Pericardial Aspiration Research Articles

Right Ventricular Diastolic Disorders

The differential diagnoses of cardiac tamponade, constrictive pericarditis, restrictive cardiomyopathy, effusive-constrictive pericarditis, and right ventricular infarction are often difficult because of the right ventricular diastolic dysfunction that frequently dominates the clinical picture in these disorders. In cardiac tamponade, key diagnostic signs are pulsus paradoxus, evidence of pericardial fluid by echocardiography or computed tomography (CT), and equalization of diastolic pressures. In constrictive pericarditis, prominent findings include Kussmaul's sign, evidence of pericardial calcification, equalization of diastolic pressures, and the square-root sign. Restrictive cardiomyopathy may be distinguished from constrictive pericarditis by the absence of pericardial calcification and, in amyloidosis, by a speckled pattern on two-dimensional echocardiogram and abnormal technetium Tc 99m pyrophosphate uptake during radionuclide examination. With effusive-constrictive pericarditis, hemodynamic signs of tamponade change to constriction with pericardial aspiration. In right ventricular infarction, constrictive-restrictive signs, as well as pulsus paradoxus, may be present. History and/or objective evidence of diaphragmatic left ventricular myocardial infarction

Surgical treatment of pneumopericardium in the neonate.

AbstractPneumopericardium occurred in 28 neonates with respiratory distress syndrome at the University of Minnesota Hospitals and St. Paul Children's Hospital from July 1, 1972 through June 30, 1976. All patients developed this complication while on mechanical ventilatory support with positive end‐expiratory pressure (2–12 cm water). In 23 patients, pneumopericardium resulted in clinical pericardial tamponade that necessitated cardiac resuscitation. The clinical presentation of pericardial tamponade consisted of muffled, distant heart sounds, hypotension, bradycardia, and hypoxia with cyanosis. The diagnosis was confirmed by chest x‐ray. Pneumothorax, pneumomediastinum, and/or pneumoperitoneum were associated with the appearance of pneumopericardium in 93% of the cases. Treatment consisted of: (a) needle pericardial aspiration in 7 patients, of which 5 survived; (b) pericardial tube placement with application of suction in 10 patients, of which 8 survived; (c) no treatment in 16 patients, of which 5 survived. Overall, 13 patients (46%) survived pneumopericardium and 15 patients (54%) died. Complications of treatment developed in 5 patients; 3 developed pneumothorax and 2 developed myocardial lacerations from percutaneous placement of a plastic drainage catheter. Of 5 asymptomatic patients, 2 (40%) died as a result of pneumopericardium. Based on our experience, it is recommended that pneumopericardium be evacuated whenever it is diagnosed. Initially, needle aspiration of the pericardial sac should be performed to manage the acute episode and stabilize the patient, and then a chest catheter of No. 10 Fr. caliber should be placed under direct vision into the pericardial sac and maintained on suction until positive end‐expiratory pressure ventilation has been discontinued.

Bloody Pericardial Fluid

Clinically notable pericardial effusions developed in three patients with renal failure. Pericardiocentesis showed hemorrhagic fluid, the source of which was not apparent. Simultaneous determinations of Pco₂, Po₂, and pH values showed a substantial increase in Pco₂levels and decrease in Po₂, pH, and bicarbonate levels in the pericardial compared with the intracardial aspirates. This was true when pericardial fluid Pco₂, Po₂, and pH values were compared with mixed venous samples. Determination of Po₂, Pco₂, pH, and bicarbonate values in pericardial aspirates may determine the source of the fluid. (<i>JAMA</i>239:2151-2152, 1978)

The treatment of pneumopericardium in the newborn infant

Pneumopericardium with cardiac tamponade is a life-threatening emergency in the newborn infant. The case fatality rate is high (75% in 41 documented cases in the English literature), and diagnosis often delayed (in 13 of 29 deaths the pneumopericardium was diagnosed postmortem). Treatment is frequently unsatisfactory, and recurrence of the pneumopericardium with tamponade is likely after initial pericardial needle aspiration--an incidence of 53%. A case of pneumopericardium in a critically ill newborn is reported; the details of successful management, using a large bore intrapericardial catheter with continuous drainage, are discussed.

