Signs Of Cardiac Tamponade Research Articles

RUSH to the Diagnosis: Identifying Occult Pathology in Hypotensive Patients

Case Presentation: A 63-year-old female presented to our emergency department with altered mental status and hypotension. She was transferred from the outpatient interventional radiology suite after becoming unresponsive during the removal of an inferior vena cava filter. The patient arrived somnolent with no other history available. Her physical exam was unremarkable. We used point-of-care-ultrasound to perform a rapid ultrasound for shock and hypotension (RUSH) exam. A large pericardial effusion along with signs of cardiac tamponade were identified. The cardiothoracic surgery team was notified, and the patient was taken to the operating room where pericardial blood and a large hematoma were evacuated. She recovered uneventfully and was discharged one week later. Discussion: The above case describes a very unstable patient whose diagnosis was obtained using the RUSH exam. History and physical did not point to a clear etiology. Options were very limited. She was too unstable to go for computed tomography, and other tests such as electrocardiogram, chest radiograph, and lab work would have been non-diagnostic. It was only after the cardiac view of the RUSH exam was obtained that a pericardial effusion and developing tamponade were identified, facilitating timely management. The RUSH exam, like the extended focused assessment with sonography for trauma, is used to help determine pathologies that need immediate intervention. Incorporation in the evaluation of critically ill patients reduces the time to diagnosis. Our case is a unique example of how point-of-care ultrasound can be used to urgently identify a life-threatening pathology.

A case report on ultrasound-guided pericardiocentesis with a right parasternal approach: a novel in-plane lateral-to-medial technique

IntroductionEmergency pericardiocentesis is a life-saving procedure that is performed to aspirate fluid from the pericardial space in patients who have severe pericardial effusion that is causing hemodynamic compromise. The current gold standard for pericardial fluid aspiration is ultrasound-guided pericardiocentesis. Echocardiography with a low-frequency transducer has generally been used in pericardiocentesis, but this method lacks real-time visualization of the needle trajectory, leading to complications. Therefore, we describe a case involving an ultrasound-guided pericardiocentesis method using a novel in-plane technique with a lateral-to-medial approach via the right parasternal and a high-frequency probe. The method was performed for an infant with cardiac tamponade.Case presentationWe present a case of a 14-month-old male infant who was brought to the emergency room with a history of cough, shortness of breath, and fever following recurrent chest infections. Despite prior treatments, his condition deteriorated, and signs of cardiac tamponade were evident upon examination. Cardiopulmonary point-of-care ultrasound confirmed the presence of a large pericardial effusion with tamponade. Emergency pericardiocentesis was performed using the novel in-plane technique, resulting in successful fluid aspiration and stabilization of the patient’s condition.Technique descriptionThe proposed technique involves positioning a high-frequency ultrasound probe over the right parasternal area to obtain real-time visualization of the needle trajectory and surrounding structures, including the sternum, right internal thoracic vessels, pleural sliding end point, pericardial effusion, and myocardium. The needle is inserted laterally to medially at a 45-degree angle, ensuring safe passage between the pleural sliding endpoint and the right internal thoracic vessels while reaching the pericardial effusion.ConclusionThe presented technique provides real-time visualization of the needle and surrounding structures, which may potentially help to avoid complications and improve accuracy. The proposed technique may potentially enable access for emergency pericardiocentesis and for loculated pericardial effusion that has formed around the right atrium. Nevertheless, further studies with large patient populations are needed.

