Early Cardiac Tamponade Research Articles

P400 WHEN COMMON VIRAL SYMPTOMS HIDE A PERFECT STORM: A CASE REPORT

Abstract A 38 years old woman without any cardiovascular risk was admitted to the Emergency Room of our Hospital symptomatic for chest pain and dyspnoea. She referred a recent holiday in Tunisia; she was excellent health until a week before when she developed flue–like symptoms, such as fever, fatigue, abdominal pain, diarrhea and myalgia, like all the family members; the night before the access to the ER, she suffered from weakness of breath. Physical examination revealed venous engorgement and sinus tachycardia with a rate of 102 bpm, blood pressure was about 85/50 mmHg, oxygen saturation in 3L nasal cannula was 92%. The EKG showed a sinus tachycardia without any ST elevation or depression and generalized low voltage. A transthoracic echocardiography revealed circumferential pericardial effusion (3,5 cm) and both right atrium and right ventricle collapse in the setting of cardiac tamponade; EF was 35% (GLS=6%). Our first clinical suspicion was viral pericarditis with pericardial effusion (early cardiac tamponade), in consideration of the anamnestic data, the holiday in Tunisia and the general symptoms. However, an urgent pericardiocentesis was performed and one liter of sero–sanguineous pericardial fluid (exudate) was drained; therefore, there was an immediate haemodynamic improvement. A pigtail was placed using the Seldinger technique. While the first sample of cytology on sero–sanguineus pericardial fluid was negative, the second sample resulted positive for malignancy. Chest CT showed bilateral pleural effusion and a mass which was compatible with a lung cancer. Lung nodule biopsy revealed a lung adenocarcinoma. Immunohistochemistry (IHC) and molecular testing for epidermal growth factor receptor (EGFR) were positive. The patient was affected by metastatic non small cell lung cancer with EGFR mutation, which was responsive to Osimertinib. Three days later, another echo was performed showing almost complete resolution of pericardial effusion and normal LV function (EF= 55%). The patient was transferred to the Oncology Department and then discharged from the Hospital. Before starting Osimertinib, she was suggested to undergo a baseline cardiovascular stratification, EKG and transthoracic echocardiogram, three–monthly echocardiography surveillance with monitoring of GLS (which guides the management of potentially cardiotoxic drugs); close monitoring of magnesium levels is also recommended to minimize the risk of QTc prolongation.

CARDIAC TAMPONADE WITHOUT THE BECK TRIAD: A COMPLICATION OF SEVERE HYPOTHYROIDISM

CARDIAC TAMPONADE WITHOUT THE BECK TRIAD: A COMPLICATION OF SEVERE HYPOTHYROIDISM

MICROSCOPIC POLYANGIITIS PRESENTING WITH CARDIAC TAMPONADE

MICROSCOPIC POLYANGIITIS PRESENTING WITH CARDIAC TAMPONADE

THE AIR IN THERE: EARLY CARDIAC TAMPONADE DUE TO PNEUMOPERICARDIUM AS A COMPLICATION OF ADVANCED MESOTHELIOMA

Cardiac tamponade is commonly due to fluid or blood in the pericardial space. We describe a case of pneumopericardium leading to echocardiographic findings consistent with early cardiac tamponade. A 75 year old male with mesothelioma presented with dyspnea. Initial blood pressure was stable at 123/

