Presence Of Pericardial Effusion Research Articles

Dynamic Variables Fail to Predict Fluid Responsiveness in an Animal Model With Pericardial Effusion.

The reliability of dynamic and volumetric variables of fluid responsiveness in the presence of pericardial effusion is still elusive. The aim of the present study was to investigate their predictive power in a porcine model with hemodynamic relevant pericardial effusion. A single-center animal investigation. Twelve German domestic pigs. Pigs were studied before and during pericardial effusion. Instrumentation included a pulmonary artery catheter and a transpulmonary thermodilution catheter in the femoral artery. Hemodynamic variables like cardiac output (COPAC) and stroke volume (SVPAC) derived from pulmonary artery catheter, global end-diastolic volume (GEDV), stroke volume variation (SVV), and pulse-pressure variation (PPV) were obtained. At baseline, SVV, PPV, GEDV, COPAC, and SVPAC reliably predicted fluid responsiveness (area under the curve 0.81 [p = 0.02], 0.82 [p = 0.02], 0.74 [p = 0.07], 0.74 [p = 0.07], 0.82 [p = 0.02]). After establishment of pericardial effusion the predictive power of dynamic variables was impaired and only COPAC and SVPAC and GEDV allowed significant prediction of fluid responsiveness (area under the curve 0.77 [p = 0.04], 0.76 [p = 0.05], 0.83 [p = 0.01]) with clinically relevant changes in threshold values. In this porcine model, hemodynamic relevant pericardial effusion abolished the ability of dynamic variables to predict fluid responsiveness. COPAC, SVPAC, and GEDV enabled prediction, but their threshold values were significantly changed.

Bedside echocardiography in internal medicine: which key questions and answers for our decision-making?

The advent of portable equipment in the last years has brought ultrasound technology available at patient bedside, giving the opportunity to non-cardiologists to extend cardiac assessment based on physical examination. Bedside echocardiography is a ‘question-driven’ examination, where simple and often dichotomic answers are searched. It is performed using phased-array probes and bidimensional images are visually evaluated to obtain information regarding cardiac size and function, presence of pericardial effusion, gross valvular diseases. Although this approach can not in any case substitute a standard 2D color-doppler echocardiography, bedside echocardiography has been demonstrated to maintain a good diagnostic accuracy when limited to basic questions, even in the hands of short-trained non cardiologist physicians. At present the bedside ultrasound approach is widely used in different settings and focused echocardiography takes part together with US explorations of lung, abdomen and deep veins in an integrated perspective that perfectly fit with the holistic approach of the internist. In this context we address two typical scenarios encountered in the internal medicine divisions -the patient presenting with dyspnea or non-post-traumatic hypotension- showing the main questions we can ask to bedside echocardiography for a rapid identification of the determinants of symptoms and consequently for a therapeutic choice based on more objective evidences.

In Patients with Light-Chain (AL) Amyloidosis Myocardial Contraction Fraction (MCF) Is a Simple, but Powerful Prognostic Measure That Can be Calculated from a Standard Echocardiogram (ECHO)