P401 A CASE OF CORTICO–DEPENDENT AND COLCHICINE–RESISTANT RECURRENT IDIOPATHIC PERICARDITIS: THE ROLE OF ANAKINRA

Abstract 68–year–old female. Arterial hypertension. Diabetes. Hyperthyroidism. History of Polyserositis: 2019 massive right pleural effusion subjected to 2 thoracentesis a few days apart. Also finding of ascitic effusion. Negative etiological investigations On 3/2022 Admission to Cardiology for dyspnea and finding of pericardial effusion. CRP 10.55. On CT chest and abdomen significant pericardial effusion, mild bilateral pleural and peritoneal effusion with liver congestion. Pericardiocentesis was performed due to the absence of improvement in the pericardial effusion and persistence of sinus tachycardia despite therapy (ASA 750 mg x 3 + colchicine). Procedure complicated by Tako Tsubo syndrome. Intra–hospitalization recurrence of pericardial effusion despite NSAID therapy. Prednisone 25 mg per day was associated to therapy on board with improvement of pericardial effusion (maximum of 8 mm). At discharge WBC: 10.8, CRP: 2 (NV < 0.5 mg/dl) 04/26/22 CRP 0.73. Pericardial effusion Resolution. Cortisone tapering continued. 5/24/2022 Dyspnea and tachycardia with recurrence of significant pericardial effusion. Diagnosis of recurrent cortico–dependent and colchicine–resistant idiopathic pericarditis. New Hospitalization. Reverted to prednisone 25 mg (previous effective dose) with no effusion reduction. Anakinra introduction. At discharge: WBC 9500, CRP 0.6. Echo: maximum pericardial effusion of 20 mm. 6/10 Boosted for 3 days prednisone (50 mg/day), reduced ASA to 250 mg x 3 6/17 WBC 11.2; PCR 0.63. echo: pericardial effusion persistence max about 2.5 cm. No signs of cardiac tamponade. Boosting prednisone for a few days is ineffective. 6/24 stop ASA 6/20 stable. Start corticosteroid tapering. 7/20 asymptomatic, stable effusion. CRP 0.87. taperig prednisone again, stop colchicine. 8/18/22 Eco: slight effusion reduction. Stable CRP. Slight weight gain and slight increase in blood pressure probably caused by cortisone intake. –> prednisone reduction. 9/18 stop prednisone 10/18/2022 WBC 8.12 CRP 0.23; +2kg since last visit in August. Perimalleolar succulence. Eco: Stable effusion 2cm max. furosemide 25 mg 1 cp is added in the morning. 06/12/2022 WBC 7.5; CRP 0.52 Eco: stable effusion. Anakinra is reduced to 6 administrations per week. Conclusions Anakinra proved to be valid in stabilizing the pericardial effusion allowing to suspend corticosteroids, colchicine and ASA.

P396 FIBRINOUS PERICARDITIS AND STILL’S DISEASE IN ADULTHOOD: A RARE AND INSIDIOUS COMBINATION

Abstract In 9/2022 we admitted a 69–year–old man with history of hypertension, in therapy with bisoprolol and edoxaban after recent diagnosis of persistent atrial fibrillation, with a minor pericardial effusion at the echocardiogram. He had dyspnea, fever, and atrial fibrillation with elevated cardiac frequency. The echocardiogram showed increased pericardial effusion, circumferential, about 2 cm, with important fibrinous organization, without signs of cardiac tamponade (fig1). Hemocultures and urocultures were repeatedly negative, with significant increase in flogosis parameters. Therapy with high–dose acetylsalicylic acid was started first and then Ibruprofene + colchicine with poor clinical response and persistence of symptoms and effusion. The presence of elevated fever, arthralgias, transient skin rush to the trunk and flogosis indices (CRP 17 mg/dl, ESR 97mm, WBC 11000/ul with 80% neutrophil, ferritin 2200 ng/ml), with negativity of antinucleus antibodies and rheumatoid factor, allowed to place diagnosis of adult Still’s disease (AOSD). High–dose steroid therapy (prednisone 1mg/kg) was initiated with fever regression, progressive normalization of inflammatory indices and spontaneous restoration of sinus rhythm. The 7–day echocardiogram showed almost complete resolution of pericardial fibrinous effusion (fig 2). At 2 months patient remained asymptomatic, no more pericardial effusion, no signs of flogosis. Differential diagnosis of pericarditis is often complex, and therapeutic attitude and prognosis are variable according to etiology. AOSD has a prevalence of about 1/100,000, affects mainly young adults, very late onset cases are rare. Transient, small, salmon–pink, not itchy rashes, usually concurrent with fever, can drive diagnosis, along with major and minor criteria of Yamaguchi. Often patients have serositic involvement with pleuritis or pericarditis, with tamponade needing drainage. Such forms respond well only to steroid treatment. However, cases of fibrinous pericarditis as marked as the one described have not been described; the so important fibrinous component would made an eventual pericardiocentesis difficult. Although infrequent, it is a differential diagnosis that the cardiologist must consider in cases of refractory pericarditis and pericardial effusion.