Indomethacin treatment of pericarditis in chronic hemodialysis patients

Symptomatic pericarditis occurs in the course of maintenance hemodialysis and often requires pericardiectomy in addition to other conventional measures. Three of 11 such patients were treated with frequent dialysis and general supportive treatment. Two of these required pericardiocentesis. The other eight received indomethacin; this was followed by prompt defervescence and abatement of pain within 6 to 24 hours. Only one patient required pericardiocentesis. On every occasion when treatment was discontinued during the first week, symptoms recurred. After three weeks to four months, the drug dosage could be tapered and discontinued. The pericardial aspirate was hemorrhagic in all three patients who required pericardiocentesis. Indomethacin appears to be effective in the treatment of the pericarditis associated with dialysis and precludes the need for invasive procedures.

Indomethacin Treatment of Pericarditis in Chronic Hemodialysis Patients

Symptomatic pericarditis occurs in the course of maintenance hemodialysis and often requires pericardiectomy in addition to other conventional measures. Three of 11 such patients were treated with frequent dialysis and general supportive treatment. Two of these required pericardiocentesis. The other eight received indomethacin; this was followed by prompt defervescence and abatement of pain within 6 to 24 hours. Only one patient required pericardiocentesis. On every occasion when treatment was discontinued during the first week, symptoms recurred. After three weeks to four months, the drug dosage could be tapered and discontinued. The pericardial aspirate was hemorrhagic in all three patients who required pericardiocentesis. Indomethacin appears to be effective in the treatment of the pericarditis associated with dialysis and precludes the need for invasive procedures.

Neonatal Pneumopericardium

Four neonates with pneumopericardium were seen within a 12-month period. All infants received various methods of assisted ventilation. Two episodes were recognized early and prompt pericardial aspiration resulted in survival. One was asymptomatic, recognized by roentgenogram and treated conservatively. The fourth infant was recognized by postmortem roentgenograms. A clinical analysis of these four infants and that of 13 others reported in the literature is presented. Awareness of this complication in infants on IPPB or CDP, prompt diagnosis and therapy may be lifesaving.

Pericardiectomy in Uremia

Pericardial effusion with cardiac tamponade in chronic renal failure is treated conventionally by aggressive dialysis, repeated pericardicentesis, and less often, by surgery (pericardial window or partial pericardiectomy). Although serious complications have followed pericardial aspiration in several reported cases, it continues to be the most widely practiced therapeutic maneuver. Pericardicentesis was performed in four patients on our longterm dialysis program during a one-year period. Serious complications occurred in all, and proved fatal in three. Surgical intervention in one of the three who died, and in two other patients, resulted in immediate relief of cardiac embarrassment without surgical complications or subsequent recurrence of tamponade. We recommend elective partial pericardiectomy in all patients with uremic cardiac tamponade. Pericardicentesis should be reserved for dire emergencies only. (<i>JAMA</i>228:1132-1135, 1974)

Pericardiectomy in uremia. The treatment of choice for cardiac tamponade in chronic renal failure.

Pericardial effusion with cardiac tamponade in chronic renal failure is treated conventionally by aggressive dialysis, repeated pericardicentesis, and less often, by surgery (pericardial window or partial pericardiectomy). Although serious complications have followed pericardial aspiration in several reported cases, it continues to be the most widely practiced therapeutic maneuver. Pericardicentesis was performed in four patients on our longterm dialysis program during a one-year period. Serious complications occurred in all, and proved fatal in three. Surgical intervention in one of the three who died, and in two other patients, resulted in immediate relief of cardiac embarrassment without surgical complications or subsequent recurrence of tamponade. We recommend elective partial pericardiectomy in all patients with uremic cardiac tamponade. Pericardicentesis should be reserved for dire emergencies only. (JAMA228:1132-1135, 1974)

Penetrating cardiac injuries. Current trends in management.

