PERICARDIS

From Big Medical Encyclopedia

PERICARDIS (pericarditis; grech, peri around, near + kardia heart + - itis) — an inflammation of a serous pericardium, a serous cover of heart. The item is seldom observed as an independent form of pathology, usually it represents private manifestation polyserositis (see) or arises as a complication various noninfectious and infectious (sepsis, pneumonia, etc.) diseases or injuries. In a wedge. to practice carry to P. quite often and such defeats of a pericardium, in particular at diseases of blood and tumors, to-rye in strict sense do not correspond to P.'s definition as inflammatory process: hemorrhages in a pericardium, infiltration by its leukemic cells, germination by tumoral fabric, etc.

About fluid accumulation, unions of parietal and visceral plates of a serous pericardium antique doctors knew of the changes developing in a pericardium still. From the beginning of pathoanatomical openings in Europe, in 17 — 18 centuries, there were more exact descriptions of P. in Stenon's works (N. Stenon, 1669), Lanchizi (G. M of Lancisi, 1728), Hallera (A. Haller, 1756), etc. Intravital diagnosis of a pericardis became possible at the beginning of 19 century thanks to development of methods of percussion and auscultation which use allowed to establish and describe such signs of P. as expansion of absolute dullness of heart (at «an edema an okoloserdiya») and a pericardial rub. L. Nagumovich (1823) for the first time described the patient who died from a cardiac tamponade as a result of a vypotny pericardis. Zh. Buyo (1835) it is intravital diagnosed exudative P. at rheumatism. In 1882 B. M. Kernig reported about dry P. as the first differential and diagnostic symptom at angina pectoris (Kernig's sign). The isolated tubercular P. was described for the first time in 1892 by Virkhov.

In 1839 — 1840 V. A. Karavayev systematically made a paracentesis of a pericardium during flash of a scurvy in Kronstadt. Pericardiocenteses gained distribution in the eighties of the 19th century after the experimental studying of a cardiac tamponade which is carried out to Roza (E. Rose, 1884). During the same period L. V. Orlov (1882) and Rosenstein (S. R about - senstein, 1881) carried out the first pericardiotomies concerning the purulent Item.

Accumulation of knowledge of P. was promoted by achievements of bacteriology, immunology, implementation rentgenol, and other methods of a research in 20 century. Allergic perikardita became known since H. Rosenhaupt in 1905 observed P. after introduction to the child of diphtheritic antitoxin and 11 were described. after administration of antitetanic serum.

In the thirties 20 century allergic P. is reproduced experimentally.

In 1956 W. Dressier described postinfarction syndrome (see) with recurrent P. of the autoimmune nature. It helped to understand a pathogeny postkomissuro-and postperikardiotomny, and also posttraumatic and iostgemorra-gichesky And.

The operative measures at the squeezing P. and ekstraperikardialny unions undertaken at the beginning of 20 century received sufficient diagnostic and technical providing in the forties (A.N. of B akulev, BB. 10. Dzhanelidze).

CLASSIFICATION

Owing to a rare nozol, P.'s independence its classification is limited to division according to an etiology and kliniko-morfol, to manifestations. In the International statistical classification of diseases (1975) this division is presented by three headings: rheumatic P., acute not rheumatic P. and other defeats of a pericardium. More detailed etiol, P.'s classification provides their division into groups by the form etiol, factors, first of all on infectious P. and noninfectious, or aseptic, and also P. caused by protozoa (amoebic, malarial); the parasitic P. (caused by an echinococcus, a cysticercus).

Carry bacterial P. to infectious — nonspecific, most often coccal, and specific: tulyaremiyny, brucellous, salmonellezny, dysenteric, syphilitic. Holds a specific place among infectious P. tubercular P. Gruppa of not bacterial infectious P. includes virus and rickettsial P. (at flu, an infectious mononucleosis, etc.); fungal P. (actinomycosis, Candidiasis). Carry to infectious also P. which are not connected with direct implementation of the activator in a pericardium and developing as infectious and allergic if the microbic nature of allergization is proved (e.g., a rheumatic pericardis).

Noninfectious consider primary and allergic P., napr, at a serum disease; The Items caused by direct injury of heart — traumatic (at the closed injuries and local burns electrocategories) and epistenokar-dichesky at a myocardial infarction; autoallergichesky P. to which carry alterogenny - posttraumatic, postinfarction, postkomissuro-and postperikardiotomny; The Item at general diseases of connecting fabric (a lupus erythematosus and a scleroderma, a pseudorheumatism, a dermatomyositis), diseases of blood and hemorrhagic diathesis, malignant tumors, diseases with deep exchange disturbances (uraemic, gouty P.).

Allocate also idiopathic, or acute high-quality, P. which etiology is not established. Such P.'s diagnosis is made, apparently, not always reasonably in cases when it is not possible by available methods to establish an infestant, or at casuistic P.' description (the allergic nature, and also caused by rare activators, especially viruses).

On a wedge, to P.'s current divide on acute and chronic, and on kliniko-morfol. allocate to manifestations fibrinous (dry), exudative (with serous, serofibrinous or hemorrhagic exudate), purulent, putrefactive, exudative and adhesive, adhesive (adhesive) and fibrous (cicatricial).

Under definition «vypotny», or «exudative», describe only that form P. at which in a pericardiac cavity a significant amount of a liquid exudate collects. The current and diagnosis of this form P. significantly differ from the so-called dry P. which is characterized by fibrinous exudate. Purulent and putrefactive P. are described also separately from exudative.

Options P. are «pearl oyster» (dissiminations on a pericardium of inflammatory granulomas) and vypotny P. with a chyle or cholesteric exudate in a pericardiac cavity. On influence on cordial activity chronic adhesive and fibrous P. divide into the blood circulations proceeding without permanent disturbances and on konstriktiv-ny, or squeezing, P. which is quite often accompanied by calcification of a pericardium (armored heart).

The STATISTICS

P.'s Statistics is based hl. obr. on pathoanatomical data since a wedge, data on P.'s incidence are doubtful because of difficulties of intravital diagnosis. Signs active or postponed in last P. are found on opening in 3 — 4% of cases. In younger and average age groups of the woman P. by 3 times are ill more often than men; after 40 — 50 years the difference in the frequency of incidence is leveled.

In the past the number P. of an infectious origin considerably surpassed number aseptic, by data by A. A. Gerke (1950) — by 5 times. From P. which were found on opening, 15,9% made P. at sepsis, 20,5% — complicating pneumonia. Share of these II. decreased respectively to 7,0 and 1,8% due to reduction of number dying of sepsis and pneumonia (at the dead from these diseases involvement of a pericardium in process is observed at least, and even more often than in the past). Decrease in frequency of infectious P. is connected with broad use of antibiotics and there was generally due to sharp reduction of number coccal P. Odnako, according to T. Brugsh (1955), P. arises also at treatment by antibiotics at 1 — 2% of patients with pneumonia, a thicket right-hand. At P.'s tuberculosis comes to light at 4 — 5% of the dead. At rheumatism M. A. Skvortsov (1938) on the basis gistol, researches established defeat of a pericardium in 90,6% of all section cases, V. T. Talalayev (1923) — in 50% of cases. At the general decrease in incidence of tuberculosis and rheumatism the frequency of defeats of a pericardium at them did not decrease. Among aseptic forms P. uraemic, after and infarctive and tumoral P.'s frequency

the AETIOLOGY increased AND the PATHOGENY

P.'s Aetiology considerably defines also their pathogeny which corresponds in general to a pathogeny inflammations (see), developing as primary, infectious or as allergic. It is necessary to carry the factors which are initially damaging a serous cover of heart to proximate causes of development of P. Depending on the nature of these factors they can be divided on infectious (various microorganisms, fungi, the elementary) and noninfectious: immune (education in a pericardium of complexes antigen — an antibody), including ekzoallergichesky and autoimmune; toxic, in particular endotoxic (e.g., a toxaemia at uraemia); the mechanical, causing alteration of a pericardium without participation allergies and inf. agents (a transmural myocardial infarction, the closed injury of heart, electric discharge, hemorrhages). Such systematization etiol, factors has relative value for understanding of an etiology of a separate case of P. since, first, influence of these factors can be combined (e.g., an injury + an infection) and, secondly, the damaging impact on a pericardium of one factor can be ambiguous. So, e.g., microorganisms and products of their life activity can act in one cases as the initiator inf. inflammations, in others — as a toxic factor, in the third — as allergic antigens. For some P. the reasons of their emergence cannot be considered finalized — idiopathic Items.

Infectious perikardita. Before broad use of antibiotics bacterial nonspecific P. most of which frequent activators were a streptococcus, a pneumococcus, staphylococcus prevailed. With implementation in a wedge, to the practician of antibacterial therapy the prevailing place was taken by staphylococcus steady against a number of antibiotics. Other nonspecific bacterial P. in comparison with coccal meet rather seldom. Among them a specific place is held by P. caused by anaerobic flora, in particular in wounded.

From specific inf. the diseases which are followed by P. the typhoid, salmonellosises, a tularemia, pulmonary plague matter. At algidny cholera fibrinous imposings on a serous pericardium were a frequent pathoanatomical find, but this defeat of a pericardium which is usually connected with dehydration happened without participation of a cholera vibrio. Ways of penetration of the activator to a pericardium differ at different diseases. At sepsis infekt gets to a pericardium gematogenno, at pericardiac inflammations (a mediastinitis, pleurisy, a pleuropneumonia, etc.) — in the contact way or limfogenno. At a bacterial endocarditis penetration of the activator into a pericardium can be connected with an ulcer penetration in a zone of the valve of an aorta or with a septiko-embolic myocardial infarction. At some diseases, especially virus etiology, the crucial role is got by decrease immunobiol, properties of an organism. So, the course of flu, measles, chicken pox in some cases is complicated by bacterial P. of the coccal nature.

The brucellosis, a malignant anthrax, collibacillary diseases, syphilis in some cases lead to P.'s development.

The tubercular pericardis most often develops at retrograde penetration of bacilli into a pericardium on limf, to ways from mediastinal (mediastinal) and tracheobronchial limf, nodes. Distinguish two forms of defeat: tubercular P. and tuberculosis of a pericardium. Understand a rash of specific hillocks without formation of an exudate as the last: miliary tuberculosis, pearl oyster, tuberculoma of a pericardium. Speak about tubercular P. in the presence of an exudate, spayechnogs) process or calcifications. In tubercular P.'s pathogeny infectious and allergic mechanisms prevail.

The rheumatic pericardis belongs to private manifestations of a serositis at rheumatism (see) which pathogeny and etiol, communication with a streptococcal infection are intensively studied.

Virus perikardita arise more often than they manage to be verified. During a flu epidemic in 1918 — 1920 («Spaniard») found P. (usually virusnobakterialny nature) in every fourth dead. In the last decades P. caused by an influenza virus of group A or B is well studied. Damage of heart at flu (usually mioperikardit) can act into the forefront and in the absence of special serol, and virusol, researches that was qualified as idiopathic, acute nonspecific or high-quality P.

Vozbuditel of acute P. can be Koksaki's virus, and in some cases P.'s symptoms are predominating in displays of a disease. On the contrary, at an infectious mononucleosis though heart is surprised often, P. arises seldom.

P.'s cases at natural smallpox, epidemic parotitis, chicken pox, adenoviral infections are described. Evans (E. Evans, 1961) considers that any viral infection can bring in some cases to acute P.

Predpolagalas a virus etiology of so-called acute high-quality or idiopathic P. which as a special form was described by Barnes and Berchell (A. Barnes, H. Burchell) in 1942. The virus nature of a disease was allowed in view of lack of the microbic activator and taking into account that such P. is usually preceded by Qatar of upper respiratory tracts. With expansion of diagnostic opportunities sluchai1 idiopathic P. found various etiol, an explanation; part of them has the allergic nature.

Rickettsial perikardita are most known at a sapropyra. Defeat of a pericardium from this disease was found in the dead in 10,5% of cases (A. A. Gerke, 1950).

Fungal perikardita meet seldom. The actinomycosis of a pericardium results from contact distribution from primary center in lungs and a pleura. Due to the broad use of antibacterial agents a nek-swarm distribution was received by a candidiasis, at Krom the pericardium is involved in process always for the second time.

Protozoan perikardita represent an exclusive rarity. Amoebas get to a pericardium only as a result of direct distribution of pyoinflammatory process of a liver or lungs. There are data on detection in a pericardiac exudate of a malarial plasmodium.

Noninfectious (aseptic) perikardita are observed at the closed injury (traumatic P.) thorax, at intrapericardiac hemorrhages with formation of a hemorrhagic exudate in a pericardiac cavity, and also owing to other direct injuries of heart.