411 AN UNEXPECTED (AND UNDESIRED) ECHOCARDIOGRAPHIC FINDING IN A PATIENT WITH RIGHT-SIDED CHEST PAIN

Abstract A 71-year-old man, former smoker, without other cardiovascular risk factors nor previously known cardiological history, was admitted to our emergency department for nonproductive cough and right-sided chest pain, worsened by inspiration. ECG documented reduced peripheral QRS voltages. Echocardiography was performed, revealing the presence of an inhomogeneous, hyperechoic neoformation involving the lateral wall of the right ventricle (RV), dislocating the right coronary artery, protruding into the cavity towards the intraventricular septum and reaching the sub-valvular apparatus of the tricuspid valve, without any hemodynamic interference. Pericardial effusion was also documented (maximum 20 mm around the atrioventricular groove), without signs of cardiac tamponade. For better mass characterization, a computed tomography (CT) scan and a cardiac magnetic resonance (CMR) were performed, confirming the presence of a solid neoformation involving the RV and pericardial effusion, also showing right pleural effusion. Furthermore, right hilar and subcarinal lymphadenomegaly with compression of the bronchi was observed. A positron emission tomography (PET) scan showed areas of increased 18-fluorodeoxyglucose (18FDG) uptake in supra- and infra diaphragmatic lymph nodes, adrenal glands, bones, and lungs. Due to the clinical suspicion of a lymphoproliferative neoplasm, corticosteroid therapy was started. Before a diagnostic lymph node biopsy could be performed, the patient had a syncopal episode due to cardiac tamponade, requiring pericardiocentesis. During hospitalization, continuous heart monitoring revealed intermittent third-degree atrioventricular block, so a permanent pacemaker was implanted. Finally, an excisional lymph node biopsy was obtained, and a diagnosis of diffuse large B-cell lymphoma was established. Treatment with Prednisone, Cyclophosphamide, Vincristine, nonpegylated liposomal Doxorubicin, and Rituximab (R-COMP) was promptly started. Seven months later, after five cycles of chemotherapy, complete remission was documented by PET scan, and the cardiac mass was no longer evident at echocardiography. Metastatic involvement of the heart is a relatively frequent event in oncologic patients, with an estimated prevalence of 8% at autopsy. Lymphoproliferive neoplasms have a not negligible rate of heart mestastatization (9,4%). Neoplastic invasion secondary to lymphoma tends to infiltrate the myocardium, typically causing arrhythmias and conduction disturbances. Diagnostic evaluation relies upon echocardiography, CT and CMR. PET/TC is of paramount importance to assess the malignant nature of the mass, to stage the disease and to evaluate the response to chemotherapy. Metastatic cardiac involvement typically occurs as a late manifestation of disseminated lymphoma and the prognosis is usually poor; however, survival is increasing thanks to new chemo-immunotherapy strategies.

Abstract 10594: Cardiac Tamponade in a Covid-19 Positive Patient With Idiopathic Capillary Leak Syndrome: A Perilous Combination

Introduction: Clarkson’s disease, more known as idiopathic systemic capillary leak syndrome (SCLS) is a rare condition characterized by hypotensive episodes due to capillary hyperpermeability and can manifest as fluid accumulation in any organ or potential space. This may cause a range of complications: respiratory failure (from pulmonary edema or pleural effusion), mesenteric hypoperfusion (from hepatic congestion and severe intestinal edema), compartment syndrome and rhabdomyolysis, and even shock from hypovolemia or cardiac tamponade. Very few cases of cardiac tamponade in Clarkson's disease and COVID-19 have been reported, and when present, is certainly a serious and life-threatening complication. Case Summary: A 44-year-old female - with prior episodes of angioedema, pleural and pericardial effusions aggravated by menstruation and infection - presented with hypotension and diaphoresis. She was exposed to a COVID patient and eventually tested positive for COVID-19 infection. Persistent hypotension warranted triple inotropic support. Initial laboratories revealed hemoconcentration and hypoalbuminemia. Urinalysis was normal. 2D echocardiography showed normal left ventricular ejection fraction but with large pericardial effusion and signs of cardiac tamponade, hence, she underwent emergency pericardial windowing. She then developed pleural effusion which was drained surgically. Hepatitis, mycoplasmal and Epstein-Barr virus were negative. Direct and indirect Coomb’s test, and Lupus panel were unremarkable. Serum free light chain panel, immunopathology and C1 inhibitor results were non-diagnostic. Patient was managed as a case of idiopathic SCLS or Clarkson's disease. Methylprednisolone pulse therapy (MPPT) and intravenous immunoglobulin (IVIg) were administered. Patient was discharged with tapering doses of oral steroids and scheduled monthly IVIg infusion. Conclusions: Cardiac tamponade is a very rare but life-threatening complication of Clarkson’s disease, and on top of a COVID-19 infection, warrants emergent intervention. The pathogenesis is not yet fully elucidated. Diagnosis of SCLS is challenging thus recurrent pericardial and pleural effusions should raise the clinician’s index of suspicion.

