Diagnosis Of Pericardial Effusion Research Articles

Pericardial Effusion and Superficial Abdominal Abscess as Complications of Malposed PICC Line in a Preterm Neonate: A Case Report

In neonatal critical care units, peripherally inserted central catheter lines are frequently used to provide venous access for continuous parenteral nutrition and medications in newborns. In this case report, a male neonate weighing 1270 grams was on Continuous Positive Airway Pressure (CPAP) for hyaline membrane disease and initially received Total Parenteral Nutrition (TPN) through a Peripherally Inserted Central Catheter (PICC) in the left long saphenous vein on the second day. The baby developed tachycardia, respiratory distress requiring mechanical ventilation, and erythematous swelling over the paraumbilical region. A diagnosis of pericardial effusion and superficial abdominal abscess secondary to a malposed PICC line in a preterm, very low birth weight neonate was made. Suspecting a misplaced line, it was immediately removed, and the patient showed improvement over the next 24 hours. Within the next 48 hours, the patient was extubated to CPAP. Therefore, daily inspection by an expert, as well as confirmation of the central line tip, will aid in preventing delays in detecting complications.

274 A FLOATING HEART IN AN EXCAVATED CHEST

Abstract Pericardial effusion is a common finding in clinical practice either as incidental finding or manifestation of a systemic or cardiac disease. The spectrum of pericardial effusions ranges from mild asymptomatic effusions to cardiac tamponade. Etiology is one of the main factors determining patient's prognosis. However, in most cases the pericardial effusion, even if large, remains of unknown origin. Pectus excavatum (PEX) is a common deformity of the chest wall in which the inferior part of the sternum and the cartilage are displaced posteriorly. PEX is present within the first year of life in most affected children, more frequently in boys than girls. The chest deformity in PEX may lead to compression of the right-sided cavities between the sternum and the vertebral column impacting right ventricular anatomy and rendering cardiac assessment by echocardiography very difficult. The diagnosis of pericardial effusion is generally confirmed by echocardiography but determining its etiology may be difficult. Although many cases are idiopathic, a careful review of the patient's medical history, physical examination, and laboratory tests can reveal the etiology in most patients. The most common causes of pericardial effusion are infections, malignant tumors, connective tissue diseases, pericardial injury syndrome, myocardial pericardial disease, uremia. In the last years, an association between idiopathic pericardial effusion and PEX has been hypnotized. We report the cases of 2 athletes, 15 and 18 years old, who came to our attention for post COVID19 infection evaluation as indicated by ministerial "Return to Play" protocol. Physical examination was negative for any signs/symptoms. Resting ECG showed normal sinus rhythm. Stress test was performed and resulted negative for signs and symptoms of reduced coronary reserve and arrhythmias. The echocardiographic evaluation showed moderate-severe pericardial effusion, 20 mm and 18 mm, in the absence of hemodynamic alteration. Blood tests were performed (including CRP, ESR, blood count, D-Dimer, IL-6, uricemia) and resulted normal. CardioRM confirmed the presence of severe effusion without signs of hemodynamic impairment/instability. Holter-ECG, performed during training session, resulted negative for arrhythmic events. Athletes were followed up with six-monthly echocardiographic, HolterECG and stress test evaluations, with unchanged entity of the pericardial effusion and any arrythmia or symptoms at serial controls. Chronic pericardial effusion without active pericardial inflammation may represent a diagnostic and therapeutic challenge, especially in the later years as COVID-19 disease and vaccination may be associated with pericardial injury. In the last years, PEX has been associated with the finding of pericardial effusion. Although of interest, caution should be used before labeling indiscriminately a pericardial effusion as due to PEX, especially when clinical insights suggesting alternative diagnosis are present, such as neoplasm or tuberculosis, or when any signs of hemodynamic instability are present. On the contrary, when an otherwise idiopathic pericardial effusion is occasionally identified in a patient with PEX, both the patient and the referring physician may be reassured of the benign association of these two clinical entities, in the proper clinical setting.