Epistenokardichesky P. is a consequence of necrotic changes at a transmural myocardial infarction. It is found in 20 — 30% of the dead of a myocardial infarction. At P.'s gout connect with microtraumas, deposits of salts.

The item at acute leukoses is caused by damage of a pericardium by leukemic cells or hemorrhages in a pericardium. At hron, leukoses the centers patol, a hemopoiesis arises in heart almost in half of cases, sometimes they form nodular growths or infiltrirut covers. In some cases P. develops at a lymphogranulomatosis and some lymphoma.

The item at tumors is usually connected with growth of malignant new growths, coming from a pericardium or sprouting it from the outside. Benign tumors seldom happen P.'s reason, except for the hemangiomas of a serous pericardium which are complicated by a hemopericardium which can lead to development of the Item.

Beam P. at an acute radial illness result from development of small multiple hemorrhages in both plates of a pericardium with the subsequent formation in some cases of a serofibrinous pericardis. P. is found in patients to whom radiation therapy on area of a mediastinum and the left half of a thorax was carried out in terms from 6 months up to 3 years after radiation in doses 2500 — 4000 is glad.

Uraemic P. arises at patients with a renal failure, usually in its terminal stages (it is observed more than at a half of patients). P.'s emergence not always corresponds to a high level of a hyperazotemia and is connected, apparently, with allocation by serous covers, including a pericardium, various toxicants collecting in an organism. Acute P. is observed also at the patients who are on a hemodialysis; at them the hemopericardium often develops that connect with the geparinization which is carried out against the background of uraemia. These forms proceed especially hard, lead to a tamponade, and in the subsequent — to a konstriktion of heart.

Immunogene perikardita are caused by changes of immune system of an organism under the influence of the different reasons. The general for all P. of this group is participation in their pathogeny of reactions antigen — an antibody that assumes presensitization of an organism of an ekzoallergenama (the noninfectious or infectious nature) or endoallergens which can be also the changed own body tissues.

Allergic P. are observed in some cases after administration of serums (antitetanic, etc.), at use of some drugs, at hay fever as manifestation of a syndrome of Leffler. Autoallergichesky, or alterogenny, P. arise after various damages of a pericardium; in particular, they make a cardial component of postinfarction, postkomissuro-volume and postperikardiotomny syndromes. The necrosis of a myocardium or injury of heart and its covers at surgical intervention can promote the beginning of autoallergichesky process which in the subsequent is implemented by diffusion recurrent P., pleurisy, pneumonia, arthritis. The similar syndrome arises also after bruises of a pericardium at persons with wound or a stupid injury of area of heart. Direct data on circulation in blood at patients with recurrent P. after a myocardial infarction and after a commissurotomy of the specific anti-cardial antibodies possessing a high caption are obtained.

The autoimmune mechanism of development of P. is implemented at such diseases as a system lupus erythematosus at which P. is observed more than in half of cases, a scleroderma, a pseudorheumatism, hron, active hepatitis, a lupoid syndrome of medicinal genesis.

A pathogeny of hemodynamic disturbances at a pericardis. The pericardium represents an important interoceptive zone of regulation of action of the heart and system blood circulation. The so-called basic function of a pericardium limiting limits of diastolic expansion of cameras of heart is to a great extent provided with an impulsation from receptors of a serous cover of heart. Not only formation of pain, but also a number of disturbances of functions of the blood circulatory systems and breath (decrease in the ABP, change of a heart rhythm, tachypnea) have the reflex nature at P. In initial phases and at dry P. these disturbances usually happen passing. At accumulation in a pericardiac cavity of exudate or adhesive P.'s formation and the dense connective tissue capsule significant effect on hemodynamics (see) renders also mechanical restriction of pumping function of heart because of decrease in diastolic volume of ventricles. At the same time there are no strict ratios between the volume of an exudate and extent of hemodynamic frustration. Pilot studies showed that disturbances of blood circulation (falling of arterial pressure, venous stagnation) arise when in a pericardiac cavity pressure of 50 — 60 mm w.g. is created. At slow accumulation of an exudate there is a gradual increase in volume of a pericardiac cavity, are filled slanting and cross bosoms of a pericardium, the fibrous pericardium stretches, intra pericardiac pressure significantly does not increase even at big exudates (to 2 — 3 l). At the same time there is a pushing off of lungs, their volume is limited, position of heart changes, but blood circulation at the same time significantly is not broken. At bystry exudation pressure in a cavity of a pericardium becomes positive. Venous pressure increases, advancing by 20 — 30 mm w.g. intra pericardiac that provides diastolic filling of cameras of heart with blood in new conditions. In process of increase in intra pericardiac pressure heart is squeezed more and stronger. It leads to characteristic disturbances of a hemodynamics to which to Roza (E. Rose, 1884) gave the name cardiac tamponade (see). The condition of the patient becomes incompatible with life at increase in intra pericardiac pressure to the indicators demanding increase in the central venous pressure 340 — 400 mm w.g. are higher. At profuse fluid accumulation in a pericardium and at ruptures of a wall of heart with intake of blood in a pericardiac cavity a stream venous pressure significantly does not increase; the patient perishes from a metastasis ad nervos of blood circulation earlier, than in a pericardiac cavity 300 — 500 ml of liquid will manage to collect.

Intra pericardiac liquid squeezes along with cameras of heart and the large venous trunks located vnutriperikar-dialno, and the lower vena cava pressed to a backbone can be squeezed and vneperikardialno. Changes of a corner of falling of large veins into auricles (excess) matter also. The prelum top and bottom venas cava is uneven: in a prone position outflow from an upper vena cava, in a sitting position — from lower hollow, especially from hepatic veins is preferential broken, into the forefront disturbances hepatic act and portal blood circulation (see). Mediastinal fibroadgezivny process can be also followed by deformation of large veins. Cases of vneperikardial-ny narrowing of veins as a result of cicatricial process represent, however, a big rarity. Usually passability of venous trunks is not broken, but in connection with involvement them in unions the deep breath not only does not strengthen inflow of blood to the main veins of a thorax, but even complicates it because of an excess of venous trunks. Cases of a solitary venous syndrome, i.e. build-up of pressure in one of venas cava are described: a verkhnemediastinalny syndrome (see. Stokes collar ) and nizhnemediastinalny, or a syndrome of the lower vena cava (see. Venas cava, pathology ).

Formation of vnutriperikardial-ny commissures and hems can lead to disturbance of action of the heart. If hems fix heart to a backbone, a thorax and a diaphragm, then on a breath when the thorax extends and the diaphragm falls, commissures show mechanical resistance to reduction of heart. At the same time premature ventricular contraction, paradoxical pulse, an asthma are observed. Plevroperikardialny unions do not limit reductions of heart, but lead to structural changes of adjacent departments of pulmonary fabric (marginal ectasia and a sclerosis).

Formation of a reinforced and dense (inextensible) pericardium at productive inflammatory process creates an obstacle to diastolic stretching of ventricles of heart, leads to their gipodiasto-liya and permanent hemodynamic disturbances described as a game-striktivny a syndrome. Distinguish primary and secondary gipodiasto-liya. Primary is a short-term result of the pulling together cicatricial process, secondary — depends on insufficient distensibility of the condensed pericardium at persons with the subsequent hypertrophy and dilatation of heart, i.e. develops without reduction of initial volume of a pericardiac bag. The first of these options of the squeezing P. is caused by the special sclerogene character of a fibroplastic component of an inflammation designated as pakhiperikardit; it is observed most often at tuberculosis, during a purulent pericardis and later, a hemopericardium. The second option arises at simultaneous defeat of two or all three covers of heart, most often at rheumatic P. when the formation of valve defect leading to compensatory expansion and a hypertrophy of ventricles happens already against the background of the changed pericardium.

The squeezing P. with the mechanism of primary gipodiastoliya have the greatest clinical value. At a prelum of heart because of pakhipe-rickardite of disturbance of a hemodynamics come in early terms, most often in several weeks or months after the beginning of a disease, at secondary squeezing (without retraction of the capsule) — always with the delay proceeding several years and never carry the fast-progressing character.

Direct measurements of pressure with the help catheterizations of heart (see) at patients with konstriktivny P. allowed to establish that the identical level of pressure in a right ventricle, the right auricle and the main veins is established at the squeezing P. long before the end of a diastole. It would be impossible if at the squeezing P. the obstacle in a zone of ways of inflow was the cornerstone of hemodynamic disturbances, it is higher than the level of a right ventricle of heart. Mechanisms of a konstriktion are comprehensively studied experimentally. When only the right auricle is squeezed, noticeable hemodynamic disturbances does not come as during a diastole even through the narrowed auricle the right ventricle manages to be filled with the necessary amount of blood. At a prelum of a right ventricle its diastolic volume and, therefore, productivity of a systole decreases. Pressure increases in veins and by the end of a diastole — in a right ventricle, At considerable dominance of hems around one of ventricles in the period of a diastole there is a deflection of an interventricular partition towards a free ventricle, and conditions of their filling are leveled. Efficiency in certain cases limited (only over ventricles) pericardectomies without release from unions of veins and the right auricle testifies to value of hems in the field of ventricles in development of a syndrome of a konstriktion.

Increase in venous pressure at patients with konstriktivny P. has a nek-swarm compensatory value since it leads to increase in end diastolic pressure in ventricles and, therefore, to nek-rum to stretching of the cicatricial capsule squeezing ventricles if it is a rastyazhima. After venous pressure pressure in a chest channel, pressure of cerebrospinal liquid increases.

Feature of retrograde circulatory disturbances at chronic cardial compression is early deterioration in hepatic and portal circulation. Quite often conducting a wedge, signs appear so-called cirrhosis (or a pseudocirrhosis) Peak and early the developing ascites (ascitis praecox). After successful pericardiotomies the condition of a liver at most of patients is recovered, portal hypertensia and ascites disappear.

PATHOLOGICAL ANATOMY

Distinctions in an etiology and feature of a pathogeny of P. are displayed by morphologically different options of inflammatory reaction in a pericardium, various character of exudate (see. Inflammation ).

Serous exudate is in pure form observed seldom, usually at allergic P., napr, at hay fever, a leffleroveky syndrome. The pericardium at serous P. is hyperemic, has a dim appearance, in his cavity the light transparent exudate rich with protein is found. Over time exudate resolves and morfol, P.'s signs are not defined. They appear only when transuding in a pericardiac cavity of fibrinogen begins. The formed fibrin drops out on serous surfaces, breaking their smoothness.

Fig. 1. Macrodrug of heart at a shaggy pericardium: massive deposits of fibrin on a surface of a pericardium ("hairy heart"). Fig. 2. Microdrug of heart at a shaggy pericardium: on a reinforced leaf of a pericardium (1) massive imposings of fibrin (2) with impurity of leukocytes and erythrocytes; coloring hematoxylin-eosine; X 80. Fig. 3. Microdrug of heart at a tubercular pericardis: tubercular granulomas (are specified by shooters) with existence of huge multinucleate cells of Pirogov — Langkhansa; coloring hematoxylin - eosine; X 80.

Fibrinous P. is observed at uraemia, rheumatism, at collagenoses, at P. developing kontaktno at pleurisy at surgeries on heart, virus P., etc. Fibrinous P. happens limited or diffusion; liquids in a cavity of a pericardium can not be (dry P.). A small amount of fibrin causes opacification of parietal and visceral plates of a pericardium, a large number — leads to formation of a hairy heart (tsvetn. fig. 1) when threads of fibrin hang down from a surface of an epicardium in a cavity. Sometimes fibrin is located in the form of the strips oriented on the course of the sarcomeres parallel each other. He quickly curls up, p leaves of a pericardium are covered with the dense yellowish-gray plaque having an appearance puff: sites of coagulation alternate with the centers of the partial organization, hyalinization. Microscopically the epicardium is edematous, dystrophy and desquamation of cells of a mesothelium and adjournment of fibrin in naked departments in the form of the dense layer in places burgeoning connecting fabric is noted, in to-ruyu the capillaries surrounded with inflammatory infiltrate with a small amount of lymphocytes and polymorphonuclear leukocytes grow (tsvetn. fig. 2).

At purulent P. in dense zhelatinoobrazny exudate of chartreuse color find abundance of polymorphonuclear leukocytes, erythrocytes and microbic flora. If fibrin is added, then exudate takes a fleecy form. Microscopically curtailed fibrin burgeons the connecting fabric rich with vessels; cells of a mesothelium metagglazirutsya in cubical.