Unusual Case Presentation of Systemic Lupus Erythematosus in a Young Woman

Systemic Lupus Erythematosus (SLE) is a chronic multisystem autoimmune disease. Serositis occurs in 16% of SLE patients, and while cardiac tamponade and acute peritonitis with ascites can occur during the course of the disease, they are rare as the first presentation. A 25-year-old woman presented to the emergency department in Tishreen Hospital with complaints of dyspnea, fever, chills, and chest and abdominal pain. Two months prior, she suffered from musculoskeletal pain, fatigue, anorexia, weight loss of about 15 kg, severe hair loss, and recurrent oral aphthous. On clinical examination, the patient was pale and tired with dyspnea and pitting edema (grade 3–4). Pericardiocentesis was emergently performed because there were signs of cardiac tamponade. Three days later, the patient developed an acute surgical abdomen due to acute peritonitis and ascites. Later, the patient was diagnosed with SLE after excluding malignant and infectious diseases. Consequently, methylprednisolone pulses, azathioprine, and hydroxychloroquine 200 mg/day were introduced immediately. The clinical status of the patient dramatically improved, and three months later, the patient was symptom-free with normal laboratory tests. In conclusion, although cardiac tamponade and acute surgical abdomen because of acute peritonitis and ascites as the initial presentation of SLE are very rare, they can occur coincidently.

CARDIAC TAMPONADE SECONDARY TO COVID-19 INFECTION

CARDIAC TAMPONADE SECONDARY TO COVID-19 INFECTION

S1961 Isolated Cardiac Metastasis as an Initial Presentation of Colorectal Cancer in a Young Male Due to Lymphatic Spread

Introduction: Malignant pericardial effusion is common, reported in 5–15% of cancer patients. It most commonly arises from metastasis of lymphomas and tumors of the lung, breast, and, infrequently, the gastrointestinal tract. We report a rare case of metastatic colon cancer without the direct involvement of other solid organs suggesting a lymphatic spread. Case Description/Methods: A 28-year-old man presented with one day of sudden onset of shortness of breath at rest. Vitals were significant for tachycardia. On examination, the lungs were clear to auscultation with distant heart sounds; the abdomen was soft without tenderness. The clinical presentation was suggestive of pericardial effusion. Laboratory studies revealed microcytic anemia with hemoglobin of 11.7 g/dl. CT angiography chest with contrast revealed moderate to large PEff and subsegmental pulmonary embolism. An ECHO showed large PEff, without any signs of tamponade. He underwent video-assisted thoracoscopic surgery for PEff with a pericardial window. The mediastinal lymph node biopsy and pericardial fluid cytology showed metastatic adenocarcinoma cells. A CT scan of the chest/abdomen/pelvis was performed to find the primary malignancy, which revealed a segmental thickening of the proximal ascending colon and ileum with proximal cecal distension, lymphadenopathy, without liver metastasis. A CF showed a large polypoidal mass in the ascending colon, and biopsy revealed poorly differentiated adenocarcinoma in ascending colon. He was started on palliative chemotherapy with capecitabine, oxaliplatin, and bevacizumab and was discharged with outpatient oncology follow-up (Figure). Discussion: Colorectal cancer (CRC) is the third most common cancer in the United States. It primarily spreads hematogenous via the portal venous system that drains the colon and proximal rectum to the liver and the lungs to the heart. However, cardiac metastasis is rare. In our patient, we assume lymphatic spread of colon cancer due to isolated pericardial involvement in the absence of solid organ involvement. To our knowledge, this is the second reported case of lymphatic spread of colon cancer. Therefore, we emphasize considering pericardial effusions as a marker of occult malignancy to facilitate rapid diagnosis and prompt treatment. However, the prognosis for carcinomatous pericarditis is poor, with a 2-5 months median survival.Figure 1.: A-Echocardiogram: Parasternal short axis view showing large pericardial effusion, no signs of cardiac tamponade. B-Colonoscopy showing a lobulated mass in cecum. C-Computed Tomography (C.T.) scan with PO/IV contrast showing mass vs segmental inflammation in proximal ascending colon (pink arrow). Mild thickening of terminal ileum (white arrow).

THE ROLE OF CHEST RADIOGRAPHY TO DIAGNOSE LARGE PERICARDIAL EFFUSION IN WOMAN 66 YEARS OLD WITH MALIGNANCY : HIDING PERICARDIAL EFFUSION

