Significant Pericardial Effusion Research Articles

Pulmonary Artery Injury Following Endocardial Left Atrial Appendage Occlusion: The Known and Unknown.

Left atrial appendage closure (LAAC) is frequent alternative for stroke prophylaxis in patients for whom oral anticoagulation is contraindicated. Pulmonary artery injury (PAI) is a feared yet rare complication of endocardial LAAC, but its surrounding literature is scarce. The aim of the current study was to review prior PAI published reports and the U.S. Food and Drug Administration Manufacturer and User Facility Device Experience (MAUDE) database to understand evidence and mechanisms of PAI after LAAC. A systematic review was conducted of the literature and MAUDE database for previously reported cases of PAI, and cases were reviewed for patient characteristics and outcomes. In addition, we identify risks and review our strategies to avoid this injury. Thirty-six cases (16 case reports and 20 MAUDE reports) of PAI were found. These patients had a mean age of 73.6 ± 8.2 years with a median CHA2DS2VASC score of 5 (quartile 1-quartile 3: 3-6). Most commonly, LAAC associated with PAI involved a dual-seal (75%) followed by lobular occlusive devices (19.4%); the device was unspecified in 2.8% of cases. PAI commonly presented postprocedurally, either within the first 24 hours (50%) or beyond (38.9%), with cardiac tamponade (61.1%) or cardiac arrest (19.4%). Overall, 52.8% required surgery with or without antecedent pericardiocentesis, and 16.7% were managed with pericardiocentesis. PAI was associated with a high mortality rate (ie,33.3%). Unfortunately, no specific cardiac imaging or procedural details to predict PAI were noted in the reports. Presentation of PAI after LAAC can occur immediately following the procedure or be delayed. Thus, the threshold for suspicion, especially with rapid and hemodynamically significant pericardial effusion, after LAAC should be low.

Percutaneous Balloon Pericardiotomy and Window Creation for Treating Recurrent Massive Pericardial Effusion in Patients with Cancer: A Case Series and Literature Review

Cancer is the second leading cause of death worldwide, and pericardial effusion is relatively common in these patients. What constitutes the best therapeutic method for treating pericardial effusion in patients with cancer is controversial. Recent decades have witnessed the introduction of percutaneous balloon pericardiotomy, an effective and less-invasive method with lower recurrence rates than pericardiocentesis for draining pericardial effusion in patients with cancer who have a poor prognosis.We herein describe 2 patients with a history of metastatic melanoma and metastatic breast cancer, presenting with symptomatic massive pericardial effusions. The patients had experienced 2 episodes of cardiac tamponade in the preceding 4 to 5 months, treated via surgical drainage. In their current episode, they were both successfully treated via percutaneous balloon pericardiotomy, and there was no recurrence of significant pericardial effusion reported during the follow-up.

Percutaneous left atrial appendage closure using a novel occlusion device for thromboembolic prevention: 3-year procedural experience

Abstract Background Stroke due to atrial fibrillation has been associated with a high risk of disability and mortality. Percutaneous left atrial appendage (LAA) closure has been established as a treatment strategy for stroke prevention in patients not eligible for oral anticoagulation as well as in patients after electrical isolation of the LAA and subsequent increased risk of thrombus formation. The aim of this study was to evaluate the feasibility and initial experience of LAA closure using a novel nitinol-based, self-expanding system in an unselected patient cohort. Methods and Results One hundred and two patients (39% female, median age 75 [71;80], median CHA2DS2-VASc score 5 [4;6]) underwent LAA closure with the novel system between October 2020 and October 2023. 61/102 (61%) patients underwent previous electrical LAA isolation, 30/102 (29%) patients had high bleeding risk as an indication for LAA closure. Median procedure time was 45 [38;59] minutes and median fluoroscopy time was 10 [7;12] minutes. Successful LAA closure was achieved in all patients, despite different LAA anatomies. Median umbrella and cover disc diameter were 22 [20;24] millimeter and 28 [20;24] millimeter, respectively. Procedure-related adverse events occurred in 2/111 (1.8%) patients. One patient had a vascular complication at the puncture site and another patient had non-hemodynamically significant pericardial effusion. Overall, the patients stayed for a median of 2 [1;4] days in hospital. Conclusion Left atrial appendage closure with a novel nitinol-based, self-expanding system is feasible and safe. LAA isolation was the most common indication for LAA closure at our institution. Further studies are needed, to identify differences and potential advantages of different LAA closure systems.