THE ROLE OF CHEST RADIOGRAPHY TO DIAGNOSE LARGE PERICARDIAL EFFUSION IN WOMAN 66 YEARS OLD WITH MALIGNANCY : HIDING PERICARDIAL EFFUSION

Introduction: Pericardial effusion refers to an increase in fluid accumulation in the pericardial cavity. This pericardial fluid acts as a lubricant between the layers of the pericardium. We report a case of pericardial effusion, which was significant but not detectable on conventional chest radiographs.Case: A 66-year-old woman with lung adenocarcinoma accompanied by large pericardial effusion without sign of impending tamponade. The diagnosis of pericardial effusion was mainly based on echocardiography, where there is a large pericardial effusion but without signs of cardiac tamponade, and the patient then underwent pericardiocentesis. Previously, the patient had undergone two examinations with two different imaging modalities, namely CXR and chest CT scan, where on the CXR results, the patient only showed cardiomegaly.Discussion: There are four parameters suggestive for assessing a pericardial effusion, namely enlargement of the heart silhouette, pericardial fat stripe, left dominant pleural effusion, and an increase in the transverse diameter of the heart compared to the previous chest X-ray. This parameter is obtained not only based on the position of the photo taken but requires another position, whereas, in this patient, only CXR was performed with the posteroanterior position.Conclusion: When there are complaints of progressive shortness of breath in individuals with an underlying disease that may cause pericardial effusion, then the CXR examination cannot be used as a reference when there are no radiographic signs that point to pericardial effusion because CXR has a low diagnostic value in assessing the presence of pericardial effusion.

ED point-of-care ultrasonography is associated with earlier drainage of pericardial effusion: A retrospective cohort study

ObjectivesTo determine the association between emergency department point-of-care cardiac ultrasonography (POCUS) utilization and time to pericardial effusion drainage during an 8-year period when the emergency ultrasound program was established at our institution. MethodsWe performed a single-center retrospective cohort study in patients undergoing pericardiocentesis or other procedure for evacuation of pericardial effusion. Data was collected using both direct queries to the electronic health record database and two-examiner chart review. The primary outcome was time to intervention for pericardial effusion drainage. Multivariable Cox regression, with and without inverse probability weighting for likelihood to receive POCUS, was used to determine the association between POCUS and time to intervention. Secondary outcomes included 28-day mortality. Results257 patient encounters were included with 137 receiving POCUS and 120 who did not. The proportion of patients receiving POCUS increased from 18.5% to 69.5% during the early to late periods of the study. POCUS was associated with an earlier median time to intervention of 21.6 h (95% CI 17.2, 24.2) compared to 34.6 h (27.0, 50.5) in the No POCUS group. After adjustment for patient demographics, anticoagulation, time of presentation and hemodynamic instability, POCUS was associated with earlier intervention (HR 2.08 [95% CI 1.56, 2.77]). POCUS use was not associated with a difference in 28-day mortality, which was evaluated as a secondary outcome. However, diagnosis of pericardial effusion by the ED physician using any means (POCUS or other imaging) was associated with decreased 28-day mortality (9.7% vs. 26.0%, −16.3% for POCUS [95% CI −29.1, −3.5]). ConclusionPOCUS was associated with an earlier time to intervention for pericardial effusions after adjustment for multiple confounding factors. Failure to diagnose pericardial effusion in the ED using any diagnostic testing including POCUS, was associated with increased 28-day mortality.