Introduction: Pericardial effusion refers to an increase in fluid accumulation in the pericardial cavity. This pericardial fluid acts as a lubricant between the layers of the pericardium. We report a case of pericardial effusion, which was significant but not detectable on conventional chest radiographs.Case: A 66-year-old woman with lung adenocarcinoma accompanied by large pericardial effusion without sign of impending tamponade. The diagnosis of pericardial effusion was mainly based on echocardiography, where there is a large pericardial effusion but without signs of cardiac tamponade, and the patient then underwent pericardiocentesis. Previously, the patient had undergone two examinations with two different imaging modalities, namely CXR and chest CT scan, where on the CXR results, the patient only showed cardiomegaly.Discussion: There are four parameters suggestive for assessing a pericardial effusion, namely enlargement of the heart silhouette, pericardial fat stripe, left dominant pleural effusion, and an increase in the transverse diameter of the heart compared to the previous chest X-ray. This parameter is obtained not only based on the position of the photo taken but requires another position, whereas, in this patient, only CXR was performed with the posteroanterior position.Conclusion: When there are complaints of progressive shortness of breath in individuals with an underlying disease that may cause pericardial effusion, then the CXR examination cannot be used as a reference when there are no radiographic signs that point to pericardial effusion because CXR has a low diagnostic value in assessing the presence of pericardial effusion.

Large Pericardial Effusion-Diagnostic and Therapeutic Options, with a Special Attention to the Role of Prolonged Pericardial Fluid Drainage.

Background: Large pericardial effusion (LPE) is associated with high mortality. In patients with cardiac tamponade or with suspected bacterial etiology of pericardial effusion, urgent pericardial decompression is necessary. Aim: The aim of the present retrospective study was to assess the short-term results of pericardial decompression combined with prolonged drainage in LPE. Material: This study included consecutive patients with LPE who had been treated with pericardial fluid drainage between 2007 and 2017 in the National Tuberculosis and Lung Diseases Research Institute. Methods: Echocardiographic examination was used to confirm LPE and the signs of cardiac tamponade. Pericardiocentesis or surgical decompression were combined with pericardial fluid (PF) drainage. Short-term effectiveness of therapy was defined as less than 5 mm of fluid behind the left ventricular posterior wall in echocardiography. Results: The analysis included 74 patients treated with pericardial fluid drainage (33 female and 41 male), mean age 58 years, who underwent pericardial decompression. Out of 74 patients, 26 presented with cardiac tamponade symptoms. Pericardiocentesis was performed in 18 patients and pericardiotomy in 56 patients. Median PF drainage duration was 13 days. In 17 out of 25 patients with neoplastic PF, intrapericardial cisplatin therapy was implemented. In 4 out of 49 patients with non-malignant PF, purulent pericarditis was recognized and intrapericardial fibrinolysis was used. Short-term effectiveness of the therapy was obtained in all of patients. Non-infective complications were noted in 16% of patients and infective ones in 10%. Conclusion: Pericardial decompression combined with prolonged PF drainage was safe and efficient method of LPE treatment.

P119 PERI– MYOCARDITIS A RARE CASE OF ESCHERICHIA COLI INFECTION, A BACTERIUM THAT SHOULD NOT BE UNDERESTIMATED

Abstract Myopericarditis is defined as inflammation of the heart muscle and pericardium, which can be caused by infectious agents, toxins, or immunological reactions. The most recognized cases are secondary to cardiotropic viral infections. Escherichia coli rarely causes myopericarditis and is secondary to the septic dissemination of bacteria or myocardial toxicity of endotoxins. We describe a case of bacterial sepsis due to Escherichia coli which caused myocardial damage with pericardial effusion. 32 year old woman without cardiovascular risk factors, suffering from congenital immunodeficiency for IG type A, B–cell NH lymphoma undergoing chemotherapy treatment, Hashimoto‘s thyroiditis. The patient arrives for dyspnoea and fever. The ECG showed mild PR depression and an over diffuse ST in all leads with low voltage QRS and increased TNI. PA 120/70 mmHg, HR 74 b / m, FR of 15 acts / m. ETT showed diffuse hypokinesia with FE40% and moderate, circumferential, corpuscular and hyperechoic pericardial effusion without signs of cardiac tamponade. CRP, ESR, Procalcitonin, Leukocytes were elevated, hypothyroidism and low gamma globulin values. The serology of pericardiotropic viruses is negative. Chest x–ray of mild bilateral pleural effusion. Urine culture was performed for pollakiuria, dysuria, fever: positive for Escherichiacoli. After gamma globulin replacement therapy, levothyroxine and targeted antibiotic therapy, the patient presents clinical and laboratory improvement and improvement in FE with persistence of pericardial effusion. Pericardiocentesis is performed with drainage of 800 ml of serous–looking liquid with coarse fibrin shoots. Cytological examination of the liquid shows a blood serum aspect with a carpet of granulocytic inflammatory elements. The patient was discharged after therapy with colchicine, prednisone, levothyroxine sodium, indomethacin, ramipril, omeprazole. The ECG showed an evolved ischemic type pattern. Conclusion Very rare cases of Escherichia coli cystitis complicated by myo–pericarditis have been described in the literature. Presumably hypothyroidism and congenital IgA immunodeficiency contributed to favoring and worsening the formation of the effusion. However, further studies are still needed to clarify the mechanisms of myocardial damage, although reversible during this type of bacterial infection.