Preliminary real-world experience on mitral isthmus ablation with a novel catheter that toggles between radiofrequency and pulsed field ablation

Abstract Background The mitral isthmus (MI) is frequently targeted during the ablation of persistent atrial fibrillation (AF). Nevertheless, achieving a complete bidirectional MI block using radiofrequency (RF) is often technically challenging and time-consuming1,2. Previously, we described a fluoroscopy-guided technique to achieve MI block using a penta-spline pulsed field ablation (PFA) catheter3. Recently, a new catheter was introduced, which toggles between RF and PFA and is integrated into a 3D mapping system, thus supposedly facilitating its use for the ablation of extra-pulmonary vein structures4. Purpose To describe the acute efficacy and procedural features of the first cases of posterior MI ablation performed with the toggling catheter at two centers. Methods We collected and reviewed demographic, clinical and procedural features of all patients who underwent ablation of the posterior MI at our centers between September and October 2023. Ablation of the MI was performed with either RF or PFA according to operator’s discretion. Bidirectional MI block was validated through activation mapping and differential pacing. Results During the study period, 44 patients were treated with the toggling catheter. Out of them, 16 patients (aged 68.3±10.1 years; 29% females) underwent posterior MI ablation for persistent AF, in addition to PVI and posterior wall isolation. Mean history of AF was 29.8±34.5 months and mean LA volume 135.6±54.9 ml. Skin-to-skin procedural time (93 minutes, IQR 64-112), LA mapping time (9.0 min, IQR 7.3-12.1) and time required for MI ablation (4.0 min, IQR 3.3-6.5) were remarkably short. In PFA-treated patients (10 cases), first-pass MI block was achieved in 8 (80%), with 16 (IQR 12-22) applications; none of these patients required RF touch-up. In the remaining 6 RF-treated patients, first-pass MI block was achieved in 3 (50%) patients with 8 (IQR 6-13) applications. Additional PFA applications (median 3, IQR 2-5) on the most venous portion of the MI were required in all RF-treated patients. In the 5 patients in whom bidirectional block could not be achieved at first-pass, remapping and touch-up application time were 2.6 (IQR 2.6- 6.3) and 2.0 (IQR 0.8-5.2) minutes, respectively. Eventually, bidirectional MI block was achieved in 16/16 (100%) patients by the end of the procedure. Importantly, no patients in the entire cohort experienced complications such as coronary artery spasm or clinically significant pericardial effusion. Conclusions Several observations can be made on this first real-world experience on posterior MI ablation with the toggling catheter: first, acute safety and efficacy in achieving a bidirectional MI block are high with both PFA and RF; secondly, patients undergoing RF ablation often require additional PFA applications on the venous segment of the MI; lastly, the time required to achieve MI block is remarkably short even when remapping and touch-up applications are needed.Figure 1Figure 2

Pericardial effusion and impaired diastolic cardiac function as a result of a giant colonic diverticulum

This case report describes a Giant Colonic Diverticulum (GCD) found in association with a significant pericardial effusion and impaired cardiac function. A 63-year-old man presented to the Emergency Department with bilateral leg edema, mild dyspnea, and diarrhea. An echocardiogram demonstrated a large pericardial effusion and abnormal diastolic cardiac function. Abdominal imaging studies identified a 29 cm x 18 cm x 13 cm gas filled structure in the left upper quadrant concerning for GCD causing significant compression of the left lung and heart. Following surgical resection, the pericardial effusion resolved, cardiac function normalized, and the patient’s leg swelling improved. This is the first case report to record an association between GCD and pericardial effusion with impaired diastolic cardiac function.

Small Left Ventricular Size Is a Risk Factor for Recurrent Pericardial Effusion after Percutaneous Drainage.

