Hydropericardium

The pericardium is the fibrous membrane surrounding the heart - the pericardium, in the cavity of which, under the influence of various pathological factors, excess fluid can accumulate, which is diagnosed as hydropericardium, pericardial effusion (effusion) or dropsy of the pericardial sac. This condition can be life-threatening and requires identification and adequate treatment.

Noninflammatory pericardial effusion is code I31.3 in ICD-10.

Epidemiology

According to foreign studies, among the causes of pericardial effusion, 15-30% are pericarditis and various infections; 12-23% - oncology; 5-15% - connective tissue pathologies; 15-20% are iatrogenic causes.

In developing countries, tuberculosis is the cause of hydropericardium in more than 60% of cases. In the presence of HIV, pericardial effusion occurs, on average, in a quarter of patients. Idiopathic hydropericardium accounts for up to half of cases.

In underweight newborns, the prevalence of fluid accumulation in the pericardial cavity during parenteral nutrition through a central venous catheter is estimated at 1-3% (with a mortality rate due to cardiac tamponade up to 30-40%). [1]

Causes hydropericardium

Any accumulation of fluid in the body cavities can be a sign of the disease. And the most common causes of hydropericardium include:

• inflammation of the pericardial sac - exudative, viral, and  tuberculous pericarditis ;
• congestive  heart failure ;
• acute myocardial infarction with the development  of Dressler's syndrome ; [2]
• viral myocarditis ;[3]
• parasitic damage to the pericardium, for example, with  trichinosis ;
• autoimmune diseases such as  rheumatic heart disease , rheumatoid arthritis,  systemic lupus erythematosus  (SLE);
• metastasis of lung cancer, breast cancer, melanoma, non-Hodgkin's lymphoma; [4]
• blunt and penetrating trauma to the heart.

Hydropericardium is observed in pneumonia, especially if it is caused by mycoplasma or Haemophilus influenzae - with complications in the form of pleurisy, pericarditis or myocarditis.

Hydropericardium occurs in hypothyroidism - its myxedema form and autoimmune thyroiditis.

Experts observe the connection of the hydropericardium with the accumulation of fluid in other cavities. In particular, effusion in one or both pleural cavities or hydrothorax and hydropericardium appear in cases of left-sided  exudative pleurisy  (especially tuberculous), pulmonary sarcoidosis, heart failure, myocarditis, SLE. Chest injuries.

In patients with  edematous syndromes  - cardiac or nephrotic, as well as with cirrhosis of the liver, edema of the subcutaneous tissue - anasarca, hydropericardium and ascites - can simultaneously develop  , that is, when fluid accumulates in the abdominal cavity in the form of peritoneal effusion.

Replacement of lung cells with connective tissue - pneumofibrosis and hydropericardium are most often associated with such an autoimmune disease as systemic scleroderma. Read more in the publication -  Features of heart damage in systemic scleroderma

In addition, the iatrogenic origin of fluid accumulation in the pericardium is possible  : after open heart surgery; after radiation therapy for mediastinal malignancies and general cancer chemotherapy; with prolonged use of certain vasodilators, anti-tuberculosis and antiepileptic drugs. [5], [6]

Idiopathic hydropericardium is often noted.

Hydropericardium in the fetus and newborns

The main factors causing hydropericardium in the fetus are intrauterine infections; chromosomal abnormalities; rhesus conflict during pregnancy ; prenatal anemia, heart failure, generalized fetal edema - dropsy with anasarca, hydrothorax and pericardial effusion; heart disease in the form of a protrusion of the wall (diverticulum) of the left ventricle.

Congenital hydropericardium in newborns is rare, and excess fluid in the pericardial sac may result from anemia, hypoalbuminemia, heart failure, as well as diaphragmatic hernia, partial displacement of the diaphragm into the chest cavity, or pericardial hypertrophy with lung compression (and severe pulmonary insufficiency).