P177 A SHOT TO THE HEART

Abstract We report the case of a 50–year–old man who, during a wild bird hunt, was accidentally fired with a shotgun loaded with pellets which hit the chest, the neck and the face of the hunter. The patient was taken to the emergency room, tachypnoic and suffering from chest pain, systolic blood pressure was 150/70 mmHg, SpO2 88%, analgesic therapy, liquids administration and O2 therapy were performed with moderate response. On physical examination there was a reduced vesicular murmur in middle field on the right, no heart murmurs; noticeable edema of face and neck soft tissues and absence of evident jugular turgor. The ECG showed sinus rhythm, HR 100/min, morphology at the limit for ST slightly rigid in the inferior site. He underwent a total body CT in which a shotgun pellet was found located at the heart base near the right atrium, with associated pericardial fluid, with a maximum thickness of about 10 mm, with blood density. A shotgun pellet was also found in the apical segment of the right upper lung lobe with associated parenchymal ground glass (the pellet site of passage) without pneumothorax and pleural effusion. CT also showed multiple hunting pellets in the soft tissues of the face and of the neck without significant lesions. The echocardiogram confirmed the presence of circumferential pericardial effusion of mild degree, but progressively worsening, mainly represented along the cardiac apex and the inferolateral wall, but without signs of cardiac tamponade (right atrium within limits, absence of significant Doppler variation in blood flow across cardiac valves). The hospital where the patient arrived was at a distance of 30 minutes from the cardiac surgery, therefore the patient was urgently transferred to the cardiac surgery room of the hub (distance of 30 minutes). Fortunately, the patient maintained hemodynamic stability and arrived in the operating room with good blood pressure, but with a pre–tamponade effusion. The man quickly underwentcardiac surgery, the pericardial effusion was drained and the responsible breach was found in at the atrio–caval junction and successfully sutured. The patient was discharged in the 6th day and currently is in good clinical condition.

Pneumopericardium in a Newborn with Respiratory Distress and COVID-19

BACKGROUND: Pneumopericardium (PPC) is one of the rarest pulmonary air leak syndromes, but the incidence is the highest in the neonatal period. Risk factors include premature infants with respiratory distress (RD) syndrome, receiving active resuscitation, meconium aspiration syndrome, and aggressive mechanical ventilation. Several cases have also been reported related to COVID-19. CASE PRESENTATION: We report a case of a female newborn with a birth weight of 3300 grams a COVID-19 confirmed 35-year-old G3P2A0 mother. The baby was not crying at born and the amniotic fluid was stained green. The baby experienced RD and was intubated. A babygram was performed at the age of 5 h with the impression of a too deep endotracheal tube, neonatal pneumonia, and PPC. COVID-19 RT-PCR examination of the baby was positive. There were no signs of cardiac tamponade, so it was decided to take conservative and supportive management. CONCLUSION: Resolution of PPC was found on repeated babygram 26 h later. The baby was then discharged after 19 days of treatment.

Efficacy of Short-Term Oral Prednisolone Treatment in the Management of Pericardial Effusion Following Pediatric Cardiac Surgery

A standard treatment for pericardial effusion without cardiac tamponade after pediatric cardiac surgery has not been established. We evaluated the efficacy of short-term oral prednisolone administration, which is the initial treatment for postoperative pericardial effusion without cardiac tamponade at our institution. Between October 2008 and March 2020, 1429 pediatric cardiac surgeries were performed at our institution. 91 patients required postoperative treatment for pericardial effusion. 81 were treated with short-term oral prednisolone. Pericardial effusion was evaluated using serial echocardiography during diastole. Pericardial drainage was performed for patients with circumferential pericardial effusion with a maximum diameter of ≥ 10 mm or signs of cardiac tamponade. Short-term oral prednisolone treatment was administered to patients with circumferential pericardial effusion with a maximum diameter of < 10 mm or localized pericardial effusion with a maximum diameter of ≥ 5 mm. Patients with localized pericardial effusion with a maximum diameter of < 5 mm were observed. Prednisolone (2 mg/kg/day) was administered orally for 3 days, added as needed. Short-term oral prednisolone treatment was effective in 71 cases and 90% of patients were regarded as responders. The remaining patients were deemed non-responders who required pericardial drainage. Overall, 55 responders were deemed early responders whose pericardial effusion disappeared within 3 days. There were no cases of deaths, infections, or recurrence of pericardial effusion. The amount of drainage fluid on the day of surgery was higher in the non-responders. In conclusion, short-term oral prednisolone treatment is effective and safe for treating pericardial effusion without cardiac tamponade after pediatric cardiac surgery.