Background: Significant pericardial effusion requires percutaneous drainage. Some patients experience recurrent pericardial effusion following index drainage, but its risk factors remain unknown. Such knowledge should further improve the clinical management of individuals presenting with pericardial effusion for risk stratification and the construction of therapeutic and management strategies beforehand. Methods: Patients who underwent percutaneous drainage for pericardial effusion between 2018 and 2023 were retrospectively included and were followed for 2 years or until November 2023. Baseline factors associated with recurrent pericardial effusion that required percutaneous drainage again were investigated to identify the high-risk cohort. Results: A total of 39 patients (83 years on median, 28 males) were included. During the 2-year observation period, 11 patients had the primary outcome. The left ventricular end-diastolic diameter at baseline was independently associated with the primary outcome with an adjusted hazard ratio of 0.88 (95% confidence interval 0.80-0.97, p = 0.013) with a cutoff of 42 mm, which significantly stratified the cumulative incidence of the primary outcome (53% versus 10%, p = 0.011). Conclusions: Recurrent pericardial effusion after percutaneous drainage is not a rare phenomenon. A smaller left ventricular endo-diastolic diameter was an independent risk factor for recurrent pericardial effusion. The clinical implications of our findings in daily clinical practice should be validated in future prospective studies. Further studies are warranted to clarify the underlying causality between them.

ANOMALY OF ORIGIN AND COURSE OF THE CIRCUMFLEX ARTERY: AN ECHOCARDIOGRAPHIC DIAGNOSIS

ANOMALY OF ORIGIN AND COURSE OF THE CIRCUMFLEX ARTERY: AN ECHOCARDIOGRAPHIC DIAGNOSIS

Pericarditis recurrence is associated with milder electrocardiographic, echocardiographic, and laboratory findings

Recurrent pericarditis (RP) complicates approximately 30% of acute pericarditis (AP) cases. We sought to compare the prevalence and severity of objective findings seen in patients with RP. A retrospective single-center study during 2010–2019, including 765 patients diagnosed with AP. Clinical, electrocardiographic, echocardiographic, and laboratory findings were extracted from the local electronic health records. Recurrence during follow-up was documented in 134 patients (17.5%), with a median time to recurrence of 101 (± 59–251) days. The median age was 60 years (IQR 45–72), 68% were male. Most patients were defined as having idiopathic\\viral pericarditis (64%). The clinical manifestation during the recurrent event of pericarditis was less prominent or attenuated when compared to the initial event—ECG signs (ST elevation 12% vs. 26%; p = 0.006, Knuckle sign 13% vs. 33%; p < 0.001, ST larger in lead L2 than L3 4% vs. 19%; p < 0.001), pericardial effusion moderate and above (11% vs. 30%; p = 0.02), and inflammatory markers (mean peak CRP levels 66 mg/l vs. 97 mg/l; p < 0.001). Similar results were seen in the subgroup of patients defined as having idiopathic\\viral pericarditis. Up to 20% of patients who did not have ECG signs or a significant pericardial effusion in their 1st event demonstrated these findings during the recurrence, though still to a lesser extent compared with those who had these signs in their 1st event. The objective findings of AP are less pronounced during recurrent events. Future studies should focus on the role of advanced biomarkers and imaging in defining true RP events.

Pericardiocentesis guiada por ecografía en el Taponamiento cardíaco: reporte de un caso

We present the case of a patient with a history of penetrating chest trauma, complicated by hemopneumothorax, resolved by pleurostomy tube. Subsequently, the patient progresses unfavorably with hemodynamic instability and is transferred to the Intensive Care Unit, where POCUS (Point of Care Ultrasound) ultrasonography is performed, showing significant pericardial effusion which is caused by cardiac tamponade, which causes a state of shock. obstructive type, so it was decided to perform ultrasonography-guided pericardiocentesis, showing a favorable evolution after the procedure

Point-of-care ultrasound guided Pericardiocentesis in cardiac tamponade: case report

We present the case of a patient with a history of penetrating chest trauma, complicated by hemopneumothorax, resolved by pleurostomy tube. Subsequently, the patient progresses unfavorably with hemodynamic instability and is transferred to the Intensive Care Unit, where POCUS (Point of Care Ultrasound) ultrasonography is performed, showing significant pericardial effusion which is caused by cardiac tamponade, which causes a state of shock. obstructive type, so it was decided to perform ultrasonography-guided pericardiocentesis, showing a favorable evolution after the procedure

Half-dose direct oral anticoagulation versus warfarin for atrial fibrillation following cardiac surgery.

