enfermedades del pericardio

“El pericardio es una suave túnica lisa
que envuelve alcorazón y que contiene una
pequeña cantidad de líquido parecido a la
orina”
Hipócrates, 460 AC
ENFERMEDADES DEL PERICARDIO
DR. ENRIQUE COURCELLES
CURSO DE POSTGRADO
2009
PERICARDITIS SEROFIBRINOSA
ETIOLOGÍA DE LA PERICARDITIS
HIPERSENSIBILIDAD
Enferm. del colágeno*
INFECCIOSA
Viral
Tuberculosa
Secundario a drogas (3)
(1)
Post IAM (Dressler*)
Bacteriana
* Pericarditis recidivante
Otras (sífilis, parásitos)
Idiopática*
Neoplasia / metástasis*
Insuficiencia renal
(2)
Traumática*
Hipotiroidismo
NO INFECCIOSA
Post pericardiectomia*
Infarto de miocardio
Quilopericardio
Post irradiación
Diagnostic criteria for acute pericarditis and myopericarditis in the
clinical setting
Acute pericarditis (at least 2 criteria of 4 should be present)*:
1. Typical chest pain (síntoma)
2. Pericardial friction rub (signología)
3. Suggestive ECG changes (typically widespread ST segment elevation) (ECG)
4. New or worsening pericardial effusion (ECHO)
Myopericarditis:
1. Definite diagnosis of acute pericarditis, PLUS
2. Suggestive symptoms (dyspnea, palpitations, or chest pain) and ECG abnormalities beyond
normal variants, not documented previously (ST/T abnormalities, supraventricular or ventricular
tachycardia or frequent ectopy, atrioventricular block), OR focal or diffuse depressed LV function
of uncertain age by an imaging study
3. Absence of evidence of any other cause
4. One of the following features: evidence of elevated cardiac enzymes (creatine kinase-MB
fraction, or troponin I or T), OR new onset of focal or diffuse depressed LV function by an
imaging study, OR abnormal imaging consistent with myocarditis (MRI with gadolinium, gallium67 scanning, anti-myosin antibody scanning)
Case definitions for myopericarditis include:
Suspected myopericarditis: criteria 1 plus 2 and 3
Probable myopericarditis: criteria 1,2,3, and 4
Confirmed myopericarditis: hystopathologic evidence of myocarditis by endomyocardial biopsy
or on autopsy.
PERICARDITIS AGUDA. ETIOLOGÍA
Imazio M. 1996-2004
Idiopático: 377 ( 83.2%)
Etiología específica: 76 (16.8%)
Neoplásica: 23 (5.1%)
Tuberculosa: 17 (3.8%)
Autoinmune: 33 (7.3%)
Purulenta: 3 (0.7%)
453 pacientes
PRESENTACIÓN CLINICA DE LAS ENF.
DEL PERICARDIO
• Pericarditis aguda fibrinosa
• Derrame pericárdico sin compromiso hemodinámico
• Taponamiento cardíaco
• Pericarditis constrictiva
PERICARDITIS AGUDA
PACIENTES DE ALTO RIESGO
QUE NECESITAN INTERNACIÓN
•Síntomas subagudos (días o semanas)
•Fiebre alta (38°C) + leucocitosis
•Evidencias que sugieran taponamiento
•Derrame pericárdico importante ( >20 mm )
•Inmunodeprimidos
•Pacientes anticoagulados
•Traumatismo de torax
•Falta de respuesta a AINES durante 7 días
•Troponina elevada que sugiera miopericarditis
TAPONAMIENTO PERICÁRDICO
Elevación de la presión yugular
Hipotensión arterial
Disminución de la presión de pulso
Pulso paradojal
Congestión pulmonar moderada
Precordio tranquilo
Cambios en el ecg
Eco (+)
Rapidez de producción
producci n
Presión
Presi n intrapericárdica
intraperic rdica
Taponamiento
Etiología: idiopático
post quirúrgico
urémico
tuberculoso
purulento
neoplásico
Pronóstico
TAPONAMIENTO EXPERIMENTAL
FISIOPATOLOGÍA
PERICARDIOCENTESIS Y TAPONAMIENTO
TAPONAMIENTO CARDÍACO
P/V en el derrame pericárdico
aspiración
aspiraci n
A: derrame hiperagudo
B: derrame subagudo
C: derrame subagudo
D: derrame crónico
Volume curves recorded from data acquired during pericardiocentesis. Curve A (in
red) plots data from a patient with hyperacute tamponade that followed laceration of
a coronary artery during an angioplasty-stenting procedure. Note the extreme
elevation of pericardial pressure and that withdrawal of only 100 ml, half the volume
we could aspirate, lowered the pressure to 10 mmHg. Curve B (in blue) plots data
from a patient who had a history of prior pericarditis, assumed to be of viral
etiology. Subsequently he developed a chronic pericardial effusion that reached at
least 1500 ml in volume. At the time of presentation to our service, the jugular
venous pressure was 22 mmHg. Aspiration of 300 ml of pericardial fluid reduced the
pericardial pressure to 10 mmHg, and removing another 600 ml achieved a nearly
normal pericardial pressure. Aspiration of the remaining large effusion did not
affect pericardial pressure. The curves of cases of intermediate acuity or chronicity
would fall between these two extremes. Courtesy of Ralph Shabetai MD.
TAPONAMIENTO PERICÁRDICO
TAAo
Resp
TA
Flujo
ESP.