Putrefactive P. develops from purulent at implementation of putrefactive bacteria; exudate gains at the same time dirty-green color, a putrefactive smell and contains vials of gas. Putrefactive exudate characterizes quite often P. at an open injury of a myocardium and at perforation in a pericardiac cavity of a round ulcer of a gullet.

Hemorrhagic P. is characterized by accession to serofibrinous exudate of blood. It is observed most often at a carcinomatosis and tuberculosis. Microscopically sometimes we will difficult distinguish from hemopericardium (see). At P. of the tumoral nature in exudate the cells of a tumor mixed with histiocytes and a mesothelium can be found.

Xanthomatous P. is characterized by exudate of yellow color with abundance of crystals of cholesterol. Histologically in an epicardium find the granulyatsionny fabric rich with foamy cells. Chyle P. is observed at an injury of the thorax which is followed by damage of a chest channel with formation of a fistula between it and a pericardiac cavity.

The partial organization of an exudate with formation of pericardiac unions (commissures) or with emergence on a surface of an epicardium of dense whitish (lacteal) spots can be acute P.'s outcome. The organization of fibrin can lead to a full or partial obliteration of a pericardiac cavity. Commissures with bodies of a mediastinum (mediasti-noperikardialny unions) can give a picture of an adhesive mediastinopericarditis. In some cases connecting fabric spreads to cellulose of a mediastinum, creating a so-called cicatricial mediastinopericarditis, at Krom the bodies located in close proximity to a pericardium appear in a uniform conglomerate.

Adhesive, or adhesive, P. obnaruyashvat at a long rassasyvaniye of exudate. The pericardium is thickened to 1 — 2 cm, its leaves are spliced among themselves, accustomed to drinking with a diaphragm, a breast, burgeon connecting fabric, limiting the movements of heart. A kind of this form P. is the konstrik-tivny P. developing more often as a result of tubercular or purulent P. or a chronic mediastinopericarditis. The pericardium is sharply thickened (to 2 — 3 cm), presented by rough cicatricial fabric, places calciphied, grown together with heart, a cut is as if built in in the mass of the dense, hyalinized fabric spliced with the diaphragm, a pleura, a mediastinum including salts of calcium and even a bone (a so-called armored heart).

The most intensive formation of cicatricial fabric and calcification of fabrics are observed at the squeezing pericardis in the field of auricles, at a confluence of venas cava, on the course of a coronal furrow. It is established, however, that diameter of venas cava and volume of a cavity of auricles at patients with konstriktivny P. usually surpass the normal sizes, they are stretched and deformed, but are not stenosed. During the formation of squeezing «capsule» in one cases at early stages of process there is soldering in a uniform conglomerate of parietal and visceral plates of a serous pericardium to inclusion in it of intracavitary deposits of fibrin. In other cases sclerosing process covers preferential parietal plate of a serous pericardium and extends mainly knaruzh in connection with existence of a layer of liquid exudate between it and an epicardium. The third option is development of fibroplastic process in an epicardium and in the layer of friable connecting fabric separating it from a myocardium.

The sclerogene type of an inflammation with dominance of a fibroplastic component is allocated as isolated morfol, the form P. — groins pericardis — and differs in massiveness of the formed dense connective tissue structures, their re-traktilnost. Sometimes sclerosing process develops preferential in the intracavitary mass of fibrin, forming a so-called intermediate fibrous cover. In the internal cicatricial capsule structures of an epicardium are dissolved, it sprouts a muscle of heart. The cicatricial capsule created from a fibrous pericardium or as intermediate even if it leads to a prelum of heart, usually easily separates from heart. In some cases in a prelum of heart the leading role is played by sites of calcification, to-rye, like tires, get into a myocardium and grow into the fabrics and bodies surrounding heart. In 30 — 40% of cases by the time of development of a konstriktion signs of an inflammation of tubercular or nonspecific character continue to be observed, between connective tissue tyazha the caseous masses, pus or liquid exudate remain. Signs of a tubercular inflammation easily are established lasting disease up to 18 months. In later terms (at vigorous antitubercular treatment in 6 — 8 weeks) the nonspecific cicatricial component prevails.

At a sclerogene form P. process often extends to adjacent bodies: a pleura and lungs (pakhiplevroperikardita, a fibrothorax), a diaphragm and the phrenic peritoneum covering it, fibrous covers of a liver and spleen and on these bodies, on large venous trunks. At late stages of a pakhiperikardit deep damage of a myocardium, its through germination on certain sites develops. Local changes are combined with a diffusion myocardiofibrosis. Muscle fibers become thinner, their fatty regeneration is observed. The weight of heart at the dead from konstriktivny P. (without cicatricial capsule) fluctuates from 175 to 300 g.

Calcification of a pericardium begins with formation of fine grains which then turn into large glybk of lime, and further can merge in plates. Calloused connective tissue layers with deposits of lime are so strong that are hardly scissored even by bone. Heart appears the surrounded continuous limy armor or the isolated rings (ring-shaped konstriktivny P.) which are located preferential on the course coronary (coronal, T.) arteries, on the phrenic surface of heart, on a coronary (coronal) sine and a coronal furrow. The last localization can be followed by the functional mitral stenosis connected with penetration of calciphied connecting fabric into thickness of a ventricle up to the left atrioventricular (mitral) valve. At konstriktivny P. the pathoanatomical picture so-called perikarditichesko-go a pseudocirrhosis of a liver (cirrhosis of Peak) with disturbance of circulation in a liver, portal stagnation, development of nodular lobulyarny cirrhosis, ascites can be observed.

Pathoanatomical diagnosis of the nature of P. is made in each case taking into account a complete picture morfol, changes in an organism, an inherent certain disease or injury. At the same time features morfol, changes of covers of heart and character of exudate are studied at different etiol, forms P., especially at such specific P. as rheumatic, tubercular, syphilitic.

Rheumatic P. is characterized by fibrinous exudate of a fleecy look, and is microscopic — growth of the granulyatsionny fabric having the centers of fibrinoid swelling, lymphoid infiltrates, eosinophils and a small number of neutrophilic leukocytes. Presence of typical rheumatic granulomas is not constant. Adhesions depend on amount of liquid in a pericardiac cavity, more often the organization comes to an end in lacteal spots. Hron, rheumatic P. can lead to fibrous changes of a pericardium with konstriktivny process.

Tubercular P. has quite various morfol, expression depending on a way of infection of a pericardium, a phase of an inflammation and participation of allergic processes in formation of the Item. At hematogenous miliary tuberculosis (see) in visceral and parietal plates of a serous pericardium small whitish hillocks classical gistol are defined. structures (tsvetn. fig. 3). At the lymphogenous distribution of process connected with tuberculosis bronchopulmonary (root) limf, nodes of a lung, P. has chronic serofibrinous or I gemorragi-will hold down a form. Tubercles are hidden under a dense fibrinous plaque; caseous P. with a thick caseous masses on a surface of an epicardium is seldom observed, with adjournment in them exhaust (armored heart). It is necessary to differentiate tubercular P. with P. at a tularemia, at Krom the similar microscopic picture is observed and are available to a tuberkuly dnya of a granuloma. The acute exudative form of tubercular P. is characterized by accumulation of fibrinous exudate, sometimes with a hemorrhagic component. In process of decrease in sharpness of an inflammation the amount of liquid decreases, the pericardium is thickened and there is a fibrokaeeozny infiltrate which is exposed afterwards to the organization with development hron, adhesive P., adjournment of salts of calcium and formation of a bone.

Syphilitic P. is observed seldom in development of visceral syphilis, usually as result hron, syphilitic myocarditis. Microscopically sometimes reveal gummas in granulyatsionny fabric.

The item caused by hit in a pericardiac cavity of parasites is characterized by serofibrinous or purulent exudate, in Krom parasites, as a rule, are found (bubbles of an echinococcus or other).

The CLINICAL PICTURE

P.'s Symptomatology is defined it kliniko-morfol, a form, a phase of inflammatory process, character and speed of accumulation of exudate in a pericardiac cavity, localization and prevalence of commissural process. In an acute phase P. which symptomatology changes in process of emergence and accumulation of a liquid exudate is usually observed fibrinous, or dry.

The dry pericardis is characterized by a stethalgia and a pericardial rub. The first complaints of patients at the beginning of P.'s development are usually connected with feeling of dull uniform aches in heart. More often pains happen moderate, but sometimes so strong that remind an attack stenocardias (see) also force to see a doctor. At the same time there can be complaints to heartbeat of short wind, dry cough, a febricula, the chilling which is pulling together clinic of a disease with symptomatology dry pleurisy (see). Idiosyncrasy of pains at P. is their dependence on breath, movements, postural changes of a body. The patient cannot make a deep breath, breathes superficially and often. Pains amplify also with a pressure upon a thorax in heart. Usually pain at acute P. has limited localization, but sometimes it extends to epigastric area, the right half of a thorax or a left shoulder-blade. In some cases pains can be connected with swallowing. There is a morbidity during the pressing over a grudinoklyuchichny joint where there passes the phrenic nerve, and at the basis of a xiphoidal shoot.

At primary inspection of the patient the greatest diagnostic value has listening of a pericardial rub. At height of pains the friction murmur happens gentle, limited on an extent, difficult distinguishable from short systolic noise. At increase in fibrinous beddings on plates of a serous pericardium pain decreases, and noise becomes rough, is heard over all zone of absolute dullness of heart. It can turn into two - or three-phase since arises in a phase of a ventricular systole, their bystry filling and a systole of an auricle. In certain cases the friction murmur can be non-constant, only several hours are listened. The friction murmur is always limited by a zone of absolute dullness of heart or is localized in its some part, is synchronous with cordial reductions. An important distinguishing character of pericardiac noise is its bad conductivity («dies where was born»); it usually is not carried out to a zone of relative cordial dullness. On the contrary, if in this zone the friction murmur, synchronous to cordial reductions is heard, it, as a rule, does not extend in a zone of absrlyutny dullness and shall be regarded as plevroperikardialny. Are characteristic variability in time of a friction murmur and quite often dependence on respiratory phases. Consider that the pericardial rub can amplify during the pressing by a stethoscope, at changes of position of a body of the patient, at a zaprokidyvaniye of the head back. At phonocardiography (see) the pericardial rub differs in dominance of high-frequency components, variability in duration and force, dependence on breath, and only high-frequency components are changeable, low-frequency — are more constant. Pericardiac noise is spaced far apart from the I tone, than valve systolic.

Depending on P.'s etiology in one cases bystry positive dynamics of process is observed, the friction murmur is listened only several hours (epistenokardiche-sky P.), in others — the current of a pericardis becomes long or recurrent (autoallergichesky P.), in the third — there is a transformation in vypotny a pericardis.

Vypotna, or exudative, the pericardis represents the stage of development of a disease which is usually following dry P. Accumulation of a liquid exudate in a pericardiac cavity can happen also passing a stage of dry. It is observed at violently beginning total perikardita (allergic) and at primary and chronic «cold» (tubercular, tumoral). At slow fluid accumulation in sharply increased pericardiac cavity the grudinoreberny surface of heart and its top keep contact with a pristenochny plate of a serous pericardium or separate from it a thin non-constant nappe. The pericardial rub disappears not at once. Also the apical beat of heart remains, but it is displaced up from lower and knutr from the left dullness of borders caused by accumulation of liquid in a pericardium since in the period of a systole because of stretching of an aorta and a pulmonary trunk blood these vessels strain, and heart is discarded to a front chest wall forward, accepting horizontal position and being established in the perednezadny direction across a pericardiac cavity. As a result of sharp moving of heart to a phase of a systole the shift of shutters of the mitral valve echocardiographic is established, a cut can mistakenly be accepted to a prolapse. After removal of liquid from a pericardium these additional shifts of valves disappear.

At big exudates expansion of cordial dullness extensively is perkutorno defined: to the left in lower parts to front and even average axillary lines, in the second and third mezhreberye — to the median and clavicular line, to the right in lower parts (the fifth mezhreberye) — to the right median and clavicular line (a sign of Rotcha), in the second — the fourth mezhreberye — it is slightly less, but also lateralny the parasternal line. The right limit of dullness at exudative P. forms an obtuse angle of transition to hepatic dullness instead of a right angle in normal conditions — Ebstein's sign. Extending also down, dullness occupies Traube's space — Auenbrugger's sign. In epigastric area protrusion at the expense of pressure of an exudate and increase in a liver can be noted (is more often at children and at hron, process). Limits of dullness change depending on position of a body of the patient: when he gets up, the zone of obtusion in the second and third mezhreberye is reduced by 2 — 4 cm from each party (it is displaced medially), and dullness in the lower mezhreberye on as much extends. Dullness over area of heart at exudative P. has unusual intensity («wooden»). Ratios between zones of relative and absolute dullness change: absolute dullness in lower parts closely rises to borders of relative, there is a sharp transition to a tympanites over the drawn-in lung — Edlefsen or Poten's sign noticed still JI. Auenbrugger (1761). At big exudates behind from a corner of a left shoulder-blade there is a dullness merging on axillary lines with dullness of heart which hardly an otlichima from arising at left-side exudative pleurisy down. However within dullness are strengthened voice trembling (see) and bronchophony (see); the breath weakened with a bronchial shade. The syndrome was described Oppoltser (J. R. Oppolzer, 1867) and Evart (W. Ewart, 1896). It is caused by a prelum of the lower share of the left lung the exudate which accumulated kzad from heart. At a body tilt of the patient forward liquid in a pericardium partially releases a slanting bosom, the lung finishes, dullness under a shovel disappears, breath is normalized, in this zone numerous kre-pitiruyuttsy and deaf small-bubbling rattles (Pins's sign) appear.