Background: Amyloidosis is a multisystem disease with extracellular deposition of pathological insoluble beta-fibrillar proteins. Involvement of the heart is seen in more than one-half of the patients with systemic AL amyloidosis and it is the most important determinant of clinical outcome. Cardiac amyloidosis is a restrictive infiltrative cardiomyopathy in which, despite declines in stroke volume that accompany disease progression, the ejection fraction (EF) often remains preserved even in advanced stages of the disease. King et al. proposed a novel index of myocardial function, the myocardial contraction fraction (MCF), defined as the ratio of stroke volume (SV) to myocardial volume (MV). MCF is a measure of myocardial shortening, which differentiated myocardial performance in patients with similar degrees of hypertrophy and in a recent small cohort of AL amyloidosis patients appeared superior to left ventricular ejection fraction (EF) in predicting overall survival (OS). It was our goal to assess the prognostic role of MCF in a large cohort of patients with AL amyloidosis in the context of other prognostic variables.Methods: Patients seen between 4/1/1999 and 2/1/2015 were eligible for this retrospective study if they had an ECHO at the Mayo Clinic, Rochester, MN within 30 days of their AL amyloidosis diagnosis with measurements of left ventricular chamber size and wall thickness needed to calculate MCF, EF, and the presence or absence of pericardial effusion. To capture the full cohort, modeling was done first excluding Mayo (2012) staging and global averaged left ventricular longitudinal peak systolic strain (LV strain) since limited numbers of patients had these studies, 342 and 294, respectively. Thresholds of continuous variables were chosen based on receiver operator curves targeting death at 1-year. Cox proportional hazards analysis was used to identify factors that were prognostic for OS. Statistical analyses were done using JMP 9.0 (SAS, Cary, NC).Results: Among the 722 patients satisfying entry criteria,median age was 64 years (range 32-94) and 66% were male. The best cutoff for MCF was 21% (sensitivity: 74%, specificity: 60%; AUC=0.699) and distinguished two groups with different OS (median 53 vs. 9 months, P<0.0001; Figure). On univariate analysis the baseline ECHO variables predicting OS were interventricular septum thickness (IVS) >12 mm (RR 1.8, P=0.0002), EF <60% (RR 1.7), MCF ≤21% (RR 2.1), and presence of pericardial effusion (RR 2.0), all with P<0.0001. On multivariate MCF ≤21% (RR 1.6, P <0.0001), EF <60% (RR 1.4, P=0.0007) and the presence of pericardial effusion (RR 1.3, P=0.002) were independent predictors of OS.Additional modeling was done with the subset of 342 patients who were assessable for Mayo (2012) staging, (i.e. measurements of immunoglobulin free light chain, NT-proBNP, and troponin T). On univariate analysis, patients with a Mayo (2012) stage ≥ 3 had a RR 2.1, p<0.0001. On multivariate, only MCF ≤21% (RR 1.5, P =0.01), Mayo (2012) stage ≥ 3 (RR 1.5, P=0.01) and EF<60% (RR 1.7, P=0.0006) were independent prognostic determinants.Finally, we addressed LV-strain among the 294 patients in whom the study was performed. There was a significant correlation between MCF and LV strain (rho =-0.86, P<0.0001). On univariate, LV-strain less negative than -13 generated a RR of 2.3, p<0.0001. In contrast to the model containing MCF, on LV-strain multivariate, EF was no longer significant, but LV-strain less negative than -13 (RR 2.0, P=0.008) and Mayo (2012) stage ≥ 3 (RR 2.0, P=0.008) predicted independently OS.Conclusions: MCF ≤21% identified a subgroup of patients with a high mortality risk, and it was independent of the Mayo (2012) staging but highly correlated with LV strain. An advantage of MCF, which is a novel volumetric measurement of the left ventricular chamber, is that, unlike LV-strain, MCF is simple to calculate from routine ECHO measures. [Display omitted] DisclosuresKumar:AbbVie: Research Funding; Celgene: Research Funding; Janssen: Research Funding; Skyline, Noxxon: Honoraria; Celgene, Millenium, Sanofi, Skyline, BMS, Onyx, Noxxon,: Other: Consultant, no compensation,; Sanofi: Research Funding; Millenium/Takeda: Research Funding; Onyx: Research Funding.

Echocardiographic and Hemodynamic Predictors of Survival in Precapillary Pulmonary Hypertension: Seven-Year Follow-Up.

