CARDIAC TAMPONADE FROM RAPID UREMIC PERICARDITIS IN PATIENT WITH WARFARIN OVER-ANTICOAGULATION

Abstract

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Cardiac tamponade constitutes a medical emergency, which requires prompt recognition, diagnosis and treatment that is geared towards preventing cardiovascular collapse and cardiac arrest. CASE PRESENTATION: 81-year-old male patient with end stage renal disease on hemodialysis, paroxysmal atrial fibrillation on warfarin anticoagulation, diabetes mellitus type II, and morbid obesity, who was evaluated for history of 24-hour progression of general malaise, orthopnea, dyspnea on exertion, and dizziness after missing two sessions of hemodialysis. Physical exam was remarkable for borderline low blood pressure, +3 leg edema, distended jugular veins, bibasilar crackles, distant heart sounds, absence of cardiac murmurs or heart sounds. ECG showed pulsus alternans and low voltage criteria. Limited bedside echocardiogram was remarkable for a moderate pericardial effusion with minimal ventricular and atrial compression abnormalities. Patient was provided hemodialysis for volume overload without hemodynamic decompensation and was monitored with telemetry and bedside hemodynamics. Shortly after hemodialysis, patient developed worsening shortness of breath and became hypotensive. Patient was started on norepinephrine vasopressor therapy. A bedside limited echocardiogram showed diastolic right ventricular and right atrial collapse, non-collapsibility of the inferior vena cava and severe pericardial effusion that duplicated in size. Bedside emergent subxiphoid echocardiography-guided pericardiocentesis with instillation of agitated saline was performed with removal of about 400cc of serosanguineous fluid with resolution of hypotension and electric alternans. Labs reflected marked uremia, elevated ESR and C-reactive protein and warfarin overanticoagulation with INR of 4.5. Pericardial fluid resulted with a culture-negative exudative effusion composed of bloody material and inflammatory cells. Chest non-contrast computed tomography showed nonspecific mild mediastinal adenopathy. Positron emission tomography–computed tomography showed no significant F-18 Fluorodeoxyglucose avid lesions that were identified. Patient was provided ultrafiltration for 5 days, and started on colchicine and indomethacin with weekly follow-up of inflammatory markers and echocardiography, with marked improvement of pericardial effusion size and return of normal hemodynamics. DISCUSSION: Uremic pericarditis was identified in setting of acute pericarditis in a patient with over-anticoagulation. The hemorrhagic component resulted in rapid fluid accumulation and tamponade. The instillation of agitated saline can help assess for inadvertent chamber puncture during procedure. CONCLUSIONS: Uremic pericarditis is now an uncommon cause of pericarditis, but it can be exacerbated in the setting of inflammatory pericarditis and over-anticoagulation, leading to rapid accumulation of bloody pericardial fluid and cardiac tamponade. Reference #1: Maggiolini S, Gentile G, Farina A, et al. Safety, efficacy, and complications of pericardiocentesis by real-time echo-monitored procedure. Am J Cardiol 2016;117:1369-74. Reference #2: Sadjadi SA, Mashahdian A. Uremic pericarditis: a report of 30 cases and review of the literature. Am J Case Rep. 2015;16:169-173. Reference #3: Osuch JR, Khandekar JD, Fry WA. Emergency subxiphoid pericardial decompression for malignant pericardial effusion. Am Surg. 1985;51(6):298-300. DISCLOSURES: No relevant relationships by VICTOR MOLINA-LOPEZ, source=Web Response No relevant relationships by Hector Santiago, source=Web Response No relevant relationships by Francisco Tirado-Polo, source=Web Response