Fifty-seven patients with acute penetrating injuries of the heart were reviewed. Forty-nine had stab wounds and eight had gunshot wounds. Thirty-six patients were treated initially by pericardicentesis and observation, and 16 required immediate operation. All patients with gunshot wounds required operation either immediately or later. Results were evaluated for three groups of patients treated: (1) pericardicentesis and observation; (2) pericardicentesis followed by subsequent thoracotomy; and (3) immediate operation. Fatality rates for the three groups were 5%, 19%, and 13%, respectively. Thirty-eight percent of the patients were managed successfully by pericardial aspiration alone, but aspiration was observed to be effective in 55% of the patients in whom it was attempted as definitive treatment. Operative treatment is preferred for (1) continued bleeding; (2) failure to respond to aspiration; (3) recurrent tamponade after aspiration; (4) cardiac arrest; and (5) gunshot wounds.

Primary Cardiac Lymphosarcoma

A 61-year-old woman who died of intractable heart failure was found at autopsy to have lymphoblastic lymphosarcoma of the heart complicated by a hemopericardium. Forty-six similar cases have been previously reported Pericardial aspiration, needle biopsy and cardiac angiography are suggested aids for diagnosis

Surgical management of penetrating cardiac injuries

Among the more spectacular wounds encountered by the surgeon are those involving the heart. Methods of managing these injuries have varied considerably since the first successful clinical cardiorrhaphy seventy years ago. It has been our policy to treat these patients primarily by pericardiocentesis with fluid and blood replacement and pulmonary reexpansion, reserving thoracotomy and cardiorrhaphy for those who fail to respond to such measures or whose condition again deteriorates after pericardial aspiration. Review of experience gained in the management of 197 consecutive patients in this manner during the period 1951 through 1965 continues to support this plan of treatment. Over-all mortality was 25.4 per cent, but this figure includes eleven patients who died before any form of treatment could be started and thirteen who experienced cardiac arrest prior to the onset of therapy but in whom thoracotomy was performed in an attempt at resuscitation. While thoracotomy and cardiorrhaphy should not be delayed when necessary, primary pericardiocentesis still appears to offer patients with penetrating cardiac injuries their best chance for survival.

Surgical Management of Penetrating Thoracic Trauma

Due to a combination of geographic and racial factors, a situation exists in which a large volume of penetrating trauma is routed to the city-county charity hospitals of Houston and Harris County, Texas. Experience in management of these patients has allowed development of certain concepts and improved methods of dealing with the numerous alterations in cardiorespiratory physiology which occur in these injuries. Heart wounds are treated primarily by pericardiocentesis, reserving cardiorraphy for those patients who do not respond to pericardial aspiration or who again develop cardiac tamponade following aspiration. Intracardiac injuries are repaired using cardiopulmonary bypass after recovery from the acute phase of injury and establishment of accurate anatomic diagnosis. Pneumo- and/or hemothorax usually are managed by intercostal thoracostomy tube drainage with fluid and blood replacement, reserving thoracotomy for specific indications. However, complete pulmonary re-expansion is accomplished prior to discharge from the hospital by whatever means necessary, thereby eliminating the need for subsequent decortication to prevent loss of pulmonary function. Results of such methods of management over the past ten years have demonstrated their effectiveness in dealing with civilian trauma. Among 921 consecutive patients with penetrating thoracic trauma there were only 57 deaths, an overall mortality rate of 6.2 per cent, including patients in whom cardiac arrest occurred before any therapy could be started. Complications among the survivors were minimal and usually were related to associated injuries rather than to the thoracic wound itself. The average period of hospitalization was only 9.8 days for the 856 survivors, and almost all have returned to normal activity.

AMOEBIC PERICARDITIS

Twenty-five patients with amoebic pericarditis were studied and the clinical findings described. Two types were recognized, one with a serous effusion associated with a left lobe liver abscess and the other with a purulent effusion resulting from rupture of a liver abscess into the pericardium. These have been termed presuppurative and suppurative amoebic pericarditis respectively. The first type may progress to the second. Five patients suffered from the presuppurative variety of pericarditis and all recovered following treatment of the liver abscess. Of the 20 patients with suppurative pericarditis 12 recovered and had no residual disability. In the eight patients who succumbed, death was due to cardiac tamponade (usually when the correct diagnosis had not been made) or to constrictive pericarditis in which surgery was unsuccessful. It appears from this series that if suppurative amoebio pericarditis is treated by pericardial aspiration to relieve tamponade, and by the anti-amoebic drugs emetine hydrochloride and chloroquine, a proportion of patients recover fully without developing constriction. When constrictive pericarditis develops, conservative treatment should be continued as resolution often occurs. Pericardectomy should be reserved for cases in which death seems inevitable unless constriction is relieved.