In this study, we looked at the prognostic value of echocardiographic and hemodynamic measures in a large cohort of patients with precapillary pulmonary hypertension before and after initiation of treatment. Data were collected prospectively in a cohort of consecutive patients with precapillary pulmonary hypertension referred between 2002 and 2011. A range of clinical and echocardiographic variables were collected and stored on a database to assess predictors of survival. Invasive hemodynamic data including pulmonary artery pressure, pulmonary vascular resistance, capillary wedge pressure, and cardiac index were also obtained at baseline in all patients. Outcome was defined as mortality because of cardiovascular-related death. The study cohort comprised 777 patients (514 women) with precapillary pulmonary hypertension. A total of 195 (25%) died. In multivariable analysis, moderate or severe tricuspid regurgitation (hazard ratio [HR], 26.537; 95% confidence interval, 11.536-61.044; P<0.001), right ventricular myocardial performance index (HR, 3.421; 95% confidence interval, 1.777-6.584; P<0.001), and the presence of pericardial effusion (HR, 1.38; 95% confidence interval, 1.023-1.862; P=0.035) were independent predictors of mortality. High pulmonary vascular resistance and right atrial pressure by invasive hemodynamic measurements were independent predictors of mortality (HR, 1.084; 95% confidence interval, 1.041-1.130, and 1.079, respectively; 95% confidence interval, 1.049-1.111; P<0.001 for both), whereas patients with a higher cardiac index had better survival overall (HR, 0.384; 95% confidence interval, 0.307-0.481; P<0.001). Right ventricular dysfunction, moderate-severe tricuspid regurgitation, low cardiac index, and raised right atrial pressure were associated with poor survival for both pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertensive disease patients. The severity of tricuspid regurgitation, myocardial performance index, presence of pericardial effusion, pulmonary vascular resistance, cardiac index, and right atrial pressure may be used to stratify risk of death.

132 Targeted Resuscitation Using Echocardiography in a Military Ebola Virus Disease Treatment Unit

<h3>Introduction</h3> Patients with Ebola virus disease (EVD) frequently suffer from haemodynamic instability and shock, leading to multiple organ failure and death. Clinical assessment of circulatory status is extremely challenging in these patients, hampered by the need for physicians to wear restrictive personal protective equipment, and adverse environmental factors within the EVD treatment unit (EVDTU). No EVDTUs currently use invasive cardiac output monitoring. Transthoracic echocardiography (TTE) can be used to assess haemodynamic status in critical care resuscitation. Additionally, the incidence of pericardial effusion in Ebola virus disease (EVD) is unknown. We describe the use of focused TTE (fTTE) in a military EVDTU in Sierra Leone. <h3>Methods</h3> Baseline fTTE was performed early during the admission of all patients presenting with confirmed EVD and haemodynamic instability. Studies were performed by either a consultant cardiologist or intensivist. The median duration of EVD was 6 days prior to initial fTTE (range 3–7). In some cases, serial studies were performed during admission. Data were collected on haemodynamics, TTE view availability, LV function, presence of pericardial effusion, IVC dimensions and variability with respiration. Where central venous catheter (CVC) insertion was performed, fTTE was used to check placement by visualisation of the CVC tip, and modified views were used to exclude pneuomothorax, as no radiology facility exists within the EVDTU. <h3>Results</h3> During the first 4 weeks of operation, 8 patients with Ebola virus disease and haemodynamic instability underwent fTTE examination. TTE windows available were as follows: parasternal long axis 60%, parasternal short axis 60%, apical 4 chamber 90%, subcostal 100%. IVC imaging was possible in 80% of cases. All hearts examined were structurally normal. LV function was normal in all cases (EF &gt;55%). Small pericardial effusions (mean 0.58 cm,) were found in 3 cases (37.5%). In 3 cases, hypovolaemia was so profound that LV systolic cavity obliteration was noted. The mean maximal IVC diameter in studies performed during inital resuscitation was 1.73 (±0.05) cm, compared with 2.10 (±0.18) in a partially resuscitated cohort. In 90% of studies, fTTE findings supported continued intravascular volume expansion. In one case, fTTE values suggested that further filing was not required, resulting in a change in management strategy. In studies following CVC placement (n = 9) the tip of the device was visualised in all cases, and lung imaging confirmed no cases of pneumothorax. <h3>Conclusions</h3> This study demonstrates, for the first time in a deployed military Ebola virus disease treatment unit, that fTTE can assist with assessment of volume status during the resuscitation phase. In addition, the incidence of pericardial effusion appears to be low.