NON-SEMINOMATOUS GERM CELL TUMOR PRESENTING AS EARLY PERICARDIAL TAMPONADE

SESSION TITLE: Critical Care 3 SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: The most frequent mediastinal lesions in adults are thymoma, lymphoma, thyroid masses and germ cell tumors. Potential complications of these masses due to localized invasion include hemoptysis, post-obstructive pneumonia, and superior vena cava syndrome. However, our patient was found to have large pericardial effusion and signs of early cardiac tamponade, which as complications of extragonadal germ cell tumors, have rarely been previously reported. CASE PRESENTATION: A 28-year-old male presented with a 1-week history of pleuritic chest pain, worsening shortness of breath and non-productive cough. On physical examination, he was in distress and preferred sitting position. JVD was elevated and heart sounds were muffled. EKG showed sinus tachycardia with low voltage complexes. CXR showed contour deformity along the R border of the heart ( Image 1). CTA chest revealed a large pericardial effusion ( Image 2) with a heterogeneous anterior mediastinal mass which abut the pericardium ( Image 3) along with two nodules in the right lung parenchyma. Patient was admitted to the ICU where emergent echocardiogram showed findings suggestive of early tamponade. It was decided to drain the effusion percutaneously followed by right thoracoscopy along with wedge resection of the lung nodules and pericardial window. On labs, AFP came out be very high at 8132 (nl<11ng/ml), LDH 453 ( nl 199-220U/L) and b HCG 46( nl<4U/L). . Pericardial fluid cytology was negative for malignant cells. Tissue biopsy of the mass was done which showed Yolk sac tumor and wedge resection of lung nodule was positive for metastatic seedings; CT abdomen and pelvis showed no intraabdominal pelvic mass or lymphadenopathy. After sperm banking, patient was started on chemotherapy with cisplatin, etoposide, ifosfamide with MESNA. DISCUSSION: Extragonadal non-seminomatous germ cell tumors (NSGCTs) primarily affect men during the third and fourth decades of life and are more aggressive than their seminomatous counterpart. Majority of patients with mediastinal NSGCTs are symptomatic at the time of diagnosis, with chest pain, hemoptysis, cough, fever, or weight loss. Superior vena cava syndrome or pericardial tamponade is occasionally present. Mediastinal NSGCT presenting as early cardiac tamponade is rarely seen in clinical practice but its early recognition and treatment by emergent pericardiocentesis can be life-saving as was done in our patient. Tumor markers including APF, b-HCG, and LDH help in the diagnosis of these tumors but the definitive diagnosis and treatment is based on the results of the biopsy of the tumor. CONCLUSIONS: One of the major causes of anterior mediastinal masses, particularly in young adult males, is an extragonadal germ cell tumor. Pericardial tamponade as a result of such tumors is rare but should always be considered in the appropriate clinical context as early recognition and management can be lifesaving. Reference #1: Nichols CR. Mediastinal germ cell tumors. Clinical features andbiologic correlates. Chest 1991;99:472–9. Reference #2: Cohn W. Anterior mediastinal mass lesions. In: Basow D, ed. UpTo-Date. Waltham, MA: UpToDate; 2012. DISCLOSURES: No relevant relationships by Taha Ahmed, source=Web Response No relevant relationships by TALHA AHMED, source=Web Response No relevant relationships by Sidra Khalid, source=Web Response No relevant relationships by Safdar Khan, source=Web Response

Spontaneous Bacterial Peritonitis (SBP) as a Rare Complication of Invasive Listeriosis: A Closer Look at Empiric SBP Coverage

Introduction: Listeria monocytogenes is an anaerobic gram-positive rod that is transmitted from contaminated food or animal products. Listeriosis is a rare but deadly disease with approximately 1600 cases per year and mortality rate of approximately 16%. Rarely, listeria has been shown to cause spontaneous bacterial peritonitis (SBP), with approximately 50 cases reported in literature. We present a rare case of invasive listeriosis manifesting with bacteremia, pericarditis, and spontaneous bacterial peritonitis. Case Report: A 58-year old female with past medical history of decompensated alcoholic cirrhosis and poorly controlled diabetes presented with a one week history of shortness of breath and dyspnea on exertion. Initial workup revealed severe pericarditis with early cardiac tamponade physiology and patient underwent urgent pericardiocentesis and pericardial window procedures. Following the procedure, the patient developed fevers and abdominal pain. Blood cultures were obtained and paracentesis was performed that revealed an absolute neutrophil count of 15,700 cells/mm3. The patient was empirically started on a third generation cephalosporin for empiric SBP coverage. Subsequently she developed high fevers and worsening sepsis and blood and peritoneal fluid cultures both grew listeria monocytogenes. Antimicrobial therapy was switched to piperacillin-tazobactam with progressive clinical improvement. The patient was discharged to rehab facility after a one month hospitalization and finished a prolonged treatment course with trimethoprim-sulfamethoxazole. Upon further questioning she did admit to frequently eating soft cheeses and deli meats; however, no absolute source of infection was identified. Discussion: Listeria often results in self-limited gastroenteritis in normal hosts, but may manifest with severe invasive disease in immunocompromised or pregnant patients. Listeria has been infrequently reported as a cause of SBP and is often associated with poor clinical outcomes in these cases. Empiric coverage for spontaneous bacterial peritonitis usually involves a third generation cephalosporin to provide coverage for enterobacteriaceae such as E. Coli or Klebsiella species. In our patient, conventional SBP empiric coverage failed to appropriately treat her infection and the patient clinically worsened. Atypical organisms such as listeria may circumvent empiric SBP coverage, making clinical suspicion for these organisms paramount in select cases.