When infants are significantly premature, pericardial effusion is idiopathic or due to problems with the functioning of the heart and lungs. In addition, very low birth weight infants who are in a maternity hospital receiving  parenteral nutrition  through a central venous catheter may develop complications in the form of fluid accumulation in the pericardium.

Risk factors

Experts refer to the number of risk factors for the development of hydropericardium:

• viral, bacterial, fungal infections and parasitic invasions;
• systemic inflammatory diseases and autoimmune diseases of the connective tissue;
• pathology of the aorta, in particular, its dissection (in children - with hereditary Marfan syndrome);
• problems with the thyroid gland and thyroid-stimulating hormone deficiency;
• renal failure with uremia;
• cirrhosis of the liver;
• metabolic disorders and anemia;
• oncological diseases and metastases of cancerous tumors;
• vascular catheterization, cardiac surgery, hemodialysis (which can cause complications).

Pathogenesis

The pericardial sac, which is attached to the diaphragm, sternum, and costal cartilage, contains the heart, the roots of the aorta and other large blood vessels. Between the two layers of the  pericardium  (parietal and visceral) there is a space or cavity with a small amount (about 20-30 ml) of fluid that contains protein, mesothelial cells, lymphocytes, granulocytes, macrophages and enzymes. The fluid is needed to protect the myocardium from infections and reduce friction on its outer surface during heart contractions.

The pathogenesis of hydropericardium is explained by an increase in the production of pericardial fluid (exudate) in response to an inflammatory process or tissue damage. Moreover, in the cytoplasm of heart cells, in erythrocytes and mononuclear phagocytes (tissue macrophages), the level and activity of a number of enzymes (cyclooxygenases, lactate dehydrogenase, etc.) increase.

Also, due to an increase in systemic venous, capillary hydrostatic and osmotic pressure, drainage and reabsorption of the fluid of the pericardium through the capillaries and lymphatic vessels of its parietal layer is impaired.

With infection or alteration of capillary membranes, exudate is formed, with diseases of a systemic nature, transudate.

Symptoms hydropericardium

To a large extent, the clinical symptoms of hydropericardium depend on the rate at which fluid accumulates, but is not always related to its volume.

If excess fluid forms within a few days, the hydropericardium is acute; when the formation of exudate lasts from a week to three months, the condition is considered subacute; with chronic hylropericardium, the process lasts more than three months.

And when the accumulation of serous fluid occurs gradually, then pronounced symptoms may be absent even in cases of its moderate volume (200-250 ml). [7]

The existing and classification of hydropericardium by volume, which distinguishes between three main degrees:

• minimal or small hydropericardium - with an accumulation of less than 100 ml of fluid (the silhouette of the heart on the roentgenogram is increased by less than 10 mm, or the size of the echo-negative space visualized by echocardiography does not exceed 10 mm);
• - moderate degree - 100-500 ml (an increase in the contours of the heart by 10-20 mm, and the size of the echo-negative space is also 20 mm);
• massive hydropericardium - more than 500 ml (with a heart silhouette exceeding the norm by more than 20 mm, with the same numerical indicator according to echocardiographic assessment).

The accumulated fluid causes an increase in pressure in the pericardial cavity and leads to a compressive effect on the heart, so the first signs will be manifested by compensatory tachycardia and a feeling of heaviness in the chest on the left.

Also, hydropericardium can manifest itself: shortness of breath and shortness of breath when lying down; a decrease in blood pressure and dizziness; violation of the heart rhythm and weakening of the pulse; cyanosis and swelling of the face; swelling of superficial veins in the neck, as well as chest pain (behind the sternum or in the region of the heart) radiating to the scapula and shoulder, and dry cough - especially in patients with massive pericardial effusion.

Complications and consequences

What is the danger of hydropericardium? Rapid accumulation of fluid in the pericardium can cause severe compression of the heart with impaired blood flow and lack of oxygen in the body due to restriction of diastolic filling of the heart and a decrease in stroke volume and cardiac output. In acute situations, this can lead to  cardiac tamponade  with impaired hemodynamics and critical hypotension, which can be fatal.