Hemodynamics in cardiac tamponade
The M-mode through the minor axis in a patient with an anterior and posterior pericardial effusion and tamponade is seen
in panel A; during inspiration, the right ventricle (RV) fills and the left ventricle (LV) becomes smaller; during expiration,
the opposite occurs. In the graph in panel B, RV (RVEDd) and LV end diastolic diameters (LVEDd) are plotted against one
another and demonstrate a negative correlation, a result of reciprocation of the chambers within the pericardium. Since
the pericardium is a rigid box, as respiration brings more blood into the RV, there is less room in the LV; blood pools in
the inflating lungs during inspiration. This blood plus the increased stroke volume sent to the lungs during RV inspiratory
expansion reaches the lLV during expiration. As the LV expands, the RV is compressed. During RV expansion underfilling
of the LV results in a drop in pulse pressure perceived as the paradoxical pulse.
ECG EN LA PERICARDITIS CON DERRAME
alternancia eléctrica
↑ST
↓PR
↓voltaje
↓T
alternancia eléctrica
bamboleo eléctrico
ECG en el derrame pericárdico importante
PERICARDITIS AGUDA
Electrocardiogram in acute pericarditis showing diffuse upsloping ST segment elevations seen best here in
leads II, III, aVF, and V3 to V6. There is also subtle PR segment deviation (positive in aVR, negative in most
other leads). ST segment elevation is due to a ventricular current of injury associated with epicardial
inflammation; similarly, the PR segment changes are due to an atrial current of injury which, in pericarditis,
typically displaces the PR segment upright in lead aVR and downward in most other leads. Courtesy of Ary
Goldberger, MD.
Causes of ST segment elevation
•Myocardial ischemia or infarction
•Noninfarction, transmural ischemia (Prinzmetal's angina pattern or acute
takotsubo cardiomyopathy)
•Acute myocardial infarction (MI)
•Post-MI (ventricular aneurysm pattern)
•Previous MI with recurrent ischemia in the same area
•Acute pericarditis
•Normal "early repolarization variants"
•Left ventricular hypertrophy or left bundle branch block (only V1-V2 or
V3)
•Other
•Myocarditis (may look like myocardial infarction or pericarditis)
•Brugada patterns (V1-V3 with right bundle branch block-appearing
morphology)
•Myocardial tumor
•Myocardial trauma
•Hyperkalemia (only leads V1 and V2)
•Hypothermia (J wave/Osborn wave)
CAUSAS DE BAJO VOLTAJE EN EL
Adrenal insufficiency
QRS
Anasarca
Artifactual or spurious, eg, unrecognized standardization of ECG
at one-half the usual gain (ie, 5 mm/mV)
Cardiac infiltration or replacement (eg, amyloidosis, tumor)
Cardiac transplantation, especially with acute or chronic
rejection
Cardiomyopathy, idiopathic or secondary*
Chronic obstructive pulmonary disease
Constrictive pericarditis
Hypothyroidism, usually with sinus bradycardia
Left pneumothorax (mid-left chest leads)
Myocardial infarction, extensive
Myocarditis, acute or chronic
Normal variant
Obesity
Pericardial effusion
Pericardial tamponade, usually with sinus tachycardia
Pleural effusions
CRITERIOS ECOCARDIOGRÁFICOS DEL
TAPONAMIENTO CARDÍACO
•Colapso de la AD al final de la diástole
•Cambios recíprocos del VI y VD en relación con la
respiración (VD>VI en inspiración)
•Aumento de la variacion respiratoria en la velocidad de
flujo en las valvulas Mi y Tricusp.
•Aumento VCI y disminución en < 50% en la inspiración
TAPONAMIENTO PERICÁRDICO
Inferior vena cava during respiration in a normal subject
The subcostal view in a normal subject shows the inferior
vena cava (IVC). Left panel: Prior to inspiration, the normal
diastolic IVC diameter (arrows) is less than 20 mm. Right
panel: During inspiration, the IVC collapses to less than 50
percent of its original diameter.
L: liver.
Inferior vena cava during respiration in tamponade
Panel A: The subcostal view of the inferior vena cava (IVC) in a
patient with tamponade. The IVC is plethoric measuring over 20
mm in diameter. Panel B: During inspiration, the IVC diameter
fails to decrease. There is a large pericardial effusion (PE)
surrounding the right atrium (RA).
TRAUMA TORÁXICO
HIPOTIROIDISMO Y DERRAME PERICARDICO
PERICARDITIS CONSTRICTIVA
ABSCESO AMEBIANO EN HIGADO
CARDIOMEGALIA VS. DERRAME PERICÁRDICO
Cardiomegalia por radiología
Ecocardiografia transtoráxica
> 1 cm liquido
Anterior
Posterior
0.5-1.0 cm líquido
sin compromiso hemodinámico
< 0.5 cm líquido o
no líquido
Taponamiento?
Observación clínica
Repetir eco en 1-2 semanas
Consulta urgente con
cardiólogo
Sospecha de pericarditis
Infecciosa o maligna
Considerar pericardiocentesis
diagnóstica o terapéutica
Observación clínica
Repetir eco en 1-7 dias
pericardiocentesis
TRATAMIENTO DE LA PERICARDITIS
AGUDA
? Derrame vs taponamiento
AINES: indometacina 50 mg tid
AAS 325- 650 mg tid
Prednisona 20-60 mg / dia
Evitar anticoagulantes
Pericarditis recurrente: colchisina 1 mg/dia
pericardiectomía
Reacumulación de líquido
Derrame lobulado
Necesidad de biopsia
Paciente anticoagulado
Derrame pequeño