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The Pericardium

The Pericardium

The Pericardium

The pericardium is the fibrous sac that surrounds the heart.  It
can be divided into three layers, the fibrous pericardium, the parietal
, and the visceral pericardium.  The parietal
and visceral pericardia together form the serous pericardium.  The
two layers of the serous pericardium are continuous with each other.

The fibrous pericardium is a layer of connective tissue that provides
support and protection for the heart.  It has a number of attachments to the
diaphragm, the sternum (via the sterno-pericardial ligaments), and the vertebral
column.  It holds the heart in place.

The inner surface of the fibrous pericardium is lined by the outer (parietal)
layer of serous pericardium.   The inner (visceral)
layer of the serous pericardium lines the outer surface of the heart
itself.  Between the two layers of the serous pericardium is the pericardial
, which contains pericardial fluid.  It is this fluid
that provides lubrication between the two layers, and allows the heart to expand and

The classic picture of the way in which the serous pericardium works is if you push
your fist into a balloon.  The layer of rubber covering your hand is analogous with
the visceral layer, the inside of the balloon is analogous to the pericardial cavity, and
the outer layer of the balloon not in contact with your hand is equivalent to the parietal

Pericarditis is an inflammation of the serous pericardium of the
heart.  It results in an accumulation of fluid in the pericardial cavity, which
effects the pattern of beating in the heart.

A massively increased amount of fluid in the pericardial cavity will result in the
heart not being able to fill properly, meaning it will be unable to propel blood around
the body in its normal manner.  This condition is called cardiac tamponade,
and will often require the fibrous pericardium to be surgically opened in order to remove
the excess fluid.


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Heart Anatomy

Pericarditis: Symptoms, Causes, Treatments


The Pericardium

The pericardium is a thin, two-layered, fluid-filled sac that covers the outer surface of the heart. It provides lubrication for the heart, shields the heart from infection and malignancy, and contains the heart in the chest wall. It also keeps the heart from over-expanding when blood volume increases, which keeps the heart functioning efficiently.

What is pericarditis?

Pericarditis is an inflammation of the pericardium. Pericarditis is usually acute – it develops suddenly and may last up to several months. The condition usually clears up after 3 months, but sometimes attacks can come and go for years. When you have pericarditis, the membrane around your heart is red and swollen, like the skin around a cut that becomes inflamed. Sometimes there is extra fluid in the space between the pericardial layers, which is called pericardial effusion. Pericarditis can affect anyone, but it is most common in men aged 16 to 65.

Symptoms and Causes

What are the symptoms of pericarditis?

Pericarditis can cause chest pain that:

  • Is sharp and stabbing (caused by the heart rubbing against the pericardium)
  • May get worse when you cough, swallow, take deep breaths or lie flat
  • Feels better when you sit up and lean forward

You also may feel the need to bend over or hold your chest to breathe more comfortably.

Other symptoms include:

  • Pain in your back, neck or left shoulder Trouble breathing when you lie down
  • A dry cough
  • Anxiety or fatigue

Pericarditis can cause swelling in your feet, legs and ankles. This swelling may be a symptom of constrictive pericarditis. This is a serious type of pericarditis where the pericardium gets hard and/or thick. When this happens, the heart muscle can’t expand, and it keeps your heart from working like it should. Your heart can become compressed, which causes blood to back up into your lungs, abdomen and legs, and cause swelling. You can also develop an abnormal heart rhythm.

If you have symptoms of constrictive pericarditis, including shortness of breath, swelling of the legs and feet, water retention, heart palpitations, and severe swelling of the abdomen, call your cardiologist to schedule an evaluation.

Pericardial effusion and cardiac tamponade

When there is a fluid build-up in the space between the pericardium, it can cause a condition called pericardial effusion. If the fluid builds up quickly, it can cause cardiac tamponade. This is a sudden build-up of fluid in between the layers of the pericardium that keeps your heart from working like it should and can cause your blood pressure to drop. Cardiac tamponade is life-threatening and requires immediate drainage of the fluid.

If you have any symptoms of acute pericarditis, call your doctor right away. If you feel your symptoms are a medical emergency, call 911 right away to get treatment at the nearest hospital.

What causes pericarditis?

There are many causes of pericarditis:

  • Viral pericarditis is caused by a complication of a viral infection, most often a gastrointestinal virus.
  • Bacterial pericarditis is caused by a bacterial infection, including tuberculosis.
  • Fungal pericarditis is caused by a fungal infection.
  • Parasitic pericarditis is caused by an infection from a parasite.
  • Some autoimmune diseases, such as lupus, rheumatoid arthritis and scleroderma can cause pericarditis. Other causes of pericarditis include injury to the chest, such as after a car accident (traumatic pericarditis), other health problems such as kidney failure (uremic pericarditis), tumors, genetic diseases such as Familial Mediterranean Fever (FMF), or rarely, medications that suppress the immune system.

Your risk of pericarditis is higher after a heart attack, heart surgery (postpericardiotomy syndrome), radiation therapy or a percutaneous treatment, such as cardiac catheterization or radiofrequency ablation (RFA). In these cases, it is likely that the inflammation of the pericardium is an error in the body’s response to the procedure or condition. It can sometimes take several weeks for symptoms of pericarditis to develop after bypass surgery.

Many times, the cause of pericarditis is unknown. This is called idiopathic pericarditis.

About 15-30% of patients with pericarditis have repeat episodes of pericarditis that come and go for many years.

Diagnosis and Tests

How is pericarditis diagnosed?

Sharp pain in the chest and back of the shoulders and difficulty breathing are 2 major clues that you may have pericarditis rather than a heart attack. Your doctor will talk to you about your symptoms and medical history, such as whether you have recently been sick and review your history of heart conditions, surgery and other health problems that could put you at a higher risk of pericarditis.

Your doctor will listen to your heart. Pericarditis can cause a rubbing or creaking sound, caused by the rubbing of the inflamed lining of the pericardium. This is called the “pericardial rub” and is best heard when you lean forward, hold your breath and breathe out. Depending on how bad the inflammation is, your doctor may also hear crackles in your lungs, which are signs of fluid in the space around the lungs or extra fluid in the pericardium.

Cleveland Clinic imaging specialists in the Center for the Diagnosis and Treatment of Pericardial Diseases often use a variety of ways to check for pericarditis and any complications, such as pericardial effusion or constrictive pericarditis. You may need one or more tests, such as:

  • Chest X-ray to see the size of your heart and any fluid in your lungs.
  • Electrocardiogram (ECG or EKG) to look for changes in your heart rhythm. In about half of all patients with pericarditis, the heart rhythm goes through a sequence of four distinct patterns. Some patients do not have any changes, and if they do, they may be temporary.
  • Echocardiogram (echo) to see how well your heart is working and check for fluid or pericardial effusion around the heart. An echo will show the classic signs of constrictive pericarditis, including a stiff or thick pericardium that constricts the heart’s normal movement.
  • Cardiac MRI to check for extra fluid in the pericardium, pericardial inflammation or thickening, or compression of the heart. A contrast agent called gadolinium is used during this highly specialized test.
  • CT scan to look for calcium in the pericardium, fluid, inflammation, tumors and disease of the areas around the heart. Iodine dye is used during the test to get more information about the inflammation. This is an important test for patients who may need surgery for constrictive pericarditis.
  • Cardiac catheterization to get information about the filling pressures in the heart. This is used to confirm a diagnosis of constrictive pericarditis.
  • Blood tests can be used to make sure you are not having a heart attack, to see how well your heart is working, test the fluid in the pericardium and help find the cause of pericarditis. If you have pericarditis, it is common for your sedimentation rate (ESR)and ultra sensitive C reactive protein levels (markers of inflammation) to be higher than normal. You may need other tests to check for autoimmune diseases like lupus and rheumatoid arthritis.

Management and Treatment

What treatments are available for patients with pericarditis?


