34. Pericardial Disease

The clinical diagnosis of acute pericarditis is based on chest pain, a pericardial friction rub and ECG changes (ST-segment elevation acutely, low voltage by effusion). Effusions can be detected best by echocardiography. Echocardiography or magnetic resonance imaging (MRI) is essential to detect concomitant myocarditis, valvular abscesses in endocarditis or aortic dissection. Idiopathic pericarditis describes our inability to define the exact aetiology, which is often viral or autoreactive. For their diagnosis, pericardiocentesis, pericardioscopy, pericardial or epicardial biopsy are essential. Polymerase chain reaction (PCR) can assess the causative microbial agent in fluid or peri- and epicardial biopsy. Autoreactive or malignant processes are detected by cytology, histopathology and immunological methods. Whereas bacterial pericarditis has become rare in Western countries, it is still a major problem in other parts of the world, e.g. for tuberculous pericarditis. Pericardiocentesis is indicated for cardiac tamponade, which occurs most frequently in neoplastic pericarditis, and in suspected purulent effusions or in larger effusion of unknown aetiology. If carried out with fluoroscopy, the halo phenomenon can guide pericardiocentesis. Aortic dissection is a contraindication for pericardiocentesis but an indication for surgery as in cardiac trauma or postinfarction myocardial rupture. Loculated effusions may require surgery or pericardiocenteses guided by echocardiography or thoracoscopy. In neoplastic effusion, intrapericardial instillation of cisplatin or thiotepa can prevent recurrences, but not the final outcome. In autoreactive effusions, intrapericardial instillation of triamcinolone is recommended to avoid the side effects of systemic corticosteroid therapy. Nonsteroidal antiphlogistics are the mainstay of acute symptomatic treatment, whereas colchicine is given in recurrent and protracted forms of acute pericarditis for longer time periods or when the effusion is too small for puncture. In constrictive pericarditis, the expansion of the ventricles is impaired due to the stiff or chronically inflamed, mostly thickened pericardium. Then pericardiectomy is to be carried out. It should not be performed too early to avoid operating for transient constriction, but also not too late to avoid myocardial fibrosis and/or atrophy.