visceral,prezenlfl ilr colcclicdc
beliziccogcncdctibrinlt,sugcrcazl natur0il)lla nlNc{ co-
lecliei.Accstcclcnrcntcrparflccventin pericardila !ubcrcu-
loasi.in pcricarditclc mrlignciiin exsridatelc inllsm{l(niidin
poliartritircunrutoidi. Prczcnlcamclelrlor dclichidiDlhmr-
&A.2Zt T0trlponnda cnrdinc!. ptrru\tcnMl
Sectiunc ax scuflin
lor constiluic lirctoridc riscri aparitiei
conslriclcipcricardicc. sistolliiili!s1oii. lr di.srolil
col0psnlVD,
cnrrtcistictanlponodc
I'r unclcpcricurditc mAligneestecvidcnltrirv 7ir lunn)- curdixcc. VShipcrco(lacti].
flrh dircctl I pcricrrdului.
LocNliraru colocticiii pcricardlocenteza. Ecogftrtir
cstccxlrcmdculill ir ghidrrcapericardiocenlczci diugnosticc . Colapsuldirstolicsl pcrcreluiliber el alriului drcpl.
ti/sautcr{pcutic(cvrcualorii).SeindicaelccluRrcn ci 8lunci o struoturamai sublireii rnri compliantfl decarvenlriculul
canddi$t8Dju dintrcfoilelepeficardului dcpdiic\itcl0-20 mm. drcpt.rcprezini!un senrndc t{nrponadA mai sensibil,dar
Prczcnld lsnrpondci cnrdiace obligaefectuircsdcurgcnltr lt lnoi pulin spccificdecatcolapsulvenLriculdr drclt. fiind de
pcricardioccntczci decompresive. altf!l ra! inrcgistrat.
TrmponNdr cardirctr. Rasunetul hcmodifidmic rl co- . Aspectulde'\winging hcan"- inimllcare.,bal$rscn-
lccljcjdcfindcdc: marimeA cordului.vilezndc ucumul.rrc { rl". rcspectiv o ioinA dedimcnsiun i rcdusehipercontractjld.
colcclicipcriclrrdicc. elasticitateapericardLrhitj dc c.rntilatcu comprinralldin exleriofde Lrnspnliucco-free,de celemai
lichiduluipcricardic.Asifel.o rantitatemodcraltrdc lichid multeori inportant.
(300-500ml) .rcumulat rapidr'ntr-unsacpcrio.lrdicnccom- ' Pletorac valli,consccinl6a pedurbiriiLmplcriivcntn-
plidnlpoatcproduceanolnalii hernodinamiccscvcrc. irclusiv culnredrepte,rezLrltiinr-un indcxrespimtorcnlalsub50-01,
lamponada cardiacd. Deace€a, unspaliuecholiccimportrnt (proccntulde reducere al diamctruluivcneicrve inlbrioffc
litcilitcazidiagnosticul detturponada cardiacA ( fig.27.5).daf dupi inspirprofund).Acestsemndparcr^raintea colapsllnl
un spaliuechoiieefredtu il excludc. atrial$i vcntriculardrepr iiesr€ultinul carcdisparcdupar dre-
Tdmponada cardiaci'nrreprezin[o anomalichcmodi- najulpericardic. Cr clcmcnide diagnoslic esr n]riscnsibil.
namicar. ce apareiD momertulegalizlrii prcsiunilor in- dar nraipxtinspccilicdccri!colapsulcordLrhri dreplU0l.