Treatment for acute pericarditis may include medication for pain and inflammation, such as ibuprofen and aspirin. Depending on the cause of your pericarditis, you may need an antibiotic or antifungal medication.

If your symptoms are severe, last longer than 2 weeks, or clear up and then return, your doctor may also prescribe an anti-inflammatory drug called colchicine. Colchicine can help control the inflammation and prevent pericarditis from returning weeks or even months later.

If you need to take large doses of ibuprofen, your doctor may prescribe medications to ease gastrointestinal symptoms. If you take large doses of nonsteroidal anti-inflammatory drugs (NSAIDs), you will need frequent follow-up appointments to look for changes in your kidney and liver function.

If you have chronic or recurrent pericarditis, you may need to take NSAIDs or colchicine for several years, even if you feel well. A diuretic (“water pill”) usually helps get rid of the extra fluid caused by constrictive pericarditis. If you develop a heart rhythm problem, your doctor will talk to you about treatment.

Your doctor may also talk to you about treatment with steroids or other medications, such as azathioprine, IV human immunoglobulins, anakinra.

Other treatments

Most times, medications are the only treatment needed for patients with pericarditis. But, if fluid builds up in the pericardium and compresses the heart, you may need a procedure called pericardiocentesis. A long, thin tube called a catheter is used to drain the extra fluid. The catheter and a needle are guided to the pericardium with the use of echocardiography. If the fluid cannot be drained with the needle, a surgical procedure called a pericardial window is performed.

If you have constrictive pericarditis, you may need to have some of your pericardium removed. The surgery is called a pericardiectomy.

Surgery is not usually used as treatment for patients with recurrent pericarditis, but your doctor may talk to you about it if other treatments aren’t successful.

Outlook / Prognosis

Will pericarditis affect me in the long-term?

After you recover from pericarditis, you should be able to return to your normal activities without any reason for concern. Your doctor will talk to you about what to expect.


How do I find a doctor who can diagnose my condition and provide treatment?

Center for the Diagnosis and Treatment of Pericardial Diseases

The multidisciplinary team of experts in the Center for the Diagnosis and Treatment of Pericardial Diseases includes cardiologists, cardiac surgeons, nurses and other specialists, such as rheumatologists and infectious disease physicians. We provide:

  • A thorough evaluation of patients using state-of-the-art diagnostic testing
  • Multi-disciplinary approach to comprehensive care for patients with pericardial diseases
  • Ongoing research and education to provide patients with high-quality and innovative therapies

For more information

If you need more information or would like to make an appointment with a specialist, contact us, chat online with a nurse or call the Miller Family Heart, Vascular & Thoracic Institute Resource & Information Nurse at 216.445.9288 or toll-free at 866.289.6911. We would be happy to help you.

Glossary of Pericarditis Terms

  • Acute pericarditis: Inflammation of the pericardium that develops suddenly and is accompanied by the sudden onset of symptoms.
  • Cardiac tamponade: A severe compression of the heart that impairs its ability to function. Cardiac tamponade is a medical emergency that requires prompt diagnosis and treatment. Chronic pericarditis:Inflammation of the pericardium that lasts for three months or longer after the initial acute attack.
  • Constrictive pericarditis: A severe form of pericarditis in which the inflamed layers of the pericardium stiffen, develop scar tissue, thicken and stick together. Constrictive pericarditis interferes with the normal function of the heart.
  • Infectious pericarditis: Pericarditis that develops as the result of a viral, bacterial, fungal or parasitic infection.
  • Idiopathic pericarditis: Pericarditis that does not have a known cause.
  • Pericardium: The thin, two-layered, fluid-filled sac that covers the outer surface of the heart.
  • Pericardial effusion: Excess fluid build-up in the pericardium.
  • Pericardial window: A minimally invasive surgical procedure performed to drain fluid that has accumulated in the pericardium. This surgical procedure involves a small chest incision through which an opening is made in the pericardium.
  • Pericardiectomy: Surgical treatment of pericarditis that involves the removal of a portion of the pericardium.
  • Pericardiocentesis: A procedure performed to drain excess fluid from the pericardium with a catheter.
  • Traumatic pericarditis: Pericarditis that develops as the result of injury to the chest, such as after a car accident.
  • Uremic pericarditis: Pericarditis that develops as the result of kidney failure.

16.3: Membranes, Surface Features, and Layers

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  1. Membranes
  2. Surface Features of the Heart

Our exploration of more in-depth heart structures begins by examining the membrane that surrounds the heart, the prominent surface features of the heart, and the layers that form the wall of the heart. Each of these components plays its own unique role in terms of function.


The membrane that directly surrounds the heart and defines the pericardial cavity is called the pericardium or pericardial sac. It also surrounds the “roots” of the major vessels, or the areas of closest proximity to the heart. The pericardium, which literally translates as “around the heart,” consists of two distinct sublayers: the sturdy outer fibrous pericardium and the inner serous pericardium. The fibrous pericardium is made of tough, dense connective tissue that protects the heart and maintains its position in the thorax. The more delicate serous pericardium consists of two layers: the parietal pericardium, which is fused to the fibrous pericardium, and an inner visceral pericardium, or epicardium, which is fused to the heart and is part of the heart wall. The pericardial cavity, filled with lubricating serous fluid, lies between the epicardium and the pericardium

In most organs within the body, visceral serous membranes such as the epicardium are microscopic. However, in the case of the heart, it is not a microscopic layer but rather a macroscopic layer, consisting of a simple squamous epithelium called a mesothelium, reinforced with loose, irregular, or areolar connective tissue that attaches to the pericardium. This mesothelium secretes the lubricating serous fluid that fills the pericardial cavity and reduces friction as the heart contracts. Figure \(\PageIndex{1}\) illustrates the pericardial membrane and the layers of the heart.

Figure \(\PageIndex{1}\): Pericardial Membranes and Layers of the Heart Wall The pericardial membrane that surrounds the heart consists of three layers and the pericardial cavity. The heart wall also consists of three layers. The pericardial membrane and the heart wall share the epicardium. (CC-BY-4.0, OpenStax, Human Anatomy)

Surface Features of the Heart

Inside the pericardium, the surface features of the heart are visible, including the four chambers. There is a superficial leaf-like extension of the atria near the superior surface of the heart, one on each side, called an auricle—a name that means “ear like”—because its shape resembles the external ear of a human (Figure \(\PageIndex{2}\)). Auricles are relatively thin-walled structures that can fill with blood and empty into the atria or upper chambers of the heart. You may also hear them referred to as atrial appendages. Also prominent is a series of fat-filled grooves, each of which is known as a sulcus (plural = sulci), along the superior surfaces of the heart. Major coronary blood vessels are located in these sulci. The deep coronary sulcus is located between the atria and ventricles. Located between the left and right ventricles are two additional sulci that are not as deep as the coronary sulcus. The anterior interventricular sulcus is visible on the anterior surface of the heart, whereas the posterior interventricular sulcus is visible on the posterior surface of the heart. Figure \(\PageIndex{2}\)illustrates anterior and posterior views of the surface of the heart.

Figure \(\PageIndex{2}\): External Anatomy of the Heart Inside the pericardium, the surface features of the heart are visible (CC-BY-4.0, OpenStax, Human Anatomy)

Pericardium – Structure & Function

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Click here to go to the Pericardium quiz.


Surrounding the heart is a fibrous sac called the pericardium (Gr., peri, around + kardia, heart), which performs several functions. Fluids within the sac lubricate the outer wall of the heart so it can beat without causing friction. It also holds the heart in place, forms a barrier against infections, and helps keeps the heart from overexpanding.

The pericardium surrounding the heart.

A coronal section of the pericardium reveals that it is composed of two walls and a thin, intervening space. The outer wall is the thickest and consists of two tissue layers.

A coronal section of the pericardium.

The external layer is formed by dense irregular connective tissue and is often called the fibrous pericardium.

The fibrous percardium.

Under the fibrous pericardium is a thin layer of serous membrane known as the parietal pericardium.