Optimal anticoagulation strategies have not been defined for patients with atrial fibrillation following cardiac surgery. From a total cohort of 228 patients with pre-existing or new onset atrial fibrillation following coronary artery bypass grafting and/or valve surgery, we compared in-hospital and 30-day outcomes in 119 patients treated with low-dose aspirin and a half-dose direct oral anticoagulant (DOAC) versus 109 treated with low-dose aspirin and warfarin. DOAC patients were older (73.1±7.0 vs. 68.7±11.4 years, P<0.001) and had a lower incidence of preoperative atrial fibrillation (37 [31.1%] vs. 69 [63.3%], P<0.001). Otherwise, the two cohorts were well matched for baseline demographics, cardiovascular risk factors, comorbidities, prior cardiac history and STS Risk Score. In comparison to Warfarin patients, DOAC patients had a shorter length of post-surgical stay (6 [5-8] vs. 7 [5-10] days, P=0.037). The two cohorts, however, had a similar incidence of stroke, transient ischemic attack, reoperation for bleeding and postoperative blood bank product usage. Follow-up 30-day outcomes did not differ between the two groups with respect to mortality (0 [0.0%] vs. 0 [0.0%], P=1.000) and hospital readmission (16 [13.4%] vs. 14 [12.8%], P=0.893), although two DOAC patients required drainage of sanguineous pericardial effusions. In comparison to warfarin, half-dose DOAC anticoagulation in patients with atrial fibrillation following cardiac surgery is associated with a shorter postoperative length of stay, without a significant increase in stroke/transient ischemic attack, reoperation for bleeding or postoperative blood product transfusion. Follow-up echocardiography in anticoagulated patients is recommended to rule out significant sanguineous pericardial effusions in the early postoperative period following hospital discharge.

Pericardial effusion requiring intervention in patients undergoing leadless pacemaker implantation: A real-world analysis from the National Inpatient Sample database

Pericardial effusion requiring percutaneous or surgical-based intervention remains an important complication of a leadless pacemaker implantation. The study sought to determine real-world prevalence, risk factors, and associated outcomes of pericardial effusion requiring intervention in leadless pacemaker implantations. The National Inpatient Sample and International Classification of Diseases-Tenth Revision codes were used to identify patients who underwent leadless pacemaker implantations during the years 2016 to 2020. The outcomes assessed in our study included prevalence of pericardial effusion requiring intervention, other procedural complications, and in-hospital outcomes. Predictors of pericardial effusion were also analyzed. Pericardial effusion requiring intervention occurred in a total of 325 (1.1%) leadless pacemaker implantations. Patient-level characteristics that predicted development of a serious pericardial effusion included >75 years of age (odds ratio [OR] 1.38, 95% confidence interval [CI] 1.08-1.75), female sex (OR 2.03, 95% CI 1.62-2.55), coagulopathy (OR 1.50, 95% CI 1.12-1.99), chronic pulmonary disease (OR 1.36, 95% CI 1.07-1.74), chronic kidney disease (OR 1.53, 95% CI 1.22-1.94), and connective tissue disorders (OR 2.98, 95% CI 2.02-4.39). Pericardial effusion requiring intervention was independently associated with mortality (OR 5.66, 95% CI 4.24-7.56), prolonged length of stay (OR 1.36, 95% CI 1.07-1.73), and increased cost of hospitalization (OR2.49, 95% CI 1.92-3.21) after leadless pacemaker implantation. In a large, contemporary, real-world cohort of leadless pacemaker implantations in the United States, the prevalence of pericardial effusion requiring intervention was 1.1%. Certain important patient-level characteristics predicted development of a significant pericardial effusion, and such effusions were associated with adverse outcomes after leadless pacemaker implantations.

Idiopathic Pericarditis Leading to Hemorrhagic Pericardial Effusion- A Case Report and Review

Pericardial effusion presentation is a large spectrum that can vary from asymptomatic to cardiac tamponade. It is a relatively common syndrome and has a diverse set of etiologies including infections, malignancy, radiation/iatrogenic, pericardial injury, metabolic disturbances, endocrine disease, connective tissue disease, autoimmune disorders, trauma, or idiopathic. Pericardial drainage is recommended in most large pericardial effusions or those causing cardiac tamponade. Pericardial fluid can be either purulent, serous, serosanguinous, or hemorrhagic. In the case of hemorrhagic effusion, the common etiologies include malignancy, iatrogenic, and tuberculosis (in endemic regions). Large hemorrhagic pericardial effusions resulting from idiopathic (presumed viral) pericarditis are rare but possible. We present an interesting case of a woman with a large hemorrhagic pericardial effusion presenting as subacute cardiac tamponade caused by idiopathic pericarditis in the setting of known malignancy. This report aims to increase awareness about pericarditis as a potential cause of significant hemorrhagic pericardial effusions, rather than solely attributing them to malignancy. J MEDICINE 2024; 25: 87-89

