介入性超声下引导心包穿刺置管治疗心包积液的临床探讨

目的探讨超声引导下经皮心包穿刺置管持续引流心包积液的临床应用。方法在100例心包积液患者心尖部或心前区置入中心静脉导管引流。结果 100例心包积液病人全部安全有效置管成功,得到有效救治,25例心脏压塞患者引流后症状迅速缓解。置管可长期保留（5~16 d）,操作并发症少。结论超声引导下经皮心包积液置管法简单、安全、有效,便于临床应用。     

香菇多糖治疗老年恶性心包积液

目的观察老年恶性心包积液患者心包腔内分别灌注香菇多糖与顺铂治疗的有效性和安全性。方法45例患者随机分为A组22例,B组23例,采用中心静脉穿刺导管行心包穿刺置管引流术,A组给予灌注香菇多糖4mg＋生理盐水20ml,B组给予顺铂40mg＋生理盐水20ml。结果A组患者有效率（完全缓解率＋部分缓解率）90．9％（20／22）例,B组患者有效率60．9％（14／23）例,A组患者有效率优于B组（P〈0．05）,且A组不良反应轻微。结论对于老年恶性心包积液的患者心包腔内灌注香菇多糖有效而且安全。     

心包积液的超声显像研究

目的研究超声心动图对心包积液的应用价值。 方法回顾性分析413例心包积液的超声心动图特征，并与X线、心电图及手术结果相对比。 结果心包积液病因依次排列前5位的是恶性肿瘤、心力衰竭、尿毒症、结核、炎症。超声心动图诊断率100％，X线诊断62例，占15％；心电图诊断12例，占3％。21例外科手术治疗。 结论超声心动图是诊断心包积液最简单、最可靠的方法，也是一种介入心包穿刺，术中动态监测，判断预后的方法。     

Non-surgical management in hemodynamically unstable blunt traumatic pericardial effusion: A feasible option for treatment

Introduction

Little is known about the outcomes of deliberate non-surgical management for hemodynamically unstable patients with blunt traumatic pericardial effusion. We evaluated the efficacy of management with pericardiocentesis or subxiphoid pericardial window in hemodynamically unstable patients who reach the hospital alive with blunt traumatic pericardial effusion.

Evaluation of intrapericardial cisplatin administration in cases with recurrent malignant pericardial effusion and cardiac tamponade

Goals To evaluate the effectiveness and side effects of intrapericardial administration of cisplatin in prevention of recurrent malignant pericardial effusion.Patients and methods Forty-six patients (33 men, 13 women; mean age 55.6±10.5 years) entered this study. The diagnosis of malignancy was based upon histological examination of samples from primary tumor. The majority of patients suffered from a neoplasm localized in the thorax (41 out of 46 patients; 89%). In 35 cases, pericardiocentesis, and in 11 cases, video-assisted thoracoscopic surgery (VATS) of pericardium was performed. Malignant etiology of pericardial fluid was confirmed by cytological examination, histology being obtained by VATS pericardial biopsy or by echocardiography (ECG). If daily drainage of pericardial fluid observed during 5–7 days exceeded 50 ml, cisplatin was instilled according to one of three regimens: (1) 10 mg of cisplatin dissolved in 20 ml of normal saline administered over 5 min during 5 consecutive days directly into the pericardial space (39 patients); (2) 50 mg of cisplatin dissolved in 100 ml of normal saline administered during 30 min (six patients); and (3) 20 mg of cisplatin dissolved in 40 ml of normal saline administered over 10 min during 5 consecutive days (one patient). Treatment was considered as successful when recurrence of symptoms of large pericardial effusion was not observed in ECG and other interventions directed to the pericardium were not required. Efficacy of investigated treatment was assessed also in the group of patients with survival longer than 30 days. Safety of treatment was assessed in the whole group of patients.Results Because of advanced malignancy eight out of 46 patients (17.4%) survived less than 30 days. Thirty-eight out of 46 cases (82.6%) survived more than 30 days. Positive effect of intrapericardial treatment with cisplatin was achieved in 43 out of 46 patients (93.5%) in the entire investigated group and in 35 out of 38 patients (92%) who survived more than 30 days. In the subgroup of patients with non-small cell lung cancer (NSCLC) and survival longer than 30 days, high efficacy was documented (29 out of 31 cases; 93.5%). Median survival time in the group of 38 patients who survived more than 30 days was 102.5 days. Atrial fibrillation due to cisplatin administration was observed in seven out of 46 patients (15.2%). Sclerosis of the pericardial space without symptoms of constriction occurred in five out of 46 cases (10.9%).Conclusions Cisplatin administered directly into the pericardial space is a very effective and relatively safe method of treatment of recurrent malignant pericardial effusion, especially in the course of NSCLC.Work was performed at the National Tuberculosis and Lung Diseases Research Institute, Warsaw, Poland. Research was performed without financial support. No author is involved with organizations with financial interest in the subject matter.     