Learn more about heart anatomy with these quizzes, diagrams and labelling worksheets. 

The parietal pericardium.

At the roots of the major blood vessels, the parietal pericardium reflects back over the surface of the heart.

The parietal pericardium reflecting back over the surface of the heart.

This layer forms both the inner wall of the pericardium, which is called the visceral pericardium, and the outer layer of the heart wall, which is called the epicardium.

The visceral pericardium.

Together, the parietal and visceral pericardial layers are also called the serous pericardium.

Between the walls of the serous pericardium is the pericardial cavity. This narrow space is normally filled with a few (10-50) millilitres of pericardial fluid, which is secreted by the serous membranes. The fluids reduce friction between membranes as they glide past one another during heartbeats.

The parietal cavity.

Test yourself:

Coronal section of the pericardium: [Show/Hide answers]

Review the coronal section of the pericardium and test yourself.

Pericardiectomy | Johns Hopkins Medicine

What is pericardiectomy?

A pericardiectomy is a procedure done on the sac around the heart. A surgeon cuts away this sac or a large part of this sac. This allows the heart to move freely.

A fibrous sac called the pericardium surrounds the heart. This sac has two thin layers with fluid between them. This fluid reduces friction as the two layers rub against each other when the heart beats. Normally, this sac is thin and flexible, but repeated inflammation can cause it to become stiff and thick. When this happens, the heart can’t stretch properly as it beats. This can prevent the heart from filling up with as much blood as it needs. The lack of blood can cause increased pressure in the heart, a condition called constrictive pericarditis. Cutting this sac away allows the heart to fill normally again. Pericardiectomy, however, doesn’t fix the problem that was causing the inflammation.

Pericardiectomy is a surgery done under general anesthesia. The surgeon makes an incision over the breastbone to access the heart. Then the surgeon removes either a large part or the entire pericardium. Or the surgeon makes an incision between the ribs to reach the pericardium. Doctors also may use a several small incisions on the side of the chest. This is called video-assisted thoracoscopy or VATS. Small cameras and tools are used to do the surgery through these small holes.

Why might I need a pericardiectomy?

Pericardiectomy is most often needed in people with chronic constrictive pericarditis. It’s not usually an option for people who have had a single instance of pericarditis. With chronic constrictive pericarditis, the pericardium has become stiff and thick. This is due to repeated scarring. This scarring constricts the heart’s movement. This can cause symptoms like fatigue and swelling. Conditions that can cause constrictive pericarditis include:

  • Autoimmune disease
  • Cancer (that has spread from elsewhere in the body or cancer in the heart tissue itself)
  • Infection of the heart or pericardial sac
  • Inflammation of the pericardial sac due to a heart attack
  • Radiation therapy to the chest
  • Reactions to certain medicines
  • Metabolic causes, like an underactive thyroid

In some cases, the cause of constrictive pericarditis is unknown.

If you have severe symptoms, you may need a pericardiectomy. Medicines may help your symptoms if you have chronic constrictive pericarditis. Surgery may be recommended when medical therapies are unable to resolve the condition.

In some cases, inflammation can cause a pericardial effusion. This is a buildup of fluid in the pericardium. This can make it difficult for the heart to beat normally. You may need a pericardiectomy to drain this fluid and prevent it from coming back. In most cases, a pericardiectomy is only done if problems with fluid buildup occur again. A less invasive method is often used for the first time fluid builds up around the heart.

What are the risks for pericardiectomy?

All procedures have some risks. The risks of pericardiectomy include:

  • Abnormal heart rhythms, which can cause death in rare instances
  • Blood clot, which can lead to stroke or other problems
  • Complications from anesthesia
  • Death
  • Excess bleeding
  • Fluid buildup around the lungs
  • Heart attack
  • Infection
  • Low cardiac output syndrome
  • Pneumonia

Your own risks may vary according to your age, general health, and the reason for your procedure. They may also vary depending on the anatomy of the heart, fluid, and pericardium. Talk with your healthcare provider to find out what risks may apply to you.

How do I prepare for a pericardiectomy?

Ask your doctor how to prepare for pericardiectomy. You should not eat or drink anything after midnight before the day of the surgery. Ask the doctor whether you need to stop taking any medicines before the surgery.

The doctor may want some extra tests before the surgery. These might include:

  • Chest X-ray
  • ECG or EKG to check the heart rhythm
  • Blood tests to assess general health
  • Echocardiogram, to view heart anatomy and blood flow through the heart
  • CT scan or MRI if the doctor needs more information about the heart
  • Heart catheterization to measure the pressures inside the heart 

Hair on and around the area of the operation may be removed ahead of time. About an hour before the operation, you may be given medicines to help you relax.

What happens during a pericardiectomy?

Talk with the doctor about what to expect during the surgery. The details of your surgery will vary according to the exact kind of repair the doctor is doing. Usually, doctors do the repair without the use of a heart-lung machine (cardiopulmonary bypass). During the repair, the team will carefully monitor your vital signs. In general:

  • An anesthesiologist will give you general anesthesia before the surgery starts. You will sleep deeply and painlessly during the operation. You won’t remember it afterwards.
  • The surgery will take several hours.
  • There are different types of procedures that may be done.
  • In some cases, the surgeon will make a vertical incision along the breastbone. This incision will be several inches long. To access the heart, the surgeon will separate the breastbone.
  • The doctor will surgically remove a large portion of the pericardium or the entire pericardium.
  • The doctor will do other repairs to the heart if needed.
  • The muscle and the skin incisions will be closed and a bandage will be applied.

What happens after a pericardiectomy?

Ask your doctor about what to expect after the procedure. In general, after your pericardiectomy:

  • You may be groggy and disoriented upon waking.
  • Your vital signs, such as your heart rate, blood pressure, breathing, and oxygen levels, will be closely monitored.
  • You may have a tube draining the fluid from your chest.
  • The drained fluid may be sent to a lab for analysis.
  • You may feel some soreness, but you shouldn’t feel severe pain. Pain medicines are available if needed.
  • Your heart symptoms will likely get better very soon after surgery.
  • You will probably be able to have liquids the day after surgery. You can have regular foods as soon as you can handle them.
  • You will probably need to stay in the hospital at least several days. This will partially depend on the reason you needed a pericardiectomy.

After you leave the hospital:

  • You will probably have your stitches or staples removed in a follow-up appointment in 7 to 10 days. Be sure to keep all follow-up appointments.
  • You should be able to resume normal activities relatively soon, but you may be a little more tired for a while after the surgery.
  • Ask the doctor if you have any exercise limitations. Avoid heavy lifting.
  • Call the doctor if you have fever, increased draining from the wound, increased chest pain, or any severe symptoms.
  • Follow all the instructions your healthcare provider gives you for medicines, exercise, diet, and wound care.

Next steps

Before you agree to the test or the procedure make sure you know:

  • The name of the test or procedure
  • The reason you are having the test or procedure
  • What results to expect and what they mean
  • The risks and benefits of the test or procedure
  • What the possible side effects or complications are
  • When and where you are to have the test or procedure
  • Who will do the test or procedure and what that person’s qualifications are
  • What would happen if you did not have the test or procedure
  • Any alternative tests or procedures to think about
  • When and how will you get the results
  • Who to call after the test or procedure if you have questions or problems
  • How much will you have to pay for the test or procedure

What is the Pericardium?

The term pericardium is derived from the Greek prefix peri– (“around”) and kardia (“heart”), implying a structure that envelops or encloses the heart. Morphologically, the pericardium is a fluid filled sac-like structure that surrounds the heart.

Anatomic structure

The pericardium is a double-walled structure made up of an outer fibrous layer and an inner serous layer.

The fibrous layer of the pericardium is a single connective tissue layer that is made up of collagen (type I and type III mainly) and elastin fibers; it is elastic and yet non-distensible. This layer of the pericardium is held in position cranially by its membranous folds that are interdigitating with the tunica adventitia of the great vessels. It is also held caudally by ligaments that are connected to the central tendon of the diaphragm, ventrally to the sternum by superior and inferior pericardiosternal ligaments, and dorsally by ligaments fastening it to the esophagus and spine.