THE STORY OF THE HEART'S WET SUIT: A CASE OF CARDIAC TAMPONADE WITH COVID-19 IN A YOUNG FEMALE

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: COVID-19 has awestruck physicians across the world with its atypical presentations. Often, pericarditis and myocarditis occur with viral infections in young adults. It is rare to see viral infections causing cardiac tamponade, which is a potentially fatal complication. Several cases of pericardial effusions and pre-tamponade physiology have been reported in elderly individuals with an extensive history of cardiac disease. Here, we describe the case of a previously healthy young adult who developed COVID-19 related cardiac tamponade without any preceding respiratory symptoms. CASE PRESENTATION: A 34-year-old female with a past medical history of hypothyroidism had tested positive for the SARS CoV-2 (Severe Acute Respiratory Distress Syndrome Coronavirus-2) one week prior to presentation. She presented with constant, central chest pain radiating to the back for 2 days. While being evaluated for hypotension, the patient broke into convulsions and was consequently intubated and mechanically ventilated. The patient's Brain natriuretic peptide (BNP) was elevated at 2,470 pg/mL (normal range: 0 – 450 pg/mL), and cardiac troponin was mildly elevated at 0.63 ng/mL. Initial electrocardiogram showed a low voltage strip with sinus tachycardia, and electrical alternans, suggestive of pericarditis(1). Computerized tomography (CT) of the chest with contrast revealed a small non-tappable pericardial effusion. CT head was negative. Over the course of a few hours, significant elevation of cardiac troponin to 5.18 ng/mL, and escalation in vasopressor requirements prompted us to obtain bedside echocardiography, which demonstrated a large pericardial effusion with pre-tamponade physiology. Emergent bedside pericardiocentesis was performed and 250cc of serous pericardial fluid was drained. A pericardial window was kept open to watch for re-accumulation. Post-procedural electrocardiogram had normal voltage, showed no electrical alternans and tachycardia had resolved. The patient was gradually weaned from vasopressor support and other supportive treatment. The pericardial drain was removed. An echocardiogram obtained at a 2-month follow-up showed a healthy heart with a normal ejection fraction. DISCUSSION: On initial evaluation, the differential diagnosis for convulsive syncope in a young patient with hypotension and COVID-19 were pulmonary embolism or a thromboembolic stroke. EKG findings and subsequent clinical course pointed towards a possible pericardial effusion. However, pericardial effusions are commonly idiopathic and only a smaller subset of cases stem from infectious disease. Viral pericarditis causes gradual accumulation of transudate leading to a pericardial effusion. Interestingly, in our patient cardiac tamponade was acute. CONCLUSIONS: This case underscores that an index of suspicion should be held for COVID-19 causing cardiac tamponade in young individuals and that prompt intervention is invaluable. REFERENCE #1: Eisenberg MJ, de Romeral LM, Heidenreich PA, Schiller NB, Evans GT Jr. The diagnosis of pericardial effusion and cardiac tamponade by 12-lead ECG. A technology assessment. Chest. 1996 Aug;110(2):318-24. doi: 10.1378/chest.110.2.318. PMID: 8697827. DISCLOSURES: No relevant relationships by Neha Panchagnula, source=Web Response

The role of point-of-care ultrasound in the diagnosis of pericardial effusion: a single academic center retrospective study

BackgroundSymptomatic pericardial effusion (PCE) presents with non-specific features and are often missed on the initial physical exam, chest X-ray (CXR), and electrocardiogram (ECG). In extreme cases, misdiagnosis can evolve into decompensated cardiac tamponade, a life-threatening obstructive shock. The purpose of this study is to evaluate the impact of point-of-care ultrasound (POCUS) on the diagnosis and therapeutic intervention of clinically significant PCE.MethodsIn a retrospective chart review, we looked at all patients between 2002 and 2018 at a major Canadian academic hospital who had a pericardiocentesis for clinically significant PCE. We extracted the rate of presenting complaints, physical exam findings, X-ray findings, ECG findings, time-to-diagnosis, and time-to-pericardiocentesis and how these were impacted by POCUS.ResultsThe most common presenting symptom was dyspnea (64%) and the average systolic blood pressure (SBP) was 120 mmHg. 86% of people presenting had an effusion > 1 cm, and 89% were circumferential on departmental echocardiogram (ECHO) with 64% having evidence of right atrial systolic collapse and 58% with early diastolic right ventricular collapse. The average time-to-diagnosis with POCUS was 5.9 h compared to > 12 h with other imaging including departmental ECHO. Those who had the PCE identified by POCUS had an average time-to-pericardiocentesis of 28.1 h compared to > 48 h with other diagnostic modalities.ConclusionPOCUS expedites the diagnosis of symptomatic PCE given its non-specific clinical findings which, in turn, may accelerate the time-to-intervention.

Cardiac point-of-care ultrasound reveals unexpected, life-threatening findings in two children

BackgroundThe diagnosis of pericardial effusion with cardiac tamponade can at times be elusive in pediatric patients since it is relatively uncommon. Point-of-care ultrasound (POCUS) can readily be performed at the bedside to assess for the presence of a pericardial effusion, tamponade, and can occasionally yield unexpected results.Case presentationTwo cases where POCUS unexpectedly identified pericardial effusions, with one patient who also had an anterior mediastinal mass.ConclusionsThough underutilized, cardiac POCUS in children can be immediately life-saving and drastically change the clinical management at the patient’s bedside.