Neoplastic Pericardial Effusion in Malignant Solid Tumors: Clinical Features, Diagnosis and Management

Introduction: Neoplastic pericardial effusion (NPE) poses a significant challenge in medical pathology, particularly due to its association with secondary involvement by malignancies originating in various organs. Timely management of NPE is pivotal for both overall survival and the patients' quality of life. However, there is a scarcity of data on NPE in our country. This study aims to provide a comprehensive description of the clinical, diagnostic, and therapeutic characteristics of consecutive Moroccan patients with NPE. Methods: A retrospective cohort study was conducted at Ibn Rochd Cardiology Department and Oncology Unit in Casablanca, covering a period of three years (January 2020 to December 2022). The study included patients diagnosed with NPE based on clinical, biological, histological, and echocardiographic criteria. Data collection encompassed sociodemographic information, performance status, clinical manifestations, ECG and echocardiography findings, grade of pericardial effusion, cytology of pericardial fluid, and details of therapeutic protocols administered. Results: Between 2020 and 2022, 49 NPE patients were admitted, with a gender distribution of 51% men and 49% women. The median age was 42 years. Most patients presented with symptomatic pericardial effusion (81%), and 61.2% had NPE at the first diagnosis of metastatic disease. Lung, breast, and other solid tumors were common etiologies. Cytology of pericardial fluid was positive in 23 patients. Clinical examination and diagnostic imaging revealed diverse presentations, including signs of right heart failure, ECG abnormalities, and echocardiographic findings indicative of significant pericardial effusion. Pericardiocentesis and drainage were performed in the majority of patients, often combined with pleuropericardial window placement. Systemic treatments, tailored to the primary tumor type, were administered, with a 60% overall mortality rate, rising to 88% in lung cancer cases. Conclusion: This study provides crucial insights into the clinical spectrum and management of NPE in Moroccan patients. The high mortality rate, particularly in lung cancers, underscores the importance of early detection and targeted therapeutic interventions in improving outcomes for patients with NPE.

Use of intracardiac echocardiography in vein of Marshall ethanol infusion for ablation of persistent atrial fibrillation

BackgroundFew methods have been reported to demonstrate real-time effects during vein of Marshall (VOM) ethanol infusion in persistent atrial fibrillation (PeAF). ObjectiveThis study was to evaluate the impact of left atrial (LA) monitoring using intracardiac echocardiography (ICE) during VOM ethanol infusion. MethodsSeventy-four consecutive patients with PeAF who underwent VOM ethanol infusion followed by radiofrequency (RF) ablation were included. Patients with findings on ICE consistent with echogenic streaming in the LA and with increased myocardial local echogenicity along the VOM area were placed into one group (group A) and those without into the other group (group B). Outcomes between the 2 groups were compared. ResultsForty-six patients (62%) were placed into group A. A new ethanol-induced low-voltage area in group A was larger than that in group B (8.5 cm2 [5.5–10.2 cm2] and 4.0 cm2 (2.4–6.3 cm2]; P < .001). The RF ablation time required to achieve MI block was reduced in group A patients (263.0 seconds [196.0–351.0 seconds] vs 417.0 seconds [315.0–709.5 seconds] in group B patients; P < .001). MI block was achieved in 46 patients (100%) via an endocardial approach in group A and 27 patients (96.4%) in group B (extra coronary sinus ablation in 4 patients). One patient developed clinically significant pericardial effusions and required pericardiocentesis in group B. ConclusionPresence of increased myocardial local echogenicity at the ridge and consistent echogenic streaming in the LA detected by ICE-based imaging during VOM ethanol infusion suggests increased ablated tissue in that region and lower RF ablation time during ablation for PeAF.

The effect of body mass index on complications in cardiac implantable electronic device surgery.