Comparatively, the serous layer of the pericardium is made up of an outer parietal layer and inner visceral layer, each of which is comprised of a single layer of epithelial cells. The parietal layer lines the inner regions of the fibrous pericardium, while the visceral layer lines the outer layer of the heart and is therefore also known as the epicardium.

Pericardium – Definition, Function & Layers – Human Anatomy | KenhubPlay

Pericardial cavity

A void space found among the two linings of the serous pericardium is called the pericardial cavity, which encircles the heart.

Between the parietal and visceral layer is the pleural cavity, which holds the pleural fluid. About 20–30 ml in volume, this serous fluid acts as a lubricant and minimizes friction between the epicardium and parietal layer as the heart muscles expand and contract with the beating of the heart. Thus, the pericardial cavity allows the heart movement to remain flexible.

The pericardial cavity surrounds the heart completely, except at the inlet and outlet of the cardiac vessels, where they form two significant tubes. One of the tubes serves as an interconnection to the inferior and superior vena cava, as well as the pulmonary veins, whereas the other connects the aorta and the pulmonary trunk.

Blood supply and innervation of the pericardium

Blood supply to the pericardium occurs mainly through the pericardiophrenic artery, although a few minor contributions also occur via the musculophrenic artery, esophageal artery, bronchial artery, and superior phrenic artery.

The coronary artery is also involved, but it supplies blood only to the visceral layer. Draining of blood from the pericardium involves the pericardiophrenic veins, as well as the azygos venous system.

The innervations of the outer fibrous and parietal pericardium are due to the phrenic nerve (C3-C5), and it also provides motor and sensory innervation to the diaphragm. This nerve originates from the neck and travels down through the thoracic cavity. The phrenic nerve is a general source of referred pain, as can be demonstrated in cases where shoulder pain arises as a result of pericarditis. Additionally, the visceral pericardium is also innervated by the vagus and sympathetic nerves.

Pericardial sinuses

In medical terminology, a sinus is a passage or channel. There are two sinuses in the pericardial cavity, which include the transverse pericardial sinus and the oblique pericardial sinus. Both of these sinuses are formed through embryonic folding of the heart tube during ontogeny.

The reflections or folds of the serosal layer result in the formation of a set of complex tubes, one enclosing the aorta and the pulmonary trunk, whereas the other encloses the superior and inferior vena cave and the pulmonary veins. This results in a transverse sinus across the pericardium that separates the arterial blood vessels and the venous blood vessels.

The index finger can pass through the transverse sinus, which helps surgeons to identify the blood vessels of the heart during coronary artery bypass surgery.

The oblique sinus is formed by the reflection of the pericardial membranes onto the pulmonary veins. It is bounded by the inferior vena cava and the right pulmonary veins on one side, as well as the left pulmonary veins on the other.

Functions of the pericardium

The pericardium is known to have some specific functions, including:

  • Tethering: The pericardium holds the heart in place within the cardiac cavity.
  • Limiting: The pericardium prevents overfilling of the ventricles and consequent overexpansion of the heart.
  • Lubrication: The pericardium lubricates the moving surfaces of the heart.
  • Protective: The pericardium is a physical barrier between the muscular heart and the surrounding organs (e.g. lung) that may be prone to infection.

The pericardium is also able to transmit intra-thoracic changes in pressure that occur with changes in respiration, as the pressure in this structure is 2–5 mm Hg lower than the normal pressure within the thoracic cavity.

Furthermore, the non-distensible nature of the pericardium provides an overall constraint on the total heart volume and prevents irregular expansion of the chambers.

Because of its enclosing anatomic structure, the pericardium ensures that the left and right ventricles are equally compliant. Moreover, as the overall volume is fixed and expansion of one chamber automatically impedes the expansion of another, thereby ensuring that the heart chambers work rhythmically and in unison.


Further Reading

The Pericardium – TeachMeAnatomy

If the heart is the fun, interesting inside bit of an orange, the pericardium could be compared to the peel around it. Like peel, it can seem vaguely unexciting – that is until you learn some of its very important (appeeling. ahem.) physiological functions 1.

In scientific terms, the pericardium is a fibro-serous, fluid-filled sack that surrounds the muscular body of the heart and the roots of the great vessels (the aorta, pulmonary artery, pulmonary veins, and the superior and inferior vena cavae).

This article will give an outline of the functions, structure, innervation, and clinical significance of the pericardium.

Anatomical Structure

The pericardium is made up of two main layers: a tough external layer known as the fibrous pericardium, and a thin, internal layer known as the serous pericardium (to overextend the orange metaphor, the outer peel could be thought of as the fibrous layer, with the inner white stuff being the serous layer).

Fibrous Pericardium

Continuous with the central tendon of the diaphragm, the fibrous pericardium is made of tough connective tissue and is relatively non-distensible. Its rigid structure prevents rapid overfilling of the heart, but can contribute to serious clinical consequences (see cardiac tamponade).

Serous Pericardium

Enclosed within the fibrous pericardium, the serous pericardium is itself divided into two layers: the outer parietal layer that lines the internal surface of the fibrous pericardium and the internal visceral layer that forms the outer layer of the heart (also known as the epicardium). Each layer is made up of a single sheet of epithelial cells, known as mesothelium.

Found between the outer and inner serous layers is the pericardial cavity, which contains a small amount of lubricating serous fluid. The serous fluid serves to minimize the friction generated by the heart as it contracts.

Fig 1 – Overview of the layers of the heart wall.

The order of these layers can be remembered using the acronym Fart Police Smell Villains:

  • F – Fibrous layer of the pericardium
  • P – Parietal layer of the serous pericardium
  • S – Serous fluid
  • V – Visceral layer of the serous pericardium


The pericardium has many physiological roles, the most important of which are detailed below:

  • Fixes the heart in the mediastinum and limits its motion. Fixation of the heart is possible because the pericardium is attached to the diaphragm, the sternum, and the tunica adventitia (outer layer) of the great vessels
  • Prevents overfilling of the heart. The relatively inextensible fibrous layer of the pericardium prevents the heart from increasing in size too rapidly, thus placing a physical limit on the potential size of the organ
  • Lubrication. A thin film of fluid between the two layers of the serous pericardium reduces the friction generated by the heart as it moves within the thoracic cavity
  • Protection from infection. The fibrous pericardium serves as a physical barrier between the muscular body of the heart and adjacent organs prone to infection, such as the lungs.
Fig 2 – Anterior view of the pericardium. Note the attachments to the diaphragm, and the roots of the great vessels.


Clinical Relevance: Transverse Pericardial Sinus

Formed as a result of the embryological folding of the heart tube, the transverse pericardial sinus is a passage through the pericardial cavity.

It is located:

  • Posterior to the ascending aorta and pulmonary trunk.
  • Anterior to the superior vena cava.
  • Superior to the left atrium.

In this position, the transverse pericardial sinus separates the heart’s arterial outflow (aorta, pulmonary trunk) from its venous inflow (superior vena cava, pulmonary veins).

The transverse pericardial sinus can be used to identify and subsequently ligate the arteries of the heart during coronary artery bypass grafting.

Fig 3 – The Transverse pericardial sinus, separating the major arteries and veins. Also note the close relationship of the fibrous pericardium and the diaphragm



The phrenic nerve (C3-C5) is responsible for the somatic innervation of the pericardium, as well as providing motor and sensory innervation to the diaphragm. Originating in the neck and travelling down through the thoracic cavity, the phrenic nerve is a common source of referred pain, with a key example being shoulder pain experienced as a result of pericarditis.


Clinical Relevance

Cardiac Tamponade

The relatively inextensible fibrous pericardium can cause problems when there is an accumulation of fluid, known as pericardial effusion, within the pericardial cavity.

The rigid pericardium cannot expand, and thus the heart is subject to the resulting increased pressure. The chambers can become compressed, thus compromising cardiac output.