Auskultativno at vypotny P. cardiac sounds quite often remain accurate and well heard even at accumulation in a pericardiac cavity of a large number of an exudate, but only if to listen to them knutr from an apical beat; in nizhnelevy departments of dullness cardiac sounds are sharply weakened since heart in the cavity stretched by an exudate is displaced up and kzad (uniform decrease in sonority of tones is a sign of myogenetic dilatation of heart). The pericardial rub in process of increase in volume of liquid in a cavity of a cordial shirt can weaken, is caught only in certain provisions of a body of the patient: at a zaprokidyvaniye of the head back (A. A. Gerke's symptom), and also on a breath. Signs of a prelum of bodies of a mediastinum belong to late manifestations of vypotny P.

Pressure of a pericardiac exudate upon a trachea can be one of the reasons persistent «barking» dry kashdya (JI. Nagumovich, 1837). The prelum of a gullet leads to difficulty of swallowing, pressure upon the left recurrent guttural nerve — to an aphonia or changes of a voice. Because of restriction of mobility of a diaphragm the stomach (Vinter's sign) ceases to participate in breath.

One of signs of accumulation of liquid in a pericardiac cavity consider dissociation of pulse and apical beat — rather full pulse at a weak push. More often, however, the apical beat remains even in the presence in a pericardium of a large amount of liquid, though is pushed aside from the left and lower bound of pericardiac dullness (Zhandren's sign) above the usual situation. It is defined in the third — the fourth mezhreberye of a knutra from the median and clavicular line instead of the fourth — it is normal of the fifth mezhreberye.

In process of development of a cardiac tamponade more and more clear are disturbances of blood circulation. There is expressed tachycardia, filling of pulse decreases. Alternating is observed from time to time pulse (see). The ABP, especially pulse falls. Developments of stagnation in lungs, as a rule, are not observed because of an obstacle to a krovenapolneniye of the right heart. At a breath to a left heart not enough blood as increase in negative pressure in a pleural cavity leads to increase of capacity of a vascular bed of lungs arrives especially. Filling of pulse at a breath decreases — this phenomenon is studied by Kussmaul (A. Kussma-ul, 1873) and JI. Traube (1876) also received the name of paradoxical pulse. A. Dobrotvorsky (1884) described also differentiated pulse at vypotny P. What the intra pericardiac pressure, especially high rates of venous pressure becomes higher (200 mm w.g. more) are registered. There is a swelling of peripheral and cervical veins. It is characteristic that the pulsation of cervical veins at the same time is absent, on a breath their filling increases. Kussmaul described paradoxical pulse and swelling on a breath of cervical veins as a double inspiratory phenomenon. Pallor with the expressed cyanosis of lips, a nose, ears increases. Puffiness of the person and neck can be considerably expressed, creating a symptom of «the consular head», «Stokes's collar». Sometimes also hypostasis of a shoulder and hand, preferential overflow of veins and a Jacob's ladder of one hand, a thicket left develops (a prelum of the left brachiocephalic vein). Increases and becomes painful at a palpation a liver, especially its left share. Ascites (see) appears earlier, than peripheral hypostases. As in certain provisions there is partial balancing of the pool of an upper vena cava, the patient with the accruing cardiac tamponade accepts characteristic situation in a bed: he sits, the trunk is inclined forward, a forehead he leans on a pillow (Breytman's pose) or kneels and nestles a face and shoulders on a pillow. During the progressing cardiac tamponades (see) at the patient there come the painful attacks of weakness which are followed by small, hardly notable pulse, the patient feels fear of death. Skin is covered with a cold clammy sweat, cyanosis accrues, extremities are cold. Times of the patient faints. Exudative forms only sometimes lead to a tamponade and force to repeated punctures. In other cases process is transformed in preferential adhesive, squeezing. In the absence of these complications the current of a vypotny pericardis happens high-quality.

Chronic exudative P. quite often begins gradually and imperceptibly, with a small asthma, increased fatigue, dull aches in heart. Nevertheless in a pericardium a significant amount of an exudate collects. In other cases hron. The item begins as acute, but exudate does not resolve, remaining in one volume or progressively collecting. Symptoms of increase in a pericardium it is long prevail over disturbances of blood circulation. In process of development of consolidation of an outside plate of a pericardium there are symptoms of the cardiac tamponade differing in a torpidnost of a current. In cases when the epicardium is condensed or the «intermediate» capsule forms, the disease approaches on a current the konstriktivny Item. Removal of a residual exudate in these conditions does not lead to improvement of blood circulation.

The xanthomatous (cholesteric) pericardis develops in those cases hron. inflammations when absorbing capacity of a pericardium is sharply reduced irrespective of P. V prime cause these conditions as a result of slow disintegration of the lipoprotein complexes which are contained in an exudate in it are formed numerous crystals of cholesterol. The dense, viscous exudate at running off from glass forms a brilliant plaque. The current of a chronic exudative pericardis is longer, the more often it is possible to find «spangles» of cholesterol in an exudate, and on section — ksantomny cells (macrophages with inclusions of a holesterinester) and crystals of cholesterol in fabric of a pericardium. Xanthomatous P. arise regardless of the level of cholesterol in blood, a current their long, the forecast favorable.

The purulent pericardis can begin as serous fib-rinozny, becoming in the subsequent purulent, or gains purulent character at early stages; from the very beginning it proceeds hard. At purulent P. in a cordial shirt a large amount of pus can accumulate (to 3 l), but more often exudate is sacculated in one or several sine of a pericardium.

The disease proceeds with a gektiche-sky temperature, a fever and pouring then. Severe long pains in heart, morbidity in epigastric area, especially on a breath (Nagumovich's symptom) are characteristic. In blood the neutrophylic leukocytosis decides on shift of a formula to young and even myelocytes, toxicogenic granularity of neutrophils, sharp acceleration of ROE. Changes in urine (protein, leukocytes, hyaline and granular cylinders) are noted. The exudate received from a cavity of a pericardium, muddy, dense, sometimes slivkoobrazny, its specific weight 1,040 — 1,050. At microscopy the set of neutrophils and a detritis is found.

The gangrenous pericardis differs in special weight of a current. In a cavity of a pericardium over liquid contents gas collects. At inspection of the patient in situation on spin the area of cordial dullness is replaced with a bandbox sound, and at vertical position — dullness in the bottom separates horizontal border from a tympanites in upper parts. This border is easily displaced at a postural change of a body, keeping horizontal level. During the listening strikes abundance and brightness of sound phenomena — it is heard splash, a sound of the falling drop, «noise of a mill wheel», «a ring of a hand bell».

Adhesive (adhesive) perikardita are clinically shown differently depending on localization and prevalence of commissural process. The disease can proceed asymptomatically. Intra pericardiac commissures and even fusion of a pericardiac cavity in most cases do not limit cordial reductions, heart involves surrounding cellulose and edges of lungs in the movements. The health at the same time is not broken. At some patients tolerance to the forced loading decreases, there are pains in heart and a circulatory disturbance at change of the mode of movements or the functional syndrome which received the name «gipodiastoliya of a bystry rhythm» or «lozhnokonstrik-tivny syndrome» for looking alike symptomatology at the squeezing P.

Neredko at adhesive P. forms the pain syndrome, a sharp asthma, weakness, dry cough arising at changes of operating conditions of heart at a postural change of a body are observed or in a start of motion, to-rye, however, pass at continuation of loading. Most often the pains amplifying at exercise stresses limit a breath, hold down the patient in a certain pose, are caused out of pericardiac unions. Functional disturbances of cordial activity join pains.

A number of signs of commissural process is found at outer inspection of the patient. It is possible to observe systolic retraction of area of an apical beat (a cardiac impulse negative, or Sali's symptom — Chudnovsky). In the period of a diastole the site involved by reduction of heart makes the return breakthrough, making an impression of a strong apical beat. Rapid filling of the stretched heart leads to two additional symptoms, to-rye along with systolic retraction of area of an apical beat make the triad characteristic for out of pericardiac unions — a diastolic venous collapse of Fridreykh and protodiastolic «tone of a throw». Sometimes at the same time the palpating hand perceives trembling of a thorax in heart, reminding protodiastolic «cat's purring». In rare instances behind below a corner of a left shoulder-blade the same site of systolic retraction of an intercostal space as in front is found (Broadbent's symptom). Unions of a pericardium with a front chest wall at the obliterated his cavity lead to the fact that limits of absolute and relative cordial dullness extend, approach among themselves and do not change at the maximum respiratory excursions (a sign Seius). At patients with front and back unions of heart at a breath only an upper part of a breast extends, the lower edges do not participate in the movement, asymmetry of excursions of a thorax since the left nipple remains on site is noted or sinks down (Venkebakh's symptom).

Auscultation of heart at adhesive P. reveals in some cases in a systolic phase an additional short sound — tone of click (click). It is close to the end of a systole and is aurally perceived as bifurcation of the II tone, but has constant character, does not change depending on respiratory phases. As well as other pericardiac noise, tone of click it is badly carried out. Except tone of click, plevroperikardialny noise are sometimes listened, is more often in the second — the third mezhreberye on the left border of heart or at a xiphoidal shoot. Expressiveness of noise changes depending on respiratory phases since noise is caused by involvement in the movements of heart of a pleura (friction of leaves of a pleura in the field of a costal mediastinal-nogo of a sine).

A variety of symptoms at extra pericardiac commissures of heart and inconstancy of their combinations depend on different localization of hems. Quite often extra pericardiac unions are combined with adhesive pleurisy (fibrothorax). At a cicatricial mediastinopericarditis of the patient sometimes on a breath holds the breath for much smaller term, than on an exhalation (Cooper's sign), because of the disturbances of the central hemodynamics caused by unions.

The Chronic (squeezing) cardial compression differs in an originality a wedge, pictures. It occurs 2 — 5 times more often at men, than at women. The greatest number of diseases are the share of age of 20 — 50 years, but sometimes the disease arises in children's or at advanced age (60 years are more senior).

Tuberculosis is the most frequent reason of konst-riktivny P.; to 20 — 30% of all tubercular P. is complicated by a konstriktion of heart. The bacterial P. proceeding as purulent also bring to a game-striktivnomu of the Item. As purulent P.' current became more favorable and mortality was reduced, the percent of their transition to chronic, in particular sclerogene, forms increased. Can come to an end with formation of rough hems and unions and after a wound howl P., especially if he is supported by a foreign body.

The leading clinical manifestations of the squeezing P. are expressed by a so-called triad of Beck: high venous pressure, ascites, «small silent heart». Some patients can sometimes have attacks of gripping pains in heart with irradiation in the left hand. They are connected with disturbances of coronary circulation because of a cicatricial prelum of coronal vessels. Patients constantly complain of unpleasant feelings in a stomach, feeling of its swelling, overflow, weight.

Venous pressure is higher than 250 — 300 mm w.g. always forces to assume the squeezing Item. Symptoms of venous hypertensia come to light at the general survey of the patient. Cyanosis of cheeks, ears, hands, puffiness of the person and neck («the consular head», «Stokes's collar») is noted. Cervical veins at P.'s game-striktivnom remain bulked up at any provisions of a body of the patient. Clearly the pulsation of large veins, their diastolic collapse is visible. Pressing area of the right hypochondrium can strengthen swelling of cervical veins (a gepatoyugulyarny phenomenon). However peripheral veins are not expanded, thanks to a high compensatory tone they become threadlike.

An asthma has stable character and never happens in the form of attacks. Equal degree of loading always causes identical intensity an asthma irrespective of time of day, degrees of exhaustion of the patient, the distracting moments. There are no periods even of partial reduction of an asthma which from month to month amplifies. Along with an asthma at a physical tension at patients considerable weakness develops. Lack of an orthopnea so characteristic of patients with heart failure even attracts attention at less expressed asthma. When the patient lays down, it has a flush on a face, but, despite a Jacob's ladder and venous stagnation, the patient lies more willingly, than sits, besides lies low, without head restraint.

