02.14a Surgical Diseases of the Pericardium

Question 1

Normal pericardial fluid

Answer 1

< 15 mL

Question 2

Acute inflammation of the parietal and visceral pericardium

Mostly idiopathic

Answer 2

Acute pericarditis

Question 3

Most common bacterial cause of pericarditis in the Philippines

Answer 3

TB

Question 4

Most common cause of idiopathic pericarditis

Answer 4

Viral infection

Question 5

Pericardial effusion two weeks after surgery

Answer 5

Postpericardiotomy syndrome

Question 6

Substernal chest pain during inspiration, worsened by supine position and relieved by leaning forward
Orthopnea, dyspnea
Pericardial friction rub
Beck’s triad (hypotension, distended neck veins, muffled heart sounds)
Four stages of ECG

Answer 6

Acute pericarditis

Question 7

ST segment elevation with concave upward ST segments
Noted in all leads except aVR
With reciprocal depressions in a aVR and sometimes in V1

Answer 7

First stage

Question 8

ST segments return to baseline with T-wave flattening

Answer 8

Second stage

Question 9

T-wave inversion without Q wave formation

Answer 9

Third stage

Question 10

Characterized by ECG normalization

Answer 10

Fourth stage

Question 11

Imaging to detect effusion

Answer 11

CXR

Question 12

Imaging to detect and determine the degree of effusion, thickness of pericardium

Answer 12

2D echo

Question 13

What do we look for on imaging?

Answer 13

Right ventricular collapse
Left ventricular collapse
Dilated inferior vena cava

Question 14

Work up to establish the etiology of pericarditis

Answer 14

Fluid examination

Pericardial biopsy

Question 15

Treatment for bacterial or purulent pericarditis

Answer 15

Antibiotics

Question 16

Treatment for postpericadiotomy syndrome, viral, post-MI, idiopathic pericarditis

Answer 16

Short course NSAIDS (5-7 days)

Question 17

Indication of surgery in patients with acute pericarditis

Answer 17

Tamponade (emergency), suppurative pericarditis
Need to perform biopsy
Not responding to treatment

Question 18

Two methods to drain

Answer 18

Pericardiocentesis

Tube pericardiostomy

Question 19

Smaller bore tube is preferred instead of a needle
Local anesthesia is given
Percutaneous insertion
Permits repeated drainage
Cannot obtain pericardium for biopsy
Prone to myocardial injury

Answer 19

Pericardiocentesis

Question 20

Bigger bore tube, less prone to clog
Subxiphoid incision down to pericadium
Less prone to myocardial injury
More painful

Answer 20

Tube pericardiostomy

Question 21

Sequelae of untreated acute pericarditis or TB pericarditis
Thickened fibrotic pericardium impedes normal diastolic filling
Male>female

Answer 21

Constrictive pericarditis

Question 22

Most common cause(s) of constrictive pericarditis

Answer 22

Idiopathic

Post-cardiothoracic surgery

Question 23

Constriction prevents dilatation, hence there will be a decrease in strove volume and consequent decrease in CO
The clinical manifestation is easy fatigability

Answer 23

Chronic constrictive pericarditis

Question 24

Most common presenting symptoms and occurs in virtually all patients

Answer 24

Dyspnea

Question 25

Elevated JVP
Sinus tachycardia
Normal or low BP
Apical impulse often impalpable
Distant or muffled heart sounds
Pericardial knock

Answer 25

Constrictive pericarditis

Question 26

Sudden cessation of ventricular filling early in diastole

Answer 26

Pericardial knock

Question 27

Work up for constrictive pericarditis

Answer 27

Blood test
Brain natriuretic peptide
CXR
EC(not reliable)
MRI
ECG (not reliable)
Cardiac catheterization

Question 28

Imaging of choice for pericardium

Answer 28

High resolution CT scan

Fast MRI

Question 29

Pathognomonic for constrictive pericarditis in cardiac catheterization

Answer 29

Square root sign

Question 30

Treatment of constrictive pericarditis

Answer 30

Pericardiectomy

Question 31

Preferred approach of pericardiectomy

Answer 31

Median sternotomy

Question 32

Priority in pericardiectomy

Answer 32

To free the ventricles

Question 33

Treatment with TB pericarditis

Answer 33

Prophylactic pericardiectomy