Exudation in the pericardial cavity: norm, technique of determination

If the volume of fluid in the pericardial space tends to a pathological increase, then they say about the appearance of effusion in the pericardium. During the study, a darkened echo-negative cavity is detected, mainly through subcostal access. The effusion in the pericardium can be caused by different factors, and the treatment is primarily directed to the elimination of the underlying causes of the pathology.

[1], [2], [3], [4]

Epidemiology

The effusion in the pericardium is found in 6-7% of adult patients. This is quite an average indicator, which depends on the age category of patients:

• less than 1% of cases with effusion diagnose in people 20-30 years old;
• about 15% of cases with effusion are detected in patients older than 80 years.

After cardiac surgery (valve system correction, coronary artery bypass grafting), effusion in the pericardium is observed in 77% of operated patients. In 76% of such cases, there is no need for additional treatment.

[5], [6], [7]

Causes of the effusion in the pericardium

With the improvement of diagnostic methods, effusion in the pericardium is detected much more often than before. In this case, the most common causes are inflammatory processes in the pericardium, tumor formations, iatrogenia.

In the absence of inflammation in the pericardium, the mechanism of development of effusion in many cases remains unclear.

A significant role in the appearance of effusion is played by certain risk factors:

• inflammatory processes in the tissues of the heart;
• cardiac surgery;
• acute myocardial infarction;
• insufficiency of cardiac activity;
• chronic renal failure;
• iatrogenic factor;
• metabolic diseases;
• autoimmune processes;
• trauma of the chest;
• chylopericard (accumulation of lymphatic fluid in the pericardial cavity);
• period of bearing of the child.

There is also the concept of "idiopathic" effusion - this type of pathology is spoken of when the cause of the disease can not be established.

[8], [9], [10], [11]

Pathogenesis

The effusion in the pericardium is the accumulation of a different volume of fluid in the environment of the heart.

Pericardium is a two-layered peculiar bag that surrounds the heart. Any healthy person in the pericardial cavity has a small amount of fluid, and this is considered the norm.

With various diseases or injuries affecting the pericardium, the fluid in the cavity becomes significantly larger. In this case, there is not necessarily an inflammatory process. Often an accumulation of bloody discharge after surgical intervention or traumatic injury becomes effusion.

If the volume of effusion becomes too large, exceeding the maximum permissible pericardial level, additional pressure on the structure of the heart can be created in the cavity. This in all cases directly affects its functionality.

If you do not provide medical assistance in a timely manner, the effusion in the pericardium can lead to a number of negative consequences, up to a lethal outcome.

[12], [13], [14], [15]

Symptoms of the effusion in the pericardium

The effusion in the pericardium in most cases is painless: the pain is characteristic for the effusion provoked by the acute form of pericarditis. When listening to draw attention to themselves muffled heart sounds, sometimes - the noise of pericardial friction. If the effusion is voluminous, it is possible to squeeze the basal segment of the left lung, which is characterized by poor breathing, microbubble wheezing, crepitus. Pulse and blood pressure indicators usually do not go beyond the norm if the condition is not close to the tamponade.

If the effusion in the pericardium is associated with a heart attack, the patient may experience a febrile condition, the noise of pericardial friction is clearly heard. Fluid also accumulates in the pleura and abdominal cavity. Similar problems are usually found, starting from 10 days and up to 2 months after the infarction.

The first signs are not always noticeable and depend on how quickly the effusion in the pericardium accumulates, how much the heart is squeezed, etc. Most often, patients complain of a feeling of heaviness and pain behind the sternum. If there is a squeezing of nearby organs, then there are difficulties with breathing and swallowing, there is coughing, hoarseness. In many patients, the face and neck swell, the venous vessels of the neck swell (during inspiration), signs of insufficient cardiac activity increase.

General symptoms may be associated with the development of exudative inflammatory process:

• infection accompanied by chills, signs of intoxication, fever;
• tuberculosis is characterized by increased sweating, loss of appetite, emaciation, increased liver size.

If the effusion in the pericardium is associated with tumor processes, then pain in the chest, atrial rhythm disturbances, and an increasing tamponade are typical for him.

With a large amount of effusion, patients often prefer to sit down, as the most optimal for their well-being.

[16]

Stages

1. Acute pericarditis with effusion in the pericardium lasts no more than 1.5 months.
2. Subacute pericarditis with effusion in the pericardium lasts from 1.5 to six months.
3. Chronic pericarditis with effusion in the pericardium lasts at least six months and more.