Fig. 1. The electrocardiogram (1) and phonocardiograms low (2), average (3) and high (4) frequencies at chronic cardial compression: I and II — the first and second cardiac sounds, Shch — tone of «click», FRIDAY — a pericardium tone (tone of a throw).

The apical beat of heart at patients does not decide on the squeezing P., and is sometimes replaced with systolic retraction in the field of a top of heart. The epigastriß pulsation is absent. Limits of cordial dullness are usually not expanded or expanded in insignificant degree. Heart of patients with konstrik-tivny P. is characterized as «small, silent and pure». Auscultation of heart really reveals a little patol, signs. Cardiac sounds (see) in half of cases are muffled, but only at some patients happen deaf and even very deaf. At many patients the three-membered heart rhythm due to additional tone in a protodiastolic phase is noted. Paid attention to diagnostic value of this sign Y. Skoda (1852). Then it was described as tone of iosts-istolichesky gallop, a pericardium tone, pericardiac knock (knock) or a throw. The pericardium tone appears only at patients with a prelum of heart or at rough ekstray ri cardial unions and does not arise at adhesive P. without design. Therefore it, known as Brouwer's sign, is regarded as surgical indication. Tone of a throw represents patholologically the changed III cardiac sound; arises at the beginning of a diastole when blood under high pressure comes to ventricles of heart and quickly fills them. Expansion of ventricles stops suddenly, encountering the low-elastic resistance of the cicatricial capsule, conditions for the sound phenomenon, on force which is not conceding to the II tone are created. After removal of the cicatricial capsule of heart tone of a throw disappears, it is succeeded by normal III cordial tone. The loudest tone of a throw happens in the field of a xiphoidal shoot and a top of heart. Auskultativno it makes an impression of bifurcation of the II tone. However the second component of the doubled II tone lags behind on time the first component less, than tone of a throw which is registered on FKG in 0,09 — 0,16 sec. after the II tone (fig. 1). The ratio of both components II of tone in case of a zakhlopyvaniye of semi-lunar valves occurring at different times changes depending on respiratory phases that does not happen to tone of a throw. At the squeezing P.

the additional presystolic tone resulting from strengthening of an auricular systole is among more rare physical symptoms. It appears only when auricles are a little damaged by cicatricial process and sharply hypertrophy, overcoming high venous pressure.

Casuistic option of a prelum of heart at konstriktivny P. is formation of a fibroznoizvestkovy hoop on the course of a coronal furrow. As a result the wedge, the symptom complex reminding a stenosis of the left atrioventricular opening on features of hemodynamic disturbances and a physical picture develops (see. acquired ), there is «an outside mitral stenosis» at the expense of an external banner of heart.

Due to the venous stagnation in a big circle of blood circulation at patients with konstriktivny P. the speed of a blood-groove decreases, the speed of a blood-groove on a small circle even increases. Paradoxical pulse — weakening of filling in the period of a breath, described at patients with exudative P., in half of cases is found and at konstriktivny P. Puls during a deep breath can disappear completely (Riegel's sign). Systolic and pulse pressure usually decrease a little.

At patients with konstriktivny P. at rest and at an exercise stress constant tachycardia is observed. At late stages in connection with cicatricial germination of a myocardium of auricles arises ciliary arrhythmia (see).

At a research of lungs at patients with the squeezing P. quite often it is possible to establish obtusion over their bottom edge, reduction of respiratory excursions, shift of borders. The pleural rub in connection with the accompanying pleurisy can be listened. Further in pleural cavities liquid (transudate) collects. Developments of stagnation in lungs are unusual for patients with squeezing P.

Konstriktivny P. never proceeds without increase in a liver, its preferential left share. Functions of a liver are broken in different degree, pigmental exchange is, as a rule, not broken. The spleen increases at the same time and condensed (at gi patients). However in case of successful operational treatment the sizes of a liver and spleen decrease to norm, also the broken functions of a liver are usually recovered.

Ascites arises often as the first sign of a hemodynamic decompensation. Reflection of preferential disturbance of portal blood circulation is development at konstriktivny P. of collateral dumping of blood from system of a portal vein through saphenas (a porto-caval anastomosis). Hypostases standing at patients with konstriktivny P. usually are absent or happen insignificant and develop already at ascites. Changes of urine are found only in 25% of patients and come down to emergence of traces of protein.

Distinguish three stages of development chronic konstriktivny P.: initial, expressed and dystrophic. In an initial stage of the patient notes weakness and an asthma during the walking, becomes incapable of exercise stresses, pastosity of the person appears; venous pressure increases preferential after loadings, there is no venous stagnation. Criterion of transition to a stage of the expressed phenomena consider development in the patient of constant venous hypertensia with puffiness of the person, cyanosis, a nabukhlost of cervical veins and especially emergence of ascites. The combination of a syndrome of hypertensia in system of an upper vena cava and disturbances of hepatic and portal circulation which ratio unlike cases of a cardiac tamponade does not depend on position of a body of the patient is characteristic.

The dystrophic stage develops at late stages of a disease, most often because of untimely diagnosis of konstriktivny P. U of patients there is a deep adynamy. They are sharply exhausted; muscles atrophy, fabrics lose turgor. There are trophic ulcers, the contracture of large joints develops. Along with ascites and an exudate in pleural cavities hypostases of the lower extremities, then generative organs, bodies, a face and hands develop. It is promoted by hypo - and a disproteinemia. Decrease in concentration of blood protein, especially albumine, is the central pathogenetic mechanism distinguishing a dystrophic stage of process from earlier stages of a disease. Disturbances of proteinaceous balance are caused by development of insufficiency of functions of a liver, and also deterioration in conditions of absorption of protein from intestines because of early ascites and dysfunction of digestion. Concentration of protein in blood falls to 3 — 2,5%, sometimes below.

The DIAGNOSIS

P.'s Diagnosis includes recognition it kliniko-morfol, forms, establishment etiol, the diagnosis which in some cases allows to diagnose the basic disease which is followed by P. and also the differential diagnosis.

The diagnosis of a kliniko-morphological form is based on establishment specific or a complex of symptoms, characteristic of this form of P., revealed by the main methods of inspection of the patient and purposeful use of additional methods among which the important place is taken electrocardiography (see) and rentgenol, research.

Valuable diagnostic information is given by the anamnesis, the analysis of complaints of the patient and Physical methods of a research, especially percussion and auscultation of heart, a palpation of arterial pulse and an apical beat of heart, and in the presence of the expressed hemodynamic changes as well survey of the patient.

Dry P.'s diagnosis is established on features of the pain syndrome accompanying it, existence of a pericardial rub and characteristic changes of an ECG (see below).

Pain at acute P. in typical cases is felt in the field of a top of heart, has constant character, amplifies at the movements of a body and especially at breath, interfering, as well as at pleurisy, to a deep breath.

The pericardial rub is a highly specific symptom, and its existence allows to establish at the patients who are under medical observation, even bezbolevy forms P. In typical cases noise has the scraping character and is listened in phases and systoles, and diastoles of heart. Three-phase pre-sistolo-systolodiastolic noise is compared on a rhythm to noise of the engine. All components of noise on character and force are similar. It is also usually simple to distinguish double, sistoloprotodiastolichesky noise from valve noise on similarity of both components, coincidence of their localization. It is more difficult to be convinced of a pericardiac origin of the noise heard only in the period of a systole if it has no roughly scraping character.

Exudative P. before development of signs of a cardiac tamponade is established by hl. obr. according to percussion and with the help rentgenol, and an echocardiographic research. Increase in intensity of percussion dullness of heart, expansion of its borders extensively with sharp expansion of a zone of absolute cordial dullness (are characteristic up to its merge to limits of relative dullness), formation of an obtuse angle between the right border of heart and the upper bound of hepatic dullness, change of a configuration perkutorno of the defined borders at a postural change of a body of the patient from horizontal to vertical. In process of accumulation of an exudate weakens and also knutr the apical beat of heart is displaced up, there is a dissociation between force of a push and size of arterial pulse.

At large numbers of an exudate in a cavity of a pericardium diagnostic value is gained by signs of a prelum of bodies of a mediastinum (the complicated swallowing, hoarseness of a voice) and a cardiac tamponade (attacks of weakness with a cold clammy sweat, decrease in the ABP, frequent small pulse, etc.). Except sharp expansion of borders of heart, decrease in loudness of its tones is noted, visible hemodynamic disturbances — cyanosis of the person and neck, a considerable nabukhlost of cervical veins are noted. Specific diagnostic value has identification of a double inspiratory phenomenon — paradoxical pulse and swelling of cervical veins in an inspiratory phase.

Final confirmation of the diagnosis of exudative P. is received at rentgenol, a research (see below) or with the help Echocardiography (see), and character of exudate (chyle, cholesteric, serous, purulent, etc.) is specified after a pericardiocentesis. The echocardiography allows to find reliably an exudate in a pericardiac cavity even at its trace amounts (50 — 100 ml) on emergence of ekhonegativny space between a back wall of a left ventricle and the parietal layer of a pericardium which is pushed aside kzad. At big exudates by this method the nappe also over a front wall of a right ventricle comes to light there is a phenomenon of «floating heart».

Adhesive (adhesive) P. in the presence of data on P. in the anamnesis can be suspected of a case of stabilization at the patient of an asthma, at emergence of complaints to dry cough, stethalgias, weakness. Before carrying out rentgenol, researches the diagnosis is established in the presence of systolic retraction of an apical beat, protodiastolic tone of a throw and detection of a diastolic venous collapse.

Fig. 3. The phonocardiogram (1), normal-curve a venous pulse (2) and its change (3 and 4) in process of strengthening of squeezing of heart at the squeezing pericardis: on a curve (3) wave (c), reflecting reduction of a right ventricle of heart, it is sharply reduced and almost disappears on a curve (4). Time x-and the y-collapses reflecting phases of bystry and slow filling of a right ventricle is reduced. Tops of waves and (auricular systole) and v (the beginning of a phase of a dpastazis) are flattened.
Fig. 2. The electrocardiogram (above) and pressure curves in a right ventricle (IZh) and the right of a red-serdiya (software) at chronic cardial compression: 1 — a protodiastolic failure. 2 — the telediastolic plateau.

Considerable weakness and fatigue of patients at an exercise stress testify to konstriktivny P. the expressed asthma without orthopnea, symptoms of high venous hypertensia with cyanosis and puffiness of the person and neck («Stokes's collar», «the consular head»), existence of the increased liver and ascites in the absence of, as a rule, hypostases standing. The apical beat of heart usually pe is defined; at auscultation of heart often it is found protodiastolicheskip tone of a throw, sometimes additional presystolic tone. Pressure curves in the right cameras of heart (fig. 2) change. During relaxation pressure in a right ventricle sharply decreases that is reflected in pressure curves protodiastolic «failure»; in a phase of bystry filling it raises, reaching the level of the central venous. At the same time on pressure curves the so-called telediastolic plateau forms. On a curve of pulse of a jugular vein (fig. 3) the characteristic two-wave curve presented by positive waves and and which tops are flattened quite often is registered, are as if cut off, and abrupt recessions. The wave with reflecting reduction of a right ventricle decreases. Distinctions in extent of reduction of volume of a right ventricle and overflow of veins cause very variable forms of a curve of a venous pulse that limits its diagnostic value.

The electro cardiographic research occupies one of the major places in diagnosis of the acute dry Item.

Fig. 4. Dynamics of changes of the electrocardiogram at an acute pericardis: and — to a disease; — in the first two days of a disease; concordant raising of a segment of ST in all assignments with increase in a tooth of T is noted; in — for the 10th day of a disease: the segment of ST fell to the izoelektri-chesky line, got the arc-shaped form, the tooth of T in the majority of assignments decreased or became isoelectric, and in the III assignment — negative.

The most precursory symptom of acute P. on an ECG (fig. 4) is concordant raising of a segment of ST usually in all standard leads (the greatest in the II assignment), and also in chest. However at lokakalizatsii inflammatory process on the limited site the shift of a segment of ST can be noted in two or even only in one of standard leads. In 1 — 2 day the segment of ST falls below the isoline, then gradually — within 3 — 20 days — is returned to the isoline, despite the continuing inflammatory process in a pericardium. At slowly progressing P. shifts of a segment of ST usually do not manage to be found. Positive and even the tooth of T which is a little increased at early stages by P. then is gradually flattened and in 10 — 15 days becomes negative or two-phase in those assignments in which there was dynamics of a segment of ST. Negative teeth of T remain is much longer, than the shift of a segment of ST. At hron. The item inversion of a tooth of T quite often remains constant. In case of involvement in process of a pericardium of auricles change of a form of a final piece of a tooth P and shift from the isoelectric line of a segment of PQ is possible.

