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Surgical Management of AHD
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Brenda Lee Ufano
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Cards (29)
Pericardium Layers:
Visceral pericardium
(serous): Supposedly non-sensitive.
Parietal Pericardium
(fibrous): Responsible for pain in pericarditis
Pericardial Fluid
:
Situated between visceral and parietal layers.
Normal Volume:
15
–
50
mL.
Ultrafiltrate of
plasma.
Functions of Pericardium:
Prevents sudden
dilatation
of cardiac chambers.
Restricts heart's
anatomic position.
Minimizes
friction
with surrounding structures.
Prevents
heart displacement
and
vessel kinking.
Retards
infection spread
, but exceptions exist.
Survival Without Pericardium:
Yes
, it can be harvested for patches in
cardiac traumas.
Acute Pericarditis Causes:
Bacterial
/
Viral
Infection.
Tuberculosis.
Acute Pericarditis Symptoms:
Chest Pain:
Retrosternal
,
left precordial
, referred to
back.
Pain quality:
Pleuritic
,
sharp
, aggravated by
coughing
, relieved by
sitting up.
Acute Pericarditis Physical Examination:
Pericardial Friction Rub: Audible in
85
%,
high-pitched
scratching.
ECG Findings in Pericarditis:
ST segment elevation in limb leads and
V2
to
V6.
Reciprocal depression in
aVR.
Evolution:
ST
returns to normal, then
T wave
inversion
ACUTE PERICARDITIS
ST elevation often with
upward
concavity
No significant changes in
QRS
complexes
ST segments return to
normal
and only then or even later do the
T waves
become
inverted
MI
ST elevations are
convex
with reciprocal depression more prominent
QRS
changes particularly
Q
with noticing
T wave
inversions are usually seen within hours before the ST segments have become
isoelectric
Different Stages of ECG in Pericarditis:
Stage 1: ST elevation in
standard leads
&
V2
to
V6.
Stage 2: ST segments return to
normal.
Stage 3:
T wave
inversion.
Stage 4: ECG may
normalize
weeks or months later.
Pericarditis Progression:
Without
intervention
, may progress to
pericardial effusion.
Pericardial Effusion:
Fluid
within pericardial sac.
Risk of misdiagnosis with
cardiomyopathy.
Often secondary to
TB
or
malignancy
(breast/liver).
Pericardial Effusion Physical Exam Findings:
Faint
heart
sounds, disappearing
friction
rub.
Vanishing
apex
impulse,
Ewart’s
sign.
Pericardial Effusion Diagnostic Imaging:
Chest x-ray: "
Water bottle
" configuration.
Echocardiography:
Echo-free space
,
electrical alternans.
Pericardiocentesis:
Fluid removal via
subxiphoid
approach.
Differentiates
exudates
and
transudates.
Identifies causes of
bloody pericardial fluid.
Cardiac Tamponade:
Accumulation
obstructs
ventricular blood flow.
Common causes:
neoplastic diseases
,
trauma.
Factors contributing to cardiac tamponade.
Clinical Signs of Tamponade:
Hypotension
,
distended neck veins
,
paradoxical
pulse.
Diminished
pulsation, reduced
QRS
complex.
Beck’s Triad:
Hypotension
,
neck vein
engorgement,
muffled
heart sounds.
Diagnosis and Treatment of Tamponade:
Diagnosis via
echocardiography
and
Doppler
ultrasound.
Emergency pericardiocentesis
and surgical drainage.
Pleuropericardial
window contraindications.
Pleuropericardial Window:
Surgical drainage
technique.
Contraindications in
acute trauma
or
bacterial pericarditis.
Distinguishing Bloody Fluid:
Coagulated blood indicates
cardiac chamber.
Non-coagulated suggests
pericardial
source.
Cardiac Tamponade Causes:
Neoplastic
diseases, idiopathic
pericarditis
,
uremia.
Cardiac operations,
trauma tuberculosis.
Pericardial Effusion in Malignancy:
Commonly from
breast
or
liver
metastatic tumors.
Echocardiography Details of Pericardial Effusion:
Echo-free space
, electrical alternans.
Estimation
of pericardial fluid amount.
Chest X-ray Configuration of Pericardial Effusion:
"
Water bottle
" appearance.
Pathognomonic
results.
Indications for Pleuropericardial Window:
Hemodynamically stable
undiagnosed effusion.
Coexistence with
pericardial
,
pleural
, or
pulmonary
pathology.
Contrast: Pericardial vs. Cardiac Chamber Blood:
Coagulation
of cardiac chamber blood.
Non-coagulation
of pericardial blood.
Cardiac Tamponade Mimickers:
Constrictive
pericarditis,
hypovolemic
shock.
Acute
/
Chronic
Obstructive
Airway Disease
,
pulmonary embolus.