Pericardial windows or pericardiocentesis for pericardial effusions

The hospital records of 20 patients admitted to Parkland Memorial Hospital in Dallas with pericardial effusion during the four-year period of 1966 to 1969, and who underwent pericardiocentesis and percutaneous open pericardial windows, were reviewed. The etiologies of the effusions were as follows: purulent pericarditis (5), hypertensive and ischemic heart disease with congestive heart failure (4), and chronic idiopathic effusion (4). Specific etiologic diagnoses were made from the pericardial biopsy in only two cases (10 per cent), while 13 (65 per cent) had at least one serious complication in the postoperative period with eight (40 per cent) developing secondary infection. Twenty-one patients underwent pericardiocenteses without complications and four etiologic diagnoses (20 per cent) were made. Suggestions for indications for these procedures are presented.     

Diagnostic value of biochemical biomarkers in malignant and non-malignant pericardial effusion

The aim of this study was to examine the biochemical composition of pericardial effusions of different etiology and to evaluate the diagnostic utility of biochemical parameters and tumor markers to discriminate malignant from benign effusion. Pericardial and serum levels of biochemical parameters and tumor markers were compared in 105 patients who underwent pericardiocentesis and pericardioscopy with targeted epicardial biopsy. Etiologic diagnosis was based on pericardial fluid and epicardial biopsy analysis by cytology, histology, immunohistochemistry, microbiology and polymerase chain reaction. The total of 105 patients comprised 29 patients with malignant and 76 patients with non-malignant pericardial effusions (40 autoreactive, 28 viral, 5 postcardiotomy syndromes and 3 associated with systemic diseases). Malignant pericardial effusions had significantly higher pericardial fluid levels of the tumor markers CEA, CA 19-9, CA 72-4, SCC and NSE (p < 0.001, p = 0.002, p < 0.001, p = 0.004 and p < 0.001, respectively) as well as higher pericardial fluid hemoglobin (p < 0.001), pericardial fluid white blood cells (p = 0.003), pericardial fluid LDH (p < 0.001) and ratio of pericardial to serum LDH levels compared to benign effusions. None of the biochemical or cell-count parameters tested proved to be accurate enough for distinguishing malignant from benign effusions. However, measurement of pericardial CA 72-4 levels offered a high diagnostic accuracy for malignancy, particularly in bloody pericardial effusions. None of the biochemical parameters tested was useful for the discrimination of malignant from benign effusions. However, measurement of pericardial CA 72-4 levels in bloody pericardial effusions yielded a high diagnostic accuracy and thus offers the potential as a diagnostic tool to distinguish between malignant and benign effusions.     

Role of biochemical tests in the diagnosis of large pericardial effusions

STUDY OBJECTIVES: To determine the biochemical characteristics of large pericardial effusions in various disease states, and to assess their utility as diagnostic tools. SETTING: An academic university hospital in the Western Cape, South Africa. DESIGN: Consecutive, prospective case series. PATIENTS: One hundred ten hospital patients > 12 years old, who presented to the echocardiography department with large pericardial effusions, and 12 control subjects who underwent open-heart surgery (coronary artery bypass graft or aortic valve replacement). MEASUREMENTS: Fluid was sent for examination of biochemistry, adenosine deaminase, microbiology, hematology, and cytology. The etiology of each pericardial fluid sample was established using predetermined criteria. RESULTS: The biochemistry of pericardial exudates differed significantly from pericardial transudates. Light' s criteria (whereby an exudate is defined as having one or more of the following: pleural fluid/serum protein ratio > 0.5; pleural fluid/serum lactate dehydrogenase [LDH] ratio > 0.6; and/or pleural fluid LDH level > 200 U/L) were applied to pericardial fluids and demonstrated to be the most reliable diagnostic tool for identifying pericardial exudates. The corresponding sensitivity was 98%. CONCLUSION: Although laboratory tests are a useful guideline when assessing the etiology and pathophysiology of pericardial effusions, the majority of large, clinically significant pericardial effusions result from exudative causes.     

