Life-threatening Cardiac Tamponade Research Articles

Asymptomatic Chronic Large Pericardial Effusions: To Drain or to Observe?

Pericardial effusions, especially large ones, have traditionally been regarded with concern by clinicians due to the sometimes unpredictable development of life-threatening cardiac tamponade. In the European Society of Cardiology Guidelines on pericardial diseases, the simplified algorithm for pericardial effusion triage and management recommends pericardial drainage in cases of cardiac tamponade and/or suspicion of bacterial or neoplastic etiology. In the presence of acute pericarditis, empiric anti-inflammatory treatment should be given, while when a specific indication known to be associated with pericardial effusion is found, then treatment of the underlying cause is indicated. Notably, the most challenging subgroup of patients includes those with large, asymptomatic, C-reactive-protein-negative, idiopathic effusions. In the latter subjects, pericardial drainage is proposed in cases of chronic effusions (lasting more than three months). However, this recommendation is based on scant data stemming from small-sized non-randomized studies. Nevertheless, recent evidence in a larger cohort of patients pointed out that a watchful waiting strategy is a safe option in terms of complication-free survival. This review summarizes the contemporary evidence on this challenging topic and provides recommendations for tailoring individual patient treatments.

Echocardiography in cardiac arrhythmias

Echocardiography plays akey role in planning and guidance of electrophysiological procedures. After exclusion of structural heart disease, echocardiography provides insight into the extent of left atrial remodeling by determining left atrial metrics. This "biomarker" is associated with the risk of new-onset atrial fibrillation and predictive of atrial fibrillation recurrence after ablation. Transesophageal echocardiography is necessary to exclude left atrial thrombi and is able to guide atransseptal puncture. In case of arare but life-threatening cardiac tamponade, an echocardiographic-guided pericardiocentesis ensures quick and effective treatment. Left ventricular ejection fraction and deformation analysis determined by echocardiography are established methods for risk stratification in patients with systolic dysfunction and used to guide pharmacological and device therapy.

Variations in current clinical practice of postoperative pericardial effusion: a questionnaire study

ObjectivePostoperative pericardial effusion (PPE) occurs frequently after cardiac surgery, potentially leading to life-threatening cardiac tamponade. Specific treatment guidelines are currently lacking, possibly leading to variations in clinical practice. Our goal...

Concurrent tuberculous pericarditis and lung adenocarcinoma presenting with cardiac tamponade

Mycobacterium tuberculosis (MTB) infection and lung malignancies are both important causes of pericardial effusion (PE), particularly in developing nations such as South Africa. They are each associated with significant morbidity and mortality and pose several public health challenges for the region. This case study discussed a 58-year-old man who presented acutely with a large PE complicated by cardiac tamponade. Pericardial fluid analysis was positive for TB and further cytopathological evaluation revealed metastatic lung adenocarcinoma. Dual diagnoses are rare; however, considering the rising incidences of lung cancer and its predisposition for infectious diseases, this may be under-reported in TB endemic regions. This case highlighted the importance of considering other causes of PE that may aggravate presentation, leading to life-threatening cardiac tamponade. Further research is needed to understand the impact of rising cancer incidences and ongoing burden of infectious diseases in sub-Saharan Africa.Contribution: The insights of this case study include the paucity of data surrounding diagnosis and treatment of lung cancer in non-smokers available for South Africa. The current data that are available is for the developed world only. Some evidence incidence might be related to exposure of biofuels, which has significance for our local population and requires more exact research.

Trauma-related pneumopericardium

Trauma-related pneumopericardium (TRPP) is the collection of air in the pericardial space secondary to trauma, potentially leading to tension pneumopericardium (TPP) in which the entrapment of air generates sufficient pressure to compromise cardiac output leading to a life-threatening cardiac tamponade and circulatory failure. We aim to classify the diagnostic and therapeutic approaches of TRPP and the causes of the subsequent development of TPP. A computer-based search of all published reports on TRPP in the medical literature from database inception to March 2020, on MEDLINE, Ovid, and Scopus; analyzing the data regarding initial status at presentation, extent of injuries, diagnostic and treatment measures with the intention to have an understanding of the clinical behavior and management outcomes of TRPP. The search identified 84 published case reports of 105 patients with TRPP. In conclusion, TRPP leading to TPP is described in the literature as a condition that involves a young male who is subjected to blunt trauma, most commonly in a motor vehicle collision, presenting as a polytrauma patient in a state of shock and low systolic blood pressure, or possibly in cardiac arrest. In addition, he might have a tracheobronchial injury with or without pneumothorax or pneumomediastinum and might require mechanical ventilation.