Pericarditis, or inflammation of the pericardium, has myriad causes, including bacterial infection and myocardial infarction. The main symptom is chest pain, and the condition can cause acute cardiac tamponade due to an accumulation of fluid in the pericardial cavity.

Fig 4 – Radiographic appearance of pericardial effusion (note the enlarged heart shape).


1  The exciting functions of orange peel are documented at length in academic literature – for instance, did you know that the juice from orange peel is highly flammable?

90,000 Heart disease and oral health

I It is increasingly heard that oral health is essential to maintaining overall health. At the same time, a larger proportion of the population of developed countries suffers from periodontal or gum disease, which often remain undiagnosed. This fact may be due to the fact that in the absence of pain in the teeth, the patient does not seek to visit the dentist, and the therapist rarely pays attention to the health of the oral cavity.

However, according to Delta Dental, there are now two specific links between oral health and heart disease. First, recent studies have shown that if you have moderate to advanced gum disease, you are at a higher risk of developing heart disease than people with healthy gums. And secondly, the state of health of the oral cavity can warn the doctor about the presence of various diseases and abnormalities, including disorders of the heart.

How are these two types of diseases related?

Oral health and heart disease are linked through the spread of bacteria from the mouth to other areas of the body through the bloodstream. If bacteria reach the heart, they can attach to vulnerable areas and cause inflammation. All this can lead to the development of diseases such as endocarditis or, in other words, an infection of the inner lining of the heart, which is confirmed by the data of the Mayo Clinic.The development of other cardiovascular diseases such as atherosclerosis (narrowing of the arteries) and stroke, according to the Cleveland Clinic, may increase the risk of heart disease and stroke

Symptoms and signs

According to the American Association of Periodontics (AAP), you can have gum disease, even at an early stage, if you have any of the following:

  • Redness, swelling of the gums and soreness when touched;
  • 90,019 gums bleed while eating, brushing or flossing;

  • You notice purulent blisters or other signs of infection around your gums and teeth;
  • gums seem to “slide” along the surface of the tooth;
  • You often notice bad breath or bad taste in your mouth;
  • Some teeth are loose or move away from other teeth.

Preventive measures

Good hygiene practices and regular dental check-ups are the best way to prevent gum disease. The American Dental Association (ADA) guidelines on the Mouth Healthy website suggest that you brush your teeth twice a day with a comfortable, soft bristled toothbrush that will reach the surface of each tooth. ADA also recommends using its approved toothpastes such as Colgate Total®, which has been proven to promote gum health.You should also brush your teeth daily with dental floss and have regular professional oral hygiene with your dentist.

By taking care of the health of the oral cavity in advance, you can protect yourself from the development of heart diseases associated with weakened oral health, as well as maintain a healthy smile, snow-white and beautiful for the rest of your life.

90,000 Causes and treatment of fluid in the heart | Cash kaleidoscope. ru

Fluid accumulates in the heart as a result of inflammation of the heart membrane.

This disease is quite serious, with chronic forms of the disease, the development of heart failure is possible.

Tamponade, or rapid accumulation of fluid in the pericardium, leads to cardiac arrest. In this case, only urgent assistance will help.

In order not to start the disease, you should recognize it in time and start treatment in a timely manner.

The two-layer membrane of the heart, consisting of connective tissue, protects the main organ from abrasion. According to some assumptions, the pericardium is a source of various biologically active elements that are involved in the regulation of the heart.The inner layer of the shell is securely attached to the heart muscle. Between the layers of the bursa there is a serous, colorless liquid, which allows the sheets of the membrane to slide without friction. Normally, it should be no more than 30 ml.

If the amount of fluid has increased significantly, this indicates the formation of pericarditis. Pericarditis can manifest itself not only in an increase in the amount of fluid, but also in the appearance of adhesions, inflammatory changes in the membrane.


Pericarditis appears as a result of complications of the underlying disease.There are various reasons for the development of the disease:

  • Viral, bacterial and fungal infections, as well as the effect of parasites, leads to inflammatory processes in the pericardium.
  • Rheumatoid arthritis, dermatomyositis, scleroderma or systemic lupus erythematosus contribute to the development of the disease.
  • Myocardial infarction or lung disease leads to pericarditis after a few days.
  • Metabolic disorders can stimulate the onset of heart disease.
  • Penetrating chest trauma contributes to the formation of traumatic pericarditis.
  • Radiation and oncological diseases, surgical interventions, including coronary artery bypass grafting, lead to pericarditis. If the cause is not established, then the resulting pericarditis is idiopathic.

Inflammation requires compulsory treatment, in the absence of which protein and calcifications will begin to be deposited between the layers of the heart membrane. This will lead to adhesion of layers and disruption of the functionality of the entire pericardium; it will not be able to protect the heart muscle from abrasion.The consequence will be a limitation of the amplitude of heart contractions, which ultimately will contribute to the growth of heart failure.

Types of pericarditis

The disease, depending on the nature of the fluid, is classified into:

  • dry – the volume of serous fluid in the membrane does not change or becomes less;
  • fibrinous – characterized by a slight increase in fluid volume and the presence of a large amount of protein;
  • exudative – characterized by a large volume of accumulated fluid.

Pericarditis can be acute, lasting no more than 2 months, and chronic, lasting more than six months.

Due to the fact that inflammation of the pericardium rarely occurs separately from other diseases, this disease goes unnoticed.

Symptoms can be expressed in varying degrees, their effect depends on the volume of fluid in the pericardium, on the speed of its accumulation, on the severity of the underlying disease. The onset of the disease can be characterized by fever, severe general weakness, muscle pain and headaches.The primary signs of the disease may be absent or mild. Many do not even associate these signs with the problems of the main organ, so the cardiologist has to treat an already advanced disease.

Excess fluid gradually increases pressure on the heart, resulting in the following symptoms:

  • chest pain;
  • Difficulty breathing;
  • persistent dry cough;
  • the occurrence of pain in the scapula, neck or left arm;
  • increased pain during exertion;
  • Difficulty swallowing;
  • attacks of palpitations.

When fluid builds up quickly, cardiac tamponade forms, which further compresses it, preventing it from contracting. Signs of tamponade are:

  • severe pain in the chest;
  • persistent shortness of breath;
  • feeling of anxiety;
  • feeling of lack of air;
  • inability to alleviate the condition in any position of the body.

The appearance of these symptoms indicates the need for urgent medical attention due to the likelihood of cardiac arrest.


In order to detect an ailment, complex procedures are carried out to determine the level of work of the heart muscle and the state of the pericardium:

  • auscultation allows you to hear the friction noise of the membrane, which may be absent at an early stage of the disease;
  • an electrocardiogram shows all the specific changes, with its help it is possible to identify myocarditis;
  • An echocardiogram can detect even small changes in fluid;
  • X-ray of the chest organs makes it possible to see the heart enlarged as a result of the accumulation of fluid, and also to determine the severity of the disease;
  • Ultrasound of the heart allows you to detect an increase in the volume of serous fluid, inflammatory processes, to determine functional failures of the heart;
  • Computed tomography makes it possible to find out the exact volume of fluid in the shell and other data.


To get rid of pericarditis, you must first determine the cause.

Having cured the underlying disease, the complication can also be eliminated.

For optimal and correct treatment, the patient must be hospitalized for observation.

If the disease is not cured in a timely manner, then it turns into a chronic stage, posing a great danger to the patient’s life.

Treatment of acute pericarditis:

  • taking medications for the treatment of the underlying disease;
  • taking non-steroidal anti-inflammatory drugs and corticosteroids;
  • Injection of corticosteroids into the cardiac sheath;
  • Pericardial puncture is sometimes performed for therapeutic or diagnostic purposes.

If tamponade or purulent pericarditis was found, then in this case pericarditis is treated with surgical methods:

  • aspiration of excess fluid with a needle, its analysis and the appointment of further treatment;
  • removal of part of the thickened layer of the pericardium;
  • pericardiectomy.

