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Lecture notes, cheat sheets
Hospital pediatrics. Pericardial diseases in children. Clinic, diagnosis, treatment (lecture notes)
Directory / Lecture notes, cheat sheets Table of contents (expand) LECTURE No. 4. Pericardial diseases in children. Clinic, diagnosis, treatment Clinical and morphological classification of pericardial lesions (A. A. Terke, Z. M. Volynsky, E. E. Gogin). 1. Malformations of the pericardium (anomalies): 1) the defects are complete; 2) partial defects; 3) pericardial lacing defects (diverticula and cysts). 2. Pericarditis: 1) acute (dry fibrinous, exudative); 2) chronic (duration - 3 months); 3) adhesive (asymptomatic, compressive, with impaired cardiovascular function, but without symptoms of cardiac compression); 4) exudative (with moderate dysfunction of the cardiovascular system, but without cicatricial compression of the heart); 5) exudative-squeezing. 3. Tumors of the pericardium (malformations of the pericardium): 1) pericardial defects (complete and partial); 2) pericardial lacing defects. The embryogenesis of these anomalies is associated with disturbances in the formation of the pericardium in the early stages of development (the first 6 weeks). 1. Congenital defects of the pericardium Congenital defects of the pericardium include the following. 1. Partial left-sided absence of pericardium 70%. Complicated by the formation of a hernia, strangulation of the heart at the site of the defect. Chest pain, shortness of breath, fainting, or sudden death occur. Surgical treatment - pericardioplasty. 2. The complete absence of the pericardium is manifested by the symptom of a “loose heart”: pain in the heart area, shortness of breath, palpitations, sometimes fainting; upon percussion there is unusual mobility of the heart; on the left side it moves to the axillary line, and when the head is lowered it moves upward. 3. Partial right-sided absence of the pericardium 17%. 4. Congenital lacing of the pericardium. 5. Pericardial cysts (tender, thin-walled formations, not fused with surrounding tissues and filled with clear liquid - “spring water”, but it can be bloody (in case of injury) and purulent (in case of inflammation). 6. Pericardial diverticula - communications with the pericardial cavity, can be wide - resembling the shape of a finger of a rubber glove, or narrow, resembling a cyst communicating with the pericardium. Pericardial cysts and diverticula in childhood are asymptomatic. Pain and shortness of breath may sometimes occur. For partial pericardial defects there are no direct clinical and radiological signs; they are detected with concomitant diseases. Pericardial cysts. Pericardial cysts are divided into pseudocysts and encysted and multichamber pericardial effusions (the appearance of which is caused by rheumatic pericarditis, bacterial infection (especially tuberculosis), trauma and surgery); echinococcal cysts (occur after the rupture of such cysts in the liver and lungs). Clinic: in most cases, cysts do not manifest themselves clinically and are detected by chance during radiography in the form of homogeneous oval-shaped radiopaque formations, usually in the right cardiophrenic angle. Complaints of chest discomfort, shortness of breath, cough or palpitations due to compression of the heart. Percutaneous aspiration and ethanol sclerosis are used to treat congenital and inflammatory cysts. Surgical excision of hydatid cysts is not recommended. 2. Pericarditis Pericarditis is an inflammation of the visceral and parietal layer, it can be fibrinous, purulent, hemorrhagic, serous. Etiology. Viral diseases, severe septic, often staphylococcal, processes, rheumatism, diffuse connective tissue diseases. Pathogenesis. The pathogenesis is of an allergic or autoimmune nature; in infectious pericarditis, infection is the trigger; direct damage to the lining of the heart by bacterial or other agents cannot be ruled out. Clinical manifestations. Acute serous-fibrinous pericarditis is manifested by the main symptoms - acute pain in the heart area, radiating to the shoulder and epigastric region and passing in an upright position and when bending forward. It is associated with damage to the pleural and diaphragmatic pericardium. Sometimes abdominal pain simulating an acute abdomen. Pericardial friction noise - detected during systole and diastole, heard during systole and diastole, aggravated in an upright position. Often not constant. Other symptoms: high temperature, tachycardia, tachypnea. Acute exudative pericarditis develops when the inflammatory process of the cardiac membrane is accompanied by total damage. Clinic: the apex beat of the heart is displaced upward and inward from the lower left border of dullness. The boundaries of the heart change depending on the position of the patient’s body: vertically, the zone of dullness in the 2nd and 3rd intercostal spaces is reduced by 2-4 cm on each side, and dullness in the region of the lower intercostal spaces expands by the same distance. Heart sounds in the lower left sections are weakened. X-ray picture: early signs and accumulation of exudate, changes in the cardiac shadow, chronic triangular pericardial effusions. A spherical shadow indicates an active process with a rapid increase in the volume of effusion. With echocardiography, the layer of fluid anterior and posterior to the contour of the heart is reliably visualized as an anechoic space. Fibrous deposits in the form of heterogeneous shadows and compaction of the pericardial layers are also often observed, and with large effusions, heart vibrations inside the stretched pericardial sac are characteristic. Chronic exudative pericarditis. The clinical picture depends on the rate of exudate accumulation. Usually the general condition sharply worsens, shortness of breath appears, dull pain in the heart area, the patient takes a forced position, the apical impulse is weakened, heart sounds are sharply muffled ECG: decreased waves, negative T waves, ST interval shift. X-ray examination: expansion of the shadow of the heart, which takes on a triangular or trapezoidal shape. Chronic adhesive (adhesive, constrictive) pericarditis. The pericardium thickens and both of its layers, visceral and parietal, grow together both with each other and with the