0534: Antenatal echocardiographic parameters to predict postnatal outcome of neonates with Ebstein anomaly

Ebstein tricuspide valve anomaly is a rare CHD with uncertain postnatal prognosis. Criteria to predict outcome are still a matter of debate. The aim of this study was to determine antenatal echocardiographic predictive parameters. Retrospective multicentric analysis of fetus with diagnosis of Ebstein anomaly. Echocardiographic measurements of ventricles, atria, great vessels and tricuspid regurgitation were collected. Comparisons were made between group I (poor outcome= death occurred in utero or within the first 3 months of life) and group II (favourable outcome: postnatal survival >3 months). 16 fetuses were included in the study: 10 in group I (62.5%: 2 TOP, 2 fetal deaths, 6 postnatal deaths) and 6 in group II (37.5%). Mean gestationnal age at diagnosis was 29weeks (22 to 38). The mean number of echocardiographic records per patient was 2 (1 to 6). LV to RV ratio, tricuspid valve regurgitation grade and retrograde or anterograde ductal flow did not differ between the 2 groups. Significative differences were found between groups I and II regarding the presence of pulmonary flow (none or mild RV to PA flow: 8 of 9 cases died= 89%), AO to PA ratio (75% death if > 97°p vs 25% if 3-97°p), RA diameter (77.3% death if > 97°p vs 0%), PA diameter (100% death if < 3°p) and pericardial effusion (80% death vs 0%). Only 1 case had arrhythmia and died. This small sample size study showed that the absence of RV to PA flow and/ or pulmonary valve opening, increased AO to PA ratio, RA and decreased PA diameter and the presence of pericardial effusion might represent prognosis factors in fetus with Ebstein anomaly. These results should be confirmed by large scale prospective study.

Echocardiographic Assessment of Estimated Right Atrial Pressure and Size Predicts Mortality in Pulmonary Arterial Hypertension

Elevated mean right atrial pressure (RAP) measured by cardiac catheterization is an independent risk factor for mortality. Prior studies have demonstrated a modest correlation with invasive and noninvasive echocardiographic RAP, but the prognostic impact of estimated right atrial pressure (eRAP) has not been previously evaluated in patients with pulmonary arterial hypertension (PAH). A retrospective analysis of 121 consecutive patients with PAH based on right-sided heart catheterization and echocardiography was performed. The eRAP was calculated by inferior vena cava diameter and collapse using 2005 and 2010 American Society of Echocardiography (ASE) definitions. Accuracy and correlation of eRAP to RAP was assessed. Kaplan-Meier survival analysis by eRAP, right atrial area, and Registry to Evaluate Early and Long-term PAH Disease Management (REVEAL Registry) risk criteria as well as univariate and multivariate analysis of echocardiographic findings was performed. Elevation of eRAP was associated with decreased survival time compared with lower eRAP (P < .001, relative risk = 7.94 for eRAP > 15 mm Hg vs eRAP ≤ 5 mm Hg). Univariate analysis of echocardiographic parameters including eRAP > 15 mm Hg, right atrial area > 18 cm², presence of pericardial effusion, right ventricular fractional area change < 35%, and at least moderate tricuspid regurgitation was predictive of poor survival. However, multivariate analysis revealed that eRAP > 15 mm Hg was the only echocardiographic risk factor that was predictive of mortality (hazard ratio = 2.28, P = .037). Elevation of eRAP by echocardiography at baseline assessment was strongly associated with increased risk of death or transplant in patients with PAH. This measurement may represent an important prognostic component in the comprehensive echocardiographic evaluation of PAH.