康莱特注射液联合顺铂腔内注射治疗恶性胸腔积液的疗效观察

目的:观察康莱特注射液联合顺铂胸腔内注射治疗恶性胸腔积液的疗效。方法:46例恶性胸腔积液患者随机分为两组,康莱特联合顺铂组22例,顺铂单药组24例。分别于胸腔穿刺引流术后胸腔内注射药物,观察其疗效和副反应。结果:康莱特联合顺铂组有效率86.4%,顺铂单药组62.5%,两组间差异有统计学意义(P<0.01)。两组患者治疗后毒副反应无明显差异。结论:康莱特联合顺铂腔内注射是治疗恶性胸腔积液的有效方法。     

ssDECT增强扫描碘浓度鉴别良恶性浆膜腔积液

目的 探讨单源双能量CT增强扫描三期碘浓度对良恶性浆膜腔积液的鉴别诊断价值。方法 回顾性分析我院行单源双能量CT增强扫描、并经穿刺脱落细胞学检查证实的浆膜腔积液患者65例,其中良性积液23例,恶性积液42例。采用单源双能量CT综合分析平台,在常规混合能量扫描下分别测量计算平扫及动脉期、静脉期、延迟期的标准化CT值（NCTval;NCTval_N、NCTval_A、NCTval_P、NCTval_D）;并计算三期标准化CT值强化程度（NCT;NCT_A、NCT_P、NCT_D）。采用能谱分析软件于碘（水）图像上分别测量并计算平扫及增强三期标准化碘浓度（NIC;NIC_N、NIC_A、NIC_P、NIC_D）;计算增强三期碘浓度强化程度（IC;IC_A、IC_P、IC_D）。比较良恶性浆膜腔积液的NCTval、NCT、NIC、IC,并进行ROC曲线分析计算各参数诊断良恶性浆膜腔积液的敏感度和特异度。结果 增强三期良、恶性浆膜腔积液NCTval、NCT差异均无统计学意义（P均>0.05）,而NIC、IC差异均有统计学意义（P均<0.05）。增强三期中IC_D的曲线下面积最大（0.82）,当阈值为0.04时,敏感度、特异度分别为76.2%、69.6%。结论 单源双能量CT增强扫描碘浓度可为鉴别良恶性浆膜腔积液提供一种敏感、有效的方法。     

超声定位下应用中心静脉导管引流治疗心包积液的护理体会

目的介绍超声定位下心包穿刺置管引流术的护理体会。方法对26例中大量的心包积液患者术前经二维超声心动图定位,应用中心静脉导管引流治疗心包积液,术前、术中、术后护理进行系统的观察、护理。结果 26例病例均一次穿刺置管成功,导管留置时间2~5 d,引流液量300~3 800 mL,心包积液引流彻底,未出现严重并发症。结论该方法简单、安全、可靠、疗效好。     

胸腔镜心包开窗术联合沙培林腔内用药治疗恶性心包积液疗效观察

【目的】探讨胸腔镜心包开窗术联合沙培林腔内用药治疗恶性心包积液的临床疗效。【方法】选择2009年1月至2013年1月本院收治的38例恶性心包积液患者,随机分为两组：对照组采用常规保守治疗,观察组采用胸腔镜心包开窗术治疗,术中心包灌注沙培林。对两组患者的近期疗效、病情进展时间和中位生存时间、手术前后Karnofsky评分进行比较。【结果】观察组的近期治疗有效率（94．7％）高于对照组（55．6％）,差异有统计学意义（P＜0．05）。观察组手术后病情进展时间和中位生存时间长于对照组,差异有统计学意义（P＜0．05）。观察组手术后的Karnofsky评分高于对照组,差异有统计学意义（P ＜0．05）。【结论】胸腔镜心包开窗术联合沙培林腔内用药治疗恶性心包积液疗效好,可明显改善患者的临床症状,延长生存时间,提高生活质量,值得进一步推广应用。     