Large symptomatic pericardial effusion as the presentation of unrecognized cancer: a study in 173 consecutive patients undergoing pericardiocentesis

Large symptomatic pericardial effusion (PE)-PE that causes hemodynamic compromise-can be the initial presentation of an unrecognized underlying malignancy. However, the prevalence and features of this association have not been thoroughly characterized.We performed a retrospective study of all patients with hemodynamically significant PE who underwent pericardiocentesis in a 9-year period (1995-2004) in a tertiary hospital. Etiologies of pericardial disease were diagnosed using predetermined criteria. Demographic and clinical data of patients with hemodynamically significant PE as the presentation of their malignant disease were compared to those with established neoplastic disease, and to those with other etiologies.We identified 173 patients who underwent pericardiocentesis during the study period. Neoplastic PE was found in 58 patients (33%), 45 of whom had a known malignant disease at the time of pericardiocentesis. Pericardial disease was found to be the presentation of an unrecognized underlying neoplastic disease, mostly a lung tumor, in 13 patients (7.5% of all etiologies). After exclusion of pericardial effusions with easily attributable causes by clinical circumstances, physical examination, and simple laboratory tests (traumatic, uremic, post-pericardiotomy, rheumatic, and effusions related to known neoplasia), newly found cancer accounted for 18% of the remaining 74 cases. No epidemiologic or clinical parameter was found useful to differentiate between cancerous and noncancerous effusions.In conclusion, a large symptomatic PE may be the presentation of an unrecognized underlying malignancy in approximately one-fifth of the patients with a nonrevealing basic workup. This grave diagnosis cannot be ruled out on the basis of any clinical parameter. Thus, a more extensive workup should probably be considered in this patient group.     

The composition of normal pericardial fluid and its implications for diagnosing pericardial effusions

BACKGROUND: Pericardial fluid obtained at pericardiocentesis is often subjected to biochemical and hematological analysis, and interpreted using criteria borrowed from pleural effusions. However, the validity and diagnostic yield of this approach is uncertain. Moreover, there is little data regarding the normal composition of the physiological pericardial fluid, which could serve as a reference for pathological effusions. METHODS: Pericardial fluid from 30 patients undergoing elective open heart surgery was collected. Patients were excluded if they had known pericardial disease, had systemic disorders known to be associated with pericardial disease, or if the fluid samples were hemolytic. The biochemical and hematological parameters of the fluid were determined using standard laboratory techniques, and compared with the results obtained for concurrently drawn venous blood. RESULTS: The median age of the study population was 64.5 +/- 10.6 years. Chemistry results of soluble molecules were consistent with the plasma ultrafiltrate nature of the fluid. However, fluid lactate dehydrogenase (LDH) level was unexpectedly high, averaging 2.4 times the serum level, and the mean protein level was 0.6 of the serum level. No correlation was found between comorbidities of patients and fluid characteristics. Fluids contained an average of 1430 leukocytes/muL, with a differential count that was predominated by lymphocytes (53.2 +/- 14%) and monocytes (11.6 +/- 6%). CONCLUSIONS: The composition of the physiologic pericardial fluid is remarkable for high LDH and protein content, and for predominance of lymphocytes. Thus, the biochemical criteria useful for diagnosing pleural effusions are probably not applicable for differentiating transudative from exudative pericardial effusions, and lymphocytosis should be interpreted cautiously.     

Feasibility and safety of CT‐aided pericardiocentesis from a subxiphoid anterior approach by using fluoroscopy in patients with chronic pericardial effusions

BackgroundPericardiocentesis is an essential procedure for the diagnosis and treatment of pericardial effusions. The purpose of this study was to evaluate the feasibility and safety of a subxiphoid anterior approach using fluoroscopy aided by a sagittal axis chest computed tomography (CT) view in comparison with an ultrasound‐guided apical approach in patients with chronic pericardial effusion.MethodsAmong 72 consecutive patients (68.8 ± 14.4 years old, 52 males) with hemodynamically stable chronic pericardial effusions, a total of 85 procedures were retrospectively analyzed. We divided them into two groups according to the site of the approach for the pericardiocentesis.ResultsA subxiphoid anterior approach (n = 53) was performed guided by fluoroscopy. The sagittal axis view of the chest CT was constructed to determine the puncture angle and direction for the subxiphoid anterior approach. An apical approach (n = 32) was performed by ultrasound guidance. The success rates of the anterior and apical approaches were 98.1% and 93.8%, respectively. There were two cases with cardiac perforations in the apical approach group, while no cases developed perforations in the subxiphoid anterior approach group.ConclusionThe subxiphoid anterior approach for pericardiocentesis was feasible and safe for managing chronic pericardial effusions. A reconstruction of the sagittal axis view of the chest CT imaging was helpful to identify the direction and depth to access the pericardial space from the subxiphoid puncture site before the pericardiocentesis using the lateral fluoroscopic view.     

Radiation-related pericardial effusions in patients with Hodgkin's disease.