P1722 Post myocardial infarction pericarditis or subacute left ventricular free wall rupture after acute myocardial infarction- a role of multimodality imaging

Abstract Introduction Moderate to severe pericardial effusion (PE) in patients with acute myocardial infarction (AMI) can be associated with a broad spectrum of etiologies like left ventricular free wall rupture (LVFWR) or post- myocardial infarction pericarditis (PMIP). We present a case of successful medical treatment of patient with subacute LVFWR after AMI, initially managed as PMIP. Case Presentation A 60- year- old man with a history of hypertension was admitted with persisting chest pain for 72 hours, with diagnosis of ST- segment elevation AMI of inferior wall. Patient underwent a percutaneous coronary intervention (PCI) of the right coronary artery as the AMI culprit vessel. Two days after PCI patient experienced progressive sharp chest pain, dyspnea and low- grade fever. Clinical evaluation revealed elevated inflammatory markers and pericardial rub. Transthoracic echocardiography (TTE) showed PE up to 10 mm. Patient has been diagnosed and treated as PMIP. During further observation patient had TTE performed repeatedly. Four days after PCI TTE revealed PE of 20 mm thickness and suspicion of subacute LVFWR of the lateral wall. Cardiac magnetic resonance (CMR) confirmed the diagnosis. Due to hemodynamic stability, the patient received only medical treatment. During further hospitalization TTE was performed every day. On fifteenth day both TTE and CMR didn’t reveal any rupture. Moreover patient was readmitted 6 weeks after initial hospitalization and TTE again did not show the LVFWR. Discussion Post AMI patients with PE who fulfill pericarditits diagnostic criteria should be managed as having PMIP. Nevertheless LVFWR should also be considered as frequent diagnosis of PE. Echocardiography is crucial in the prompt diagnosis of PE. In our presented case, the TTE did not show initially the LVFWR, only repeatedly performed investigation showed the increasing amount of PE and raised suspicion of subacute LVFWR, which was confirmed in CMR. CMR has become a tool providing accurate diagnosis and visualization of the localization of rupture. Moreover CMR imaging can show LVFWR revealing whether the hematoma is circumscribed to the myocardium or communicates with ventricular cavity or the pericardial sac. LVFWR is a catastrophic complication accounting for a significant proportion of in-patient deaths. It is accepted that emergent surgical repair is the cornerstone treatment for patients with LVFWR. However, similarly to ours, some cases with fairly good survival rates following isolated medical treatment have been reported. This clinical situation stands somewhere between the insidious free rupture into the pericardial cavity and the formation of the pseudoaneurysm. Conclusions Our presentation illustrates the usefulness of repeated multimodality imaging for the diagnosis and follow up of patients with PE after AMI. Our case also underscores the value of a conservative approach as a valid alternative to surgery in some patients with subacute LVFWR.

POINT-OF-CARE ULTRASOUND EVALUATION IN CARDIAC TAMPONADE: FIRST DESCRIPTION OF A "SONOGRAPHIC EWART SIGN"