Lrafcricardici$i intraventriculxri (VD) rczLrlrrind scardereu Pcricarditaconstrictiyr.EsLcdc obicei consecmta peri-
brulalia urnpleriiverltriculare. Consccinlclc hcmodinamice carditci(maiales tubercnLonsc) sdua hcnnpericafdului ;i se
alc tamponadei cardiacesunt:scndcroumplcriidiastolice poatedczvoltapc o perioadicevariaza dc la cn|cvnsiptimirni
 f:cogrulid .o|dului ti ra\elot de Id bdza ininii

pani la calivaanidela episodulinilial.ingro$arcapcricardi dici sauchiartanponadi ca(liacn.Ecog|alia2D evid€nli^za

cn poatcIi ti rczultatulunci invazijtumonle(mezolclion, coleclia pericardicn $i uneori. nasa dc linfom sau doar
mctastrizc ri hntbame). ingro;area pericardici. In hnfomul pcricadic poa€ apare
Consecintele clinice aparcendingroiareapericardice riscul de constricliepericardicd.secundarhcrnopericarduluj
pertu$e umplereacardiacd,conducandla distemiavenelor ce complici limfonul sau consecutiviradi€di mcdiaslinalc
sistemiceti pulmonare9i eventualIa rcducerea debitului terapeuticeu2,13,141.
cardiac.In toatecazurilcde pcricardillconstrictivlcxistn Anomaliilecongcnitslcalc pericardului
o fLziunca celor doua lbilc al€ pericardulxi,carc dcvin Chktele pericardicc,Selocalizeaziin recesclc cardio-
ingro$at€, nedistensibile ii in 30% din cazuricaicificate. ftenice(70%in dreapta, 20%in stangari 10%in altesedii)
Fiziopatologic sereducedistensibilitatea inimii in diastola qi nu comudcacu spaliulpericardic.Nu se vizualiTeaza
rezuldndo disturcliediastolcade tip restri€1ir sarisftcalorin modulM. iar la ecografia 2D apff ca o /oni
Aportuldiagnostic al ecocardiogr4fici r'npcric.rdrtacon anecogena localizad in vecinetatea cordului,dar evident
strictivaestemai redusdecatin pericarditalichidiane.Nici un separatnde oricaredin cavitilile cardia€eprintr-un stat de
semnnu estepatognomonici rotugidaci suntinnunitedoui miocard.Chistelemari realizeazacompresiunialestuctunlor
saurnaimullcs!'mnccompalibildcuconslricliapccardica, cardiac€cu obstruclieintracardia€dSicreareaunor gadiente
diagnosticul trebrieseriosluatin considerarc [10]. prcsionalc.Diagnosriculdilcrcnlials€ realizeazA cu: aite
Suntdescrise urmitoarelemodifrcAri e\ridenliate lndeo- structurichislicc(chisthidaiic,
tcratoamc chislice), culumon
scbiprincco2Dringro;arca pcricardului, abscnla alunccarii solrJc.BrdsrmL, lrlloamcrr Lu chrsrclcbronhog(nicc.
foilelor pericardice li pletoracavaltr.Absenlasemnuluide AbsenF pericarduluic$tcrarl ii constituico aiecliune
pletor! cavalAfaceimprobabildiagno$ticul de constriclie benigntr.Poatefi complet!sru pa4irll. ln cazulabscnlci
pericardicdsemnificativ:l hemodinamic. Metodanu poate pa4irle existtrriscul dc $trangularc lll vcnlricululuistdng
evaluaexactgrosimeapericardului, ,ceasta6ind masurati in defect.In 30% din situaliise a$ociaza $i altc anomalii
corcctprin CT sauRMN. congenitale: chistebron$ioe,defectdc scptalrial,tctralogic
EcoglanaDopplff evid€4iazl o disfunctiediastolicddetip Fallot.herniehiatala,sechestrare pulmonarr.cordcotopic.
rcstrictivcuraportulUA supraunihr,TRIV<60ms,m< I 60ms. Ecocardiografc suntevidenter dilatarcavcntricululuidrcpt.
Conlinnarca dccisivia diagDosticului dc pcricarditn milcareaparadoxala a sepn ui interventricular ii clcmcntc
conslriclivnrcvinccalctcrisnrul cardiac,dcAidiagnoslicul de supmincarcare volemicaa ventricululuidrept[31.
diierential cu cardiolnioporiareslrictivdralnanedilicil.