In addition, the possible consequences and complications of chronic hydropericardium are associated with fibrous thickening and calcification of the walls of the pericardium, diagnosed as constrictive pericarditis or "armored" heart.

Diagnostics hydropericardium

Diagnostics of the hydropericardium includes a medical history, examination of the patient, and a complete  examination of the heart .

General clinical and detailed biochemical blood tests (for various antibodies, eosinophils, TSH levels, etc.) are required. If a bacterial or tumor etiology of the effusion is suspected, a biochemical study of the pericardial fluid (for bacteria, viruses, tumor markers) is required. To obtain a sample, a puncture is performed - diagnostic pericardiocentesis under the control of echocardiography or X-ray. In these cases, a pericardial biopsy may be required.

The decisive role is played by instrumental diagnostics -  instrumental methods of studying the heart . So, on an ECG with a hydropericardium with a large amount of exudate, an alternation of the voltage of the ventricular complex (QRS) is observed: when the left ventricle is close to the surface of the chest, it increases, and when the ventricle is deviated, it decreases. Experts call this "rocking" of the heart in the pericardium. [8]

A chest X-ray when fluid accumulates in the pericardial cavity reveals an increase in the silhouette of the heart, but if the volume of the effusion is insignificant, the X-ray will not show it.

With computed tomography of the chest CT, signs of hydropericardium are enlargement of the contours of the heart with a low density (up to 20-30 HU). However, usually CT and MRI are not used to diagnose pericardial effusions, since the most effective imaging method in this case is ultrasound of the heart -  echocardiography . And to identify fluid in the pleural cavity - chest ultrasound. [9], [10]

Ultrasound signs of hydrothorax and hydropericardium - anechoic (echo-negative) space in the pleural cavity and between the two layers of the pericardium, behind the heart (in the atrioventricular groove). Moreover, in the pericardial cavity, the fluid is usually identified only in systole, when the heart moves away from the inner surface of the pericardial sac.

Differential diagnosis

Differential diagnostics with exudative pericarditis, hemopericardium , muscular hypertrophy of the heart is carried out . Also, exudative effusion is differentiated from transudate. [11]

Treatment hydropericardium

If possible, treatment of hydropericardium should eliminate its root cause, and the choice of method is determined, first of all, by the etiology. That is, they are  treating pericarditis  or myocarditis, pneumonia or pleurisy, hypothyroidism or cancer. [12]

In the drug therapy of pericardial effusion of inflammatory origin, non-steroidal anti-inflammatory drugs (NSAIDs) are used, that is, drugs such as: Aspirin (0.7-1 g per day for 10 days); Ibuprofen  (0.6 g twice a day); Indomethacin (50 mg twice a day). It should be borne in mind that with gastritis and stomach ulcers, these drugs are contraindicated.

Antibiotics are prescribed to treat hydropericardium caused by a microbial infection, and in cases of heart failure, diuretics (with serum sodium control).

For recurrent effusions, NSAIDs and colchicine are used (daily dose - 1 mg), and in cases of systemic inflammatory diseases -  glucocorticoids , for example, Prednisolone or Dexamethasone (daily vine is 0.2-0.5 mg per kilogram of body weight). [13]

It is not worthwhile on your own - without consulting a doctor - to use alternative methods, in particular, herbal treatment, taking decoctions of lingonberry leaves, bearberry herb, naked hernia, horsetail or marsh dryweed. [14]

Surgical treatment is the removal of liquid which has accumulated in the pericardial cavity, the details in the publication -  Puncture pericardium pericardiocentesis  [15],  [16], [17]

With frequent recurrences of effusion, a minimally invasive operation can be performed to create the so-called pericardial window - a small opening in the lining of the pericardial sac to drain the accumulating fluid. [18]

Prevention

In most cases, there is no way to prevent the occurrence of hydropericardium. [19]

Forecast

Considering that the hydropericardium occurs for various reasons, the prognosis of its outcome cannot be equally favorable in all cases. Although small accumulations of serous fluid may disappear spontaneously or require minimal therapeutic intervention.