Pericardial Effusion Is a Marker of Increased Mortality in Thalassemia Major Patients

Introduction. In different types of not-hematological diseases the presence of a small pericardial effusion (PE) was associated with worse survival even after adjustment for patient characteristics, suggesting that it is a marker of underlying disease.In thalassemia major (TM) pericardial effusion was shown to be one of the manifestations of heart disease but its potential prognostic importance has never been investigated in the modern era. Cardiovascular Magnetic Resonance (CMR) by cine SSFP sequences was demonstrated to be extremely sensitive to even a small amount of PE.This is the first prospective study evaluating if the presence of pericardial effusion is associated with increased mortality in TM.Methods. 1259 patients (648 females, mean age 31.02 ± 8.64 years) enrolled in the Myocardial Iron Overload in Thalassemia (MIOT) were prospectively followed from their first Magnetic Resonance Imaging (MRI) scan. CMR was used to quantify myocardial iron (MIO) overload by a multislice multiecho T2* approach and to assess biventricular function parameters and to detect PE by cine SSFP sequences.Results. PE was present in 25 (2.0%) patients.Patients with and without PE were comparable for age and ratio of men/women. At the baseline, the percentage of patients with MIO (global heart T2* value < 20 ms) was comparable between patients with and without PE (12.0 % vs 28.7%; P=0.074) and left ventricular and right ventricular ejection fractions were not significantly different between the two groups.Mean follow-up (FU) time was 44.55 ± 20.35 months and there were 15 deaths.Mortality was greater for patients with PE compared to those without an effusion (8.0% vs 1.1%, P=0.034).PE was a significant predictive factor for death (hazard ratio-HR=12.64, 95%CI=2.78-57.42, P=0.001). PE remained a significant prognosticator for death also in a multivariate model including MIO ms (PE: HR=17.36, 95%CI=3.65-82.62, P<0.0001and global heart T2* < 20 ms: HR=3.07, 95%CI=1.07-8.75, P=0.036).Conclusions. PE is quite rare in TM patients and it is not related to myocardial iron overload. An important role in the development of PE could be played by the 'iron-induced’ pericardial siderosis but, due to the limitations of the current non-invasive CMR techniques, we were not able to address this issue.PE was found to be a strong predictor for death, independently by the presence of myocardial iron overload. The non-invasive diagnosis of pericardial effusion is important for a more complete definition of the cardiac involvement of TM patients. The increased risk of death associated with PE may be used along with other clinical characteristics when estimating a patient’s prognosis and monitoring. DisclosuresPepe:Chiesi: Speakers Bureau; ApoPharma Inc.: Speakers Bureau; Novartis: Speakers Bureau.

Abstract 11636: Right Ventricle Lymphatic Vessel Insufficiency Contributes to Interstitial Fluid Stasis, Inflammation, Fibrosis, and Failure in Pulmonary Hypertension

Introduction: Pulmonary hypertension (PH) is characterized by cardiopulmonary remodeling. The ensuing right ventricular (RV) hypertrophy and failure contribute to significant mortality. Pericardial effusion worsens the prognosis for PH patients, yet no mechanistic data are available. Hypothesis: We hypothesized that lymphatic vessels in rat models of PH would be decreased and dysfunctional compared to controls. Methods: We used the Sugen 5416-hypoxia (Su-Hx) and monocrotaline (MCT) models of PH. To assess the degree of cardiac lymphatic vascularity, identify cell types, and to evaluate cell junction complexes in PH rats vs. controls, we used flow cytomtery, qPCR, immunofluorescence, and immunoblot. To assess myocardial edema, we used wet-to-dry weight ratios, echocardiography, and magnetic resonance imaging (MRI). In patients, we used echocardiography and magnetic resonance imaging to quantify RV edema and pericardial effusion. Results: We found that the presence of pericardial effusion by either MRI or echocardiography correlated with lower cardiac output in patients with PH (n =6). We found decreased lymphatics in RVs of rats with PH due to either Su-Hx or MCT, compared to controls (n= 5 per group). In the heart, AQP-1+/vWF-/KDR- lymphatic vessels co-expressed podoplanin and were distributed throughout the RV in controls and much less so in PH rats. Lymphatics appeared unchanged in size or number in the left ventricle of all rats. We found increases in myocardial fluid in RVs of PH rats vs. controls, which correlated positively with fibrosis and negatively to cardiac output. The presence of excess myocardial fluid coincided with collagen deposition but without increases in CD68, CD11b, CD11c, or CD163 macrophage infiltration. We observed disturbed connexin-43 and claudin-5 junctional complexes around alpha-actinin+ myocytes and TCF21+ cardiac fibroblasts in PH RVs compared to controls. Conclusions: In severe PH, RV function is likely impaired by insufficient lymphatic-mediated fluid clearance and the presence of dysfunctional cell junctions. A clearer understanding of how the cardiac lymphatic system impacts the pathobiology of PH may lead to novel therapy.