Pericardial effusions following radiotherapy for Hodgkins Disease have previously been described as infrequent and related to the total dose of radiation received. Analysis of all chest x-rays on 81 patients who received upper-mantle radiotherapy for Hodgkins Disease at the Baltimore Cancer Research Center between 1968 and 1972 disclosed an incidence of pericardial effusions of 30.9% (25 of 81), with 13.6% (11 of 81) requiring limitation of activity (5) or pericardiectomy (6). Clinical presentation of radiation-related percardial effusions was subtle, with signs and symptoms a late finding if they occurred. Radiotherapy data was reviewed and no difference in total dose (rads) or time-dose relationships (rets) was found between the groups who did or did not develop effusions. Analysis of multiple pre-treatment clinical and pathological characteristics disclosed four parameters that were felt to be related to the development of pericardial effusions; elevated ESR, normal absolute lymphocyte count, initial presence of extensive mediastinal adenopathy and the addition of adjuvant chemotherapy. The presence of increasing combinations of these pretreatment 'risk factors' led to an increasing likelihood of developing a radiation-related pericardial effusion such that six of seven patients with all four 'risk factors' developed a pericardial effusion. Nine of 13 clinically significant effusions were associated with the addition of adjuvant chemotherapy. Possible pathogenetic mechanisms that include factors other than radiation dosage and the clinical management of radiation-related pericardial effusions are discussed.     

Diagnostic value of C-reactive protein in exudative pleural effusions

BACKGROUND: Tests able to help in the diagnostic work-up of pleural exudates are needed. C-reactive protein (CRP) may be useful for distinguishing between benign and malignant exudates. METHODS: A total of 123 consecutive patients diagnosed as having exudative pleural effusion (60 associated with malignancy and 63 benign effusions) were included in the study. Sensitivity, specificity, positive and negative predictive values (PV+, PV-), and positive and negative likelihood ratios (LR+, LR-) were established at different cut-off points. RESULTS: Pleural fluid CRP level was 23+/-12 mg/l (mean+/-S.D.) in pleural exudates associated with malignancy and 50+/-33 mg/l in benign effusions (P<0.001). With a cut-off point below 20 mg/l for malignancy, sensitivity of CRP was 0.50, specificity 0.89, PV+ 0.81, PV- 0.65, LR+ 4.50, and LR- 0.65. With a cut-off point above 45 mg/l for benign diseases, sensitivity was 0.44, specificity 0.95, PV+ 0.90, PV- 0.62, LR+ 8.89, and LR- 0.58. CONCLUSIONS: The pleural CRP level provides useful information for the study of pleural exudates. A level below 20 mg/l suggests a malignant origin and a level above 45 mg/l virtually rules out this possibility. Additional advantages of measuring CRP level are that it is an inexpensive test and is easy to perform.     

内科胸腔镜对老年疑难性胸腔积液的诊断价值

目的内科胸腔镜在诊断老年疑难性渗出性胸腔积液的价值。方法应用内科胸腔镜对56例老年疑难性渗出性胸腔积液患者进行检查,术中对可疑病变部位进行直视下多点活检,比较镜下表现与病理结果相关性,评价手术的安全性。结果56例疑难性渗出性胸腔积液患者中病理确诊51例,诊断阳性率92．9％,其中转移性腺癌16例（28．5％）,鳞癌7例（12．5％）,小细胞癌2例（3．6％）,食道癌胸膜转移1例（1．8％）,淋巴瘤2例（3．6％）,恶性胸膜问皮瘤4例（7．1％）,结核病20例（35．7％）,非特异性慢性炎症2例（3．6％）;2例（3．6％）病理为阴性,所有病例均未发生严重并发症。结论内科胸腔镜检查对老年性疑难性渗出性胸腔积液诊断阳性率高、简单、安全、并发症发生率低。     

Diagnostic value of sialic acid in malignant pleural effusions.

In this study, we measured pleural fluid and serum sialic acid levels in 70 consecutive patients hospitalized with pleural effusions and serum sialic acid concentrations in 20 healthy individuals chosen as control group. The cause of 26 pleural effusions was malignancy, and diseases other than malignant neoplasms were determined as the cause of 44 cases. Mean serum sialic acid levels in the patients with malignancies were higher than the levels in patients with nonmalignant diseases and the control group. Mean sialic acid level in the patients with nonmalignant diseases was increased compared with control group, but this increase was not as high as that in the patients with malignancies. In the patients with malignant neoplasms, mean pleural fluid sialic acid content was also higher than that found in other diseases. Sialic acid concentration of pleural fluid was correlated with serum concentration. However, pleural fluid to serum sialic acid ratio in malignant diseases was greater than that in the others. The specificity and sensitivity of pleural fluid sialic acid level in excess of 0.075 mg/ml in distinguishing malignant effusions were 68 percent and 77 percent, respectively. These values for pleural fluid/serum sialic acid ratio with the cut-off level of 0.7 were 55 percent and 65 percent. Our findings indicate that determination of sialic acid level in malignant pleural effusions has a diagnostic value.     