Initial changes of an ECG at exudative P. do not differ from described at dry P., decrease in a voltage of teeth of an ECG, electrical alternation of ventricular complexes is noted further.

The triad is most characteristic of changes of an ECG at konstriktivny P.: an expanded high tooth P, the low-voltage QRS complex, a negative tooth of T (in all standard and precardiac leads). Except decrease in a voltage, changes of a form of the QRS complex are observed: splitting, expansion, formation of jags, deepening of a tooth of Q, to-rye testify to depth of involvement in patol, process of a myocardium. The increased tooth of P sharply contrasts with the low-voltage QRS complex, testifying to a working hypertrophy of auricles. After a pericardectomy the voltage of ventricular teeth of an ECG gradually increases, the tooth T.

Rentgenol about a gichesky research is quite often normalized a little informatively at fibrinous (dry) P., but has big, sometimes crucial importance for diagnosis of exudative and adhesive forms of a pericardis.

Fig. 5. Roentgenogram of a thorax of the patient with an exudative pericardis: the shadow of heart is increased in cross sectional dimension, arches are badly differentiated, a shape of heart trapezoid.
Fig. 6. The roentgenogram of a thorax of the patient with a pericardis after imposing of a pneumopericardium: 1 — gas in a cavity of a pericardium; 2 — a reinforced pericardium.

Exudative P. at the beginning of the development is shown by change of a configuration of a cordial shadow due to straightening of a waist of heart; further it can become even convex. In process of accumulation of an exudate the cordial shadow becomes more and more spherical, the silhouette of heart loses the differentiation on arches, bystry increase in a shadow of heart with a prevalence of its cross sectional dimension over a longitudinal axis, dextroposition of an arch of the right auricle is noted. The shadow of the descending part of an aorta disappears, the vascular bundle extends at the expense of an upper vena cava and it is represented rather shortened. Cardiophrenic corners, especially right, are pointed. At repeated researches bystry dynamics of increase in the sizes of a shadow of heart is noted. At change of position of a body the form of a cordial shadow changes. Amplitude of a pulsation of contours of heart decreases up to full Me of disappearance at preservation of a pulsation of large vessels. The pulmonary drawing remains normal, despite the expressed increase in the sizes of a cordial shadow (fig. 5). The decisive diagnostic method combining and therapeutic influence, is the pericardiocentesis with imposing artificial pneumopericardium (see) and especially a research with a double contrast study of a pericardium. The pericardium is thickened, especially at a diaphragm that is well visible during the imposing of a pneumopericardium (fig. 6); sometimes in it massive calcifications meet.

Differential diagnosis between the exudative P. and heart diseases which are followed by expansion of his cavities is very difficult and demands use of additional receptions of a research, in particular rentgenokimografiya (see).

At the chronic squeezing P. the sizes of heart are not increased or increased slightly more often; contours of a cordial shadow of a rasplyvch you, are angular, its partition on separate arches is not expressed because of separate ledges as «sails» — plevroperikardialny unions. At change of position of a body the smeshchayemost of heart is limited. Quite often the increase in the left auricle reminding a mitral stenosis is defined.

The etiological diagnosis of a pericardis represents an important independent task since defines the purposeful choice of remedies. In many cases it is established on the basis of the accompanying signs of a basic disease, but sometimes definition of an etiology of P. requires a pericardiocentesis or its biopsy.

The diagnosis of the rheumatic nature of P. is facilitated in the presence of rheumatism in the anamnesis and at the available picture of the accompanying myocarditis, polyarthritis or other displays of rheumatism. Matter also biochemical, and a lab. indicators (see. Rheumatism ). The first signs of P. at rheumatism arise usually at the end of the 1st or at the beginning of the 2nd week from the date of the beginning of the joint attack, at a recurrence of polyarthritis — in later terms, on 3 — 4-y-week. At a cardial form of rheumatism the pericardis arises from the first days of a disease. Dry P. is diagnosed at rheumatism three times more often than vypotny. Big pericardiac exudates represent an exception, the cardiac tamponade at adults almost never develops. Disturbances of blood circulation are a consequence of rheumatic myocarditis more often, increase in limits of dullness is caused not only accumulation vypoty', but also dilatation of heart. Rheumatism is one of the frequent reasons of formation of intra pericardiac unions. About a rheumatic etiology of an adhesive pericardis judge by the anamnesis and existence at sick rheumatic heart disease.

At tubercular P.'s diagnosis consider that it arises at persons with active tubercular process of other localization or at more often had tuberculosis in recent times. Pains in heart arise seldom and do not happen strong. Subfebrile temperature, perspiration during sleep by the morning, dry cough are observed. The course of a disease is characterized by duration and a torpidnost, the intra pericardiac exudate can become considerable without development of a tamponade. The greatest diagnostic difficulties are presented by cases when P. is one of initial symptoms of tuberculosis in the absence of defeats of easy and other bodies. At microscopy of the liquid received from a cavity of a pericardium dominance of lymphocytes is characteristic; the Guinea pig can reveal presence of mycobacteria more often only by an inoculation. Attach significance to high tuberkulinovy tests (see. Tuberculinodiagnosis ). In late terms radiological it is possible to find sites of calcification.

Nespetsif chesky coccal and bacterial P. are reliably diagnosed at purulent character of an exudate, in other cases the diagnosis is established presumably on the basis of other displays of a disease as P. happens in these to a sl teas one of its complications.

Specific bacterial P. are most often distinguished on all symptom complex of a disease, and at the isolated defeat of a pericardium etiol, their diagnosis is always difficult. Specific character of P. at patients with a tularemia is confirmed characteristic gistol, a picture (granulematozny small knots), a high aglutination titer by vnu-triperikardialny liquid on-lochek a tularemia, direct detection of a microbe in fabric of an epicardium. Proceeds in the form of fibrinous, serofibrinous or hemorrhagic process, starting with the first and finishing seventh decade of a disease. Other signs tularemias (see) can be absent.

Its combination to pharyngitis, rhinitis, herpes, focal or intersticial pneumonia or to a herpangina, a mi-algiya, pleurisy, serous meningitis, increase limf, nodes, a liver and a spleen, with a peculiar rash (an infectious mononucleosis) can testify to a virus etiology of P.; sometimes the leykotsitopeiiya, mononuclear reaction of blood have diagnostic value. The current is favorable, sometimes recurrent. P.'s diagnosis of a virus etiology becomes reliable in the following cases: 1) if it is possible to find a virus in a pericardiac exudate or other biosubstrates and washouts by method of hemagglutination (with typification on reaction of a delay of hemagglutination) or by means of reaction of binding complement (with immune serum); 2) if at a research of pair serums in replicate sample substantial increase of a caption of specific antibodies is observed; 3) if it is possible to allocate and cultivate a virus on special environments or by infection of susceptible animals; 4) if there occurs heterophyllous agglutination of erythrocytes with a caption not less than 1: 112 (Paul's reaction — Bunnellya at an infectious mononucleosis).

At fungal P. the culture of a fungus is sowed from blood, urine, a phlegm, a pericardiac exudate. The diagnosis shall be confirmed positive serol, and skin tests.

Allergic, including infectious and allergic, P. are characterized by the acute beginning with sharp pains in heart and tendency to a recurrence (acute high-quality), they arise through some term after influence of the allowing factor (e.g., administrations of serum). Proceed usually in the form of a mioperikardit with formation of a serofibrinous exudate, skin rashes and other manifestations of allergic process.

Autoallergichesky (alterogen-ny) P. are always connected with various damages of a pericardium that quite often takes place at a myocardial infarction, commissurotomies, pericardiotomies. Autoallergichesky P. develops on 2 — the 3rd week after damage, is sometimes much later (on 8 — the 11th week), is often combined with pleurisy, focal pneumonia, sometimes arthritis; is followed by temperature increase within several days. At a recurrence of an alterogenny syndrome patients can have no leading wedge, P.'s sign — a pericardial rub if there was an obliteration of a pericardiac cavity. Pains, changes an ECG and other signs of a recurrence of P. at the same time remain. In blood the high eosinophilia is often noted, the exudate contains many eosinophils, is sterile.

Lupoid P. is found more often in young women. As a rule, pleurisy and a pneumonitis are at the same time noted. Sometimes P. arises earlier, than other manifestations of a general disease develop, begins sharply, is characterized by a persistent recurrent current. Distinctive features of a disease are joint pains, long fervescence, changes of urine, increase in a liver and spleen, a micropolyadenitis, anemization, bent to a leykotsitopeniya, acceleration of ROE, increase in content in serum of gamma-globulins, immunoglobin fractions, a high caption of antinuclear antibodies, LE cells in blood and marrow.

P.'s diagnosis of the tumoral nature most often is based on results of a puncture. In half of cases the first pericardiocentesis finds the exudate which is not painted by blood, it becomes hemorrhagic later. In a cavity a large number of an exudate accumulates. At cancer P. in exudate quite often to 90% of leukocytes make lymphocytes, conglomerates of tumor cells are found. There can be bleeding from an arrozirovan-ny vessel or a rupture of the heart which sprouted a tumor. Sometimes process gains purulent character or cancer «armor» is formed.

Uraemic P.'s diagnosis is established at emergence in patients with uraemia (see) pericardial rub. Pericardiac exudate at uraemia contains about 80 mg / 100 ml of urea and to 180 mg / 100 ml of residual nitrogen.

Etiol, diagnosis at the squeezing P. represents a complex challenge. Even according to an intraoperative biopsy the answer happens certain only in cases of detection of signs of a specific inflammation. At a part of patients the cause of illness becomes clear on the basis of data of the anamnesis. In the specified cases hron. Items most often appear a tubercular etiology or effects of purulent process. Etiology of considerable number hron. The item does not manage to be established even after operation or on section. However at the squeezing P., to-rye already lost the active character, it has smaller practical value, than in cases of the acute, actively proceeding or recurrent Items.

The differential diagnosis at different kliniko-morfol, forms P. is carried out with various diseases.

At acute P. the pain syndrome and disturbances of action of the heart quite often demand carrying out differential diagnosis with manifestations coronary heart disease (see). At P., unlike pains of coronary genesis, pains have more gradual beginning, are uniform, last for hours and days, they do not act nitroglycerine, temporarily weaken at use of analgetics. Usually there is no anamnesis, typical for coronary heart disease, pains develop for the first time. Unlike changes of an ECG at acute myocardial infarction (see), at acute P. there are no changes of the QRS complex and there are specific changes of an ECG: a) raising of a segment of ST has concordant character; b) gradual distribution of characteristic changes of an ECG from several assignments on almost all or all assignments is quite often noted; c) the segment of ST during the early period is raised more by the end of an electrical systole and turned by concavity up, and the tooth of T is kept and is even raised; d) more bystry dynamics of changes of a tooth of T within 1 — 2 days is observed; e) transition of a tooth of T to negative happens only after return of a segment of ST to the isoline.

It is necessary to differentiate chronic vypotny P. most often with accumulation in a pericardiac cavity of contents of a noninflammatory origin (a hydrocardia, a hemopericardium). It is reliable to distinguish from the vypotny Item. hydrocardia (see) perhaps only by a puncture about a lab. a research of the received liquid. Liquid at a hydrocardia differs from exudate in transparency, poverty in uniform elements of blood, low specific weight (less than 1,018) and low (less than 3%) protein content with negative reaction of Rivalta (see. Rivalta test ). At vypotny P. of the tumoral nature quite often there is a need of their differentiation with the tubercular Item. The gradual beginning (except cases of break in a cavity of a pericardium of the breaking-up tumor), a steady current with continuous accumulation of an exudate («inexhaustible exudate»), inefficiency of antitubercular and antiinflammatory treatment is characteristic of tumoral P.

Konstriktivny P. needs to be differentiated with diseases at which similar disturbances of blood circulation at the expense of a gi-podiastoliya (a so-called konstriktiv-ny cardiopathy) are observed. Carry a fibroplastic parietal endocarditis of Leffler to such diseases (see. Endocarditis ), primary amyloidosis of heart (see. Amyloidosis ), separate cases cardiosclerosis (see). Signs of a preferential prelum of the right departments of heart, in particular a razgruzhennost of a small circle, it is necessary to consider as an argument in favor of konstriktivny P. (at konstriktivny cardiopathies the left ventricle more suffers). In favor of a pericardiac prelum acute P. in the anamnesis, a wedge, or rentgenol, signs of outside unions of a pericardium, sites of calcification on a contour of heart testify; lack of shift of heart at postural changes of a body, and also a nesmeshchaye-most of its electrical axis; availability of exudate in a pericardiac cavity. In the absence of at least part from these signs the exception of konstriktivny cardiopathies is difficult, indications to surgical treatment are doubtful.