肺癌心包积液与其影像及病理分型关系的临床分析

目的　探讨肺癌心包积液与影像学及肺癌病理组织学分类关系。方法　分析近一年来经胸部CT或心脏B超证实肺癌伴有心包积液患者的影像及病理特点。结果　在 2 0 5例肺癌患者中 ,①影像学方面 :中央型肺癌伴心包积液占 10 6 % ,周围型肺癌伴心包积液占 10 1% ,弥漫型肺癌伴心包积液占 3 5 7% ;②病理组织学方面 :肺腺癌伴心包积液占 12 12 % ,肺鳞癌伴心包积液占 3 17% ,肺小细胞癌伴心包积液占2 2 72 % ,肺腺鳞癌伴心包积液占 9 0 9% ,未分化大细胞癌伴心包积液占 10 %。经比较 ,提示肺癌影像学分型方面中央型肺癌与周围型肺癌的心包积液差异无显著意义 ,而病理组织学分型差异有显著意义 ,肺小细胞癌的心包积液较肺腺癌、肺鳞癌高。结论　肺癌发生心包积液与肺癌的病理组织学分型有密切关系 ,肺小细胞癌较肺腺癌、肺鳞癌更易发生心包积液 ;而与肺癌的影像学分型无明显关系。     

Echocardiographic M-scan technique in the diagnosis of pericardial effusion

M-scanning was found useful in eight patients in whom the diagnosis of pericardial effusion was negative or equivocal with conventional echocardiography. With the patient in the semi-recumbent position, the records were obtained while the ultrasound beam was sector scanned base toward the cardiac apex. With this technique, a separation of the posterior pericardium epicardium by a divergent echo-free space was noted when pericardial effusion was present. The divergent nature of the echo-free space was due to accumulation of pericardial fluid toward the cardiac apex. The shift of pericardial fluid toward the cardiac apex was further demonstrated by elevation of the patient supine to the semi-recumbent position. The latter position enhances the sensitivity of M-scanning in the detection of pericardial effusion.     

心包积液122例的病因诊断

目的分析心包积液的病因,比较临床常用检查对心包积液诊断及鉴别诊断的价值。方法回顾分析122例心包积液患者的临床及实验室检验资料。结果心包积液的病因包括慢性心肾功能不全(25例)、甲状腺功能减低(6例)、肿瘤(20例)、结核性(59例)及特发性(12例)。心包积液中腺甘脱氨酶(ADA)的活性在结核组较肿瘤组及特发组显著增高,但血清中ADA活性三组未见显著性差异;抗结核抗体在结核组阳性率较肿瘤组及特发组明显增高;血清癌胚抗原(CEA)、癌抗原199(CA199)阳性率在肿瘤组明显高于结核组及特发组;癌抗原125(CA125)阳性率在所有患者中均增高,各组之间差异无统计学意义。结论结核是心包积液最常见病因,CEA、CA199、ADA、抗结核抗体(TBanti-body)等检测指标可对临床诊断有较大帮助。     