SESSION TITLE: Tuesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Diagnosing a large pericardial effusion using Point of care ultrasound (POCUS) can be done rapidly and, if needed, may expedite intervention. In 1896, Dr William Ewart described 12 physical exam signs that were indicative of large pericardial effusions needing surgical intervention due to cardiac tamponade. The tenth physical finding, “The Posterior Pericardial Patch of Tubular Breathinq and Agophony” (1) was believed to be “very commonly, if not always, present in cases of considerable effusion"(1). This physical examination finding, described 123 years ago, has been dubbed Ewart’s Sign. We present a sonographic depiction of this classical physical exam finding in a patient who presented with cardiac tamponade to intensive care unit. CASE PRESENTATION: 55-year-old male patient with a past medical history of End Stage Renal Disease, who presented with breathlessness at rest, low blood pressure and new onset atrial fibrillation with rapid ventricular response during hemodialysis. On physical exam, his blood pressure was 94/68 mmHg, heart rate of 124 bpm and respiratory rate of 24 bpm. He had a pulsus pardoxus of 15 mmHg, dullness to percussion of the left posterior chest at the tip of the scapula. Asucultation revealed bronchial breaths sounds and egophony below the left scapula (Ewart’s Sign). A bedside POCUS showed a large pericardial effusion with tamponade physiology; diastolic collapse of the right atrium (RA) and right ventricle (RV). The probe was then placed below the tip of the scapula demonstrating a large pericardial effusion, left lung atelectasis and large left sided pleural effusion (Figure 1); the “Sonographic Ewart’s Sign”. The patient underwent thoracentesis the day of ICU admission with improvement in his breathlessness and a pericardial window the next day resulting in resolution of the cardiac tamponade. DISCUSSION: In this case, we provided a visual depiction of a classical physical exam finding accurately described 123 years ago by Dr. William Ewart using percussion, palpation, and auscultation. In an illustration in the original article, Dr Ewart placed the stethoscope “immediately below or slightly to the left of the tip of the left scapula"(1) to illicit tubular breath sounds and egophony. The sign occurs secondary to compression of the left lower lobe bronchus due to the weight of the pericardial effusion resulting in atelectasis of the left lower lobe. A 123 years later, using POCUS, we were able to visualize what was accurately described. To our knowledge, this is the first description of a "Sonographic Ewart Sign” in literature. CONCLUSIONS: In addition to the presence of large pericardial effusion, RA and RV diastolic collapse, we describe a "Sonographic Ewart Sign” as another sign that physicians could elicit in the point of care evaluation of cardiac tamponade. Reference #1: Ewart, W., 1896. Practical aids in the diagnosis of pericardial effusion, in connection with the question as to surgical treatment. British medical journal, 1(1838), p.717. DISCLOSURES: No relevant relationships by Thamer Sartawi, source=Web Response No relevant relationships by Christine Warner, source=Web Response No relevant relationships by Peter White, source=Web Response

Clinico-Epidemiological Study of Pericardial Effusion in Northern India

Background: Pericardial effusions may be discovered incidentally or as life-threatening scenario of cardiac tamponade. Hence, etiological identification of pericardial effusion proves crucial in-patient management. Aim: To assess the clinical presentation and etiology of pericardial effusion at a tertiary-care centre in India. Methods: This was a retrospective, observational, single-centre one-year hospital-based study. Data from 70 diagnosed cases of pericardial effusion from our tertiary-care centre in India from August 2016 to July 2017 was retrospectively reviewed. A diagnosis of pericardial effusion was confirmed based on findings from clinical history, examination, specific laboratory investigations, and radiological investigations. Pericardial fluid analysis was also performed. Results: The mean age of the patients was 46.87±14.40 years. Almost equal frequencies of men 36 (51.4%) and women 34 (48.6%) were observed. The most commonly observed signs/symptoms of patients diagnosed with pericardial effusion was raised jugular venous pulse in 39 (55.7%) patients, breathlessness in 36 (51.4%) patients, and tachypnea and tachycardia (heart rate >100 beats per minute) in 33 (47.1%) patients each. An etiology of tubercular effusion was common in 32 (44.4%) patients. On analyzing data according to the underlying etiology, the most frequent sign/symptom was raised jugular venous pulse in 20 (62.5%) patients diagnosed with tubercular effusion, tachypnea in 10 (52.6%) patients diagnosed with hypothyroidism and tachycardia in 12 (63.2%) patients with a diagnosis other than pericardial effusion or hypothyroidism. Conclusions: The high prevalence of tuberculosis in India warrants increased control and awareness of this infection.

Agreement between Emergency Physicians and a Cardiologist on Cardiac Function Evaluation after Short Training

