Bolile pericardului

Dr. Dan Victor Spataru

Sef de lucrari UMF Carol Davila
• Anatomia si fiziologia pericardului
• Pericardita acuta
– Etiologie
– Istoric / diagnostic diferential
– Examen fizic
– Examen paraclinice
• Revarsatul lichidian pericardic/tamponada
– Etiologie/fiziopatologie
– Tablou clinic/paraclinic
• Pericardita constrictiva
– Etiologie
– Diagnostic clinic/paraclinic
– Diagnostic diferential CMR
 Anatomia si fiziologia pericardului
• Pericard visceral membrana seroasa –
un singur strat celule mezoteliale aderent
de epicard
• Pericard parietalfibros/ grosime 2mm/
acelular – colagen si fibre elastice
• Spatiul pericardic  50ml fluid seros
• Sinus oblic  AS/AO desc
• Sinus transvers  vene pulmonare/AO, AP
 Anatomia si fiziologia pericardului
• Cord pozitie relativ fixa (respiratie, pozitie)
• Bariera infectie
• Lubrefiere miscare
• Inervatie foarte abundenta (mecano/chemo)
• Secretie prostaglandina (circ. coronariana)
• Functie mecanica de rezistenta la dilatatie
de volum
 Etiologii boli pericard
• Traumatice
• Infectioase
• Radiatii
• Amiloidoza
• Tumori – primitive
- metastaze (plaman, san, limfom)
• Colagenoze
• Post IM (Dressler)
• Post medicamentos
• Disectie aorta
 Pericardita acuta

• Etiologie: idiopatica
• Simptomatologie: 1-2 sapt.
• 1% din supradenivelare ST (upu)
• Semnele bolii de baza
• Durere toracica
• Dispnee, febra
• Manifestari sistemice
 Durerea
• Intensitate foarte mare
• Caracter variabil (junghi/pleuritic)
• Debut abrupt
• Localizare: retrosternal, laterotoracic stang,
epigastru
• Iradiere: trapezius ridge, supraclavicular, brat
stang
• Ameliorare: aplecat in fata
• Insotit de tuse, sughit
 Istoric

• Febra
• Sindrom viral
• Semnele bolii de baza
• Durere toracica
 Diagnostic diferential
• Pneumonie
• Pleurezie
• TEP
• Costocondrita
• BRGE
• CIC/IM
• Pneumotorax
• Disectie aorta
• Patologie abdominala
• Herpes zoster
 Examen clinic
• Bolnav anxios, nelinistit
• Febril/subfebril
• Tahicardie sinusala

• Frecatura pericardica
“Like the squeak of leather on a new saddle
under a rider, or grating in the knee joint on
moving the patella over the femoral
condyles.”
V. Collin, 1955
 Frecatura pericardica
• clasic – patognomonic pt pericardita acuta
• 3 componente:
– Sistolic/Protodiastolic/Contractie atriala
• Intensitate maxima: parasternal jos/apex
• Auscultatie dinamica: aplecat in fata
• Disparitie/reaparitie repetata 
auscultatie frecventa
• 2 sau chiar 1 componenta  dg. dif. Suflu
• Calare pe zgomotele cardiace
 EKG

• Supradenivelare ST difuz
• Dg. dif. ischemie miocardica/repolarizare
precoce
• Depresie segment PR
 Enzime miocardice

• CK – MB
• Troponina
 uneori crescute fara afectare miocardica
 RX pulmonar

• Normal
• Boala de baza: pneumonie, pleurezie,
TBC, tumora pulmonara
 ECOCARDIOGRAFIE

• Normal
• Revarsat lichidian pericardic
• Afectare miocardica: functia VS, IM
 Revarsat lichidian pericardic si
tamponada
• Alte cauze:
– IRC – dializa
– Hipotiroidie
– Amiloidoza
– Disectie aorta
• Tamponada:
– Traumatic
– Infectios
– neoplazie
 Clinica tamponada
• Dispnee
• Ortopnee
• Tahicardie
• PVC crescuta si hepatomegalie
• Scadere TA sistolica
• Puls paradoxal
• Zgomote cardiace diminuate
• Grafie pulmonara: cord marit/plaman clar
• Scopie: pulsatie cardiaca diminuata
• EKG: microvoltaj/alternanta electrica/ST
 Tablou clinic
• Semne/simptomele bolii de baza
• NU simptome pana la tamponada
• Pozitie aplecat in fata
• Soc apexian greu palpabil
• Semn Ewart (matitate si respiratie suflanta
varf scapula stang)
• Diaforeza
• extremitati reci, cianoza
 Triada Beck (1935)

• PVC crescuta
• TA scazut
• Precordiu linistit
 Richard Lower (1669)
“It sometimes happens that a profuse
effusion oppresses and inundates the heart.
The envelope becomes filled in hydrops of
the heart; the walls of the heart are
compressed by the fluid circling everywhere,
so that the heart cannot dilate sufficiently to
receive the blood; the pulse becomes
exceedingly small, until finally it becomes
utterly suppressed by the great innundation
of fluid, thence succeed syncope and death
itself.”
 Pericardita constrictiva

• Stadiu final proces inflamatoriu

• Mai frecvent:
– infectios
– Postchirurgical
– Postiradiere
– TBC
• Evolutie luni/ani => IC dr
 Clinica pericardita constrictiva

• Diagnostic dificil
• IC dreapta cu FE normala (in forme usoare)
• Progresia bolii catre:
– Icter
– Ascita
– Anasarca (fara lichid in pericard)
– Ciroza cardicaca
 Clinica pericardita constrictiva
• Presiune venoasa pulmonara crescuta:
– Dispnee
– Tuse
– Ortopnee
• FA
• Inusificenta mitrala si tricuspidiana
• DC scazut:
– oboseala
– slabiciune musculara
– scadere in greutate
 Clinica pericardita constrictiva
• Mai rar:
– Revarsat lichidian pleural
– AIT
– Sincopa
• Diagnostic diferential
– Insuficienta cardiaca dreapta severa
– Ciroza hepatica
 Examen fizic
• Jugulare turgescente
• Semn Kussmaul
• Puls paradoxal (la 1/3 din bolnavi)
• Pericardial Knock (zgomot protodiastolic)
 EKG pericardita constrictiva

• Modificari nespecifice ST
• FA
 RX pericardita constrictiva

• Calcificare pericard
• Marirea atriului drept
Cardiomiopatii si miocardita