underlying myocardium. The onset is gradual, edematous syndrome develops, enteropathy with protein loss appears, leading to hypoalbuminemia with subsequent intensification of edematous syndrome, development of hepatomegaly, ascites and severe edema of the extremities. The pulse is small, blood pressure with a small amplitude. Heart sounds are weakened, galloping rhythm. Diagnostics. Diagnosis of acute pericarditis: during auscultation, pericardial friction noise (one-, two- and three-phase). ECG Stage I: Concave ST segment elevation in the anterior and posterior leads, PR segment deviations opposite to the polarity of the P wave. Early stage II: ST junction returns to baseline, PR interval deviation persists. Late stage II: T waves gradually flatten and begin to invert. Stage III: Generalized T-wave inversion. Stage IV: restoration of the original ECG characteristics observed before the development of pericarditis. Echo-CG: effusion types BD. Signs of cardiac tamponade Blood tests: 1) determination of ESR, level of C-reactive protein and lactate dehydrogenase, number of leukocytes (markers of inflammation); 2) determination of the level of troponin I and the MB fraction of creatine phosphokinase (markers of myocardial damage). Chest X-ray - The image of the heart may vary from normal to a "water bottle" silhouette. During this study, it is possible to identify concomitant diseases of the lungs and mediastinal organs. Diagnostic interventions that are mandatory for cardiac tamponade are a class I indication; at the discretion of the doctor, for large or recurrent effusions or if the previous examination is insufficiently informative - Pa class indication; and also for small effusions - a class IIb indication. Pericardiocentesis with drainage of the pericardial cavity: the results of polymerase chain reaction and histochemical analysis allow us to determine the etiopathogenesis of pericarditis (infectious or tumor). Diagnostic interventions that are used at the discretion of the doctor or when the previous examination is insufficiently informative are indications of class Pa. Computed tomography: effusions, condition of the peri- and epicardium. Magnetic resonance imaging: effusions, condition of the peri- and epicardium. During pericardioscopy, a biopsy of the pericardium is performed to determine the etiology of pericarditis. Diagnosis of constrictive pericarditis. The clinical picture is manifested by signs of severe chronic systemic venous congestion caused by low cardiac output: swelling of the jugular veins, arterial hypotension with low pulse pressure, increased abdominal volume, peripheral edema and muscle weakness. ECG - the results are either normal, or there is a decrease in the amplitude of the QRS complex, generalized inversion (or flattening) of the T wave, changes in the electrical activity of the left atrium, atrial fibrillation, atrioventricular block, intraventricular conduction disorders, and in rare cases, pseudo-infarction changes. An X-ray examination of the chest reveals pericardial calcification and pleural effusion. Echo-CG reveals thickening of the pericardium and its calcification, as well as indirect signs of constriction: an increase in the PP and LA with a normal ventricular configuration and preserved systolic function; early paradoxical movement of the IVS (sign of “diastolic retraction and plateau”); flattening of the waves of the posterior wall of the LV; no increase in LV size after the early rapid filling phase; the inferior vena cava and hepatic veins are dilated and their sizes change little depending on the phases of the respiratory cycle. Limitation of LV and RV filling; when assessing blood flow through the atrioventricular valves, differences in filling levels during inspiration and expiration exceed 25%. Doppler - Echo-CG is determined by measuring the thickness of the pericardium. When using esophageal echo-CG, thickening and/or calcification of the pericardium, a cylindrical configuration of one or both ventricles, narrowing of one or both atrioventricular grooves, signs of congestion in the vena cava, and an increase in one or both atria are determined. Computed tomography and/or magnetic resonance imaging determines the sign of “diastolic retraction and plateau” on the pressure curve in the RV and/or LV. Equalization of end-diastolic pressure in the LV and RV in the range < 5 mm Hg. Art. Angiography of the RV and/or LV reveals a decrease in the size of the RV and LV, and an increase in the size of the RA and LA. During diastole, after the early rapid filling phase, there is no further increase in ventricular size (a sign of “diastolic retraction and plateau”). Angiography of the coronary arteries is indicated for all patients over 35 years of age, as well as at any age if there is a history of indications for irradiation of the mediastinal area. Treatment. Therapeutic actions: general measures, suppression of the inflammatory reaction, etiotropic treatment, unloading therapy, symptomatic therapy. Implementation of the tasks of complex therapy: 1) bed rest; 2) good nutrition; 3) NSAIDs; 4) glucocorticosteroids; 5) broad-spectrum antibiotics; 6) pericardiocentesis; 7) diuretics; 8) relief of pain syndrome; 9) correction of hemorrhagic syndrome; 10) if conservative therapy is ineffective - pericardiectomy. 3. Tumors of the pericardium Primary pericardial tumors are less common than cardiac tumors. Clinical manifestations. Clinically, they manifest themselves as symptoms of hemorrhagic or serous fibrous pericarditis, sometimes with suppuration. The diagnosis of a pericardial tumor is established by cytological examination of punctate contents of the pericardial cavity, injection of carbon dioxide into the pericardial cavity, histological examination of a pericardial biopsy or angiocardiography. Treatment. Treatment of malignant heart tumors is most often symptomatic. The most common treatments are radiotherapy and chemotherapy. Author: Pavlova N.V. << Back: Cardiomyopathy in children. Clinic, diagnosis, treatment (Dilated cardiomyopathy. Hypertrophic cardiomyopathy. Restrictive cardiomyopathy) >> Forward: Chronic heart failure in children. Clinic, diagnosis, treatment (Clinical manifestations. Clinical manifestations of chronic heart failure)
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