[17], [18], [19], [20]

Forms

The effusion in the pericardium can be different - in the first place, the composition of the liquid in the sweat is different. So, it is serous, fibrous-serous, purulent, bloody (hemorrhagic), putrefactive, cholesterol. Serous effusion is typical for the initial inflammatory stage: in the composition of such a fluid there is protein and water. In fibro-serous exudate, fibrin strands are additionally present. Bloody effusion occurs with vascular damage: it has a lot of red blood cells. In purulent exudate there are leukocytes and particles of dead tissue, and in putrefactive - anaerobic flora.

Clinical features also affect the development of a particular type of effusion in the pericardium: thus, pathology may or may not be accompanied by cardiac tamponade.

[21], [22], [23], [24], [25], [26]

Complications and consequences

The pericardial cavity is capable of retaining only a certain volume of fluid in itself. If the effusion in the pericardium exceeds the permissible limits, then violations of a different nature occur.

The inner covering of the pericardium is formed by a thin cell layer adjacent to the heart. The outer layer is thicker and more elastic, so when the excess of effusion is accumulated, the pericardial tissue is squeezed inward, exerting pressure on the heart.

The stronger the pressure exerted by the fluid, the more difficult it is for the heart to work. Chamber structures are not filled enough, or even partially damaged. Such processes lead to the so-called tamponade of the heart: the function of the organ is disrupted, systemic hemodynamics is upset. With the rapid exacerbation of pathology, the heart rhythm is disrupted, a heart attack, cardiogenic shock and even death can develop.

Late consequences include the development of fibrinous pericarditis and loss of impulse conductivity between the ventricles and atria.

[27], [28], [29], [30]

Diagnostics of the effusion in the pericardium

Preliminary diagnosis of effusion in the pericardium can be based on a characteristic clinical picture. But most often doctors think about the possible appearance of effusion only when examining the results of an X-ray, where the cardiac outline is clearly seen.

The ECG demonstrates a decrease in the voltage of the QRS complex, with a preserved sinus rhythm in the absolute majority of patients. If it is a question of a pronounced amount of effusion, then it is displayed on the ECG as an electrical alternative (increasing and decreasing the amplitude of the P, T, or QRS complex, depending on the moment of cardiac contraction).

Echocardiography is a particularly sensitive method, which is often used in cases of suspected effusion in the pericardium. The diagnosis is confirmed when visualizing a stable echo-negative space in the anterior or far segment of the pericardium bursa. As a rule, circulation is typical for effusion, but the liquid can be located regionally. In the latter case, echocardiography-2D is successfully used for diagnosis. If there is no chamber collapse, then one can exclude cardiac tamponade.

Additional instrumental diagnostics can be represented by methods such as computer and magnetic resonance imaging. These procedures allow you to accurately assess the spatial localization and volume of effusion in the pericardium. However, their use is justified only if it is not possible to carry out echocardiography, or with local sweating.

Analyzes in the laboratory are conducted to assess the general condition of the body:

• blood coagulation, cholesterol levels are assessed;
• the presence of an inflammatory process in the body is determined;
• the functional capacity of the kidneys and liver is traced.

[31]

Differential diagnosis

Echocardiographic data for pericardial efflorescence should be differentiated with left-sided pleurisy and increased proliferation of epicardial fatty tissues.

With accumulation of effusion, the atria suffer, which causes cardiac and aortic separation: these changes are not characteristic of pleural effusion. Nevertheless, in many cases there are difficulties with differentiation of the listed pathologies. In addition, often pleural and pericardial effusion are present together. Right-sided pleural effusion can be considered in subcostal access: pathologists have the form of an echo-negative space located close to the liver.

The fat layer of the epicardium on the echocardiogram is distinguished by a granular or small-crusted structure. It is localized around the free edge of the right ventricle. A similar condition is more often present in elderly patients, or in people who have problems with obesity or diabetes.

Treatment of the effusion in the pericardium

Treatment measures include the effect on the underlying disease - if it is defined. Then they act directly on the presence of effusion in the pericardium.

With a slight exhalation - if the patient does not make any complaints, the treatment may not apply. It is recommended to undergo repeated echocardiography after three months and six months to assess the dynamics.

Dynamic clinical control is necessary for both moderate and severe exsanguination, along with conservative treatment.

Use the treatment with nonsteroidal anti-inflammatory drugs. More often among such drugs, preference is given to Diclofenac-sodium, as well as Nimesulidu and Movalis. Reception of Acetylsalicylic acid allows you to eliminate pain, and Colchicine can prevent the repeated appearance of effusion.

