Chronic Pericardial Effusion Research Articles

Acute Cardiorenal Syndrome by High Flow Arteriovenous Fistula after Kidney Transplantation

The aim of this work was to increase recognition of high flow arteriovenous fistulas in kidney transplant patients. Here, we report the case of a 22-year-old man with repeated hospitalizations for cardiomegaly and chronic pericardial effusion after kidney transplantation. Eventually, high flow of his arteriovenous fistula was recognized 5.5 years after transplantation when he developed acute cardiorenal syndrome. Access flow reduction markedly improved kidney graft function along with reversion of cardiomegaly, which was impressively demonstrated by follow-up chest-x-rays. Arteriovenous fistulas should be monitored regularly after kidney transplantation to avoid congestive heart failure and other serious complications.

COMPARATIVE OUTCOMES OF PERICARDIOCENTESIS VERSUS SURGICAL PERICARDIOTOMY IN PATIENTS WITH CHRONIC KIDNEY DISEASE AND PERICARDIAL EFFUSION IN THE UNITED STATES

At this time, the comparative in-hospital outcomes for pericardiocentesis and surgical pericardiotomy (pericardial window) in patients with chronic kidney disease (CKD) and pericardial effusion are unknown. The Nationwide Inpatient Sample (NIS) was used to identify patients with CKD who underwent

Chronic pericardial effusion secondary to a influenza virus A (H1N1)/2009 infection

We report, to our knowledge, the first successful treatment of novel Influenza A (H1N1)/2009 chronic pericardial effusion in an adult. This patient presented on admission respiratory failure and cardiac tamponade which required non invasive ventilation and drainage. Pericardial fluid polymerase chain reaction sequences were positive for Influenza A (H1N1)/2009 virus. Any other etiologies were discarded. Recidivating pericardial effusion after medical treatment, firstly with Oseltamivir, and afterwards, with colchicine and corticosteroids during six months, was solved with pericardiectomy.

Idiopathic pericardial effusion in 2 year old labrador managed with ultrasound-guided pericardiocentesis: Case report

A two-year old, 38kg-wt male Labrador was presented for management because of progressive exercise intolerance. At presentation, rectal temperature was 38.5°C, pulse rate was 135 beats per minute (but weak). There was ascites along with oedema of the extremities. The heart sound was muffled and pulsus paradoxus was very mild. The patient was well hydrated. Thoracic radiography revealed a globoid shaped heart occupying most of the equatorial thoracic volume; there was loss of details of cardiac silhouette and there was dorsal deviation of trachea at carina. Ultrasonography revealed a distinct epicardium, pericardium and a very wide anechoic space in between. Blood picture was within normal findings. Idiopathic chronic pericardial effusion was diagnosed. Ultrasound-guided pericardiocentesis was carried out using a 16 gauge over the needle catheter attached to a 3-way stopcock and a 20mls syringe; about 65mls of clear effusate was aspirated. Laboratory analysis of the effusate revealed that it was a transudate. The patient was placed on 3mg/kg furosemide, twice daily for 5 days and the patient returned to gradual exercise during hospitalization. Oedema of the extremities and ascities decreased, the appetite improved and the dog became more active. Thoracic radiography fourth week post pericardiocentesis revealed a normal cardiac silhouette. The cause of pericardial effusion was not known.

Pericardial Window by Videothorascopy

IntroductionPericardial effusion is a clinical condition requiring multidisciplinary management. There are several surgical techniques for its diagnosis and treatment. In the present study we report our experience in performing a pericardial window (PW) by videothorascopy. Material and methodsWe performed surgery on 56 patients (20 females and 36 males), with a mean age of 56±1.22 years, and diagnosed with moderate to severe chronic pericardial effusion. The side chosen for the approach depended on whether there was an associated pleural effusion or lung lesion, and if not the left side was chosen. ResultsThe mean duration of the surgery was 37.6±16min. The definitive diagnoses were malignant processes in 23% of cases, including bronchogenic carcinoma and breast cancer. The intraoperative mortality was 0%. ConclusionsVideothorascopic pericardial window is an effective and safe technique for the diagnosis and treatment of chronic pericardial effusion, and which enables it to be drained and perform a pleuropulmonary and/or mediastinal biopsy during the same surgical act.

