**3. Pathology**

There are a number of pericardial pathologies which can be a cause for concern in the peri-operative period [2–4, 9, 10].

#### **3.1 Congenital defects**

Congenital defects are rare, usually associated with other cardiac, pulmonary and skeletal abnormalities, and are often only found at autopsy with an incidence of 1:10,000 [9]. The absence of the pericardium is more commonly partial with the left side being affected about 70% of the time. Left-sided defects predispose to herniation of the heart which may become haemodynamically significant during

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*Anaesthesia for Patients with Pericardial Disease DOI: http://dx.doi.org/10.5772/intechopen.82540*

**3.2 Acute pericarditis**

may be present on examination.

sions with tamponade.

cardiac diseases.

induction of anaesthesia or cause prolonged ischaemia due to compression of the coronary vessels. Right-sided defects may cause significant compression of the vena cava compromising venous return and cardiac output. Total pericardial absence is rare. Excessive cardiac motion and displacement associated with complete absence

Acute pericarditis is an inflammatory disease of the pericardium lasting less than 6 weeks and the most common pericardial pathology encountered in clinical practice [6, 9–16]. It may be a self-limiting benign condition or the first presentation of an underlying infectious or neoplastic disease process. In this setting, it is prudent to postpone elective surgery for diagnosis and initiation of appropriate treatment. Causes of acute pericarditis vary widely and may be idiopathic, infectious, non-infectious or autoimmune. The most common causes encountered in the perioperative period are non-infectious post-cardiac surgery, associated with trauma, uraemia in patients with chronic renal failure or post-myocardial infarction.

Symptoms include a sharp left precordial or retrosternal chest pain which may

In the peri-operative period, differentiating between acute pericarditis and other causes of chest pain is of utmost importance. Careful clinical examination and special investigations should be carried out to make the correct diagnosis and allow for the institution of appropriate treatment. Three of the more important differential diagnoses are acute coronary syndrome, aortic dissection and pulmonary embolism. Patients suffering from pericarditis associated with bacterial or fungal infections, malignancies, end-stage renal disease or post-cardiac surgery are at an increased risk to progress to pericardial effusion and tamponade [12].

*Post-cardiac injury syndromes*, also known as post-pericardiotomy syndromes, are being recognised as an important cause for pericardial disease [13, 14]. This clinical syndrome is characterised by a febrile illness associated with pleuritic chest pain and effusions of the pleura and pericardium. The initiating event is an injury to the pericardium, myocardium and pleura from ischaemia, post surgery or a noniatrogenic traumatic event. In predisposed individuals, an autoimmune-mediated response is triggered that can vary from a simple, self-limiting pericarditis to a complicated pleuropericarditis, resulting in massive pericardial and pleural effu-

Special investigations would include a 12-lead electrocardiogram (ECG) which will show sinus tachycardia, PR interval depression and diffuse concave upward sloping ST-segment elevation. Transthoracic echocardiography (TTE) may show an associated pericardial effusion and tamponade as well as other cardiac or para-

Treatment for acute pericarditis remains symptomatic with non-steroidal anti-inflammatory drugs (NSAIDs) for pain and potentially adding colchicine as an adjunct to prevent recurrence [15]. Low-dose corticosteroids may also be introduced by the primary care team if there is an associated autoimmune disease or in

the case of a post-cardiac injury syndrome [13, 14, 16].

be pleuritic in nature and varies with posture, being decreased on sitting and increased on lying supine. The pain may radiate to the trapezius ridge. This pain referral is due to the involvement of the phrenic nerve which traverses the pericardium and supplies its sensory innervation. Often there are associated prodromal symptoms of malaise, fever and generalised myalgia. Tachycardia and tachypnoea are usually out of proportion to the low grade fever. A tri-phasic friction rub corresponding to atrial systole, ventricular systole and rapid early filling during diastole

predispose to an increased risk of traumatic aortic dissection.

induction of anaesthesia or cause prolonged ischaemia due to compression of the coronary vessels. Right-sided defects may cause significant compression of the vena cava compromising venous return and cardiac output. Total pericardial absence is rare. Excessive cardiac motion and displacement associated with complete absence predispose to an increased risk of traumatic aortic dissection.