Proper treatment and implementation of all recommendations after heart surgery will help the body to rehabilitate with the least health complications.


COVID-19 – heart disease? The main thing about the pandemic from foreign media

COVID-19 most often gives complications to the lungs, but it is known that the disease-causing SARS-CoV-2 virus directly or indirectly damages other organs, including the heart. Recently, a lot of data has accumulated that indicate that heart damage is not uncommon, even in those who have been ill with mild or no symptoms. Scientific American writes about this.

The article begins with the stories of American athletes who developed heart problems after COVID-19.Usually it is myocarditis – inflammation of the heart muscle. In half of all cases (not only with COVID-19), myocarditis passes without consequences, but sometimes arrhythmia occurs because of it, and someone dies.

On this topic

According to one estimate, myocarditis is the cause of 7% of deaths of those infected with the new coronavirus. True, some doctors and scientists consider this number to be overestimated. In another study, which examined health workers who had recovered, ten weeks after the onset of symptoms, 37% were diagnosed with myocarditis or myopericarditis (this is when both the muscle and the lining of the heart are inflamed).True, the article with the results has not yet been reviewed by independent scientists. A study in Germany showed that 78% of those who had recovered after two months have abnormalities in the work of the heart, 60% have myocarditis. Most of them had mild to moderate COVID-19.

Even severe myocarditis often goes away on its own, you just need to be observed by a doctor, sometimes – to take medications. But this is not always the case, and athletes are especially at risk. It is better for them to give up competition for three to six months in order not to get arrhythmias or die.

Disturbing news from Europe

More and more new cases of COVID-19 are being registered in Europe. In Spain and France, the count is again in the thousands, in some places there are daily “records”. Science says what has changed since spring and what experts are proposing.

The new statistics should be carefully compared to the April peaks. Now they test much more often (in most countries, positive results are less than 3%), it is easy to get masks (at first they were not even advised to wear them), mobile applications for tracking contacts have appeared (although many of them are far from perfect, but about the best ones it is difficult say how good they are), and now they treat better.Nevertheless, new cases suggest that the authorities of European countries lifted too many restrictions too early.

Outbreaks occur in offices, and COVID-19 is “younger” because people go to parties as if nothing had happened. Newly opened schools can add even more problems. Until the death rate has jumped, but it is a matter of time before the elderly start to get sick.

Different countries have their own restrictions, but within one country the rules are either toughened up, then softened, then again toughened up.It would be nice to establish uniform requirements for all, but the European Union does not have such powers.

On this topic

Compared to spring, more is known about the virus, and therefore the measures to combat its spread have changed. Hand washing is not considered that important because dirty surfaces do not play a significant role. In the spring, in some places it was not even possible to run down the street, but now attention is paid to what is happening in the premises.

Experts believe that the most important thing is to identify disease clusters and cases of “super-spread”: according to some estimates, 10% of those infected provide 80% of new infections.One should look not only for those whom a person could infect, but also those from whom he could get the virus. One expert interviewed by Science suggests quarantining only possible participants in the “superproliferation” along with those who have found the virus. But this should be done immediately, and after five days these people should be tested. Then resources will be used in the best possible way and it will be possible to better understand how clusters generally arise.

Probably, all this will not be enough, and at some point there will be so many patients again that stricter restrictions will have to be introduced.But, perhaps, this time it will be possible to avoid complete lockdowns.

The unfortunate flight in China

An example of “superproliferation” is the case in China, reported in the scientific journal JAMA Internal Medicine and retold in The New York Times.

On January 19, a group of Buddhists went to the ceremony in the city of Ningbo, which is located almost a thousand kilometers from Wuhan. The pilgrims traveled by bus. In one of them was a woman who had dined with friends from Hubei province two days earlier.It is in Hubei, Wuhan, where an outbreak of a strange disease now known as COVID-19 occurred shortly before.

Within a few days, 23 passengers on the bus also fell ill. Chinese scientists have found out the circumstances of the incident. Even those who were sitting in the last row, that is, seven rows from that woman, were infected. The only thing that could somehow help was open windows or a place near the doors.

On this topic

It is also known that 68 people were traveling on the bus, all were without masks, an air conditioner was installed inside, and a one-way trip took 50 minutes.There was also a second bus with 60 passengers, but no one got sick there. An article in JAMA Internal Medicine says the woman had no symptoms, and a preprint of the same article, published in China, said that the day before, the woman felt unwell, took medication, but did not go to the doctor.

This case serves as further confirmation that SARS-CoV-2 is transmitted not only with relatively large droplets of mucus, but also through the air with tiny particles. In addition to the passengers of one of the buses, seven more participants in the ceremony in the temple fell ill.All of them had close contact with an infected woman. The ceremony lasted 2.5 hours, then the people dined together in a spacious but unventilated room. Then those who got there by buses took the same places and went back.

With the approach of cold weather, people will increasingly find themselves in similar situations. If possible, large crowds should be avoided in poorly ventilated areas where masks are not worn.

Prepared by Marat Kuzaev

90,000 Heart sounds: cardiologist of the FTsVMT Pavel Zolotukhin talks about heart murmurs in adults

Heart murmur in adults

Sometimes, when listening (auscultation) of the heart, doctors talk about the presence of some kind of “noise”.What are these sounds? Are they dangerous to health? Are there signs of heart disease? Let’s try to figure it out.

The article was published in the new issue of the journal of the Center for High Medical Technologies.

Read entire issue

The work of the heart is always accompanied by sounds. In the overwhelming majority of cases, there are two of them. They are called the first and second heart sounds because they follow each other and make up the heart cycle together. Tones are associated with vibrations of various structures of the heart, as well as the muscles and walls of blood vessels during the movement of blood.The cardiac cycle consists of two large phases. The first phase, which begins with the first tone, is systole, when blood is expelled from the heart by the force of muscle contraction into large vessels (aorta and pulmonary artery). Therefore, the first heart sound is also called systolic. The second phase begins with the second tone and is called diastole. At this time, the heart muscle relaxes, and the chambers of the heart are filled with a new portion of blood. Another name for the second tone is diastolic. Heart sounds have certain signs that characterize their duration, sonority, time of occurrence.

All other sounds that occur while listening to the heart are called “noises”. The characteristics of the noise depend on the general condition of the person, his constitution, the frequency of the rhythm and many other factors. It is important to understand that any sound outside the normal two-tone cardiac cycle requires compulsory comprehensive assessment and attention.

Noises are divided into two large groups: organic and functional.

The first group – organic murmurs – occurs with various structural changes in the heart.This means that they are based on heart defects – congenital or acquired. The noise may indicate, for example, damage to the heart valves – valve stenosis, valvular insufficiency, or their simultaneous combination. Organic noise also appears with cardiomyopathy (enlargement of the cavity of the heart chambers or hypertrophy (thickening) of the myocardium), endocarditis (inflammation of the inner lining of the heart (endocardium), acute pericarditis (inflammation of the pericardial sheets lining the heart outside).All of these pathologies are very serious and life-threatening conditions that require urgent medical attention. Therefore, the presence of “murmur” in the heart is an important signal for additional diagnostics and detection of the disease.

The second group of murmurs, the so-called functional murmurs, are either not associated with the heart, or are based on abnormalities that do not affect its work. The causes of functional noise are different. They can occur due to vegetative-vascular dystonia, as well as during the period of rapid growth in children and adolescents.Also, sometimes they testify to some features of the structure of the human heart that arose during intrauterine development. In this case, a systolic murmur can accompany a person throughout his life. In addition, functional murmurs can be caused by the anatomical features of large bronchi located next to the aorta and pulmonary artery, which simply “squeeze” these vessels with accelerated blood flow through their valves. Prolonged overstrain, both mental and mental, and physical, can contribute to the appearance of noise.One of the common causes of sound phenomena is pregnancy, during which there is an increase in the volume of circulating blood in the mother’s body for optimal blood supply to the fetus. In this regard, during pregnancy, changes in intracardiac blood flow also occur with listening to systolic murmur. In some cases, functional murmurs, although not associated with problems in the heart itself, often indicate other, sometimes serious diseases. Functional noises can also appear against the background of metabolic disorders.For example, with anemia (a decrease in hemoglobin in the blood), thyrotoxicosis (an excess of thyroid hormones) or with fever.

