Management of Pericardial Disease Complicating Acute Coronary Syndrome

The pericardium is a sac containing the heart and proximal parts of the great vessels [1, 2]. It consists of two layers:

• The visceral pericardium is a single-layer serous membrane that refl ects back near the origins/insertions of the great vessels and becomes continuous with and forming the inner layer of the parietal pericardium.

• The parietal pericardium is an acellular tough, fi brous coat composed mainly of collagen and elastin fi bers, about 2 mm thick, and surrounds most of the heart.

The space between the two serous layers is named pericardial space and normally contains up to about 50 mL of plasma ultrafi ltrate. The left atrium is largely an extrapericardial chamber, explaining why the effusions generally are not seen behind this structure [2, 3]. The parietal pericardium is anchored by ligamentous attachments to the diaphragm inferiorly and to the sternum anteriorly. These ligamentous attachments ensure that the heart occupies a relatively fi xed central position within the thoracic cavity regardless of phase of respiration and body position. Pericardium receives its arterial supply from branches of internal thoracic and musculophrenic arteries as well as directly from descending aorta. The veins are tributaries of the azygos system [2]. Pericardium is innervated by branches from vagus, phrenic nerves, and the sympathetic trunks [2]. Of importance is the fact that phrenic nerves descend on the lateral sides, between the fi brous pericardium and mediastinal pleura.