1935. Cardiac Tamponade Following COVID-19 Vaccination

Abstract Background While numerous, most described cases of myocarditis and pericarditis following COVID-19 vaccination are mild and self-limited. We present two cases of life-threatening cardiac tamponade following COVID-19 vaccination. Methods Two cases of cardiac tamponade in temporal association with COVID-19 vaccination were reviewed Results Case 1 : 75-year-old male with rheumatoid arthritis admitted with chest pressure and hypotension 2 days after his 1st dose of Pfizer-BioNTech COVID-19 vaccine. Pericardiocentesis removed 275 ml of exudative effusion with 14,140 nucleated cells/ml. Fluid bacterial and fungal cultures were negative; cytology was inconsistent with malignancy. He had no Epstein-Barr virus (EBV) or cytomegalovirus (CMV) viremia. Symptoms resolved on prednisone and colchicine. A week later, he had an uneventful second COVID-19 vaccine. He went on to have 3 recurrences of pericarditis starting two months after his first. One was within 48 hours of his COVID-19 booster. He is on long term prednisone. Case 2: 66-year-old male with non-Hodgkin’s lymphoma in remission. He developed chest pain a day after his 2nd dose of Pfizer-BioNTech COVID-19 vaccine. Admitted 4 days later with pericardial effusion and managed medically. Readmitted a week later with fever and chest pain. Echocardiogram now showed cardiac tamponade. Pericardiocentesis removed 400 ml of exudative fluid with 1,191 nucleated cells/mL. Cultures for bacteria, fungi, and mycobacteria were negative. Cytology didn't show malignancy. Serologies for CMV, EBV and parvovirus represented past infection. He was discharged with a pericardial drain, colchicine, and NSAIDs. He was later readmitted with fevers. Echocardiogram only showed small pericardial effusion, which did not require drainage. Figure 1Circumferential pericardial effusion seen on trans-thoracic echocardiography from patient in case 1. Conclusion Given the proximity to COVID-19 vaccination and lack of alternative explanations, we believe that tamponade was a direct result of post-vaccine inflammatory pericarditis. Neither patient had a prior history of pericardial effusion. Both tested negative for SARS-CoV-2 by nasopharyngeal swab excluding active infection. Healthcare providers should consider the possibility of pericardial effusion and tamponade in patients with chest pain, shortness of breath, or hypotension following COVID-19 vaccination. Disclosures All Authors: No reported disclosures.

Exploring variations in current clinical practice regarding postoperative pericardial effusion: a questionnaire study

Abstract Background Postoperative pericardial effusion (PPE) is a frequently occurring event after cardiac surgery, potentially leading to life-threatening cardiac tamponade. Unfortunately, no guidelines are currently available on this subject, possibly leading to unwarranted variations in care in clinical practice. Purpose The goal of our study was to determine the diagnostic and therapeutic preferences of cardiologists and cardiothoracic surgeons in the Netherlands regarding PPE, and to evaluate possible variations in this matter between specialties and centers. Methods A web-based questionnaire was sent to all interventional cardiologists and cardiothoracic surgeons in the Netherlands. Diagnostic preferences for the evaluation of PPE were examined. Additionally, clinical preferences were explored in response to 4 patient scenarios with each illustrating a combination of either high or low clinical suspicion of cardiac tamponade and either high or low echocardiographic suspicion. Each scenario was also stratified by 3 different amounts of PPE (<1cm, 1–2cm, >2cm), leading to a total of 12 fictional patient cases (Figure 1). Results From 27 of the 31 contacted centers, a total of 94 clinicians responded to the survey, of whom 46 interventional cardiologists and 48 cardiothoracic surgeons. Cardiologists were more in favor of routine postoperative echocardiography in all patients (44%), whereas cardiothoracic surgeons preferred routine imaging after specific procedures, especially after mitral (85%) and tricuspid (79%) valve surgery. Overall, drainage of PPE (>48 hours postoperatively) was preferred through pericardiocentesis (83%) instead of surgical evacuation (17%). Regarding the patient scenarios, cardiothoracic surgeons were significantly more inclined to evacuate PPE compared to cardiologists for all scenarios combined (51% vs 37%, p<0.001) (Figure 1). In addition, evacuation was overall significantly more preferred by cardiologists employed in surgical centers when compared to those working in non-surgical centers (43% vs 31%, p=0.02). Results from the interrater agreement analysis of groups of clinicians working in the same center varied from very poor up to very good (kappa value of 0.22–0.67), suggesting existing variation of PPE treatment preferences even within one center. Conclusions Our study highlights the significant variation of preferences in contemporary PPE management between cardiothoracic surgeons and interventional cardiologists in the Netherlands, sometimes even within the same center. These findings are the possible consequences of a current lack of general recommendations or guidelines. This could lead to unwarranted variation in care and additional research is necessary to provide general recommendations. Funding Acknowledgement Type of funding sources: None.