Cardiac implantable electronic device (CIED) procedures are prone to complications. In our study, we investigated the effect of body mass index (BMI) on CIED-related complications. 1676 patients who had undergone CIED surgery (de novo implantation, system upgrade, generator change, pocket revision or lead replacement) at two heart centers in Turkey and met the study criteria were included in our study. For analysis of primary and secondary endpoints, patients were classified as non-obese (BMI<25kg/m2 ), overweight (25 ≤ BMI<30kg/m2 ), and obese (BMI ≥ 30kg/m2 ). The primary endpoint was accepted as cumulative events, including the composite of clinically significant hematoma (CSH), pericardial effusion or tamponade, pneumothorax, and infection related to the device system. Secondary outcomes included each component of cumulative events. The rate of cumulative events, defined as primary outcome, was higher in the obese patient group, and we found a significant difference between the groups (3.0%, 4.3%, 8.9%, p=.001). CSH and pneumothorax rates were significantly higher in the obese patient group (0.3%, 0.9%, 1.9%, p=.04; 1.0%, 1.4%, 3.3%, p=.04, respectively). According to our multivariate model analysis; gender (OR:1.882, 95%CI:1.156-3.064, p=.01), hypertension (OR:4.768, 95%CI:2.470-9.204, p<.001), BMI (OR:1.069, 95%CI:1.012-1.129, p=.01) were independent predictors of cumulative events rates. Periprocedural complications associated with CIED (especially hematoma and pneumothorax) are more common in the group with high BMI.

Hand-held echocardiography-based heart failure screening in hypertensive or diabetic patients in community: a pilot study

Abstract Background There is lack of solid data on screening methods for preclinical heart failure (HF) in primary care settings. Standard echocardiography is not regarded as a routine test due to high cost and need of operation by specialists. Hand-held echocardiography (HHE) has been used in various clinical settings with easier access and lower price but has never been integrated into HF screening programme. Purpose This study aimed to explore the feasibility and cost-effectiveness of hand HHE-based HF screening strategies in patients with risk factors in community. Methods The registered patients with hypertension or diabetes at two Chinese community health service centres (CHSCs) who had not been diagnosed previously as HF were recruited. Every patient received symptom assessment (dyspnea and/or lower limb edema), blood test for N-terminal-probrain natriuretic peptide (NT-proBNP ≥ 125 pg/ml regarded as positive), and HHE for any indexed abnormality in the dedicated protocol with focused and semiquantitative scanning [i.e. left ventricular (LV) dilation, left atrial (LA) dilation, interventricular septum (IVS) thickening, LV systolic dysfunction by calipers, as well as region wall motion abnormality, valvular stenosis, ≥moderate valvular regurgitation, significant pericardial effusion by eyeballing). By using the results of all the three modalities for screening compared to the concurrent guidelines, the patients were categorized into HF stages A, B, or C as the "gold standard". Three screening strategies were proposed (Figure 1), of which Strategy I was designed as a single test, Strategy II as a combined test, and Strategy III as a stratified stepwise test. Diagnostic accuracy and cost-effectiveness of each strategy was calculated in comparison with the "gold standard". Results A total of 423 patients (70 ± 9 years; 46.6% males) were enrolled. There were 166 (39.2%) symptomatic patients, while 106 (25.1%) patients had elevated NT-proBNP. HHE abnormalities were found in 286 (67.0%) patients, of which IVS thickening was the most common finding (47.0%), followed by LA enlargement (30.0%). LV systolic dysfunction was identified in 18 (4.3%) patients. 232 (54.8%) and 59 (13.9%) patients were reclassified as HF stage B and C, respectively. As shown in Figure 2, the stepwise Strategy III of using symptoms for the first stratification, followed by choosing HHE or NT-proBNP test led to a 100% accuracy and a 35.6% reduction in cost. Conclusions HHE-based focused screening detects HF earlier in high-risk populations. The screening strategy combined with symptoms, NT-proBNP, and HHE is feasible for identifying underdiagnosed HF stage B or C that may be considered in primary care.Scheme of HF stage screening strategiesHF Screening and cost-effectiveness

Abstract 13611: Right Ventricular Perforation and Subsequent Tamponade Due to Fractured Inferior Vena Cava Filter Strut