Early Cardiac Tamponade in a Patient with Postsurgical Hypothyroidism.

Pericardial effusion is a common cardiac manifestation of hypothyroidism, but effusion resulting in cardiac tamponade is extremely rare. We present a case of a 56-year-old African American woman with slurred speech and altered mental status that was initially suspected to have stroke. Her chest X-ray revealed cardiomegaly and subsequent echocardiogram showed a large pericardial effusion with echocardiographic evidence of cardiac tamponade. Clinically, patient did not have pulsus paradoxus or hypotension. Further questioning revealed a history of total surgical thyroidectomy and noncompliance with thyroid replacement therapy. Pericardiocentesis was performed promptly and thyroxine replacement therapy was started. Thereafter, her mental status improved significantly. The management of pericardial effusion associated with hypothyroidism varies depending on size of effusion and hemodynamic stability of the patient. The management strategy ranges from conservative management with close monitoring and thyroxine replacement to pericardiocentesis or creation of a pericardial window.

POPE-2: No Benefit with Colchicine to Reduce Persistent Postoperative Pericardial Effusion

Postoperative pericardial effusion (POPE) is present within the first 7 days after cardiac surgery in 50% to 80% of patients, and the risk for early cardiac tamponade ranges from 0.5% to 1%. There is no drug that can treat this local hemorrhagic complication. The Colchicine Treatment for Post-operative Pericardial Effusion [POPE-2; NCT01266694] was a double-blind, placebo-controlled study to evaluate whether COL could reduce the volume of POPE.

Cardiac tamponade in a woman with preeclampsia

AbstractPreeclampsia is associated with alterations in maternal vascular permeability and can thus cause intravascular volume depletion and pathologic extravascular fluid accumulation. Although typically manifesting as peripheral edema or, in more severe cases, non-cardiogenic pulmonary edema, preeclampsia-associated vascular abnormalities can theoretically cause abnormal fluid collection in any extravascular space, including the pericardium.We report the case of a 30-year-old gravida 1 female admitted at 31 weeks 4 days’ gestation with mild preeclampsia, tachycardia, and dyspnea, whose initial workup was only significant for a small pericardial effusion. Over the course of the next 4 weeks, however, the effusion evolved into early cardiac tamponade that required expeditious pericardiotomy and cesarean delivery. The effusion virtually resolved over the first month postpartum.The case describes a unique presentation of preeclampsia and suggests that echocardiography to evaluate for pericardial effusion be considered in cases of otherwise-unexplained cardiopulmonary symptoms in the setting of preeclampsia. If detected, cardiac tamponade should be managed in association with a multidisciplinary team familiar with the physiology of cardiac tamponade.

Presumed hydrochlorothiazide-associated immunologic-hypersensitivity-induced pericardial effusion.

A 50-year-old Caucasian female presented for a second opinion regarding a newly diagnosed pericardial effusion. Seven months previously, hydrochlorothiazide was introduced into her pharmacologic regimen to aid in the management of her hypertension. A routine echocardiogram indicated a large pericardial effusion with signs of early cardiac tamponade. The patient subsequently underwent successful pericardiocentesis with complete drainage of the pericardial effusion. The effusion was empirically attributed to a viral etiology. Repeat echocardiograms showed recurrence of the pericardial effusion. Prior to undergoing a second pericardiocentesis with pericardial biopsy, as her physicians recommended, the patient sought a second opinion. While obtaining the patient’s history, an allergy to sulfa was elicited. The possibility that the pericardial effusion may be secondary to an immunologic-hypersensitivity reaction was considered. It was recommended the patient discontinue the use of hydrochlorothiazide. Nine days following discontinuation of hydrochlorothiazide and without any other intervention, an echocardiogram was reported to show the size of the pericardial effusion had subsided substantially. Nine weeks following discontinuation, almost complete resolution of the pericardial effusion was reported. It is hypothesized that when treated with hydrochlorothiazide, the patient had an immune response leading to the pericardial effusion.