TREATMENT

P.'s Treatment consists of performing causal, pathogenetic and symptomatic treatment, rklyuchy, if necessary, surgical treatment.

Etiotropic treatment is most effective at infectious, in particular coccal and bacterial, P.'s etiologies when use of antibiotics and other antibacterial agents is possible. In cases when dry or exudative P.'s nature is not found out, it is necessary to refrain from antibacterial therapy, considering the increasing number of the noninfectious forms connected with a sensitization of an organism. If the purulent pericardis or its communication with purulent process is established, antibiotics shall be appointed immediately. At nonspecific bacterial P. and the infected wounds of a thorax appoint penicillin or its semi-synthetic derivatives, antibiotics from group of aminoglycosides (gentamycin, Kanamycinum, streptomycin, etc.). When the microbe activator is established, the antibiotic is chosen on an action spectrum, the most corresponding this microbe. Applies also streptocides, Bactrimum.

In staphylococcal P.' treatment the supporting role belongs to hyperimmune antistafilokokko-vy serums and gamma-globulins. At purulent P. antibiotics shall be entered directly into a cavity of a pericardium after the greatest possible removal of purulent exudate and washing of a cavity. For this purpose make a pericardiocentesis with introduction of a catheter to his cavity where it is left for a period of up to 3 days.

Specific P. at various inf. diseases treat antibiotics according to sensitivity of activators. At tubercular P. appoint streptomycin or rifampicin in combination with other tuberculostatic drugs.

Pathogenetic therapy includes use of the means possessing antiinflammatory, antiexudative action that is connected with participation in patol, process at infectious P.' most of infectious and allergic mechanisms with hyperreactivity. At allergic and autoimmune forms P. nonspecific antiinflammatory therapy becomes the leading direction of treatment. At easy subclinical options of dry P. (epistenokardichesky, uraemic) are limited to treatment of a basic disease, sometimes enter analginum taking into account its antiinflammatory and anesthetizing action. As well as at other serosites, at active P. it is necessary to cancel anticoagulants if the patient received them, and at the low maintenance of a prothrombin appoint phthiocol.

As to the most powerful antiinflammatory treatment resort to glucocorticoid therapy at a system lupus erythematosus, a pseudorheumatism, and also rheumatism since involvement in process of a pericardium testifies to high activity of rheumatism (the III degree), and P. worsens the forecast of a disease. Small doses of Prednisolonum (10 — 15 mg a day) apply also at autoallergichesky (alterogenny) P. at patients with a myocardial infarction or after heart operations, and after subsiding of a postinfarction or pe-rikardiotomny syndrome replace them with drugs of a pyrazolon row, salicylates or an ibuprofen (Brufenum). Hormonal therapy in idiopathic P.' cases quite often promotes regress of a disease. At indications to a pericardiac puncture, especially in cases of rough exudation with development of a tamponade, the hydrocortisone, Prednisolonum or Triamcinolonum enter vnu-triperikar dialno. For long irrigation through a microcatheter each 4 — 6 hours enter io 30 — 50 mg of Triamcinolonum within 24 — 72 hour. In cases of a long current of bacterial and tubercular perikardit of means of nonspecific antiinflammatory action use counting on weakening of adhesive and sclerogene processes. However in some cases treatment is ineffective. Also antihistaminic drugs at allergic P. belong to means of pathogenetic therapy and use of vitamins, especially ascorbic to - you which in acute cases is entered intravenously (to 5 ml of 5% of solution).

At dry P. appoint analgetics and non-steroidal anti-inflammatory drugs — analginum, Rheopyrinum, an ibuprofen, Voltarenum, acetilsalicylic to - that.

Symptomatic therapy at dry P. is directed to elimination of pain (administration of analginum, Rheopyrinum, sometimes narcotic analgetics), and at vypotny and adhesive forms P. — to recovery of action of the heart, normalization of blood circulation.

At development of a cardiac tamponade use of cardiotonic means is inefficient and is not shown. Only in cases when the diagnosis is not clear and it is necessary to exclude myogenetic character of a circulatory unefficiency, it is admissible to carry out trial therapy by cardiac glycosides.

At bystry accumulation of an exudate appoint an electrolyte-deficient diet, amount of the liquid used within a day limit up to 500 — 600 ml. Enter diuretics — 40 mg furosemide and (lasixum) intravenously, in the subsequent inside on 80 — 120 mg of furosemide a day. At hron, exudative P. attempts to reduce quantity of an exudate in a pericardium by means of diuretics quite often are successful. At acute P., during their initial period, diuretics are ineffective, and the pericardiocentesis after which purpose of diuretics in some cases helps to prevent repeated punctures is shown to patients or to increase intervals between them.

Indications to a pericardiocentesis are a cardiac tamponade (vital indications, the puncture is made quickly), the purulent nature of process and the dragging-on rassasyvaniye of exudate (a medical and diagnostic puncture), vypotny a pericardis which nature needs specification or verification (a diagnostic puncture).

At the squeezing forms P. only surgical treatment is effective. Conservative treatment can be experienced at patients with yet not proved konstriktivny P. and at insignificant degrees of a prelum of heart while the issue of expediency of operation cannot be resolved, and also at patients whose serious condition is made by an operative measure by unpromising. The purpose of conservative treatment is elimination of those disturbances of blood circulation, to-rye depend on muscular insufficiency of heart or are connected with a metastasis ad nervos of its activity (a lozhnokonstriktivny syndrome). Create to the patient conditions of physical unloading, appoint a bed rest, a sparing diet, restriction of salt and liquid. Apply cardiac glycosides, diuretic, and at suspicion of active myocarditis — drugs of pyrazyl ketone or glucocorticoids. Patients whose condition excludes a possibility of surgical treatment of the squeezing P. demand permanent care; they shall observe a semi-bed rest, use food easy, but rich with protein with restriction of salt. By it appoint diuretics, and at massive ascites and a hydrothorax resort to punctures.

Surgical treatment of perikardit is performed as according to urgent indications (at threat of a cardiac tamponade), and in a planned order at recurrent exudates in a pericardiac cavity and at the squeezing Item.

The choice of a method of surgical treatment of P. (a puncture, a pericardiotomy, a pericardectomy) depends on the nature of defeat of a pericardium. At a vypotny pericardis — serous, serofibrinous, hemorrhagic and purulent — apply most often a puncture of a pericardiac cavity, opening of the last is more rare. At the squeezing P. almost completely delete a pericardium — subtotal pericardectomy (see).

Distinguish three ways of introduction of a hypodermic puncture needle of a pericardium: to the left of a breast in the third — the fourth mezhreberye (N. I. Pirogov, V. A. Karavayev, etc.); to the right of a breast (A. R. Voynich-Syanozhentsky); from a stomach (D. Larrey, 1829; A. Marfan, 1911).

Transpleural pericardiocenteses apply now rather seldom in connection with danger of injury of heart, internal chest artery, and also pleura (threat of its infection with contents of a pericardium). The greatest distribution in connection with relative safety got access from a stomach. It is convenient and in the respect that exudate accumulates in lower parts of a pericardium.

By Larrey's method the needle is entered into a corner between the basis of a xiphoidal shoot and the place of an attachment of the VII costal cartilage at the left and advanced in the cranial direction approximately at an angle 45 ° to a body surface. Approach to a pericardium is felt on the beginning fluctuations of a needle in beat of reductions of heart. By Marfan's method the needle is entered on the centerline directly under a xiphoidal shoot, then direct it slantwise up, to a back surface of a breast.

The pericardiocentesis is made under a local anesthesia in position of the patient semi-sitting. Use a long needle with a diameter not less than 2 mm; the needle shall have a stupid cut that reduces danger of injury of heart. Advance a needle deep into carefully, and back motions of the piston control the moment of its hit in a pericardiac cavity. At hemorrhagic P. liquid usually comes to the syringe, to-ruyu it is often difficult to distinguish by the form from blood from a cardial cavity. Therefore it is quite easy to make the wrong conclusion about hit of a needle in heart. In similar doubtful cases it is necessary to determine urgently the level of hemoglobin in the received hemorrhagic liquid. Uniform in beat reductions of heart release of blood from a needle, and also high content of hemoglobin in punctate demonstrate hit of a needle in a cardial cavity. In these cases the needle should be taken a little that its end remained in a pericardiac cavity, and then to slowly evacuate its contents. After the maximum suction of exudate the cavity is washed out. For the prevention of formation of unions between a pericardium and an epicardium recommend to enter oxygen into a pericardiac cavity (see. Pneumopericardium ).

At acute exudative P.'s treatment sometimes resort to repeated puncturation of a pericardiac cavity, a cut not always gives steady effect. In these cases carry out pericardiotomies) — opening of a pericardiac cavity with the subsequent its drainage. There are 4 accesses for an exposure and opening of a pericardium: intercostal, trepanation of a breast, parasternal (by a resection of costal cartilages), epigastric. The first two accesses are not applied since at intercostal access conditions for infection of a pleural cavity are created, and trepanation of a breast gives limited access to a pericardium. Extra-pleural access by a resection of one or several costal cartilages is more perfect. After education to the left of a breast of a musculocutaneous rag podnadkostnichno resect cartilages of the V—VI — VII edges. The transitional pleural fold is displaced knaruzh, and by such way along the left edge of a breast the pericardium is bared. The last is stitched and sipped on itself then the pericardium is cut in lengthwise direction; it is very important not to open a pleura at the same time.

After emptying of a cavity of a pericardium from contents it is washed out, and then drained by means of a rubber tube that allows it is long to sanify a cavity.

Epigastric access which allows to open a pericardium in a transition range of its phrenic part in grudinoreberny is rational; in this site there is the maximum accumulation of pus. Access this vneplev-ralny and Extra peritoneal. The skin section is done higher and lower than a xiphoidal shoot with a section of an aponeurosis on the white line of a stomach and an exposure of the small site of a breast together with a xiphoidal shoot. The shoot either is excised, or cut longwise. Stupidly a finger otslaivat fabrics of a mediastinum from a back wall of a breast, baring a pericardium on the small site. It is stitched two ligatures and, sipping for them, cut a pericardium. The cavity is washed out and drained.

The surgical method of treatment gained the greatest distribution at squeezing P. Mysl about release of heart from the unions complicating its sokratitelny function was stated in 1886 by I. N. Zaborovsky. In the subsequent for surgical treatment of the squeezing P. three main types of an operative measure are offered: a cardiolysis — a section of outside and internal commissures with a pericardium; atrial torakoliz — excision of a bone and cartilaginous part of a thorax in heart; a pericardectomy — excision of a part of a pericardium.

Developed operation of a cardiolysis on corpses and E. Delorm suggested to apply in clinical practice to treatment of the squeezing pericardis. Operation consisted in a section of unions between parietal and visceral plates of a serous pericardium. The effect of operation was unstable: rather quickly there were new unions between plates of a pericardium and there came the recurrence of a disease.

Observing noticeable retractions of edges in heart during a systole at patients with the squeezing pericardis, L. Brauer suggested to remove an osteoarticular basis in this area. So the idea of a precordial torakoliz — a resection of cartilages and part IV-V — the VI left edges with their periosteum was born. As a result heart remained the covered pliable musculoskeletal rag that to a lesser extent complicated its reduction. L. Brauer emphasized that his operation is shown only to that patients who have a clear systolic retraction of edges, i.e. in the presence of commissures between heart, a pericardium and a front wall of a thorax. Nevertheless results of this operation, as well as a cardiolysis, were short-term and the technique did not gain distribution.

In 1913 L. Rehn for the first time carried out a resection of the struck pericardium in combination with a cardiolysis. In Russia the pericardectomy okologrudinny (parasternal) access was executed in 1916 by M. M. Trofimov. The pericardectomy was an effective method of surgical treatment of the squeezing P. and gained the general recognition. The pericardectomy is preceded by thorough preoperative training.

At a preparation for surgery of a cardiolysis if it is necessary to suppress active inflammatory process, carry out vigorous etiotropic and nonspecific treatment. For reduction of the phenomena of a circulatory unefficiency, elimination of hypostases and ascites, decrease in venous pressure (at least to level 180 — 220 mm w.g.) the semi-bed rest, the diet poor in sodium, effective combinations of diuretics are necessary. At the long course of a disease apply intravenous injections of strophanthin (on 0,3 ml of 0,05% of solution in 10 ml of solution of glucose of 1 — 2 time a day). Appoint vitamins, sedatives.