Penetrating Wounds of the Heart: Experience with 249 Patients

SUMMARY AND CONCLUSIONS 1.Pertinent data relative to penetrating wounds of the heart are presented; the Physiopathologic and clinical effects of cardiac tamponade are particularly stressed. Diagnostic criteria and the methods of treatment are discussed. 2.This study clearly indicates that if a patient with a heart wound reaches the hospital emergency ward alive, the chances of survival under prompt and intelligent treatment are indeed very good, probably in the range of 80 to 90 per cent. 3.The author is convinced that thoracotomy with pericardiotomy and direct repair of the wound is the most effective method in the definitive treatment of patients with penetrating wounds of the heart. The reasons for selecting open operative therapy as opposed to pericardial aspiration have been enumerated. Pericardiocentesis as definitive treatment is to be employed only in special situations and is not to be adopted as recommended procedure.

IMMEDIATE THORACOTOMY FOR A STAB WOUND OF THE HEART.

PENETRATING WOUNDS of the chest involving the heart may allow survival for a variable period of time after injury. In those wounds that are not rapidly fatal, a fairly uniform approach has evolved in which cardiac tamponade is treated by pericardial aspiration, and shock with blood transfusion.1-4Failure to respond to these measures, or recurring tamponade, requires a planned thoracotomy. Some have proposed a planned thoracotomy for all such wounds.5, 6 An occasional patient will survive long enough to get to a hospital but will die shortly thereafter. Such patients have not been included in treated series because of the overwhelming problems involved. The following case illustrates a problem in which an immediate thoracotomy in an emergency room a few minutes after admission was necessary and successful. Report of a Case A 27-year-old man was admitted to the emergency ward with a 3 cm stab wound in the

Massive pericardial effusion due to meningococcic pericarditis.

MENINGOCOCCAL DISEASE is primarily an invasion of the blood stream by the organism. Secondary localization occurs in such susceptible parts of the body as the meninges, followed in frequency by the lungs, the joints, the eye, the serous membranes, the testicle, and the heart. Because the cardiac complications of meningococcic disease have rarely been reported, a case of massive pericardial effusion with cardiac tamponade and associated myocarditis, which was treated with pericardial aspiration and corticosteroids, is presented. To my knowledge this is the first report of such a case treated successfully with corticosteroids. The meningococcus can involve all layers of the heart. It may produce an endocarditis occasionally associated with myocarditis. Gore1described myocarditis in 111 of 256 cases of meningococcemia observed at postmortem examination. The myocarditis was characterized by microscopic foci of interstitial and perivascular cellular infiltrations, with occasional microscopic or macroscopic abscesses and destruction of muscle fibers.

Cardiac contusion, puncture and tamponade

In most cases of cardiac injury not immediately fatal, hemorrhage is controlled by the development of tamponade. This tamponade may then become life threatening. Relief of tamponade without recurrence may be achieved by pericardial aspiration. In the occasional case with uncontrollable hemorrhage or with deterioration following multiple aspirations thoracotomy and cardiorrhaphy are required. A practical plan of management for cases of cardiac injury has been presented.

A pericardiocentesis electrode.

IN 1956 Bishop, Estes and Mclntosh¶ reported the value of electrocardiographic monitoring during pericardial aspiration. They pointed out that the needle used during pericardial aspiration could ac...

Pericarditis complicating myocardial infarction

Pericarditis accompanying myocardial infarction is a benign condition with few clinical manifestations. It is incidental to a transmural infarct and, aside from this, anatomic correlation is not significant prognostically. Since the essential clinical feature of a rub is evanescent, many occurrences are probably unrecognized. Treatment is essentially asymptomatic and pericardial aspiration is rarely needed. Anticoagulant therapy should be stopped if there is evidence of diffuse pericarditis or effusion to prevent hemopericardium.