With severe pain and fever, in some cases it is appropriate to use glucocorticoids - for example, Prednisolone, a short course with absolute cancellation after 7-14 days. Glucocorticoids are used mainly for autoimmune or post-operative reasons for effusion.

To prevent the development of bleeding, the use of anticoagulants is often avoided. They are not prescribed if the patient develops an acute inflammatory process in the pericardium.

Pericardial effusion: drugs

• Diclofenac-sodium - administered by 75 mg in the form of intramuscular injection, every day for 10-12 days. You can use a tablet preparation - 100 mg / day, for 1-1.5 months.
• Nimesulide - take inside 100 mg per day. The duration of treatment is determined by the doctor.
• Movalis - take 7.5 mg daily for two weeks or one month.
• Celebrex - take 200 mg in the morning and in the evening, for two weeks (you can continue taking up to one month).
• Prednisolone - take 40-60 mg daily, minimally short course.

During treatment, it is necessary to take into account the high probability of developing side effects from medications. So, non-steroidal anti-inflammatory drugs can provoke drowsiness, headaches, dizziness. Often there are malfunctions in the digestive system: nausea, abdominal pain, heartburn, mucosal erosion. The picture of blood can change: anemia, thrombocytopenia, leukopenia, agenulocytosis are found.

The use of prednisolone is accompanied by side effects mainly with prolonged treatment. Therefore, it is not recommended to conduct a long therapeutic course, as well as to abruptly cancel the drug.

Vitamins

The list of useful substances that are very important for heart health is wide enough. Nevertheless, if there is such a problem as effusion in the pericardium, then you must try to include in the diet, at least most of the vitamins listed below:

• Ascorbic acid - improves the course of basal metabolism, strengthens the heart muscle and blood vessels, prevents hypercholesterolemia.
• Vitamin A - prevents the development of atherosclerosis, strengthens blood vessels.
• Vitamin E - inhibits the oxidation of fats, protects the heart tissue from damage.
• Vitamin P - helps strengthen the arterial walls, prevents bleeding.
• Vitamin F (fatty acids: linolenic, linoleic and arachidonic) - strengthens the heart tissues, normalizes the level of cholesterol in the blood, prevents increased thrombus formation.
• Q10 coenzyme is a vitamin-like component synthesized in the liver, which is able to prevent damage to the heart tissues, prevents early aging of the body, and has a beneficial effect on the heart rhythm.
• Vitamin B ₁  - is necessary for the qualitative transmission of nerve impulses and improvement of myocardial contractility.
• Vitamin B ₆  - favors the removal of excess cholesterol from the body.

Physiotherapeutic treatment

Physiotherapy and exercise therapy can be used only at the stage of rehabilitation of the patient, after stabilization of all vital indicators. It is recommended massage, easy gymnastics for all muscle groups. Gradually add employment with the ball, sticks, on the simulators. As recovery is restored, slow-moving strength exercises and games are allowed. Recommended dosed walking, morning warm-up.

Of physiotherapy, the following are often recommended:

• Electrosleep with a frequency of 5-10 Hz, for 20-30 minutes, once every two days. The course of therapy - up to 12 procedures.
• Oxygenotherapy - 50-60% with the duration of the session 20-30 minutes, 2-3 times a day.
• Carbonic acid, sulphide, radon and iodide-bromine baths every other day. The course involves 10-12 procedures.

A good recovery effect is expected from aerotherapy, air baths.

Alternative treatment

To maintain heart health is very important to eat properly and do not overeat. In the diet should be present seafood, nuts, citrus, pumpkin, greens, berries, dried fruits. In addition, it is recommended to take flaxseed oil, fish oil, honey, pergue.

• A fresh alternative to effusion in the pericardium is a freshly squeezed juice from the mother-and-stepmother (leaves). The juice is drunk up to six times a day, 1-2 tablespoons. L. According to specialists, it is enough to have one two-week course of treatment a year in order to improve the heart.
• Prepare a mixture of an equal amount of honey and walnuts. To quickly cure the effusion in the pericardium, you should eat 60 g of this mixture daily.
• Mix 100 ml of juice from the leaves of aloe and 200 ml of natural honey, add 200 ml of quality Cahors. The mixture is taken for 1 tsp. Before each meal.

If the effusion in the pericardium is associated with inflammatory processes in the heart tissues, then the cornflower tincture can become a good therapeutic agent. Take one tablespoon of dried cornflowers (flowers), pour 100 ml of alcohol (or high-quality vodka), insist in a closed container for two weeks. Next tincture is filtered and taken on 20 drops three times a day, half an hour before meals. Duration of treatment varies, depending on the patient's condition.