Ventana pericárdica por videotoracoscopia

Introduction Pericardial effusion is a clinical condition requiring multidisciplinary management. There are several surgical techniques for its diagnosis and treatment. In the present study we report our experience in performing a pericardial window (PW) by videothorascopy. Material and methods We performed surgery on 56 patients (20 females and 36 males), with a mean age of 56 ± 1.22 years, and diagnosed with moderate to severe chronic pericardial effusion. The side chosen for the approach depended on whether there was an associated pleural effusion or lung lesion, and if not the left side was chosen. Results The mean duration of the surgery was 37.6 ± 16 minutes. The definitive diagnoses were malignant processes in 23% of cases, including bronchogenic carcinoma and breast cancer. The intra-operative mortality was 0%. Conclusions Videothorascopic pericardial window is an effective and safe technique for the diagnosis and treatment of chronic pericardial effusion, and which enables it to be drained and perform a pleuro-pulmonary and/or mediastinal biopsy during the same surgical act.

The Prognosis Investigation in Patients with Chronic Heart Failure and Pericardial Effusion

The Prognosis Investigation in Patients with Chronic Heart Failure and Pericardial Effusion

Heart Failure

Heart Failure

Diagnosis and management of pericardial effusion

Pericardial effusion is a common finding in everyday clinical practice. The first challenge to the clinician is to try to establish an etiologic diagnosis. Sometimes, the pericardial effusion can be easily related to a known underlying disease, such as acute myocardial infarction, cardiac surgery, end-stage renal disease or widespread metastatic neoplasm. When no obvious cause is apparent, some clinical findings can be useful to establish a diagnosis of probability. The presence of acute inflammatory signs (chest pain, fever, pericardial friction rub) is predictive for acute idiopathic pericarditis irrespective of the size of the effusion or the presence or absence of tamponade. Severe effusion with absence of inflammatory signs and absence of tamponade is predictive for chronic idiopathic pericardial effusion, and tamponade without inflammatory signs for neoplastic pericardial effusion. Epidemiologic considerations are very important, as in developed countries acute idiopathic pericarditis and idiopathic pericardial effusion are the most common etiologies, but in some underdeveloped geographic areas tuberculous pericarditis is the leading cause of pericardial effusion. The second point is the evaluation of the hemodynamic compromise caused by pericardial fluid. Cardiac tamponade is not an "all or none" phenomenon, but a syndrome with a continuum of severity ranging from an asymptomatic elevation of intrapericardial pressure detectable only through hemodynamic methods to a clinical tamponade recognized by the presence of dyspnea, tachycardia, jugular venous distension, pulsus paradoxus and in the more severe cases arterial hypotension and shock. In the middle, echocardiographic tamponade is recognized by the presence of cardiac chamber collapses and characteristic alterations in respiratory variations of mitral and tricuspid flow. Medical treatment of pericardial effusion is mainly dictated by the presence of inflammatory signs and by the underlying disease if present. Pericardial drainage is mandatory when clinical tamponade is present. In the absence of clinical tamponade, examination of the pericardial fluid is indicated when there is a clinical suspicion of purulent pericarditis and in patients with underlying neoplasia. Patients with chronic massive idiopathic pericardial effusion should also be submitted to pericardial drainage because of the risk of developing unexpected tamponade. The selection of the pericardial drainage procedure depends on the etiology of the effusion. Simple pericardiocentesis is usually sufficient in patients with acute idiopathic or viral pericarditis. Purulent pericarditis should be drained surgically, usually through subxiphoid pericardiotomy. Neoplastic pericardial effusion constitutes a more difficult challenge because reaccumulation of pericardial fluid is a concern. The therapeutic possibilities include extended indwelling pericardial catheter, percutaneous pericardiostomy and intrapericardial instillation of antineoplastic and sclerosing agents. Massive chronic idiopathic pericardial effusions do not respond to medical treatment and tend to recur after pericardiocentesis, so wide anterior pericardiectomy is finally necessary in many cases.

Clinical review: Intrapericardial fibrinolysis in management of purulent pericarditis

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.

Right ventricular tear mimicking myocardial infarction following pericardiocentesis

A 72-year-old female was admitted to the CCU with a recent onset of progressive breathlessness for bedside pericardial drainage for chronic pericardial effusion. After an uncomplicated drainage procedure, initially a serous straw coloured fluid was aspired with subsequent hemorrhagic aspiration with haemoglobin value similar to the peripheral blood. The patient showed initially transient improvement followed by rapid deterioration into severe shock and death. Signs of infero-posterior myocardial infarction (MI) were seen on the ECG. Before death, further interventions were refused by her and her family but a permission was given for autopsy. At autopsy, right ventricular rupture was seen with a 0.6 cm tear with a large amount of 800 cc bloody fluid with clots. The result of histopathologic study of the tear was resembling three-days old MI. The drain was found to be properly localized in the pericardial space, was not blocked and caused no harm to the myocardium. Furthermore, histopathologic examination revealed pulmonary adenocarcinoma of the left upper lobe, pleuritis and lymphangitis carcinomatosa and enlarged mediastinal lymph nodes. A case of fatal complication is reported following bedside pericardial drainage. Postmortal, right ventricular tear mimicked myocardial infarction.