Transitory effusive-constrictive pericarditis

Pericardial effusion of various sizes is a quite common clinical finding, while its progression to effusive-constrictive pericarditis occurs in about 1.4–14% of cases. Although available evidence on prevalence and prognosis of this rare pericardial syndrome is poor, apparently a considerable proportion of patients conservatively managed has a spontaneous resolution after several weeks.A 61-year-old female presented to our emergency department reporting fatigue, effort dyspnea and abdominal swelling. The echocardiography showed large pericardial effusion with initial hemodynamic impact, so she underwent a pericardiocentesis with drainage of 800–850 cm³ of exudative fluid, on which diagnostic investigations were undertaken: possible viral and bacterial infections, medical conditions, iatrogenic causes, neoplastic and connective tissue diseases were all excluded. Despite empirical therapy with NSAIDs and colchicine, after about one week she had a recurrence of pericardial effusion and progressive development of constriction. Echocardiography performed after a few weeks of anti-inflammatory therapy showed resolution of constriction and PE, with clinical improvement.If progression of pericardial syndromes to a constrictive form is rarely described in literature, cases of transitory effusive-constrictive phase are even more uncommon, mainly reported during the evolution of pericardial effusion. According to the available data, risk of progression to a constrictive form is very low in case of idiopathic pericardial effusion. We report a case of large idiopathic subacute pericardial effusion, treated with pericardiocentesis and then evolved into an effusive-constrictive pericarditis. A prolonged anti-inflammatory treatment leads to complete resolution of pericardial syndrome without necessity of pericardiectomy.     

经皮穿刺心包置管引流治疗心包积液—附38例报告

目的探讨经皮穿刺置入导管引流心包积液的疗效及安全性。方法38例中等量至大量心包积液患者，在超声引导下置管行心包闭式引流，观察其效果和安全性。结果38例患者均置管成功，置管时间6～30d（平均10d），均无脏器、组织损伤或感染等情况出现。3例发生导管堵塞，经肝素盐水冲洗后再度通畅；1例出现症状性低血压，以予补液体、升血压药治疗后血压恢复。结论经皮穿刺置入导管行心包引流是一种安全、有效治疗心包积液的方法。     

心包积液的病因及误诊分析

目的分析心包积液患者的病因及误诊原因。方法收集2007～2011年收治的65例心包积液患者的临床资料并进行回顾性分析。结果本组资料心包积液常见病因依次为肿瘤性(33.85%)、结核性(23.08%)、心力衰竭性(10.77%)、非特异性(7.69%)和结缔组织疾病(6.15%),其他各种原因引起者占18.48%。误诊4例。结论肿瘤是心包积液的首要病因。误诊的主要原因是将其他性质的心包积液误诊为肿瘤性心包积液。     

Selective positive end-expiratory pressure and cardiac function in dogs

Effects of general (G) versus selective (S) right (R) and left (L) positive end-expiratory pressure (PEEP) were compared during differential lung ventilation in 11 anaesthetized dogs in the supine position. GPEEP 20 cm H₂O decreased cardiac output (1 min^–1) from 2.9±0.2 (mean±SE) to 1.7±0.5 (p<0.05), RPEEP from 2.8±0.2 to 2.2±0.2 (p<0.05) while LPEEP caused no significant change in cardiac output. GPEEP increased pleural pressure more than SPEEP. Pleural pressure was asymmetric during SPEEP. Both SPEEP and GPEEP increased pericardial pressure uniformly, but the increase was less marked with SPEEP. During GPEEP 20 cm H₂O transmural left ventricular end-diastolic pressure (LVEDP) decreased markedly. SPEEP caused less marked reductions in transmural LVEDP. Qualitatively similar, but less marked changes were observed with PEEP 10 cm H₂O. In conclusion, cardiac output decreased less with selective PEEP than with general PEEP. This was explained by less increase in pleural and pericardial pressure, and accordingly less decrease in LV transmural filling pressure.     

超声心动图诊断心包积液的价值

目的 探讨超声心动图在心包积液诊断中的价值。方法应用超声心动图对不同病因所致心包积液进行定量检测,并与普通X光的检出率进行比较。结果 创伤性心包炎成为临床最常见的心包积液病因,少中量心包积液占大多数,在此种情况下超声心动图较X线检查更敏感。结论 超声心动图对心包积液的定性诊断有优势,对病因诊断亦有一定帮助。     

Traumatic pericardial effusion: Impact of diagnostic and surgical approaches

Introduction

In trauma patients with chest injuries, traumatic pericardial effusion is an important scenario to consider because of its close linkage to cardiac injury. Even with advances in imaging, diagnosis remains a challenge and use of which surgical approach is controversial. This study reviews the treatment algorithm, surgical outcomes, and predictors of mortality for traumatic pericardial effusion.

Patients and methods

Information on demographics, mechanisms of trauma, injury scores, diagnostic tools, surgical procedures, associated injuries, and hospital events were collected retrospectively from a tertiary trauma center.