Antenatal echocardiographic parameters to predict postnatal outcome of neonates with Ebstein anomaly

Ebstein tricuspide valve anomaly is a rare CHD with uncertain postnatal prognosis. Criteria to predict outcome are still a matter of debate. The aim of this study was to determine antenatal echocardiographic predictive parameters. Retrospective multicentric analysis of fetus with diagnosis of Ebstein anomaly. Echocardiographic measurements of ventricles, atria, great vessels and tricuspid regurgitation were collected. Comparisons were made between group I (poor outcome = death occurred in utero or within the first 3 months of life) and group II (favorable outcome: postnatal survival > 3 months). 16 fetuses were included in the study: 10 in group I (62.5%: 2 TOP, 2 fetal deaths, 6 postnatal deaths) and 6 in group II (37.5%). Mean gestational age at diagnosis was 29 weeks (22 to 38). The mean number of echocardiographic records per patient was 2 (1 to 6). LV to RV ratio, tricuspid valve regurgitation grade and retrograde or anterograde ductal flow did not differ between the 2 groups. Significative differences were found between groups I and II regarding the presence of pulmonary flow (none or mild RV to PA flow: 8 of 9 cases died = 89%), AO to PA ratio (75% death if > 97 p vs. 25% if 3–97 p), RA diameter (77.3% death if > 97 p vs. 0%), PA diameter (100% death if < 3 p) and pericardial effusion (80% death vs. 0%). Only 1 case had arrhythmia and died. This small sample size study showed that the absence of RV to PA flow and/or pulmonary valve opening, increased AO to PA ratio, RA and decreased PA diameter and the presence of pericardial effusion might represent prognosis factors in fetus with Ebstein anomaly. These results should be confirmed by large-scale prospective study.

CHOLESTEROL PERICARDITIS WITHOUT ACTIVE INFLAMMATORY CHANGE: EVALUATION BY POSITRON EMISSION TOMOGRAPHY AND COMPUTED TOMOGRAPHY

Cholesterol pericarditis is a rare clinical entity characterized by the presence of pericardial effusion containing cholesterol crystals and high concentrations of cholesterol. An 82-year-old man was admitted with a 1-month history of exertional dyspnea without other symptoms (such as pain, fever

Resuscitative EChocardiography for the Evaluation and management of Shock: The RECES protocol

Purpose: Ultrasound use by emergency medicine and critical care physicians in the evaluation of the critically ill patient has increased in recent years. Several protocols exist to aid in diagnosing the etiology of shock and identifying rapidly reversible conditions in the undifferentiated hypotension patient. Currently, no protocol provides hemodynamic data or is designed to guide ongoing resuscitation of the critically ill patient with hypotension. Methods: An evidence-based protocol was developed based on the components of echocardiography that have been supported in the literature for bedside evaluation of the critically ill patient. Results: The RECES protocol provides diagnostic and hemodynamic information regarding volume responsiveness , presence of pericardial effusion with tamponade physiology (right ventricular diastolic collapse), systolic failure (poor contractility, decreased stroke volume and cardiac output), diastolic dysfunction (mitral valve inflow velocities and tissue Doppler), Right ventricular systolic failure, acute valvular rupture, obvious wall motion abnormalities, and signs of pressure or volume overload (septal flattening on parasternal short axis). Conclusion: The RECES protocol is a proposed instrument for rapidly and repeatedly assessing the etiology and initial hemodynamic parameters of the patient in shock. Additionally, repeated exams will allow monitoring interventions and guide ongoing resuscitation.