E0602 The prognosis investigation in patients with chronic heart failure and pericardial effusion

BackgroundResearchers still do not reach the consensus on the incidence, characters and the prognostic value of pericardial effusion (PE) in patients with chronic heart failure (CHF).Methods1189 patients, with a diagnosis...

Autoimmunity puzzle in Down syndrome

One of the most common genetic abnormalities, Down syndrome is associated with intellectual disabilities as well as increased incidence of autoimmune diseases. Endocrine disorders, such as diabetes and thyroid dysfunction are amongst the most common. We describe the case of a 27 year old woman diagnosed with diabetes at the age of 9, who had associated crises of loss of consciousness from the age of 23 and developed primary autoimmune hypothyroidism from the age of 25 years with chronic pericardial effusion. Neurological examination considered the diagnosis of absence crises; therefore she started taking Carbamazepine 400 mg daily since the age of 23. At admission, the patient was obese (BMI =32 kg/m2), with neck localised acanthosis nigricans. The clinical examination revealed signs of hypothyroidism without goitre. Diagnosis was confirmed by TSH = 350 mUI/L, anti TPOAb = 329.9 U/ml as well as pericardial effusion on echocardiography. She started thyroxine replacement therapy, while being on basal/bolus insulin regimen (short and intermediate acting insulin). Full control of diabetes was not achieved until she also received metformin and basal insulin analog. TSH level reached normal values of 2.4 mU/L only after a LT4 substitution dose of 150 µg daily. Evolution of thyroid status and diabetes under progressive thyroxine substitutive treatment is discussed. Compliance to diet, diabetes and myxoedema treatment is severely influenced by her intellectual disabilities. Screening for thyroid status and autoimmunity in order to detect subclinical hypothyroidism, should be performed in patients with Down syndrome.

Echocardiography of isolated subacute left heart tamponade in a patient with cor pulmonale and circumferential pericardial effusion

Patients with advanced idiopathic pulmonary artery hypertension have often a chronic pericardial effusion. It is the result of increased transudation and impaired re-absorption due to elevated venous pressure. These patients have pre-existent symptoms and signs of chronic right heart failure. High degree of suspicion is required to detect of development of an atypical form of tamponade with isolated compression of left heart chambers as shown in present case report. Transthoracic echocardiography provides a rapid access to the correct diagnosis, a prompt relief of symptoms following the ultrasound guided pericardiocentesis and important diagnostic tool for regular follow up of patients thereafter as shown in our case report.

Contrast-fluid level in the inferior vena cava (IVC niveau sign) in patients with acute type A aortic dissection: computed tomography findings during acute cardiac tamponade

The purpose of this study was to report a new computed tomography (CT) finding in acute cardiac tamponade: a contrast-fluid level in the hepatic inferior vena cava (IVC) during an arterial dominant phase CT study (IVC niveau sign) in patients with acute type A aortic dissection. We retrospectively reviewed CT studies with the diagnosis of proximal aortic dissection (Stanford type A) with acute cardiac tamponade. There were 12 patients enrolled in the study (6 women, 6 men; mean age 66 years). A total of 62 patients were selected as a control chronic pericardial effusion group to compare with the acute cardiac tamponade group. Among the 12 patients with acute cardiac tamponade, the IVC niveau sign was seen in 7 (58%). In the control chronic pericardial effusion group (n = 62), we identified the IVC niveau sign in only one patient (1.6%). There was a significant difference in the presence of the IVC niveau sign between the acute cardiac tamponade and chronic pericardial effusion groups (P < 0.0001). The presence of the IVC niveau sign suggests acute cardiac tamponade in patients with acute type A aortic dissection.

