Clinical review: Intrapericardial fibrinolysis in management of purulent pericarditis

Pascal Augustin,Sigismond Lasocki,Nicholas Heming,Jean-Michel Maury,Philippe Montravers,Mathieu Desmard,Pierre Mordant

doi:10.1186/cc10022

Abstract

Purulent pericarditis (PP) is a potentially life-threatening disease. Reported mortality rates are between 20 and 30%. Constrictive pericarditis occurs over the course of PP in at least 3.5% of cases. The frequency of persistent PP (chronic or recurrent purulent pericardial effusion occurring despite drainage and adequate antibiotherapy) is unknown because this entity was not previously classified as a complication of PP. No consensus exists on the optimal management of PP. Nevertheless, the cornerstone of PP management is complete eradication of the focus of infection. In retrospective studies, compared to simple drainage, systematic pericardiectomy provided a prevention of constrictive pericarditis with better clinical outcome. Because of potential morbidity associated with pericardiectomy, intrapericardial fibrinolysis has been proposed as a less invasive method for prevention of persistent PP and constrictive pericarditis. Experimental data demonstrate that fibrin formation, which occurs during the first week of the disease, is an essential step in the evolution to constrictive pericarditis and persistent PP. We reviewed the literature using the MEDLINE database. We evaluated the clinical efficacy, outcome, and complications of pericardial fibrinolysis. Seventy-four cases of fibrinolysis in PP were analysed. Pericarditis of tuberculous origin were excluded. Among the 40 included cases, only two treated by late fibrinolysis encountered failure requiring pericardiectomy. No patient encountered clinical or echocardiographic features of constriction during follow-up. Only one serious complication was described. Despite the lack of definitive evidence, potential benefits of fibrinolysis as a less invasive alternative to surgery in the management of PP seem promising. Early consideration should be given to fibrinolysis in order to prevent both constrictive and persistent PP. Nevertheless, in case of failure of fibrinolysis, pericardiectomy remains the primary option for complete eradication of infection.

Highlights

Purulent pericarditis (PP) usually occurs in the compromised host [1]
Taken together these studies suggest a curative role of pericardiectomy by achieving complete eradication of the infection and a role in preventing persistent PP and constrictive pericarditis
PP managed with simple pericardial drainage may evolve to constrictive and persistent PP

Summary

Introduction

Purulent pericarditis (PP) usually occurs in the compromised host [1]. Predisposing factors have changed over time. Bloodstream infections or underlying non-infectious conditions such as thoracic surgery, chronic kidney disease, immunosuppression, or malignancy (Table 1) are new predisposing factors. PP is still associated with high mortality (20 to 30%) attributed to both early and late complications, namely persistent PP and constrictive pericarditis [1,2]. These late complications may be prevented by early pericardiectomy, a surgical procedure known for its potential morbidity. In light of the physiological and histological data, we review the rationale of fibrinolysis in PP, the evidence for its efficacy, and all publications on indications, timing, results, and complications

Methods

Total pericardiectomy

None 3 None 1 None

Findings

Conclusion