[32], [33], [34]

Herbal Treatment

Recipes of alternative medicine often mean and treatment with herbs. There are many ways to get rid of effusion in the pericardium with the help of medicinal plants. We list the most popular of them.

• Prepare a collection of leaves of motherwort, cotton grass, hawthorn and medicinal chamomile. All ingredients are mixed well, pour 1 tbsp. L. Mixture in 250 ml of boiling water. Insist under a lid overnight, filtered. Take 100 ml three times a day between meals.
• Mix the asterisks, crushed valerian root, yarrow and lemon balm. One tablespoon of the collection is poured 250 ml of boiling water, kept under cover for about half an hour, filtered. Drink the received amount of infusion during the day for 2-3 times.
• Take large birch "earrings", pour them into a jar (1 liter), filling it with 2/3, then fill up the jar with vodka. The capacity is closed and the medicine is insisted for two weeks. Filter the tincture should not be. Every day, you need to drink 20 drops of money 30 minutes before breakfast, lunch and dinner.

In addition, daily it is recommended to prepare herbal infusions and teas, which include such herbs: dandelion, aspen buds, spores, hop cones, melissa leaves, thyme, spring mountain, mint leaves.

Homeopathy

Treatment prescribed by a doctor can be successfully supplemented with homeopathic medicines. They are selected, depending on the cause of the appearance of effusion in the pericardium. Also take into account the main symptoms of pathology, the constitutional features of the patient, his age and the presence of concomitant diseases. Most often with the sweat in the pericardium, experts advise to use such drugs:

• Aconite - helps to eliminate the pain behind the sternum, normalize the heart rate and blood pressure. Aconite is particularly recommended for the rapid development of cardiac pathology.
• Arnica - often used to restore the heart after a heart attack, as it leads to tonus myocardium, normalizes heart contractions, promotes healing of damage in the tissues of the heart.
• Cactus - it is prescribed if the effusion in the pericardium is accompanied by a decrease in pressure, a small pulse fullness, a sense of compression in the chest.
• Arsenicum albumum - is used with a weak constitution with increased fatigue, with chronic effusion in the pericardium, with burning pain in the chest.
• Carbo vegetabilis is prescribed for chronic tissue hypoxia, with violation of pericardial blood flow, with chronic cardiopulmonary insufficiency.
• Glonoin helps if effusion in the pericardium is associated with angina, acute coronary insufficiency, hypertension.
• Kretegus - used to eliminate effusion in the elderly, as well as with cardiac edema, myocardial hypertrophy, with stable angina.

Surgery

When accumulating a large volume of effusion, it must be pumped out. For this, a surgical pericardial puncture is performed, with the insertion of a hollow needle into the pericardial space. This procedure is often performed to facilitate the work of the heart and remove excess fluid, and is considered a relatively safe method of treatment.

Puncture is performed only by a doctor. At a certain point just below the border of the heart, a special needle with a large lumen is inserted. If the effusion is a lot, then it is not output immediately, approximately 150-200 ml. When pus is found in the sweat inside the pericardial cavity, solutions of antibiotics can be introduced.

In severe cases, there may be a need for thoracotomy - an operation to dissect the thorax with a pericardial resection. Such intervention is not often performed, and the mortality rate for resection is up to 10%.

Prevention

Basic prophylaxis of effusion in the pericardium is aimed at preventing pathologies that contribute to its appearance. Particular attention should be paid to general strengthening of the body and improving the quality of immune protection.

Doctors advise:

• often stroll in green areas, breathe clean air;
• practice moderate exercise, do morning exercises;
• maintain electrolyte balance, drink enough liquid;
• fully nutrition, supplying the body with all the necessary nutrients;
• avoid smoking (including passive), do not abuse alcohol.

Even completely healthy people, doctors recommend systematically monitoring the state of the cardiovascular system: once every 2 years, do an ECG or ultrasound of the heart.

[35], [36], [37]

Forecast

The prognosis of effusion in the pericardium depends on many factors. The main probable complication is the development of cardiac tamponade, as well as paroxysmal atrial fibrillation, or supraventricular tachycardia. Exudative pericarditis often acquires a chronic and constrictive course.

The highest percentage of mortality is found with cardiac tamponade, so it is not possible to predict the outcome of the disease clearly in such a situation. Experts point out that the quality of such a forecast largely depends on the cause of the pathology, on the timeliness of the medical care provided. If you do not allow the development of tamponade, then effusion in the pericardium can be eliminated without any negative consequences for the patient.

[38], [39]