Diagnosis of unrecognized primary overt hypothyroidism in the ED

Objective The aims of the study were to evaluate the incidence of newly diagnosed primary overt hypothyroidism among adults admitted through the emergency department (ED) and to assess how previously undiagnosed hypothyroidism presents. Methods From July 1, 2002 to June 30, 2006, 56 adult patients were enrolled for further analysis. Results The incidence of newly diagnosed primary overt hypothyroidism among adults admitted through the ED is 0.1%. The mean age of the patients was 75.8 ± 12.8 years (range, 27-98 years). Most of our patients presented in the winter. Individual symptoms and signs were not sensitive. Drugs (13 patients, 23%), nongoitrogenous autoimmune thyroiditis (12 patients, 21%), and previous surgery or irradiation related (11 patients, 20%) are frequent causes of unrecognized hypothyroidism in this iodine-replete region. Only 21% of patients were admitted with a correct initial impression. Half of myxedema coma patients were missed during the initial ED stay. Thirty-three patients (59%) had cardiomegaly on chest x-ray receiving further echocardiography examination. Pericardial effusion was found in 18 patients. Of these, 7 patients had moderate to large pericardial effusion, but none had cardiac tamponade. Only 6 patients have depressed left ventricular ejection fraction (<40%). Conclusions The diagnosis of hypothyroidism is often missed during the ED evaluation of patients at risk for this uncommon disease. Hypothyroidism should always be considered in patients who present with nonspecific symptoms suggestive of the disease, including weakness, cold intolerance, and alterations in mental status, and receive drugs impairing thyroid function or treatment of advanced head and neck cancer. In addition, patients with stable chronic heart failure or unexplained pericardial effusion warrant serum thyroid testing.

Controversial Issues in the Management of Pericardial Diseases

The management of pericardial diseases is largely empirical because of the relative lack of randomized trials. The first published guidelines1,2 are a first attempt to organize current knowledge. At present, no specific guidelines have been issued by the American Heart Association and American College of Cardiology. After a literature review including a Medline search with the MeSH terms “pericarditis” and “pericardium,” we identified the following controversial issues related mainly to the management of pericarditis and pericardial effusion: (1) etiological search and hospitalization; (2) role of pericardiocentesis, pericardial biopsy, and pericardioscopy; (3) myopericarditis; (4) use of corticosteroids, nonsteroidal antiinflammatory drugs (NSAIDs), and colchicine; (5) management of refractory cases and long-term outcome; (6) role of pericardiectomy, pericardial window, and other interventional techniques; and (7) management of chronic idiopathic pericardial effusion. At the end of each issue, key points are summarized. Management of most cases is done by general practitioners or different healthcare specialists and does not require specific expertise; nevertheless, incessant and recurrent cases and specific forms (eg, tuberculous pericarditis, neoplastic pericardial disease, autoimmune conditions) require cooperation among specialties (eg, cardiology, infectious diseases, rheumatology, oncology). Specific interventional techniques (eg, pericardioscopy) and pericardiectomy should be performed in referral centers. ### Pericarditis Although the clinical diagnosis of pericarditis is relatively simple (Tables 1 and 2⇓),1–13 establishing the cause may be more difficult. A major controversy in “pericardiology” is the role of an extensive etiologic search and hospital admission for all patients with pericarditis or pericardial effusion.1–8 The causes of pericarditis are varied (Table 3),9 and the clinician should identify causes that require targeted therapies. The epidemiological background is essential to develop a rational cost-effective management program3,4,15,16; the approach may be different for research, when we attempt to reduce the number of “idiopathic” cases. In developed countries, idiopathic …

Pneumopericardium

We present a case of a 43-year-old woman with a history of chronic idiopathic pericardial effusion, which has been diagnosed 6 years ago. The patient reported an increasing dyspnea over the last 2 months. Echocardiographic examination showed a massive pericardial effusion with compromise of the right atrium and ventricle, and an increase in the respiratory variation of mitral valve inflow velocities, suggested of haemodynamic compromise. A therapeutic pericardiocentesis was performed using a subxyphoidal approach. Five hundred millilitres of serous fluid were drained and a marked reduction of the effusion was achieved. On day 1 after the pericardiocentesis, the patient developed a left sided chest pain. The chest radiography showed a new lucent outline around the heart representing the existence of air in the pericardial space (Fig. 1).

Successful Transabdominal Subxiphoid Pericardiostomy to Relieve Chronic Pericardial Effusion in a Sumatran Orangutan (Pongo abelli)

A 46-yr-old female Sumatran orangutan (Pongo abelli) was first diagnosed with pericardial effusion in July 2006. Pericardiocentesis performed in January 2007 only provided short-term relief. In May 2007, a pericardial-peritoneal window was created using a transabdominal subxiphoid pericardiostomy technique, providing immediate and long-term relief. Seven months later, the orangutan was euthanized due to worsening heart failure, and no pericardial effusion was present. Transabdominal subxiphoid pericardiostomy offers a straightforward surgical approach that can provide significant relief in cases of chronic pericardial effusion in great apes.

Acute Pulmonary Edema After Pericardial Drainage for Cardiac Tamponade

Pericardial effusions with tamponade may present a clinical challenge in management for the cardiothoracic surgeon. We report a case of acute pulmonary edema secondary to the rapid release of a chronic traumatic pericardial effusion that resulted in the death of the patient.