Clinically silent pericardial effusions in patients on long-term hemodialysis. Pericardial effusions in hemodialysis.

The danger of cardiac tamponade occurring when pericarditis is accompanied by pericardial effusion, as opposed merely to the presence of a friction rub without effusion, has been unclear. Forty patients on hemodialysis were studied by physical examination, chest x-ray film, and echocardiography for evidence of pericarditis and pericardial effusion. Only two patients developed a friction rub during the study and were placed on regional heparin. Ten of 11 patients who were positive on echocardiogram for pericardial effusion had unremarkable physical examinations. These 11 patients had cardiomegaly as noted on chest x-ray examination. Eighteen of 25 patients without effusion also had cardiomegaly on chest x-ray film. No patient remaining on systemic heparin and having a pericardial effusion developed cardiovascular complications during hemodialysis. This study suggests that while many patients on longterm hemodialysis have pericardial effusion undiagnosed on the basis of physical examination, but noted on echocardiogram, special precautions to prevent tamponade during hemodialysis are not necessary. Also, posterior-anterior chest x-ray film showing a normal-sized heart will usually exclude significant pericardial effusion.     

持续性心包引流合并症的探讨

目的 持续性心包穿刺引流是治疗大量心包积液和心包填塞的常用方法,本文旨在探讨心包穿刺引流的合并症。方法 本文对5例发生了心包穿刺引流合并症的住院患者进行分析。结果 在5例合并症中,有2例因导管前端刺激发生神经介导性晕厥,1例发生急性右心室扩张并死亡,1例发生心包积液经导管管侧孔漏入左侧胸腔,1例出现急性肺水肿和心包积液经穿刺处漏入皮下组织。结论 应充分认识持续心包引流所引起的血流动力学改变,对危重患者应行床旁血流动力学监测。同时应注意引流导管本身对患者可能造成的损伤。     

78例老年胸积液联检加胸部CT的诊断价值

目的探讨老年人胸腔积液的病因。方法选择78例患者做胸部CT检查,同时取胸腔积液做PCR,结核抗体,胸膜活检,细胞学检查。结果胸部CT检查,确定有胸腔积液78例,肺部和纵膈有病变60例,无肺部、纵膈等病变18例。结论PCR,结核抗体在诊断结核性胸腔积液中阳性率高,RCP特异性高,胸膜活检与细胞学检查在两种疾病检测标准不同,阳性率及特异性均高。     

胸腔积液中白细胞介素6、18的变化与意义

目的　探讨胸腔积液患者血清及胸腔积液中白细胞介素6(IL -6)、白细胞介素1 8(IL -1 8)的变化及其临床意义,并明确其在胸腔积液免疫发病机理中的作用。方法　应用双抗体夹心酶联免疫吸附测定法(ELISA)检测2 0例结核性胸腔积液患者、2 0例恶性胸腔积液和1 5例漏出性胸腔积液患者血清及胸腔积液中IL -6、IL -1 8的水平。结果　结核组胸腔积液中IL -6、IL- 1 8水平分别为(468.1±1 4 2 .4)和(759.3±2 85 .1 )pg/ml显著高于恶性组(2 2 0 .8±50 .7)和(2 73 .7±93 .7)pg/ml及漏出液组(36 .4±4 .8)和(40 .6±5 .4)pg/ml。结论　IL- 6、IL -1 8在结核性、肿瘤性和漏出性胸腔积液患者的表达水平不同,可作为临床上鉴别诊断的参考指标,在结核和肿瘤性胸膜病变局部的免疫病理生理过程中起着重要作用。     

Diagnostic value of adenosine deaminase in nontuberculous lymphocytic pleural effusions.