The Incidence and Clinical Outcome of Cardiac Tamponade Following an Open Heart Surgery in a Developing Country

Introduction: Pericardial effusion is not uncommon following an open heart surgery, thus, it may progress to cardiac tamponade. This is a retrospective cross-sectional analysis evaluates the incidence, the potential perioperative and surgical risk factors causing cardiac tamponade following an open-heart surgery of patients during the period 2001-2006 at Ahmed Gasim Cardiac Center in Khartoum, North Sudan.&#x0D; Methods: Diagnosis of cardiac tamponade was based on clinical and echocardiographic findings. Univariate analysis was performed to assess possible risk factors related to both, early and late cardiac tamponade.&#x0D; Results: Among the 890 patients who underwent open heart surgery in this study, 47(5%) patients developed tamponade (early 49% or 51%). Early cardiac tamponade was found to be present with significant cardiac compromise and can easily be detected using echocardiography. In contrast the presentation of late cardiac tamponade, atypical and echocardiography was inconclusive. The mean age of patients was 31 ± 12 with slight female predominance. The main indication for the operation was rheumatic heart disease (89%), mainly mechanical valve replacement of the mitral valve. Eight (17%) patients were receiving warfarin preoperatively. Oozing wounds and blocked drains were encountered in 27% and 37%, respectively. About 6% of the patients recollect tamponade after decompression and one in-hospital death directly related to the cardiac tamponade.&#x0D; Conclusion: Significant cardiac tamponade was associated with preexisting rheumatic heart disease, (preoperative warfarin use), mechanical valve replacement in the mitral position, oozing wounds and blocked drain. Echocardiography was reliable in early diagnosis, but not late, hemodynamically significant cardiac tamponade.

The Incidence and Clinical Outcome of Cardiac Tamponade Following an Open Heart Surgery in a Developing Country

Introduction: Pericardial effusion is not uncommon following an open heart surgery, thus, it may progress to cardiac tamponade. This is a retrospective cross-sectional analysis evaluates the incidence, the potential perioperative and surgical risk factors causing cardiac tamponade following an open-heart surgery of patients during the period 2001-2006 at Ahmed Gasim Cardiac Center in Khartoum, North Sudan.&#x0D; Methods: Diagnosis of cardiac tamponade was based on clinical and echocardiographic findings. Univariate analysis was performed to assess possible risk factors related to both, early and late cardiac tamponade.&#x0D; Results: Among the 890 patients who underwent open heart surgery in this study, 47(5%) patients developed tamponade (early 49% or 51%). Early cardiac tamponade was found to be present with significant cardiac compromise and can easily be detected using echocardiography. In contrast the presentation of late cardiac tamponade, atypical and echocardiography was inconclusive. The mean age of patients was 31 ± 12 with slight female predominance. The main indication for the operation was rheumatic heart disease (89%), mainly mechanical valve replacement of the mitral valve. Eight (17%) patients were receiving warfarin preoperatively. Oozing wounds and blocked drains were encountered in 27% and 37%, respectively. About 6% of the patients recollect tamponade after decompression and one in-hospital death directly related to the cardiac tamponade.&#x0D; Conclusion: Significant cardiac tamponade was associated with preexisting rheumatic heart disease, (preoperative warfarin use), mechanical valve replacement in the mitral position, oozing wounds and blocked drain. Echocardiography was reliable in early diagnosis, but not late, hemodynamically significant cardiac tamponade.

Acute pericarditis induced stress cardiomyopathy

A 67-year-old Caucasian woman presented with chest pain suggestive of acute pericarditis. On initial evaluation the apical ballooning variant of stress-related cardiomyopathy (CMP) was present.The stress CMP and acute pericarditis resolved within a week. The patient returned in four weeks with early cardiac tamponade, which required a pericardial window. Stress cardiomyopathy (CMP) has been described as a complication of post-myocardial infarction pericarditis (Dressler syndrome). Stress CMP can also be complicated by pericarditis.We describe the novel observation where idiopathic pericarditis is the primary disease, which precipitated stress CMP.To the best of our knowledge this is the first report of acute idiopathic pericarditis causing stress-related cardiomyopathy.