C21. Cardiac Complications in Immunocompromised Patient : A Case Report

Abstract Background Cardiovascular diseases in human immunodeficiency virus (HIV)-positive patients are becoming increasingly detected in developing countries. Pericardial involvement may be manifested as acute pericarditis, constrictive pericarditis, symptomatic pericardial effusion and cardiac tamponade. The aim of this report is to present a patient with AIDS clinical stage IV who developed pericarditis and pericardial effusion. Case Summary A 27-year-old male came to our ER with 7-day fever and delirium syndrome. He has been diagnosed with AIDS clinical stage IV for the past 3 years with the latest CD4 count was 6/mm3. Serial Transthoracic Echocardiography (TTE) revealed small to moderate circumferential pericardial effusion, thickening of pericardium and reduced left ventricular ejection fraction without signs of cardiac tamponade from TTE. Upon hospitalization, he developed signs of hypotension without distended jugular veins nor muffled heart sounds. It was decided to initiate supportive treatment and NSAIDs without pericardiocentesis. The patient recovered uneventfully. As an outpatient, no other cardiovascular complications developed. Discussion Pericardial conditions are the most frequent cause of heart disease in patient with HIV infection. Most cases are mild and asymptomatic. Pericardial effusion may be marker of end-stage HIV infection because it is associated with low CD4 cell count and is often caused by opportunistic infections and malignant neoplasms. Treatment of pericarditis in HIV patients is no different from that in general population. Asymptomatic patients with small pericardial effusion without tamponade require no intervention.

C21. Cardiac Complications in Immunocompromised Patient : A Case Report

Abstract Background Cardiovascular diseases in human immunodeficiency virus (HIV)-positive patients are becoming increasingly detected in developing countries. Pericardial involvement may be manifested as acute pericarditis, constrictive pericarditis, symptomatic pericardial effusion and cardiac tamponade. The aim of this report is to present a patient with AIDS clinical stage IV who developed pericarditis and pericardial effusion. Case Summary A 27-year-old male came to our ER with 7-day fever and delirium syndrome. He has been diagnosed with AIDS clinical stage IV for the past 3 years with the latest CD4 count was 6/mm3. Serial Transthoracic Echocardiography (TTE) revealed small to moderate circumferential pericardial effusion, thickening of pericardium and reduced left ventricular ejection fraction without signs of cardiac tamponade from TTE. Upon hospitalization, he developed signs of hypotension without distended jugular veins nor muffled heart sounds. It was decided to initiate supportive treatment and NSAIDs without pericardiocentesis. The patient recovered uneventfully. As an outpatient, no other cardiovascular complications developed. Discussion Pericardial conditions are the most frequent cause of heart disease in patient with HIV infection. Most cases are mild and asymptomatic. Pericardial effusion may be marker of end-stage HIV infection because it is associated with low CD4 cell count and is often caused by opportunistic infections and malignant neoplasms. Treatment of pericarditis in HIV patients is no different from that in general population. Asymptomatic patients with small pericardial effusion without tamponade require no intervention.

Double Pigtail to Manage Pericardial Rupture of Left Lobe Liver Abscess

Background: Liver abscess if left untreated can rupture into adjoining pleura, pericardium, peritoneum. Rupture into pericardium, though very rare, is a dreaded complication and worsens the prognosis. Presentation here can be nonspecific. Rupture into pericardium if associated with cardiac tamponade often requires pericardiotomy. Case information: A 16-year boy presented with epigastric pain, fever and recent onset chest discomfort. No signs of cardiac tamponade were seen on clinical examination. Investigations revealed a left lobe liver abscess rupturing into pericardium and asymptomatic pericardial effusion. Serological testing confirmed the etiology to be amebic. The condition was using pigtail catheter drainage in both the pericardial cavity and hepatic abscess. Discussion: Ruptured liver abscess occurs more commonly due to delay in diagnosis. It increases the severity of disease depending upon the site of rupture. Pericardial rupture is the most feared complication out of these. Published literature lacks reports of asymptomatic pericardial rupture of liver abscess, and management options. Available literature reports invariable requirement of surgical drainage for this entity. This report shows that lesser invasive drainage procedures can successfully resolve this dreaded complication. Conclusion: Amoebic liver abscess rupturing into pericardium can be asymptomatic. Successful management with percutaneous drainage and double pigtail catheters offers resolution and avoids morbidity associated with surgical drainage.