Very often the patient does not even suspect about the presence of heart murmurs, and even more so, about the type and cause of their occurrence. A heart murmur can be diagnosed by a doctor while listening to it. You need to see a doctor if you have any of the following symptoms:

Symptoms of a murmur in the heart:

  • Rapid heart rate at rest and light exertion.
  • Shortness of breath. Pay attention to your health if even walking makes you short of breath.
  • Chest pain that worsens after exercise.
  • Blue lips and fingertips from brisk walking or running.
  • Swelling of the extremities.

The presence of one or more of the above symptoms is a reason to see a doctor. And remember – heart murmur is not always caused by a serious illness.But all the same, you should undergo an examination on time in order to exclude such a disease or, if it is detected, to start treatment in a timely manner.

Pericarditis: diagnosis and treatment of heart inflammation in Odessa

Types of pericarditis

Distinguish between dry and exudative pericarditis.

At dry pericarditis there is almost no fluid, and the pericardial sheets rub against each other. Because of this, there is a very strong constant pain, aggravated by breathing.

At exudative pericardium , on the contrary, a huge amount of fluid accumulates between the leaves of the heart sac. It compresses the chambers of the heart, and the heart cannot cope with its function. The patient develops heart failure, and in the most severe cases, a tamponade: the heart cannot contract and the person dies.

If pericarditis is left untreated, pericardial tissue may degenerate and acute pericarditis becomes chronic.

Over time, the fluid dissolves, the walls of the pericardium thicken, the cavity is overgrown and the so-called constrictive pericarditis occurs.It is also called the “carapace heart”: the pericardium forms a hard carapace around the heart, which prevents the heart from contracting. It beats inside, but cannot fully fill with blood and throw it out.

Causes of pericarditis

Most often, it is impossible to determine the exact cause of pericarditis. It almost always develops as a complication of other diseases or injuries. If pericarditis is not treated, it quickly becomes the main problem – not only because inflammation is accompanied by severe pain in the heart, but also because its consequences are much more dangerous than most diseases that led to inflammation.

The main causes of pericarditis include:

  • infections and viruses are the most common cause;
  • diseases caused by bacteria, including rheumatism and tuberculosis;
  • fungal diseases: often they are latent, and pericarditis develops already in the late stages;
  • pericardial injuries: gunshot wounds, stab and cutting injuries, injuries from impacts, traffic accidents or falls from a height;
  • radiation sickness, as well as radiation therapy for tumors in the chest cavity;
  • myocardial infarction;
  • heart surgery;
  • systemic connective tissue diseases and other autoimmune processes: systemic lupus erythematosus, rheumatoid arthritis, systemic scleroderma, sarcoidosis, vasculitis;
  • endocrinological disorders, in particular, hypothyroidism, gout;
  • renal failure;
  • allergic diseases;
  • malignant tumors, especially in the breast.

Symptoms of pericarditis

Acute pericarditis is more dangerous, as it develops rapidly – within a week or two. Due to inflammation, the pericardium quickly fills with fluid or, conversely, dries out, due to which its walls stick together.

This is the main symptom of pericarditis – severe pain and heaviness behind the breastbone and in the heart area already in the first hours after the onset of inflammation. The localization of pain varies depending on the position of the body and intensifies in the supine position, when food is swallowed (the liquid can be swallowed practically without pain), coughing and deep breathing.

Other symptoms of pericarditis include:

  • temperature rise,
  • weakness, loss of appetite, weight loss,
  • shortness of breath, feeling short of breath,
  • cough,
  • dizziness,
  • swelling of the legs and abdomen,
  • arrhythmia.

Chronic pericarditis can be symptom-free for a long time.


Pericarditis, which develops against the background of other chronic diseases, can be difficult to detect even in a hospital setting.This requires a comprehensive diagnosis, which will help to distinguish the signs of pericarditis from the manifestations of concomitant diseases.

The basis for suspicion of pericarditis may be the results of the initial examination of the patient by a cardiologist – noises when listening with a stethoscope, similar to crackling, creaking, rustling of sheets of paper, rhythmic rustles. These signs appear literally an hour after the onset of inflammation and persist at all stages of the disease.

To clarify the diagnosis, the doctor prescribes the following studies:

  • Electrocardiography – gives an idea of ​​the heart rate and abnormalities in the work of the pericardium,
  • chest x-ray or EchoCG – allows you to see how fluid is distributed in the pericardium,
  • general and biochemical blood test,
  • Additional tests to clarify the cause of inflammation, such as pericardial biopsy or pericardial fluid analysis.

Pericarditis treatment

To cure pericarditis, first of all, it is necessary to cure the disease that caused the inflammation of the pericardium.

If pericarditis is caused by an infection, antibiotics are prescribed. Pericarditis caused by viral diseases is treated symptomatically with the use of antiviral drugs.

Pericarditis diagnosed in time, with proper treatment, rarely gives complications. But nevertheless, sometimes against the background of inflammation of the pericardium, heart failure, cardiac tamponade, pathological deposition of salts in the heart can develop.

Rarely, surgery is required for pericarditis. In particular, the operation is indicated for constrictive pericarditis, in which the pericardium compresses the heart. In this case, pericardectomy is performed – removal of the cardiac membrane.

90,000 Epidural analgesia in adults with heart surgery with or without a heart-lung machine

Review Question

We decided to study the effect of epidural pain relief on the number of postoperative deaths and the risk of cardiac, pulmonary, and neurological complications in adult heart surgery based on the results of randomized clinical trials.

This review was first published in 2013 and updated in 2019.


For epidural pain relief, a local anesthetic, opioid, or a mixture of these drugs is injected through a catheter into the epidural space, which is located on the outside of the membrane that surrounds the spinal cord. Epidural pain relief could reduce the risk of complications after surgery, such as lung infections, including pneumonia, difficulty breathing (respiratory distress), heart attack, and irregular heart rhythm caused by atrial fibrillation.The concern is that during heart surgery, blood must be thinned to reduce clotting. And it can increase the chances of bleeding around the spinal cord. The accumulation of blood puts pressure on the spinal cord and can lead to permanent nerve damage and disability.

Research characteristics

We included randomized controlled clinical trials in adults who underwent any cardiac surgery under general anesthesia with or without cardiopulmonary bypass, and in which investigators compared epidural pain relief in the perioperative period (period “around” the operation – before, during, after surgery) with other forms of pain relief.Surgeries performed included coronary artery bypass grafting, heart valve surgery and congenital heart disease. The average age of the participants was from 43 to 75 years. Outcomes were measured within a year after surgery.

We included 69 studies with 4860 participants. Where indicated, research was funded by public funds (five studies), philanthropy (eight), institutional funds (23) and, in part, by industry (two).Overall, 31 trials did not indicate a funding source. The evidence is current to November 2018.

Key Outcomes

When the researchers compared epidural pain relief with systemic pain relief (for example, by injecting pain reliever directly into a vein), they found no difference in the number of deaths in the first 30 days after surgery (38 studies, 3418 participants). There may be differences in the number of people who have had heart attacks (26 studies, 2713 participants).These findings are supported by low quality evidence. We found a small reduction in the risk of respiratory depression with epidural pain relief (21 studies, 1736 participants), but not in the risk of pneumonia (10 studies, 1107 participants) (low to moderate quality evidence). The reduction in the risk of respiratory depression was more evident with cardiopulmonary bypass surgery. Epidural analgesia reduced the risk of atrial fibrillation and atrial flutter early in recovery, in the first two weeks after surgery (18 studies, 2431 participants; moderate-quality evidence).There were no clear differences in the number of cerebrovascular events (18 studies, 2232 participants), and there were no reports of long-term neurological complications or epidural hematomas (53 studies, 3982 participants; very low or low-quality evidence). Although epidural analgesia may have shortened the duration of tracheal intubation, this was noted mainly in older studies and clinical practice has changed since then (40 studies, 3353 participants; moderate-quality evidence).