Objective: Delayed diagnosis and treatment of shock patients may lead to multiorgan dysfunction syndrome and death. Volume status assessment in shock patients is crucial for guiding early management. Focused echocardiography has become an important tool for assessing volume status because it is non-invasive and easy to perform. We aimed to ascertain the degree of agreement between emergency medicine (EM) residents and a cardiologist on cardiac function evaluations using echocardiography. We also assessed the extent of agreement on pericardial effusion diagnoses. Methods: A cross sectional study was conducted at the Emergency Department, Siriraj Hospital. The EM residents who had limited experience in ultrasound examination underwent a 3-hour echocardiography training course consisting of a lecture and a workshop before starting the study. Patients with shock or suspected hypervolemia were included. Echocardiography was performed by EM residents to evaluate ventricular function of each patients. With visual estimation, they classified the left ventricular function (LVF) into 3 categories: good, moderate and poor. The video files were recorded and re-evaluated by a cardiologist offline. The correlation of left ventricular function estimation and the diagnosis of pericardial effusion between the two operators were determined. Results: Ninety-two patients were enrolled between October and December 2014. The overall agreement of ventricular function assessment between the EM residents and the cardiologist was 79.4% (weighted kappa = 0.73). The degree of agreements of LVF classified as poor, moderate and good LVF were 87.5%, 37.5% and 95% respectively. Moreover, the residents diagnosed the pericardial effusion with 100% accuracy, compared to the cardiologist. Conclusion: Following a short educational training, the EM residents efficiently assessed the left ventricular function with a high level of agreement with a cardiologist.

Diagnosis and surgical management of pericardial effusion due to paragonimiasis

ObjectivesThe pericardial effusion (PE) caused by paragonimiasis is rarely reported. This study aims to present experience in the diagnosis and surgical management of PE due to paragonimiasis. MethodsMedical records of 57 children who were diagnosed with PE due to paragonimiasis and underwent surgery at Children’s Hospital of Chongqing Medical University between January 2012 and August 2018 were retrospectively reviewed. ResultsThe average age of this group was 7.6 ± 3.0 years. Patients were mainly from Chongqing and Sichuan areas. ELISA for Paragonimus skrjabini in all 57 patients showed positive results. Moderate or large PE were identified in 12 and 45 patients, respectively. All patients underwent surgery either by pericardectomy or thoracoscopic surgery. Pathological exams indicated massive eosinophil infiltration in all 57 specimens. After 3–4 courses of praziquantel therapy, the clinical outcomes were satisfactory. ConclusionsTypical endemic history, eosinophilia and multiple serous effusion raise suspicions of paragonimiasis. Once moderate to large PE is identified in patients with paragonimiasis, surgical treatment is necessary.

Study of Etiological Profile, Clinical Profile and Short Term Outcome of Patients Presenting with Pericardial Effusion in a Tertiary Care Center, Nepal

Introduction: Pericardial effusion is one of the common cardiac problems in our part of the world and adds burden to the health and economy of the country, as it is associated with high risk of morbidity and mortality. Our objective of the study was to determine the etiological spectrum of pericardial effusion, their clinical presentations and complications and assessing the usefulness of echocardiographic features of effusion in helping to determine the etiology. Methods: A cross-sectional observational prospective study of 63 patients with diagnosis of pericardial effusion was enrolled in the study. Pericardial effusion was diagnosed by echocardiography and pericardiocentesis was done in the cardiac catheterization room. Patients were followed up 3 monthly for 1 year and reassessed clinically and by echocardiography. Results: Patients presenting with pericardial effusion belonged to the age group of 8 to 88 years. The most common etiology was tuberculosis (36.5%) followed by malignancy (19%) and idiopathic/Viral (12.6%). Among malignancies, carcinoma lung was the most common cause followed by lymphoma. Pericardiocentesis was done in 46 patients (73%) and the approach was subxiphoid. The procedure-related complications were in 4 patients (6.3%) and there was no death as a consequence of the procedure. The total mortality was 12 (19%) with in-hospital death of 6 patients (9.5%). Conclusions: The study showed tuberculosis as the most common cause of pericardial effusion in developing countries like Nepal and as a cause of cardiac tamponade in contrast to the studies from the developed world where malignancy remains the leading cause.

Cardiac Tamponade from Pericardial Mesothelioma Causing Acute Renal Insufficiency in Dog

