Konstriktivny perikardit – the fibrous thickening of leaves of a pericardium and an obliteration of a pericardiac cavity leading to a sdavleniye of heart and violation of diastolic filling of ventricles. Konstriktivny perikardit is shown by weakness, short wind at physical activities, puffiness and cyanosis of the person, swelling of cervical veins, a gepatomegaliya, ascites, hypostases. The diagnosis of a konstriktivny perikardit is confirmed by data of a laboratory research, the ECG, EhoKG, X-ray analysis, KT and MPT of heart, a biopsy of a myocardium, sounding of cavities of heart. At a konstriktivny perikardit surgical treatment – a perikardektomiya is shown.
Konstriktivny perikardit is among adhesive perikardit and is the most severe form of pericardiac pathology. Prevalence of a konstriktivny perikardit does not preyovyshat 1% of all diseases of cardiovascular system. At men konstriktivny perikardit meets by 3-5 times more often, usually the disease develops at the age of 20 - 50 years. As synonyms of a konstriktivny perikardit in cardiology serve the concepts "squeezing perikardit", "armour-clad heart".
Reasons of a konstriktivny perikardit
Konstriktivny perikardit can be called by recently postponed sharp or chronic ekssudativny perikardit of various genesis. The most widespread etiologichesky factor of a konstriktivny perikardit (in 30% of cases) is tuberculosis, bacterial, viral and fungal infections are more rare.
Emergence of a konstriktivny perikardit can be connected with wounds, thorax injuries, radiation of a sredosteniye, new growths (limfogranulomatozy, a breast cancer). Konstriktivny perikardit can develop several weeks later or months after cardiac intervention. In yard of cases konstriktivny perikardit acts as a complication of diffusion diseases of connecting fabric (rheumatoid arthritis, a system red volchanka) and a terminal renal failure (at patients on a hroniyochesky hemodialysis).
Now the number of cases of an idiopathic konstriktivny perikardit which reason remains neyoizvestny grows.
Pathogenesis of a konstriktivny perikardit
Formation of rough cicatricial fabric at a konstriktivny perikardit leads to consolidation and reduction of the sizes of the pericardium squeezing heart and preventing normal expansion and filling of ventricles during a diastola. Adjournment of calcium in a pericardium meets at a long current of a konstriktivny perikardit and can be continuous ("armor-clad heart") and limited, in the form of a fibrous and limy strip on an atrioventricular furrow, around hollow or pulmonary veins.
At a konstriktivny perikardit also cardiac muscle and surrounding bodies is exposed to sclerous defeat: a pleura, a diaphragm, a subdiafragmalny peritoneum, hepatic and splenic capsules, trunks of coronal arteries with development of a diffusion miofibroz and coronary insufficiency. The Utolyoshchenny calciphied pericardium at a konstriktivny perikardit can grow to a diaphragm, a pleura and fabrics of a sredosteniye, to squeeze the top and lower hollow veins, a portal vein.
Restriction filling of the right ventricle during a diastola and venous return to the right auricle promotes increase in pressure in system veins and to development of right ventricular insufficiency. Partial filling of the left ventricle at a konstriktivny perikardit leads to decrease in shock volume, warm emission and arterial pressure. Owing to decrease in working load of muscle fibers the atrophy of a myocardium and reduction of mass of heart is observed.
Symptoms of a konstriktivny perikardit
In most cases konstriktivny perikardit has gradually progressing current including 4 periods: hidden, initial, the expressed clinical manifestations and dystrophic. During the hidden period of a konstriktivny perikardit (lasting from several months up to several years) the residual phenomena the postponed sharp or initially chronic perikardit, formation in a pericardiac cavity of the easy solderings which are not exerting negative impact on work of heart and the general haemo dynamics are noted.
The fibrous sdavleniye of heart with gradual violation of haemo dynamics in an initial stage of a konstriktivny perikardit is characterized by emergence of the general weakness, stable intolerance of physical activities; development of fatigue and short wind when walking and physical tension. Puffiness and cyanosis of integuments of the person, neck, auricles, swelling of cervical veins, increase in the central venous pressure (CVP), tachycardia, pulse of small filling and the muffled tones of heart are observed. The initial stage of a disease is followed by a gepatomegaliya, weight in the right podreberye, an abdominal distension, appetite loss, dyspepsia, weight loss.
During the expressed clinical manifestations of a konstriktivny perikardit strong weakness, sharp and permanent raising of TsVD is noted (more than 250-300 mm w.g.), strengthening of puffiness and cyanosis of the person and neck ("consular head"), development of considerable ascites. At a konstriktivny perikardit usually is absent, its development is possible at the accompanying gidrotoraks or high standing of a diaphragm owing to ascites.