With a dystrophic stage surely try to obtain improvement of proteinaceous composition of blood from patients (by use of proteinaceous drugs and blood-substituting liquids) and normalization of electrolytic balance.

For an exposure of a pericardium and release of heart four accesses were used: 1) extra pleural parasternal, 2) unilateral Transpleural, 3) chrezdvuplev-ralny with a cross section of a breast, 4) a full longitudinal section of a breast. From vneplevralno-go okologrudinny access refused because it allows to remove only the small site of a pericardium and therefore noticeable improvement of sokratitelny function of heart does not occur. At the same time after a resection of cartilages with adjacent sites IV—V — the VI edges and a part of a breast there is a bone defect of a front chest wall. Development интратрахеально™ an anesthesia with the managed breath gave the chance to apply the accesses connected with broad opening of pleural cavities. Transpleural access at the left or on the right is carried out by a section of the fourth and fifth of mezhreberiya. This access allows to release the corresponding half of heart more fully: at left-side access — a left ventricle and partially left auricle, at right-hand — preferential right auricle and mouths of venas cava. Such limited excision of a pericardium not always happens sufficient for lasting therapeutic effect of operation.

At the choice of quick access proceed from the fact of total defeat of a pericardium, but not localized unions. Therefore excise a pericardium as it is possible from the bigger surface of heart, i.e. do surely subtotal pericardectomy. Broad approach to all departments of heart gives chrezdvuplev-ralny access with a cross section of a breast. However this access is traumatic as it is followed by opening of two pleural cavities, a section of a big muscular array that promotes development of respiratory insufficiency.

The greatest distribution got access to heart by full longitudinal crossing of a breast now. Using this access, excise the pericardium covering the left and right ventricles, partially left auricle and completely right auricle, an opening of a pulmonary trunk, an aorta and venas cava. This access is less traumatic in comparison with chrezdvuplev-ralny. During the performance of a pericardectomy usually observe the following sequence of release of heart: begin to excise the pericardium covering a left ventricle (its top), then the left auricle, aortic ostiums, a pulmonary trunk, a right ventricle and at the end the right auricle and mouths of venas cava. Reliable visual sign of radical removal of a pericardium (all covers) is clear projection of coronal (coronary) vessels. If the surgeon does not differentiate them after removal of a pericardium, then it demonstrates that there were yet not remote covers, to-rye squeeze heart. During operation constantly measure the central venous pressure. By the end of operation it usually decreases. Recovery and improvement after operation is noted in 76% of cases.

The FORECAST

At idiopathic acute P. and in most cases virus and allergic P. the forecast for life favorable. At P. of other nature the forecast is defined by hl. obr. P.'s etiology and a current of a basic disease, and also timeliness and adequacy of the carried-out treatment. At tumoral P. the forecast always bad. At coccal and bacterial P. the forecast considerably improved in connection with implementation in practice of their treatment of antibiotics, but at gangrenous and purulent forms worsens both the direct vital forecast, and remote — in connection with formation of adhesive forms of a pericardis.

Exudative P. at tuberculosis, rheumatism, a serum disease or arising after a hemodialysis can lead to a cardiac tamponade that sharply worsens the vital forecast. The progressing tamponade at violently growing exudate threatens with death if the urgent pericardiocentesis is not made. However in most cases exudative P. at these diseases only temporarily makes heavier disease. At uraemia emergence of a pericardial rub was always considered as a sign of fast death («a knell of braytik»); it can disappear after a hemodialysis, but the last sometimes is complicated by a cardiac tamponade.

At konstriktivny P. the forecast is defined generally by extent of hemodynamic disturbances. Duration of a disease of patients with konstriktivny P. from emergence of the first its wedge, signs to a pericardectomy varies from 1 month to several years. Especially quickly the syndrome of a prelum develops in cases of a purulent pericardis. Sometimes there is sufficient term of 3 — 6 weeks from the beginning of inflammatory process that there were heavy disturbances of blood circulation. Timely surgical treatment improves the forecast at kostriktiv-nokhm P., but in a dystrophic stage of a course of process rendering the surgical help considerably becomes complicated.

CHILDREN

at children's age have Authentic data on P.'s prevalence of no FEATURE of the PERICARDIS. Pathoanatomical it, according to G. A. Roshchina (1957), comes to light almost in 4% of cases, i.e. approximately with the same frequency, as at adults.

At children of the first 3 years of life of P. arises at sepsis and destructive pulmonary and pleural diseases more often; sometimes it accompanies an enteroviral carditis. At preschool and school age tuberculosis and general diseases of connecting fabric — rheumatism, a system lupus erythematosus, a pseudorheumatism, etc. are more frequent reasons. It is usually observed mioperikardit or P. in combination with other serosites, and at rheumatism — pancarditis (see). More rare, as well as at adults, P. of other etiology meet.

Clinically in the early period of P. rise in temperature, a heartache, sometimes — in a stomach, pallor, a loss of appetite, short wind, a painful tussiculation is observed. There can be a fever, a headache.

The shaggy (dry) pericardium is shown at children the same as at adults. Borders of heart and sonority of tones are not changed. The pericardial rub is listened. The sizes of a liver can be moderately increased. Dry P.'s diagnosis at children is more difficult to be established, than at adults. Children of the first years of life often incorrectly specify localization of pain, and at babies in general it is difficult to reveal a pain syndrome; the gentle pericardial rub can not be caught because of concern of the child and tachycardia, and at a pleuropericarditis it sometimes is accepted to a pleural rub. Complicates fibrinous P.'s diagnosis and absence typical rentgenol. changes. Rentgenokimografiya at children of early age is impracticable since the small child does not hold the breath. Therefore the pericardial rub often remains the only reliable sign of the fibrinous Item n shall come to light the doctor in appropriate cases by careful auscultation of heart in various provisions of the patient. During the involvement in process of subepicardial departments of a myocardium P.'s diagnosis can be facilitated by identification of changes of an ECG (an elation of a segment of ST at the kept tooth of T, later — the arc-shaped deformation of a segment of ST camber up, a depression of a tooth of T). Also the Echocardiography has diagnostic value.

Acute vypotny the pericardis, especially purulent or fibrinopurulent, is characterized considerably by bigger weight of a current. Integuments of the child are sharply pale with an earthy shade, it is uneasy. Small children rush about, without finding a comfortable position; children of advanced age sit or lie, as if pressing area of heart to a pillow. Short wind and tachycardia accrue. Vomiting is possible. At survey swelling of cervical veins, pastosity of the person and neck are noted, children of early age have a smoothness of mezhreberiya in heart. The apical beat is displaced up and medially, later — is weakened. Percussion limits of relative and absolute dullness of heart are expanded, their contours approach. Sonority of cardiac sounds can be kept, especially in situation on spin when exudate moves kzad. At accumulation of an exudate or at the accompanying myocarditis of a tsna considerably are muffled, are sometimes arrhythmic. A large amount of liquid leads to disappearance of a pericardial rub if he was listened in the beginning. Pulse, as a rule, small filling. By the ABP it is lowered. At children the circulatory unefficiency with a hepatomegalia, a delay of a diuresis quickly develops.

Radiological increase in borders of a cordial shadow, sometimes its rounded shape (is more often with more expressed protrusion of the left contour), decrease in a pulsation on contours of heart, a smoothness of cardiophrenic corners is characteristic. Data of an ECG same, as at P. at adults. In blood the considerable leukocytosis, shift of a formula to the left, acceleration of ROE, signs of an anemization are noted.

Most hard acute purulent P. with bystry increase in quantity of an exudate proceeds: repeated collapses with a loss of consciousness and signs of a cardiac tamponade — the expressed and stable falling of the ABP, increase in venous pressure, strengthening of cyanosis, swelling of cervical veins, increase and morbidity of a liver are observed; dullness of cardiac sounds; frequent small pulse; the superficial, sharply speeded up or aperiodic breath.

The adhesive pericarditis at children develops most often in the outcome of the purulent nonspecific or tubercular Item. At purulent P. at a part of children cicatricial changes arise against the background of yet not ended inflammation. Since 70th years more rare formation hron, konstriktivny process after purulent P. at children is noted.

Tuberculosis happens the reason hron, adhesive P. often, at P.'s Krom in an acute stage sometimes it is not distinguished against the background of exudative pleurisy.

Quite often tubercular P. has also primary and chronic character with gradual development of the cicatricial squeezing changes and formation of an armored heart. At the same time into the forefront disturbance of portal blood circulation acts: hepatomegalia, ascites. Reduction of cordial emission and depression of function of a liver lead to the accruing general dystrophy, anemia, the hypoproteinemia aggravating further and an edematous syndrome. Unlike adults at konstriktivny P. borders of heart more often remain expanded with children; existence of a negative cardiac impulse is possible.

Quite often short systolic noise, late systolic click are defined. The ciliary arrhythmia at children's age is observed seldom.

The low voltage of all teeth of an ECG, weak pulsation on contours of heart and «mute zones» on a rentgenokimogramma confirm adhesive P.'s diagnosis, permanent increase in venous pressure, and also these flebografiya, the Echocardiography

P.'s Treatment at children is carried out the same as at adults. At threat of a cardiac tamponade the urgent pericardiocentesis before which carrying out it is important to otdifferentsirovat vypotny P. from the cardiomegaly caused by a hypertrophy or dilatation of a myocardium is shown. At a recurrence of an exudate and at purulent P. sometimes apply a drainage of a pericardiac cavity.

Carry out correction of exchange disturbances, an immunotherapy and vigorous antibacterial therapy along with opening of suppurative focuses. Antibiotics if necessary enter into a pericardiac cavity in combination with proteolytic enzymes, oxygen, suspension of a hydrocortisone for the purpose of reduction of commissural process.

At high-quality idiopathic P., rheumatism and other diseases of connecting fabric, virus P. (when the exudate has serous or serofibrinous character) the puncture, as a rule, is not carried out.

Active therapy of a basic disease with use of corticosteroid drugs in necessary doses promotes reduction of exudation.

At konstriktivny P. operational treatment is shown.



Bibliography: Astapov B. M. and Gogin E. E. Diagnostic value of an artificial pnevmoperikardium, Vestn, rentgenol. and radio-gramophones., t. 36, No. 1, page 15, 1961; Volynsk 3. M and Gogin. E. Diseases of a pericardium, JI., 1964; Of au g and N of E. E. Diseases of a pericardium, M., 1979; Ermolenko V. M., the P e of and e in V. A. and Balkarov I. M. Perikardit and a cardiac tamponade at patients on a regular hemodialysis, Cardiology, t. 15, No. 5, page 47, 1975; 3 about d and e in V. V. Radiodiagnosis of heart diseases and vessels, page 227, M., 1957; Krasnova M. N. About an acute high-quality pericardis at children, Vopr. okhr. mat. also it is put., t. 19, No. 8, page 51, 1974; Kudryavtsev V. A. Treatment of an exudative pericardis at children, Vestn, hir., t. 115, No. 7, page 114, 1975; L of fleo in S. L., Grebennikov A. T. K. F. Perikardita's i'shiryaeva at children and their surgical treatment, L., 1979, bibliogr.; V. I Pipia. Surgical treatment of the chronic squeezing pericardis and using cross chrezgrudinny access, Tbilisi, 1959; Tkachenko G. T. ides of river. Purulent perikardita at children, Vopr. okhr. mat. also it is put., t. 22, No. 12, page 65, 1977; Dressier W. Idiopathic recurrent pericarditis, comparison with postcommissurotomy syndrome, Amer. J. Med., v. 18, p. 591, 1955; Gibbon J. H. Gibbon’s surgery of the chest, Philadelphia a. o., 1976; Harada K. Pericarditis in children, Jap. circulat. J. (En.) v. 42, p. 175, 1978; The pathology of the heart, ed. by A. Pomerance and. Y. J. Davies, p. 413, Oxford a. o., 1975; Petre n k o I. E. Die Rontgendiagnostik der exsudation Perikarditis beirn akuten Herz-infarkt, Radiol, diagn. (Berl.), Bd 19, S. 186, 1978; Steinberg I. Roentgenography of pericardial disease, Amer. J. Cardiol., v. 7, p. £33,961, bibliogr.; Van Der Horst R. L. a. L e R o u x B. T. Pericardiectomy in children, Thorax, v. 31, p. 391, 1976.


E. E. Gogin; B. M. Astapov (rents.), A. M. Vikhert (stalemate. An.), H. N. Malinovsky (hir. to lay down.), O. G. Solomatin (ped.).

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