Pericardial mesothelioma is a rare malignancy tumor in dog. Due to an aggressive tumor and low survival rates, mesothelioma is frequently diagnosed at an advanced stage. The objective of this clinical report is to highlight the characteristic of this malignancy tumor to help an early diagnosis and to improve the therapeutic outcomes of this neoplastic tumor. A 10-year-old crossbreed was referred to Kasetsart University Veterinary Teaching Hospital Kamphaengsaen for the evaluation of a history of abdominal distension, lethargy and weekness. During the physical examination, the dog was tachycardia and tachypnea. Ultrasonography imaging of spleen revealed an inhomogeneous appearance and thoracic radiograph showed cardiac enlargement. Electrocardigraphy examination revealed low voltage of QRS complex amplitude. A transthoracic echocardiogram showed a large pericardial effusion with cardiac tamponade and masses were visualized in pericardial sac. Pericardiocentesis was immediately performed to alleviate the cardiac tamponade and cytologic examination was performed to identify the characteristic of pericardial effusion fluid. Clinical symptoms of acute kidney injury were progressed from the second visit including azotemia, hyponatraemia, hyperkalemia and anuria. The dog died about 2 days after admission in the critical care unit. Histopathological examination of the pericardial fluid and pericardial mass confirmed the diagnosis of pericardial mesothelioma. Mesothelioma should be considered in the diagnosis of pericardial effusion in dog. An early stage detection of pericardial mesothelioma may significantly reduction in mortality and allow for more beneficial treatment.

Bortezomib-Induced Cardiac Tamponade in a 49-Year-Old Man.

Proteasome inhibitors such as bortezomib and carfilzomib have been used effectively to treat patients who have certain hematologic malignancies. Proteasome activity is elevated in the heart, and potent inhibition results in accumulation of misfolded intracellular protein aggregates and apoptosis. Heart failure, conduction disturbances, and premature atherosclerosis have been associated with bortezomib therapy. We describe the case of a 49-year-old man who was taking bortezomib for graft-versus-host disease, when he developed cardiac tamponade and needed emergency pericardiocentesis. At that time, there was no evidence of graft-versus-host disease. To our knowledge, this is the first time that a pericardial effusion without underlying cardiac dysfunction has been reported in relation to bortezomib therapy. The diagnosis of pericardial effusion during bortezomib therapy, the absence of other causative agents-including graft-versus-host disease-and no recurrence of pericardial effusion after discontinuing bortezomib therapy suggest that bortezomib caused our patient's tamponade.

Ultrasound-guided pericardiocentesis: a novel parasternal approach.

The aim of this study was to evaluate a novel pericardiocentesis technique using an in-plane parasternal medial-to-lateral approach with the use of a high-frequency probe in patients with cardiac tamponade. Echocardiography is pivotal in the diagnosis of pericardial effusion and tamponade physiology. Ultrasound guidance for pericardiocentesis is currently considered the standard of care. Several approaches have been described recently, which differ mainly on the site of puncture (subxiphoid, apical, or parasternal). Although they share the use of low-frequency probes, there is absence of complete control of needle trajectory and real-time needle visualization. An in-plane and real-time technique has only been described anecdotally. A retrospective analysis of 11 patients (63% men, mean age: 37.7±21.2 years) presenting with cardiac tamponade admitted to the tertiary-care emergency department and treated with parasternal medial-to-lateral in-plane pericardiocentesis was carried out. The underlying causes of cardiac tamponade were different among the population. All the pericardiocentesis were successfully performed in the emergency department, without complications, relieving the hemodynamic instability. The mean time taken to perform the eight-step procedure was 309±76.4 s, with no procedure-related complications. The parasternal medial-to-lateral in-plane pericardiocentesis is a new technique theoretically free of complications and it enables real-time monitoring of needle trajectory. For the first time, a pericardiocentesis approach with a medial-to-lateral needle trajectory and real-time, in-plane, needle visualization was performed in a tamponade patient population.

Emergency Medicine Resident Assessment of the Emergency Ultrasound Milestones and Current Training Recommendations.