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

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

Primary cardiac diffuse large B-cell lymphoma presenting with cardiac tamponade: a case report

BackgroundPrimary cardiac tumours are extremely rare with an autopsy incidence of 0.05%. They can present with a variety of symptoms, including life-threatening arrhythmia and cardiac tamponade. In this case report, we focus on the diagnostic process and management of a primary cardiac lymphoma (PCL) presenting with cardiac tamponade.Case summaryWe report on a 71-year-old male presenting with a large pericardial effusion, tamponade, and a mass in the right atrioventricular groove. Multimodality imaging was performed, including transthoracic echocardiography, computed tomography, magnetic resonance imaging, positron emission tomography, and computed tomography-guided transthoracic biopsy. The final diagnosis of a double-hit diffuse large-cell B-cell lymphoma was made, for which treatment consisting of a combination of chemotherapy and immunotherapy was initiated. Low-dose colchicine was also added to the treatment.DiscussionPrimary cardiac lymphoma remains a very rare diagnosis and this case highlights the need for multimodality imaging and imaging-guided biopsy to differentiate cardiac masses. First-line treatment for PCL remains a combination of chemotherapy with immunotherapy, with the addition of low-dose colchicine to prevent recurrence of malignant pericardial effusion.

Pericardial Diseases

Diseases of the pericardium represent a wide range of clinical syndromes that vary substantially in severity, from a benign pericardial effusion to fatal constrictive pericarditis or hemopericardium. Acute pericarditis is the most common pericardial disease, with viral and idiopathic as the most frequent etiologies. Typically, acute pericarditis can be managed as an outpatient with dual-agent therapy consisting of aspirin or nonsteroidal anti-inflammatory drug plus colchicine and rarely requires admission. Pericardial effusions are fluid collections in the pericardial cavity. They are a common incidental finding, can be associated with other systemic disease, and at their extreme, cause life-threatening cardiac tamponade. Cardiac tamponade exists on a spectrum with patients who are quasi stable to those where cardiovascular collapse and death are imminent. Cardiac tamponade may be temporized with fluid boluses, but treatment is through pericardiocentesis and occasional surgical intervention. Constrictive pericarditis is progressive process with poor prognosis in which the pericardium becomes rigid and causes diastolic dysfunction, leading to heart failure. Once the diagnosis is made, definitive management is surgical but carries a high operative risk. This review contains 7 highly rendered figures, 5 videos, 3 tables, and 42 references. Key Words: cardiac tamponade, constrictive pericarditis, effusive-constrictive pericarditis, pericardial effusion, pericarditis, pericardiocentesis

New Approaches to Management of Pericardial Effusions.

Purpose of ReviewPericardial effusion is a challenging pericardial syndrome and a cause of serious concern for physicians and patients due to its potential progression to life-threatening cardiac tamponade. In this review, we summarize the contemporary evidence of the etiology; diagnostic work-up, with particular emphasis on the contribution of multimodality imaging; therapeutic options; and short- and long-term outcomes of these patients.Recent FindingsIn recent years, an important piece of information has contributed to put together several missing parts of the puzzle of pericardial effusion. The most recent 2015 guidelines of the European Society of Cardiology for the diagnosis and management of pericardial diseases are a valuable aid for a tailored approach to this condition. Actually, current guidelines suggest a 4-step treatment algorithm depending on the presence or absence of hemodynamic impairment; the elevation of inflammatory markers; the presence of a known or first-diagnosed underlying condition, possibly related to pericardial effusion; and finally the duration and size of the effusion. In contrast to earlier perceptions, based on the most recent evidence, it seems that in the subgroup of asymptomatic patients with large (> 2-cm end-diastolic diameter), chronic (> 3 months) C-reactive protein negative, idiopathic (without an apparent cause) pericardial effusion, a conservative approach is the most reasonable option.SummaryAt present there is an increasing interest in the pericardial syndromes in general and pericardial effusions in specific, which has consistently expanded our knowledge in this “hazy landscape.” Apart from general recommendations applied to all cases, an individualized, etiologically driven treatment is of paramount importance.

