Causes and routes of infection spread
The disease extremely rarely occurs on its own. A primary process is possible exclusively in cases of direct penetrating wounds of the heart or the pericardial sac itself. In the vast majority of cases, this is a secondary pathology developing as a complication.
Infection can enter the pericardial cavity in three ways:
- Lymphogenous (most common).
- Hematogenous (less common).
- Contact (spread of inflammation from adjacent anatomical structures).
Sources may include purulent mediastinitis, purulent pleuritis, peritonitis, as well as a liver abscess. Sometimes inflammation is triggered by more distant or systemic foci: osteomyelitis, erysipelas, various phlegmons. In addition, the pathology can become a postoperative complication following intrathoracic surgical interventions.
Inflammatory dynamics and tissue changes
The inflammatory process starts with pronounced hyperemia and tissue edema. Then, exudate begins to accumulate in the cavity. At first, it is serous in nature, but over time it transforms into purulent.
Sometimes the effusion becomes hemorrhagic. This occurs due to continuous heart contractions, which lead to microtrauma of blood vessels dilated due to inflammation. The total volume of accumulating fluid can reach 0.5–1.5 L.
The infection often spreads to the epicardium and myocardium with the development of secondary myocarditis. Fibrin precipitates on the leaflets of the pericardium. Over time, this causes the surfaces to stick together, the formation of intrapericardial adhesions, and, with massive proliferation of adhesions, complete obliteration (fusion) of the cavity.
Clinical presentation and prognosis
The symptoms of purulent pericarditis are based on two key pathological factors:
- Cardiac compression by a massive accumulation of exudate (significantly hinders the adequate pumping function of the organ).
- Severe purulent intoxication of the body.
The prognosis for this pathology is always serious. Even with successful treatment and a reduced risk of immediate mortality, coarse scars often form in the pericardium. Subsequently, these scarring changes limit myocardial mobility and cause severe heart failure.
Surgical treatment: Pericardiotomy
Treatment often begins with aspirations (punctures). If 3–4 therapeutic punctures are unsuccessful, the patient's condition remains severe, and pus accumulates rapidly, open intervention — pericardiotomy — is indicated. The goal of the surgery is to ensure a continuous outflow of pus through the lowest point of the pericardial sac. The operation is prescribed only when closed treatment is ineffective due to the risk of secondary infection.
Execution Technique:
- The intervention is performed under general anesthesia or local anesthesia.
- The approach is performed — an incision along the xiphoid process.
- The process is transected at its very base and reflected upward.
- The upper surface of the diaphragm and pericardium is exposed, after which the pericardial sac is opened directly above the diaphragm.
- After evacuating the purulent contents, a drain is installed so that the edges of the wound do not stick together. Important: the tube must not be inserted deeply so as not to injure the beating heart.
The surgery is only part of comprehensive treatment. It must necessarily be supplemented by antibacterial and detoxification therapy, as well as active treatment of the primary disease that caused the pericarditis.
To remember the main sources of secondary pericarditis, focus on "neighbors" (mediastinitis, pleuritis, liver abscess) and "systemic infections" (osteomyelitis, phlegmons, erysipelas).
Class and exam questions
When is purulent pericarditis primary?
Primary inflammation occurs exclusively after penetrating wounds of the heart and the pericardial sac itself.
Why can exudate in pericarditis acquire a hemorrhagic character?
This occurs due to continuous heart contractions that cause microtrauma to blood vessels dilated due to severe inflammation.
What are the main indications for performing a pericardiotomy?
Surgery is resorted to in cases of rapid pus accumulation, a severe patient condition, and the complete lack of effect from 3–4 previously performed therapeutic punctures.
What is the delayed danger of the disease even after successful treatment?
There is a high risk of coarse adhesions and complete obliteration of the pericardial cavity, which in the future leads to severe heart failure.
What else to study on this topic
- Technique of pericardial puncture in purulent inflammation
- Specifics of antibacterial and detoxification therapy
- Pathogenesis of heart failure in exudative compression (tamponade)
- Mechanism of formation of intrapericardial adhesions and scars
- Thoracostomy surgery and its connection with intrathoracic purulent processes
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Other topics from the section "CHAPTER 11. SURGICAL INFECTION (PURULENT-INFLAMMATORY DISEASES)"
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