D€nronstrarea pfin tornog66econputefizati a pericardului
ingroinlsnucrl0ilicatla bolnrvulcu rcstricliccardircl con-
stituicun clc|ncnl dccisivdcdirgnostio dilcrcDll.
'lumorilcpcricardului
Bibli0grsfie
I umorilchcnign(:t.'rrn'rne.nbr,'rn'r.Ip, Jrne.rrrynrF
lncsunirarc$1auo ori81n€ frczenchirrull lhgnostreul lol
estebun. cLrexceplircllzLrrilof 0soclrtecu coleclreperjcardicl l . l ) ( i u 1 l A , H o l i r x n i I 'K . / \ L r c s . r u s ss c e L n f Mc c t t d n n , B l n h i r
n u b o d l i ) r c s l n r r n g t h t \ o l $ n c o l h r y e t r c r r r i r L r l i r $ o r \ . l Jl
rbulrdenlii$i ronponr(iar cllrriircill1).
lumorilc malign(porli: pnmrtile(ruezote|omrl lefr
(caIcerrlbrrrrhopulnronar: l . l ) . l l i ( l d V , \ . I i n c | . l l t r r l l 'c r u r d . l L . ' N l l ) . \ l c \ $ . l t '! c .rM
cardic) sxnrrrehstotrce rnar!ar:
Scli\r.rrnc11ir U.cr r (.)L 1 icdrJio [c i.ard]il .lltrsnr.hl
lirnioarre rralLgrre. rrrnrofi lDedL0srInale if !'lld,rnte). l h r . . {l m r n s r o n x l . . h o . ! t uol g t u n b ! . l A n r C o l L L r t r hlo'rl') . 1 . : r: 5 1 tr )
Setru/if ri subiir nr colcclrer periefiticclie.lc r hcnro I l \ l r l i r ) l l . \ t r r ! \ '( l K ! \ ! 1 . r 1 . \ . s r u l l l I , r i d L r n N ( i l l . u 0 i t n i ll
.'. rJ Jur tliJ.,r'.u r.,rrtur.,,d. \:.rdJ!r '.,.,(. r';ri \: J , i f D i g i 'g i r l i ! d i i g r \ \ . r! .irdrlnh.i\..(\ ( r ( 1 . R .l )
pcicrdrc| rrprdc\oluri!acrlIccorsrricrrc
Tu iofi['pericrrdrcc sc pot.t$cu cu iu!.tzirLumofala ,lntrngTS.OhlK,Sr$of JB nLtrLAl Drrgn.dir\rlr.fl0cho.xr'
nlcur.li)i cu colcclicplcul..ll. lt).l0.lll d osritht ir r! d x. t.fi|ln.(j. llo?]l)00r15111lli
Niczorcll(nn uI pcD.ardicaparcrar.lnarliec!cnl linxlnrc 5 . 1 )( i r L / l . R . h a r A t r . H r n . . ! l H l Q r L r n a h c . c b . i i n J g . t h I
zolcli(nnu I plcurdlcu in!rzic pcri.rrdica.ScporlcmdnilcslN r$essDenlnr pen.rrf rrl {]|rerre.E.ho.Jdtugrxfh\ 99r.l l:l0r l 1
.r irrfcdcr iLn.oDslficli\ !. tcri.aRlili cr ud.rli!4.obstuclic a..Pxrrmc$rrrn R. (nnJbcrg II lcho.xrJbgnfhic fuxnhurk[ 01
cr!rli. sNu.olcclic])cricardicn.simtLlnnrticn. f$icrfdi.L.ftiNnJn alr.sl lt)Nlitilr6r r{r
Lnnlbamclcnr{ligDcDonhoclgkinicnc dctcrmin.r in 250:; 7 AInrid N1 Rca lli!'11r.! dirn.r\io iil ccliorard.gup r! li ascs
J,r ..,/u',.,1r."'. t.-i.:,rJi.i Nn.1 J r:'..1,1(r'(fc|c ,F D e n r0 1h e r . Ld N n s e E c n o t x i d r o g r r f hl !0 0 l : 1 8 : l l l