Resuscitative transesophageal echocardiography in the diagnosis of post-CABG loculated pericardial clot causing cardiac tamponade

BackgroundPericardial effusion is a known complication of post-open cardiac surgery which can progress to life-threatening cardiac tamponade. Classical signs of tamponade such as hypotension and pulsus paradoxus are often absent. Diagnosing acute cardiac tamponade with transthoracic echocardiography (TTE) can be challenging in post-cardiac surgical patients due to distorted anatomy and limited scanning windows by the presence of surgical dressings or scar. Additionally, this patient population is more likely to have a loculated pericardial effusion, or an effusion that is isoechoic in appearance secondary to clotted blood. These findings can be challenging to visualize with traditional TTE. Missed diagnosis of cardiac tamponade due to loculated pericardial clot can result in delayed diagnosis and clinical management.Case presentationWe report a case series that illustrates the diagnostic challenge and value of resuscitative transesophageal echocardiography (TEE) in the emergency department (ED) for the diagnosis of cardiac tamponade due to posterior loculated pericardial clot in post-surgical coronary artery bypass graft (CABG) patients.ConclusionsCardiac tamponade due to loculated posterior pericardial clot post-CABG requires prompt diagnosis and appropriate management to avoid the potential for hemodynamic instability. Transesophageal echocardiography allows a rapid diagnosis, early appropriate referral and an opportunity to institute appropriate therapeutic measures.

Contemporary management of pericardial effusion.

Pericardial effusion is a relatively common clinical condition with a variety of clinical manifestations ranging from incidentally discovered asymptomatic cases to life-threatening cardiac tamponade. The etiology encompasses idiopathic cases and forms secondary to different conditions, including autoimmune diseases, malignancies, metabolic disorders, etc. While medical therapy should be offered to patients with elevation of inflammatory markers, in specific forms treatment should be appropriate to the underlying disorder. In cases with hemodynamic compromise pericardial drainage either with pericardiocentesis or pericardial "window" is indicated for therapeutic and diagnostic purposes. In the remainder, factors like comorbidities, size and location of the pericardial effusion will influence the clinical decision making. In asymptomatic or minimally symptomatic chronic large idiopathic pericardial effusions, according to recent evidence, a conservative approach with watchful waiting seems the most reasonable option. The prognosis of pericardial effusions largely depends on the underlying etiologies. Metastatic spread to the pericardium has an ominous prognosis whereas large to moderate effusions have been often associated with known or newly discovered specific underlying causes. Chronic small idiopathic effusions have an excellent prognosis and do not require specific monitoring. Large chronic idiopathic effusions in clinically stable patients require a 3 to 6-month assessment ideally in a specialized unit.

Chylous cardiac tamponade after single-port VATS lobectomy in NSCLC

: Chylothorax is the accumulation of chyle in the pleural space. The primary cause of chylothorax is injury to the thoracic duct, through which chyle travels to the subclavian vein. Cardiothoracic surgery is a main cause of traumatic chylothorax. If left untreated, chylothorax may prove dangerous for patients. Chylous pericardial effusion carries a higher risk of fatality than chylothorax and can lead to life-threatening cardiac tamponade. Emergency treatment should be carried out. However, there is no effective drainage method for chylous pericardial effusion after thoracic surgery. Here, we report a case of chylous cardiac tamponade after lobectomy with mediastinal lymph node (LN) dissection in non-small-cell lung cancer. A patient visited our emergency room (ER) for dyspnea with a large amount of pleural and pericardial effusion. He had received lobectomy for lung cancer 1 month previously. Pleural effusion evaluation showed that chylothorax and chylous pericardial tamponade had developed during conservative care. The patient underwent thoracic duct ligation and was discharged without any sequela in the following 4 months. This case indicates that thoracic duct ligation could provide effective treatment for patients with both chylothorax and chylous pericardial tamponade.

Common Conditions Requiring Emergency Life Support.