The Abnormal and Rapid Movement of Sewing Needle From Chest Toward Heart

: We herein introduced a 3 years old girl, who is a rare case of penetrating intracardiac damage severely induced by the abnormal movement of a sewing needle form the right lung toward the heart and entering in the right ventricle, which created Right Pneumothorax and right side bleeding. In clinical examinations, all vital symptoms were normal, and there was no sign of Cardiac tamponade, except reduced sound in the right lung base. Also, the external object was retained in the midclavicular line between the third rib, which was significant. In the Simple posterior-anterior and lateral graphics of chest radio opacity linear image on the lower part of the heart, the shadow was also significant. This is a rare case of abnormal needle movement from the right thorax to the right ventricular apex, which caused pulmonary problems. Following necessary diagnostic tests, a surgery was performed to remove the needle from the patient’s chest without open-heart surgery and CPB. Finally, 3 days after the operation, the patient was discharged from the cardiac surgery service in good general condition.

CARDIAC TAMPONADE AS A PRESENTATION OF AN ASYMPTOMATIC EXTRACARDIAC MALIGNANCY

SESSION TITLE: Medical Student/Resident Lung Cancer Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pericardial tamponade is a life-threatening event secondary to inhibition of passive diastolic filling by rapid accumulation of fluid leading to right atrioventricular diastolic collapse. Patients with pericardial metastasis showing symptoms of cardiac tamponade as the first presenting sign of extracardiac malignancy is very uncommon. CASE PRESENTATION: A 24-year-old female presented to the hospital with progressive dyspnea and lower extremity swelling that started 3 days ago. She had no significant past medical history and was taking no prescription medications. She denied illicit drug use or smoking. There was no family history of malignancy or autoimmune disorder. Her vital signs were: afebrile, blood pressure 90/60 mmHg, heart rate140bpm, respiratory rate 30/min, oxygen saturation 95% on 10 liters of a nonrebreather mask. On physical examination jugular venous distention was 2 cm.Decreased breath sounds on the right hemithorax. Heart sounds were muffled, tachycardia, with a regular rhythm. The patient had 1+ edema bilaterally in the lower extremities. Other exams were unremarkable. CT angiogram of chest found a large right pleural effusion, 2.6 cm pulmonary nodule at right lower lobe,mediastinal lymphadenopathy, and a large pericardial effusion (Fig.1). An echocardiogram showed signs of pericardial tamponade(Fig.2). Cardiology team was consulted and took the patient for an urgent pericardiocentesis with pericardial chest tube placement which drained 650 mL of hemorrhagic fluid. Pulmonology service was consulted for right-sided chest tube placement which drained 600 mL of straw-colored fluid. The patient was then returned to MICU with significantly improvement in vital signs. Pericardial cytology demonstrated malignant cells positive for BerEP4, CK-7, and TTF-1 indicating pulmonary adenocarcinoma, stage 4 given the pericardial tamponade. DISCUSSION: In a young patient without any recent cardiac procedures, history of heart disease or renal failure, other possibilities for hemorrhagic pericardial effusion should be considered such as metastatic cancers including lymphoma, autoimmune disorders, and infectious causes such as tuberculosis and HIV. The treatment of pericardial tamponade in the setting of non-small cell lung cancer is urgent pericardiocentesis, followed by pericardial window if effusion is recurrent. The overall survival in patients with malignant pericardial effusion is dictated by histological type of the underlying malignant process. CONCLUSIONS: Cardiac metastasis is mostly asymptomatic, and pericardium is most common site of metastasis. Pulmonary adenocarcinoma involves lymphatic drainage of the heart and presents with signs of cardiac tamponade even before signs of pulmonary disease. A careful physical exam, imaging, surgical intervention and critical care management were crucial as demonstrated in our case. Reference #1: Fraser, R.S., Viloria, J.B. and Wang, N.-S. (1980), Cardiac tamponade as a presentation of extracardiac malignancy. Cancer, 45: 1697-1704. doi:10.1002/1097-0142(19800401)45:7<1697::AID-CNCR2820450730>3.0.CO;2-J Reference #2: Muir, Keith & Rodger, J. (1994). Cardiac tamponade as the initial presentation of malignancy: Is it as rare as previously supposed?. Postgraduate medical journal. 70. 703-7. 10.1136/pgmj.70.828.703. Reference #3: Bussani R, De-Giorgio F, Abbate A, Silvestri F. Cardiac metastases. J Clin Pathol. 2007;60(1):27-34. doi:10.1136/jcp.2005.035105 DISCLOSURES: No relevant relationships by Kanak Parmar, source=Web Response No relevant relationships by Wasawat Vutthikraivit, source=Web Response