Pericardium: Understanding Anatomy, Function, Development and Congenital Anomalies ,Clinical Significance
INTRODUTION: What is pericardium ? Term pericardium is derived from the Greek prefix :peri means – Around and Kardia means- Heart pericardium is a double walled fibro serous sac which encloses the heart and roots of great blood vessels. It is situated in middle mediastinum. It consists of 2 layers , they are as follows : STRUCTURE AND FUNCTIONS OF PERICARDIUM: 1.Fibrous Pericardium It is the outer most layer , which encloses the heart and fuses with the roots of great vessels which enter or leave the heart .It is conical sac and made up of dense and loose connective tissue, mainly collagen and elastin .It is non pliable [inflexible] , it can change some what. 1.1 Relations Of Fibrous Pericardium APEX : It is blunt, lies at the level of sternal angle [ angle of louis ] . It fuses with the roots of great vessels and with the pre tracheal fascia. BASE: Broad and inseparably blended with central tendon of the diaphragm. ANTERIOR: It is connected to upper and lower ends of body of sternum [breast bone] by weak superior and inferior sternopericardial ligaments. POSTERIOR It relates to: Each side 1.2 Functions : Protection: As it is made up of dense fibrous tissue it cushions the heart from outside forces and sudden pressure changes . Anchorage: As it is shows attachments with the diaphragm and sternum [ breast bone] it keep the heart in place. Restricting the heart volume : As it is made up of fibrous dense connective tissue .It prevents heart from more expansion than needed. Fibrous prolongations of pericardium: Vessels like aorta, superior vena cava, right and left pulmonary arteries and 4 pulmonary veins receives prolongations of fibrous pericardium up to 5 to 6 mm NOTE: Inferior vena cava doesn’t receive any covering from fibrous pericardium , it enters the pericardium through the diaphragm’s central tendon Protection from infections : Protects heart from infections that might spread from nearby organs like lungs. 2. Serous pericardium : It is a thin double layered serous membrane made up of mesothelium. Parietal layer : This layer fused with the inner surface of fibrous pericardium. Visceral layer: This layer fuses with the heart , except at the cardiac grooves. These two layers, parietal and visceral pericardium continues with each other at roots of great vessels. Pericardial cavity: The space between the parietal and visceral layers is called as pericardial cavity It is filled with pericardial fluid [serous fluid] –15 to 50 ml which is secreted by serous layer. 2.1 Functions: Secretion Of Pericardial Fluid: SINUSES OF PERICARDIUM: Sinuses are the extensions of the pericardial cavity that form between the pericardium and heart surface. There are 3 types of sinuses : TRANSVERSE SINUSES : It is located behind the aorta and pulmonary trunk, and in front of superior vena cava . horizontal gap between arterial and venous ends of heart tube Bounded by : OBLIQUE SINUSES :It is j-shaped narrow space located behind the heart , particularly the left atrium. Bounded by : IMPORTANCE : It permits pulsations of left atrium to take place freely. SUPERIOR SINUSES: It is located in front of ascending aorta and the pulmonary trunk NOTE: it can’t be accessed during electrophysiology procedures. CONTENTS OF PERICARDIUM : BLOOD SUPPLY : Fibrous and parietal layers are supplied by branches of: NERVE SUPPLY: DEVELOPMENT AND CONGENITAL ANOMALIES OF PERICARDIUM: Pericardium embryological development is a complex process that involves several stages, which are intricately linked to the formation of the heart and the cardiovascular system. The pericardium forms from mesodermal layers during embryonic development and undergoes key changes as the heart evolves into its mature anatomical state. 1. Embryological Origins of the Pericardium The pericardium develops from two main mesodermal sources: the somatic mesoderm and the splanchnic mesoderm. The space between these two layers, called the pericardial cavity, is initially a small slit, which later expands and houses the heart. 2. Stages of Pericardium Formation 2.1. Primitive Heart Tube Development (Week 3) At around the third week of embryonic development, the heart begins as a simple, tubular structure formed from the cardiogenic mesoderm. This tube undergoes folding and looping to form a more complex structure, eventually forming the heart with the atria and ventricles. Simultaneously, the pericardial cavity begins to form. Initially, the heart is surrounded by a small amount of mesodermal tissue derived from the lateral mesoderm. The pericardium begins as a continuous sheet of mesoderm surrounding the heart tube. As the heart tube folds, this mesoderm differentiates into the somatic mesoderm (which will form the parietal pericardium) and the splanchnic mesoderm (which will form the visceral pericardium). 2.2. Formation of the Pericardial Cavity (Week 4) By the fourth week, the pericardial cavity becomes more defined. The space between the parietal and visceral layers of mesoderm get enlarged and filled with fluid, allowing the heart tube to move freely within this sac. This fluid-filled pericardial cavity acts as a cushion, reducing friction as the heart begins to beat. 2.3. Development of Pericardial Layers (Week 5 to 6) During weeks 5 and 6, the pericardial cavity enlarges, and the pericardial layers become distinct. The visceral pericardium becomes intimately associated with the developing myocardium (heart muscle), and the parietal pericardium becomes a separate layer, lining the pericardial cavity. At this stage, mesodermal cells in the region of the epicardium (visceral pericardium) also begin to differentiate into epicardial cells, which will contribute to the development of the heart’s coronary vasculature. Meanwhile, the parietal pericardium develops a fibrous structure that will become the fibrous layer of the adult pericardium. 3. Maturation and Differentiation 3.1. Formation of the Fibrous Pericardium The fibrous pericardium is derived from the surrounding mesodermal tissues and becomes an important structure as the heart grows. During the later stages of embryonic development (by week 7-8), the parietal pericardium becomes organized into the fibrous pericardium, which is a tough, inelastic membrane that limits excessive movement of the heart and helps anchor it within the thoracic cavity. 3.2. Pericardial Fluid