1. Kelsey Fawcett, MD*,† 2. Nicole Gerber, MD*,† 3. Shweta Iyer, MD*,† 4. Guillermo De Angulo, MD, MPH*,† 5. Martin Pusic, MD, PhD* 6. Michael Mojica, MD*,†,‡ 1. *Department of Emergency Medicine and 2. †Department of Pediatrics, New York University School of Medicine, New York, NY 3. ‡Department of Emergency Medicine, Bellevue Hospital Center, New York, NY * Abbreviations: AHA: : American Heart Association CPR: : cardiopulmonary resuscitation CT: : computed tomography ED: : emergency department ICP: : intracranial pressure ROSC: : return of spontaneous circulation Providers should be up to date on the evidence-based current guidelines for pediatric resuscitation and be able to identify and manage life-threatening illness and injury. After completing this article, readers should be able to: 1. Understand the major changes in the 2015 American Heart Association guidelines for pediatric basic life support, advanced life support, and postresuscitation care. 2. Initiate the management and identify prognostic factors associated with near drowning. 3. Identify the signs and symptoms of life-threatening thoracic injuries, including pneumothorax, hemothorax, flail chest, and cardiac tamponade. 4. Identify and manage cerebral edema in the asphyxiated patient. There are common emergencies in pediatrics that any pediatrician needs to be equipped to handle. Common office emergencies include respiratory distress, dehydration, seizures, and anaphylaxis. However, pediatricians also need to be prepared for common conditions that require emergency life support. These include, but are not limited to, cardiac arrest, near drowning, thoracic injuries, and cerebral edema. This article focuses on these common conditions that require emergency life support. ### Introduction Cardiac arrest is rare in the pediatric population. In 2015, the American Heart Association (AHA) released updated recommendations for pediatric advanced life support. (1) These updated guidelines, incorporating the available evidence, can guide resuscitation efforts to continue to improve overall survival after pediatric cardiac arrest and, in particular, improve survival with a favorable neurologic outcome. ### Basic Life Support An estimated 6,000 children experience out-of-hospital cardiac arrest per year in the United States. (2) The survival to hospital discharge is 11.3%, and survival with a neurologically favorable outcome is …

Spontaneous, Life-Threatening Hemorrhagic Cardiac Tamponade Secondary to Rivaroxaban

Bleeding is the most feared complication of anticoagulants. Rivaroxaban is a newer oral anticoagulant with a favorable regimen due to lack of frequent blood monitoring and fewer drug interactions. We report a case of spontaneous pericardial hemorrhage associated with rivaroxaban. Within 10 days of starting rivaroxaban for atrial fibrillation, the patient developed a life-threatening cardiac tamponade leading to shock and multiorgan failure. After urgent pericardiocentesis/drainage, the patient recovered. This case highlights the necessity of larger clinical trials and consensus guideline on monitoring the effects of novel oral anticoagulants and development of an antidote for reversal in cases of major bleeding events.

Unexpected perforation leading to life-threatening cardiac tamponade six years after patent foramen ovale closure with an intrasept device

(2016). Unexpected perforation leading to life-threatening cardiac tamponade six years after patent foramen ovale closure with an intrasept device. Acta Cardiologica: Vol. 71, No. 2, pp. 247-248.

Optimal contact forces to minimize cardiac perforations before, during, and/or after radiofrequency or cryothermal ablations.

Catheter perforations remain a major clinical concern during ablation procedures for treatment of atrial arrhythmias and may lead to life-threatening cardiac tamponade. Radiofrequency (RF) ablation alters the biomechanical properties of cardiac tissue, ultimately allowing for perforation to occur more readily. Studies on the effects of cryoablation on perforation force as well as studies defining the perforation force of human tissue are limited. The purpose of this study was to investigate the required force to elicit perforation of cardiac atrial tissue after or during ablation procedures. Effects of RF or cryothermal ablations on catheter perforation forces for both swine (n = 83 animals, 530 treatments) and human (n = 8 specimens, 136 treatments) cardiac tissue were investigated. Overall average forces resulting in perforation of healthy unablated tissue were 406g ± 170g for swine and 591g ± 240g for humans. Post-RF ablation applications considerably reduced these forces to 246g ± 118g for swine and 362 ± 185g for humans (P <.001). Treatments with cryoablation did not significantly alter forces required to induce perforations. Decreasing catheter sizes resulted in a reduction in forces required to perforate the atrial wall (P <.001). Catheter perforations occurred over an array of contact forces with a minimum of 38g being observed. The swine model likely underestimates the required perforation forces relative to those of human tissues. We provide novel insights related to the comparative effects of RF and cryothermal ablations on the potential for inducing undesired punctures, with RF ablation reducing perforation force significantly. These data are insightful for physicians performing ablation procedures as well as for medical device designers.

Life-threatening cardiac tamponade: a rare complication of acupuncture

Acupuncture as an ancient Chinese treatment has proven effective and is utilized worldwide. Although it is generally believed to be a safe clinical procedure, serious lethal complications including death have been reported. We present a rare case of life-threatening cardiac tamponade due to penetration of an acupuncture needle directly into the right ventricle.

Perioperative avulsion of a left internal mammary artery graft in a patient with syphilis.

Avulsion of a graft after coronary artery bypass grafting surgery is a rare but very serious complication which leads to massive bleeding and possible life-threatening cardiac tamponade. In this paper we report a very rare case of a left internal mammary artery graft avulsion on the day of surgery in a patient with syphilis.