We found only six studies comparing epidural analgesia with local anesthetic on the body surface to create blocks of peripheral nerves, directly into the space around the lungs (intrapleural analgesia) and into a surgical wound (wound infiltration). These studies provided low to very low quality evidence and did not report many of the outcomes of this review. The study authors reported no heart attacks or epidural hematomas.

Quality of evidence

We rated the quality of the evidence as moderate, low, or very low. There are too few participants in our review to argue that there is no difference in the number of deaths of patients who received epidural or systemic analgesia, and there is no increase in the risk of epidural hematoma formation.

Pericarditis in dogs and cats


  1. Symptoms
  2. Predisposition to pericarditis
  3. Diagnosis
  4. Treatment

Perhaps many have never heard of this disease in animals touch on this topic.Very often this diagnosis remains undetermined, which means that the animal does not receive proper treatment, and sometimes it loses its life due to “something with the heart”. But knowing the features of this disease, the owner can render a great service to his pet.

Pericarditis in dogs and cats is an inflammation of the outer lining of the heart. The pericardium covers the heart and great vessels, normally contains from 1-15 ml of liquid rich in phospholipids, which provides sliding without additional friction.


The most common complaints from owners of dogs with pericarditis are lethargy, exercise tolerance, lack of appetite, collapse or fainting, bloating and shortness of breath, mucosal pallor, bluish mucous membranes.The intensity of the clinical manifestations of pericarditis, directly, depends on whether the process is acute or chronic and on the volume of free fluid in the pericardial cavity.

If your pet has pericarditis or the symptoms described above, please contact one of our veterinary centers at +7 499 110 66 86 (24 hours a day).

Predisposition to pericarditis

Pericarditis, according to various sources, occurs in middle-aged and elderly dogs and makes up from 3.5 to 0.4% of all dogs examined by a cardiologist.These are mainly dogs of large and medium breeds, over 5 years old, more often males, there is a breed predisposition (Labradors, Golden Retrievers, German Shepherds, Great Danes).

There are no statistics on pericarditis in cats, but on average the figure does not exceed 1-5% and is mainly associated with infectious peritonitis, less often it is a consequence of congestive heart failure.

According to various sources, neoplasms cause pericarditis from 30% to 80%, which is nevertheless a low percentage of the total number of neoplasms (only about 0.19%).In cats, the figure is even lower, it is only 0.03% and almost always lymphomas.


The diagnosis is based on the data of physical examination, X-ray, ECHOkg of the heart, blood tests, ECG.

Examination of an animal with suspicion of pericarditis should be carried out efficiently, but with some caution. Often the patient comes to the doctor’s office in a serious condition, with severe symptoms of right-sided heart failure, as a result of cardiac tamponade, sometimes such symptoms can develop during the day.At the same time, weakness, shortness of breath are expressed, cardiac impulse is reduced, pulse is weak or not felt at all, jugular veins are dilated, mucous membranes are pale, SNK is more than 3-5 s. Abdominal enlargement due to ascites and wheezing due to developing pulmonary edema and chest effusion may also be observed. Such patients should not be thoroughly diagnosed; it is enough to make sure of the presence of free fluid with the help of ECHO and carry it through a skin puncture of the pericardium.

If the patient’s condition is more stable, a thorough examination should be performed.X-ray examination reveals the rounded contours of the heart. Also, the method allows you to determine the metastasis of the lung tissue.

On ECG , R-wave alteration is diagnosed, sometimes a decrease in voltage and depression of the ST segment.

The gold standard for diagnosing pericarditis is cardiac echocardiography, this method also allows you to assess hemodynamics, the presence of chest effusion, and sometimes to identify neoplasms (the right atrium is most often affected).The presence of fluid in the pericardial cavity is defined in all projections as an echo-negative space bounded by the pericardial layers; abnormal (from side to side) movement of the heart is also observed.

Blood tests are required for differential diagnosis. Sometimes they may not have serious abnormalities, but leukocytosis, increased urea and creatinine, anemia are common.

Analysis of the pericardial fluid is used for differential diagnosis.The resulting material is examined to identify the causative agent of the infection, exclude a purulent process. The resulting fluid is sent for cytological examination to exclude the tumor genesis of the disease


Depends on the rate of development of the process and the cause of the disease, and is mainly reduced to three components:

– pericardial puncture and fluid removal.

– antibiotic therapy and heart failure control.

– pericardiotomy.

Conservative treatment. If it was possible to identify the pathogen is selected individually, routine antibiotic prescription is recommended for all patients to prevent complications. Diuretics and ACE inhibitors are also indicated, but with caution so as not to provoke a decrease in blood pressure. It is important to control the work of the kidneys, as they primarily suffer from sudden changes in pressure. With severe anemia, iron and folic acid preparations are recommended, in acute cases – blood transfusion.It is also possible to use drugs with antihypoxic and antioxidant properties.

In cats, conservative treatment is more effective, and almost always proceeds with the appointment of steroids. Surgical treatment is ineffective because in severe cases, unlike dogs, pulmonary edema often develops.

It is better to prepare a wide surgical field from 2 to 8 intercostal space, the puncture is performed in the thoracic position or in the lateral position. On the right side to reduce the risk of injury to the left coronary artery.To do this, use guides from under intravenous catheters, the catheters themselves or spinal needles, depending on the size of the patient. Before puncture, sedation is necessary (nalbuphine 0.4 mg / kg + propofol 6 mg / kg if necessary), most patients, due to the severity of the condition, behave calmly. It is also important to provide venous access, a resuscitation kit and control of the electrical activity of the heart and pressure.

The injection site can be infiltrated with a 1% lidocaine solution, usually the injection is performed in 4-5 intercostal spaces, slightly above the junction of the ribs with the sternum, an ultrasound sensor can also be used to select a site.Due to the fact that the pericardium is overstretched, it is not always possible to feel resistance when it is punctured, so you can focus on the free movement of the needle tip, the depth of needle insertion, and the presence of fluid freely flowing under pressure. If the fluid is serous or purulent, it is important not to confuse it with the contents of the chest, and hemorrhagic exudate with blood from the chambers of the heart. To clarify the location of the needle, you can use an ultrasound sensor, also when the myocardium is injured, as a result of a puncture or touching with a needle, ventricular extrasystoles often appear on the ECG.

In response to fluid removal, the patient’s condition improves rapidly, primarily due to an increase in cardiac output. After aspiration of fluid, it is necessary to carry out replacement therapy with colloidal and crystalloid solutions and leave the patients for observation for at least 6-12 hours.

Often a single puncture is not enough, you have to repeat them 3-4 times or resort to pericardiotomy. It is important to inform the owner of this so that he is prepared for possible deterioration and constantly keeps in touch with the attending physician.According to some reports, timely surgical treatment can significantly increase the duration and quality of life. For patients with idiopathic pericarditis, it can also have a therapeutic effect and does not allow the development of concentric pericarditis, with tumor pericarditis, this will avoid tamponades, improve the quality of life and obtain material for histological examination, which means the possibility of chemotherapy. As for excision of neoplasms, opinions differ here.Surgical excision of angiosarcoma will have a poor prognosis, given that micrometastases are usually already present, the average survival rate is about four months. With other types of neoplasms, the survival rate is slightly higher up to 5-8 months. After performing pericardiotomy, the survival rate increases (according to some reports, up to 3 years).

Conclusion: Males are more prone to pericarditis, the average age is 5-12 years, the Labrador Retriever is a more susceptible breed.Echocardiography is the most sensitive diagnostic tool for pericarditis, in particular, it makes it possible to differentiate between various acquired heart diseases that cause cardiomegaly on radiographs.