In a dystrophic stage at patients with a konstriktivny perikardit extreme deterioration in the general state with the sharp exhaustion, degenerate changes in bodies and heavy functional violations of a liver expressed by an asthenic syndrome, hypostases of the lower and top extremities, persons and bodies is noted. An atrophy of skeletal muscles, contractures of large joints and trophic ulcers develop, at most of patients violation of a warm rhythm is observed.
Possible complications of a konstriktivny perikardit are vibrating arrhythmia (at 70% of patients), miokardialny insufficiency, kardialny cirrhosis, a nephrotic syndrome, an ekssudativny enteropatiya, at the long course of a disease - "armor-clad heart".
Diagnostics of a konstriktivny perikardit
Diagnostics of a konstriktivny perikardit is helped by studying of the anamnesis, carrying out fizikalny survey, a laboratory research, the ECG, EhoKG, X-ray analysis, KT and MPT of heart, a biopsy of a myocardium, sounding of cavities of heart.
Fizikalny inspection of the patient with a konstriktivny perikardit reveals a gepatomegaliya, the expressed ascites, peripheral hypostases, a bloated face with a tsianotichny shade (a syndrome of the top hollow vein), the sharp swelling of cervical veins amplifying on a breath (Kussmaul's sign). High TsVD, a resistant takhikaryodiya, decrease in pulse pressure, small soft (sometimes paradoxical) pulse, lack of a top push, an additional pericardium tone is characteristic.
The changes at a konstyoriktivny perikardit revealed during the ECG confirm involvement of a myocardium in inflammatory and cicatricial processes, development of an atrophy of a cardiac muscle and a hypertrophy of auricles. The results of EhoKG received at patients with a konstriktivny perikardit show a pericardium thickening, existence of pericardiac unions, lack of increase in the sizes of heart, the paradoxical movement of an interventricular partition.
The X-ray analysis of heart allows to define reduction of the size of heart, impoverishment of the drawing of roots of lungs, existence of adjournment in a pericardium of the centers of calcium, expansion of the top hollow vein, ekstrakardialny unions, a pleural exudate. Biochemical blood test finds signs of functional violations of a liver in a considerable part of patients with a konstriktivny perikardit: gipoalbuminemiya, proteinuria, povyyosheniye of level of bilirubin and urea, increase in bromsulfoleinovy test.
For the purpose of specification of the diagnosis of a konstriktivny perikardit carry out MCKT and MPT, a ventrikulografiya, a myocardium biopsy, sounding of cavities of heart; in the most difficult cases resort to a diagnostic torakotomiya for direct survey of a pericardium.
The differential diagnosis of a konstriktivny perikardit is carried out with myocardium diseases (heavy myocarditis, a dilatatsionny and restrictive cardiomyopathy, coronary heart disease, essentsialny arterial hypertension), damages of heart at an amiloidoza, hemochromatosis, a sarkoidoza and a system sklerodermiya; chronic pulmonary heart; insufficiency of the trikuspidalny valve, mitralny stenosis; miksomy right auricle; cirrhosis and cancer of a liver, thrombosis of a voyorotny or hepatic vein.
Treatment of a konstriktivny perikardit
At a konstriktivny perikardit conservative therapy is inefficient, the only radical method of treatment - the perikardektomiya consisting in fuller removal of pericardial bag and release of heart and vessels from a sdavleniye. Before carrying out operation the low-salt diet and reception of diuretics are shown. Full surgical excision of the calciphied and soldered to heart pericardium is connected with risk of perforation of walls of heart, an injury of coronary arteries and hollow veins, danger of bleeding. The lethality at a perikardektomiya makes 5%.
At a konstriktivny perikardit of tubercular genesis antitubercular medicines are shown before and after a perikardektomiya. After operation medicamentous and physical rehabilitation of patients for elimination of stagnant processes and improvement of a functional condition of a myocardium is carried out.
Improvement of health after a perikardektomiya can occur at once or after a while, necessary for permanent restoration of normal warm activity. Perikardektomiya is insufficiently effective at development of irreversible changes in a myocardium and a liver.
Forecast of a konstriktivny perikardit
At not operated konstriktivny perikardit or lack of effect of a perikardektomiya the remote forecast in general adverse. Surgical treatment of a konstriktivny perikardit can provide 10-15 summer survival: in the absence of a decompensation – with an opportunity to do manual work, in the presence of the residual phenomena of heart failure – with receiving group of disability.