Results

Between June 2003 and December 2009, 31 patients (23 males and 8 females) with a median age of 31 (range 16-77), who had undergone surgical drainage of pericardial effusion were enrolled in the study. Blunt trauma accounted for 27 (87.1%) insults, and penetrating injury accounted for 4 (12.9%). Patients were diagnosed by Focused Assessment with Sonography for Trauma (FAST) (8 patients), computerized tomography (7 patients), echocardiography (9 patients), and incidentally during surgery (7 patients). Notably, sixteen (51.7%) patients required surgical repair for traumatic cardiac ruptures, including 6 (19.6%) with pericardial defects who presented initially with hemothorax. The surgical approaches were subxiphoid in 8 patients (25.8%), thoracotomy in 7 (22.6%), and sternotomy in 19 (61.2%), including 3 conversions from thoracotomy. The survival to discharge rate was 77.4% (24/31). Concomitant cardiac repair, associated pericardial defects, and initial surgical approach did not affect survival, but the need for massive transfusion, cardiopulmonary cerebral resuscitation (CPCR), trauma score, and incidental discovery at surgery all had a significant impact on the outcome.

Conclusions

Precise diagnoses of traumatic pericardial effusions are still challenging and easily omitted even with FAST, repeat cardiac echo and CT. The number of patients with traumatic pericardial effusion requiring surgical repair is high. Standardized therapeutic protocol, different surgical approaches have not impact on survival. Correct identification, prompt drainage, and preparedness for concomitant cardiac repair seem to be the key to better outcomes.     

Prenatal diagnosis of cor triatriatum sinister associated with early pericardial effusion: A case report

BACKGROUNDCor triatriatum sinistrum or cor triatriatum sinister is a rare congenital heart disease that accounts for approximately 0.1% of all cardiac abnormalities. It is defined as the presence of an anomalous septum that divides the left atrium into two cavities, and in most cases, it can be asymptomatic or less frequently very severe.CASE SUMMARYA 37-year-old pregnant woman visited our hospital. In the first trimester scan, we detected signs of fluid in the pericardium (pericardial effusion) that reached the atriums. In the third trimester, an anomalous septum in the left atrium suspicious of cor triatriatum sinister was detected. Expectant management was decided, the pregnancy evolved normally and resulted in uncomplicated delivery of a healthy child. The findings in the prenatal scan were confirmed by echocardiography and the diagnosis of cor triatriatum sinister was confirmed. The newborn was asymptomatic at all times.CONCLUSIONWe show expectant management of cor triatriatum sinister and suggest an association between this entity and early pericardial effusion.     

Hypovolemia-induced Cardiac Tamponade in a Patient with Hypothyroidism

Background

Pericardial effusion occurs frequently in patients with hypothyroidism and is typically mild. Although extremely uncommon, massive pericardial effusion can compromise hemodynamics and cause cardiac tamponade. Reduced plasma volume has been reported to induce cardiac tamponade in massive pericardial effusion, but to our knowledge, hypovolemia-induced cardiac tamponade has not been reported in cases of hypothyroidism with pericardial effusion.

Objectives

We describe a case of hypothyroidism with cardiac tamponade due to an uncommon cause that, to our knowledge, has never been reported.

Case Report

A 64-year-old woman with untreated hypothyroidism presented with acute abdominal pain and watery diarrhea. The patient experienced shock and cardiac arrest during the examination. Massive pericardial effusion was detected and cardiac tamponade was diagnosed. We suspected that the pericardial effusion was pre-existing due to an 11-year history of untreated hypothyroidism. On presentation, there was no hemodynamic compromise. Watery diarrhea persisted and intravenous fluid supplementation may have been inadequate. Hypovolemia developed and induced cardiac tamponade in the presence of the massive pericardial effusion. Successful resuscitation was achieved after cardiopulmonary resuscitation, aggressive intravenous fluid supplementation, and immediate pericardiocentesis.

Conclusion

Pericardiocentesis is indicated for hypothyroid patients with cardiac tamponade. We recommend the use of small, multi-hole catheters and daily measurement of drainage fluid. If the pericardial effusion does not resolve, a pericardial window with chest tube drainage should be performed.