Cholesterol pericarditis without active inflammatory change: Evaluation by positron emission tomography and computed tomography

Cholesterol pericarditis is a rare clinical entity characterized by the presence of pericardial effusion containing cholesterol crystals and high concentrations of cholesterol. An 82-year-old man was admitted with a 1-month history of exertional dyspnea without other symptoms (such as pain, fever

Acute myocardial infarction after a gunshot wound

A gunshot injury is a type of penetrating trauma of the thoracic wall. The clinical presentation depends on the size of the wound, the size of the bullet, the location of entry, damage of the great vessels, perforation of the cardiac wall, and the presence of pericardial effusion. Different complications have been reported after gunshot wound such as hemorrhage (intrathoracic and extrathoracic), systemic air embolism, pericardial tamponade, great vessel injuries, and peripheral ischemia. Dissection of the vessels, coronary arteriovenous fistula, and pellet embolization can also be seen after gunshot injury.

The potential additional diagnostic value of assessing for pericardial effusion on cardiac magnetic resonance imaging in patients with suspected myocarditis

The presence of pericardial effusion (PE) is considered to be suggestive of inflammation in suspected myocarditis. However, the incremental value of assessing for PE in addition to comprehensive cardiac magnetic resonance (CMR) imaging remains unclear. In total, 132 patients with suspected acute (AMC) or chronic myocarditis (CMC) were included. All patients underwent endomyocardial biopsy (EMB) and CMR. Imaging protocols included T2 imaging for the assessment of myocardial oedema (oedema ratio [ER]), T1 imaging before and after contrast agent administration for global relative enhancement (gRE) calculation, and late enhancement (LE). Furthermore, the presence and extent of PE were determined. The potential incremental diagnostic value of PE was determined by applying a two, three, or four out of four criteria approach including ER, gRE, LE, and PE. PE was present in 84 of the 132 patients (63.6%) and was more common in suspected AMC vs. CMC (56 of 70 vs. 28 of 62; P < 0.001). According to EMB results, PE was found in 86% of patients with AMC, 67% with chronic myocarditis, and 56% without evidence of myocardial inflammation. Implementing PE into a three out of four approach did not result in improved accuracy compared with the established two out of three approach using ER, gRE, and LE (59 vs. 68% for the total population, 69 vs. 79% for suspected AMC, and 48 vs. 52% for suspected CMC). The finding of PE in unselected patients with suspected AMC or CMC is not specific to myocarditis. Therefore, with the currently applied criteria and methods, assessment of PE does not improve the diagnostic performance of CMR in this patient cohort.

Purulent pericarditis: A rare diagnosis

The authors present two cases of purulent pericarditis secondary to pneumococcus pneumonia, a rare entity in the antibiotic era, one of them in an apparently healthy person. A systematized diagnostic approach to moderate pericardial effusion is presented, together with a review of purulent pericarditis. The presence of pericardial effusion with persistent fever with or without known etiology, particularly in the immunocompromised but also in the apparently healthy patient, should always raise the possibility of purulent pericarditis.

Pericardite purulenta: um diagnóstico raro

The authors present two cases of purulent pericarditis secondary to pneumococcus pneumonia, a rare entity in the antibiotic era, one of them in an apparently healthy person. A systematized diagnostic approach to moderate pericardial effusion is presented, together with a review of purulent pericarditis. The presence of pericardial effusion with persistent fever with or without known etiology, particularly in the immunocompromised but also in the apparently healthy patient, should always raise the possibility of purulent pericarditis.