Microscopic Polyangiitis Presenting as Early Cardiac Tamponade

Microscopic Polyangiitis Presenting as Early Cardiac Tamponade

P5-118: Right ventricular lead perforation causing left pleural effusion and early cardiac tamponade

P5-118: Right ventricular lead perforation causing left pleural effusion and early cardiac tamponade

Arrow wounds to the heart and mediastinum.

Wooden tipped arrows are still used in tribal fighting in the Highlands of Papua New Guinea. Thirteen cases of arrow injury to the heart and mediastinum, presenting at Mt. Hagen Hospital in a 2-year period, are described. Ten cases presented early (within 3 days) while the remaining 3 cases presented late and suffered from mediastinal abscesses. Removal of the arrow, after full visualization with repair where possible, was performed in all cases with two deaths and little morbidity. Most of the 13 patients arrived in a stable condition, withstood surgery well and made a rapid recovery (average stay in hospital 20 days). Unstable presentations included 2 cases of mild shock, one with early cardiac tamponade and one case of acute aortic incompetence. Survival figures justify attempted salvage of these patients, even with the limited facilities available.

Postoperative cardiac tamponade in the modern surgical era

Background. Pericardial effusions resulting in cardiac tamponade (CT) are uncommon after open heart surgery (OHS) and are associated with significant morbidity and mortality. Characteristics and outcomes of patients who develop postoperative CT are poorly defined. Our objective was to further analyze the population at risk for developing postoperative CT, identify potential perioperative and surgical risk factors, and evaluate the impact of CT on patient outcomes. Methods. A retrospective analysis of 4,561 consecutive patients undergoing OHS at our institution was performed. Patients with clinical suspicion of pericardial effusion following surgery were evaluated by transthoracic or transesophageal echocardiography, and clinical parameters were analyzed. Results. Forty-eight (1%) of the 4,561 patients were found to have echocardiographic evidence of a moderate or large pericardial effusion, of whom 36 (74%) had evidence of CT. The mean age of the patients with CT was 61 years. Coronary artery bypass grafting (CABG) had been performed in 24% of these patients, valve ± CABG in 73%, and other OHS procedures in 3%. The incidence of CT following CABG alone was 0.2%, whereas it was 0.6% after valve ± CABG. Females had a higher risk for developing CT, and this occurred earlier in the postoperative period when compared with men. Aspirin, heparin, or warfarin were given to 84% of patients within 3 days of surgery. Mean time to diagnosis of CT was 10 ± 1 days after OHS. Prior to diagnosis of CT, the maximum international normalized ratio (INR) and partial thromboplastin time (PTT) were 2.7 ± 0.3 and 68 ± 5 seconds, respectively. Forty-nine percent of pericardial effusions were posterior and 46% were circumferential; one-third of the effusions were considered large by echocardiography. There was one in-hospital cardiovascular death. Conclusions. CT after OHS is more common following valve surgery than CABG alone and may be related to the preoperative use of anticoagulants. Females appear to be at higher risk for developing early postoperative CT. When diagnosed and treated promptly, postoperative CT should not significantly increase mortality.

Regional distribution of blood flow at the onset of right ventricular diastolic collapse during cardiac tamponade

The onset of right ventricular diastolic collapse has been shown to be a very sensitive and specific sign of cardiac tamponade in both clinical and consclous canine studies, and is associated with a decline in cardiac output of about 20%. To determine if blood flow to critical regions was affected at the time of onset of right ventricular diastolic collapse, seven unanesthetized, chronically instrumented dogs were studied during cardiac tamponade induced by the intrapericardial infusion of warm saline solution. Aortic blood pressure, heart rate, and cardiac output (electromagnetic flowprobe) were recorded at baseline (drained pericardial space) and at the onset of right ventricular diastolic collapse as seen on two-dimensional echocardiography. Regional blood flow was measured with radionuclide-labeled microspheres. Despite the expected decline in cardiac output, there was no significant change in cardiac, ronal, or cerebral cortical blood flow at the onset of right ventricular diastolic coliapse. Therefore, this noninvaslve marker of early cardiac tamponade begins before vital organ perfusion is compromised, thus strengthening its clinical value.

Pericarditis and early cardiac tamponade as a primary manifestation of lymphosarcoma cell leukemia

Pericarditis and early cardiac tamponade as a primary manifestation of lymphosarcoma cell leukemia