Emergency ultrasound (EUS) has been recognized as integral to the training and practice of emergency medicine (EM). The Council of Emergency Medicine Residency-Academy of Emergency Ultrasound (CORD-AEUS) consensus document provides guidelines for resident assessment and progression. The Accredited Council for Graduate Medical Education (ACGME) has adopted the EM Milestones for assessment of residents' progress during their residency training, which includes demonstration of procedural competency in bedside ultrasound. The objective of this study was to assess EM residents' use of ultrasound and perceptions of the proposed ultrasound milestones and guidelines for assessment. This study is a prospective stratified cluster sample survey of all U.S. EM residency programs. Programs were stratified based on their geographic location (Northeast, South, Midwest, West), presence/absence of ultrasound fellowship program, and size of residency with programs sampled randomly from each stratum. The survey was reviewed by experts in the field and pilot tested on EM residents. Summary statistics and 95% confidence intervals account for the survey design, with sampling weights equal to the inverse of the probability of selection, and represent national estimates of all EM residents. There were 539 participants from 18 residency programs with an overall survey response rate of 85.1%. EM residents considered several applications to be core applications that were not considered core applications by CORD-AEUS (quantitative bladder volume, diagnosis of joint effusion, interstitial lung fluid, peritonsillar abscess, fetal presentation, and gestational age estimation). Of several core and advanced applications, the Focused Assessment with Sonography in Trauma examination, vascular access, diagnosis of pericardial effusion, and cardiac standstill were considered the most likely to be used in future clinical practice. Residents responded that procedural guidance would be more crucial to their future clinical practice than resuscitative or diagnostic ultrasound. They felt that an average of 325 (301-350) ultrasound examinations would be required to be proficient, but felt that number of examinations poorly represented their competency. They reported high levels of concern about medicolegal liability while using EUS. Eighty-nine percent of residents agreed that EUS is necessary for the practice of EM. EM resident physicians' opinion of what basic and advanced skills they are likely to utilize in their future clinical practice differs from what has been set forth by various groups of experts. Their opinion of how many ultrasound examinations should be required for competency is higher than what is currently expected during training.

Peritoneopericardiale hernia diafragmatica met eenmalige pericardiale effusie bij een beagle

Een mannelijke, gecastreerde beagle werd op vierjarige leeftijd aangeboden omwille van ascites, tachypnee, partiële anorexie en lethargie. Via radiografie, echocardiografie en computertomografie werd de hond gediagnosticeerd met pericardiale effusie en een peritoneopericardiale hernia diafragmatica, waarbij vermoedelijk enkel omentum was geherniëerd in het hartzakje. Een abdominocentese en pericardiocentese werden uitgevoerd. De peritoneopericardiale hernia diafragmatica werd niet chirurgisch gecorrigeerd, aangezien er na een eenmalige pericardiocentese geen nieuwe pericardiale effusie ontstond en de patiënt het klinisch goed stelde. Tijdens het controlebezoek, een half jaar na de pericardiocentese, was de patiënt actief en speels en was er nog steeds geen sprake van recidiverende pericardiale effusie.

Predictive factors for pericardial effusion identified by heart dose-volume histogram analysis in oesophageal cancer patients treated with chemoradiotherapy.

To identify predictive factors for the development of pericardial effusion (PCE) in patients with oesophageal cancer treated with chemotherapy and radiotherapy (RT). From March 2006 to November 2012, patients with oesophageal cancer treated with chemoradiotherapy (CRT) using the following criteria were evaluated: radiation dose >50 Gy; heart included in the radiation field; dose-volume histogram (DVH) data available for analysis; no previous thoracic surgery; and no PCE before treatment. The diagnosis of PCE was independently determined by two radiologists. Clinical factors, the percentage of heart volume receiving >5-60 Gy in increments of 5 Gy (V5-60, respectively), maximum heart dose and mean heart dose were analysed. A total of 143 patients with oesophageal cancer were reviewed retrospectively. The median follow-up by CT was 15 months (range, 2.1-72.6 months) after RT. PCE developed in 55 patients (38.5%) after RT, and the median time to develop PCE was 3.5 months (range, 0.2-9.9 months). On univariate analysis, DVH parameters except for V60 were significantly associated with the development of PCE (p < 0.001). No clinical factor was significantly related to the development of PCE. Recursive partitioning analysis including all DVH parameters as variables showed a V10 cut-off value of 72.8% to be the most influential factor. The present results showed that DVH parameters are strong independent predictive factors for the development of PCE in patients with oesophageal cancer treated with CRT. A heart dosage was associated with the development of PCE with radiation and without prophylactic nodal irradiation.

A serial echocardiographic study of myocardial abscess in a patient surviving staphylococcal septicemia

2D echocardiography was performed on a 4-year-old child suffering from right thigh abscess due to MRSA infection following diagnosis of pericardial effusion by USG abdomen. It revealed myocardial abscess and pericardial effusion. This child underwent series of 2D echocardiographic studies which showed image appearance of myocardial abscess with its time course of healing.