Thirty year experience of constrictive pericarditis: one-hundred and forty cases with a long-term follow-up

Objectives and methods: 1. To describe the clinical presentation, etiology, diagnostic tecniques, surgical findings and long-term follow-up of patients operated of Constrictive Pericarditis (CP). 2. To identify independent predictors of poor outcome after pericardiectomy. Retrospective analysis of all operated cases of CP: Clinical data, surgical findings and follow-up (FU) were recorded. Results: Between 1978 and 2012, 140 patients underwent pericardiectomy for CP (Male = 99 (71%), age=54 years-old, range (17-80y). Clinical presentation: Congestive heart failure (124p, 87%), chest pain (46p, 33%) or fever (33, 23.4%). Forty-nine patients (35%) were in an advanced NYHA class (III or IV) before surgery. The most frequent etiology of CP was idiopatic (71%). In patients with a specific cause of CP, tuberculosis (11%) was the most frequent diagnosis. Sixteen patients (11%) died perioperatively. Predictors of perioperative mortality were age (66±11 vs 53±16 years, p=0.002), NYHA status III or IV (31% vs 62%, p=0.014) and presence of pericardial effusion (27% vs 60%, p=0.01). Overall mortality during FU (12 years (range 0.1 to 34.5y)) was 39%. Long-term FU analysis (124 patients) showed that independent predictors of death were age at surgery (HR 1.05, 95% CI: 1.017-1.088), a previous episode of acute pericarditis (HR 2.93, 95% CI 1.26-6.81) and a preoperative NYHA status III or IV (HR 4.03, 95% CI 1.79-9.05). Etiology did not have an impact neither in perioperative survival nor in the long-term FU. View this table: Use of diagnostic procedures Conclusions: Idiopatic pericarditis is the most frequent cause of CP. Perioperative mortality is high. Factors associated with a poor perioperative outcome are age, advanced NYHA status and moderate or severe pericardial effusion. Long-term FU shows that independent predictors of poor outcome are age at surgery, advanced NYHA status and a previous episode of acute pericarditis.

Critical cardiac tamponade in newborn, life-saving emergency interventions and possibility of parvovirus B19 congenital infection

Abstract The presence of pericardial effusion in neonates usually indicates a poor prognosis. Here, we report a case of isolation of cardiac tamponade in a newly born. This may be related to vertical human parvovirus B19, an infection with atypical clinical manifestation. Any neonate with unexplained fetal pericardial effusion should always be tested for parvovirus B19 infection, even in the absence of known and proved fetal exposure. Despite the etiology of a tamponade the only reasonable procedure is a surgical evacuation during diagnosis.

Jellyfish in the Heart

A 41-year-old man with a partially cystic cardiac mass was referred to our institutions. About 17 years previously, he had undergone the excision of a lipoma in the left popliteal region. The patient had been well until 3 to 4 months earlier, when dyspnea on exertion developed. Two-dimensional echocardiography (Figure 1A and 1B), computed tomography (Figure 2A and 2B), and magnetic resonance imaging (Figure 3A and 3B and Movies I–3 in the online-only Data Supplement) displayed a patchy lobulated epicardial mass (transversal diameter, 7 cm; thickness, 4 cm) near the left cardiophrenic angle, partially occupying the left ventricular chamber. Figure 1. Echocardiography. Apical 4-chamber view showing a large cardiac mass infiltrating the apex, lateral, and anterior walls of the left ventricle. A second small cardiac mass is attached to the left wall; presence of pericardial effusion. Contrast-enhanced ultrasound shows the large infiltrative cardiac mass. Inside the mass are large nodular, nonperfused or hypoperfused areas surrounded by vascularized nonmyocardial tissue infiltrating the normal myocardium. Figure 2. Multislice computed tomography axial image of the mass …