Description of Case: A 39-year-old woman with a remote history of unprovoked pulmonary embolism (PE) treated with a retrievable inferior vena cava (IVC) filter presented with chest pain and syncope. Initial vital signs and examination were unremarkable. ECG showed diffuse ST elevations with PR depression consistent with acute pericarditis (Figure 1A). Given her history, CT angiogram (CTA) was performed and revealed complex pericardial effusion without PE. Echocardiogram confirmed large pericardial effusion with evidence of right ventricular diastolic collapse, raising concern for impending cardiac tamponade (Figure 1B). Urgent pericardiocentesis yielded 500 mL of sanguineous fluid, with resolution of effusion. A pericardial drain was left in place. Overnight she became hypotensive, tachycardic, diaphoretic, with muffled heart sounds on exam. Rapid re-accumulation of blood was noted from the drain, confirmed by repeat echo showing enlargement of the pericardial effusion. She was diagnosed with recurrent hemorrhagic pericardial effusion (HPE) of unclear etiology and was emergently taken for mediastinal exploration, where a metal shard measuring 2.2 cm was seen protruding though the RV (Figure 1C), confirmed on intraoperative TEE (Figure 1D). It was determined that a fractured IVC filter strut had migrated into the RV causing perforation and recurrent HPE. The strut was removed and RV defect patched. The patient did well post-operatively without effusion recurrence. Follow up CTA confirmed fractured IVC filter strut, with another filter strut also seen extending through the IVC wall (Figure E). Discussion: Rapid reaccumulation of a hemorrhagic, hemodynamically significant pericardial effusion without clear etiology, as in this case, should prompt consideration of surgical exploration to assess for bleeding source. As strut fractures are a known complication of retrievable IVC filters, these filters should be removed when no longer indicated.

Differences in outcomes between surgical pericardial window and pericardiocentesis in children with postpericardiotomy syndrome.

Children with postpericardiotomy syndrome may develop hemodynamically significant pericardial effusions warranting drainage by surgical pericardial window or pericardiocentesis. The optimal approach is unknown. We performed a retrospective observational study at two pediatric cardiac centers. We included 42 children aged <18 years who developed postpericardiotomy syndrome following cardiac surgery between 2014 and 2021. Thirty-two patients underwent pericardial window and 10 underwent pericardiocentesis. Patients in the pericardial window group presented with postpericardiotomy syndrome sooner than those who underwent pericardiocentesis (median 7.5 days vs. 14.5 days, P = 0.03) and tended to undergo earlier intervention (median 8 days vs. 16 days, P = 0.16). No patient required subsequent drainage. There were no differences between groups in days of pericardial tube duration (median 4 days), complications, and subsequent days of intensive care or hospitalization. For children with postpericardiotomy syndrome with a pericardial effusion warranting drainage, these data suggest that pericardial window and pericardiocentesis have similar efficacy, safety, and resource utilization.

Retrieval of Chronically Implanted Dual-chamber Leadless Pacemakers in an Ovine Model.

The clinical utilization of leadless pacemakers (LPs) as an alternative to traditional transvenous pacemakers is likely to increase with the advent of dual-chamber LP systems. Since device retrieval to allow LP upgrade or replacement will become an important capability, the first such dual-chamber, helix-fixation LP system (Aveir DR; Abbott, Abbott Park, IL) was specifically designed to allow catheter-based retrieval. In this study, the preclinical performance and safety of retrieving chronically implanted dual-chamber LPs was evaluated. Atrial and ventricular LPs were implanted in the right atrial appendage and right ventricular apex of 9 healthy ovine subjects. After ≈2 years, the LPs were retrieved using a dedicated transvenous retrieval catheter (Aveir Retrieval Catheter; Abbott) by snaring, docking, and unscrewing from the myocardium. Comprehensive necropsy/histopathology studies were conducted to evaluate device- and procedure-related outcomes. At a median of 1.9 years postimplant (range, 1.8-2.6), all 18 of 18 (100%) LPs were retrieved from 9 ovine subjects without complications. The median retrieval procedure duration for both LPs, from first-catheter-in to last-catheter-out, was 13.3 minutes (range, 2.5-36.4). Postretrieval, all right atrial, and right ventricular implant sites demonstrated minimal tissue disruption, with intact fibrous tissue limited to the distal device body. No significant device-related trauma, perforation, pericardial effusion, right heart or tricuspid valve injury, or chronic pulmonary thromboembolism were observed at necropsy. This preclinical study demonstrated the safe and effective retrieval of chronically implanted, helix-fixation, dual-chamber LP systems, paving the way for clinical studies of LP retrieval.