Adenosine deaminase (ADA) can aid in the diagnosis of tuberculous pleural effusions, but false-positive findings from lymphocytic effusions have been reported. The purpose of this study is to assess the ADA levels in nontuberculous lymphocytic pleural effusions (lymphocyte count > 50%) of different aetiologies. Altogether, 410 nontuberculous lymphocytic pleural fluid samples were consecutively selected. These included malignant effusions (n = 221), idiopathic effusions (n = 76), parapneumonic effusions (n = 35), postcoronary artery bypass graft surgery effusions (n = 6), miscellaneous exudative effusions (n = 21) and transudative effusions (n = 51). The ADA level reached the diagnostic cut-off for tuberculosis (40 U x L(-1)) in seven of the 410 cases (1.71%). The negative predictive value of ADA for the diagnosis of pleural tuberculosis was 99% (403 of 407 cases) in the group of lymphocytic pleural effusions. In five of these seven patients ADA1 and ADA2 were measured, and in all these cases (100%) ADA1/ADA(p) correctly classified these lymphocytic effusions as nontuberculous (ratio < 0.42). This prospective study provides additional evidence that adenosine deaminase levels in nontuberculous lymphocytic pleural effusions seldom exceed the cut-off set for tuberculous effusions. The pleural fluid adenosine deaminase levels were significantly higher in different types of exudative effusions than in transudates. An adenosine deaminase level < 40 IU x L(-1) virtually excluded a diagnosis of tuberculosis in lymphocytic pleural effusions. Adenosine deaminase1/adenosine deaminase(p) correctly classified all nontuberculous lymphocytic pleural effusions with high adenosine deaminase levels.     

Intrapericardial treatment of neoplastic pericardial effusions

Pericardial effusion and cardiac tamponade are known complications of many advanced malignancies as lung cancer, breast cancer, lymphomas and leukemias. Initial relief can be easily obtained with percutaneous echo-guided pericardiocentesis, without significant mortality and morbidity and well-tolerated even in critically ill patients. Effusion recurrences can be observed, however, in up to 40% of cases if only simple pericardial drainage is performed. Effective management can be obtained by instillation in the pericardial sac of different agents, with sclerosing or cytostatic activity, like tetracyclines, bleomycin, thiotepa or radionuclides. Intrapericardial sclerotherapy is associated to good results in terms of recurrence prevention and survival improvement. Absence of pericardial effusion at 30 days after drainage can be observed in 70 to 90% of all treated patients, without significant variations among different treatments. No significant side effects are observed, with the exclusion of chest pain during tetracyclines instillation. In our opinion pericardiocentesis associated to intrapericardial sclerotherapy with thiotepa is the best compromise in terms of recurrence prevention, tolerability and costs. Real randomized, case-control studies are moreover required to assess the gold standard of malignant pericardial effusions treatment.     

Etiologic diagnosis of 204 pericardial effusions

The etiologic evaluation of pericardial effusion is frequently unsuccessful when noninvasive methods are used. To determine the cause of the current episode, all patients with echographically identified pericardial effusion from May 1998 to December 2002 underwent noninvasive diagnostic testing of blood, throat, and stool samples. Patients with postpericardiotomy syndrome were excluded. To analyze the value of our tests, we tested randomly selected blood donors as negative controls. Among 204 included patients, 107 (52.4%) had a final etiologic diagnosis: the etiology of 52 was highly suspected at first examination and later confirmed (thyroid deficiency, 5 cases; systemic lupus erythematous, 7; rheumatoid arthritis, 7; scleroderma, 3; cancer, 25; and renal insufficiency, 5). A definite etiologic diagnosis was made in 11 patients from pericardial fluid analysis (cancer, 5 cases; tuberculosis, 3; Streptococcus pneumoniae, Citrobacter freundii, and Actinomyces, 1 case each). Among 141 patients considered to have idiopathic pericarditis, 44 (32.1%) gained an etiologic diagnosis by our systematic testing strategy. This included serologic evaluation of serum (Coxiella burnetii, 10 cases; Bartonella quintana, 1; Legionella pneumophila, 1; Mycoplasma pneumoniae, 4; influenza virus, 1), viral culture of throat swabs (enterovirus, 8 cases; and adenovirus, 1), high-level antinuclear antibodies (>1/400, 3 cases), and thyroid-stimulating hormone (15 abnormal results). Antibodies to Toxoplasma and cytomegalovirus, enterovirus recovered from rectal swabs, and low-level antinuclear antibodies were seen with equal frequency in patients and controls.Using our evaluation strategy, the number of pericardial effusions classified as idiopathic was less than in other series. Systematic testing for Q fever, Mycoplasma pneumoniae, thyroid abnormalities, and antinuclear antibodies, accompanied by viral throat cultures, frequently enabled us to diagnose diseases not initially suspected in patients with pericardial effusion.