Clinical, microbiologic and therapeutic aspects of purulent pericarditis.

Twenty-six patients with purulent pericarditis were seen at the Massachusetts General Hospital between 1960 and 1974. The diagnosis was made in 18 of them during life, but only 6 survived, with an over-all mortality rate of 77 per cent. In eight patients, purulent pericarditis developed in the early postoperative period after thoracic surgery. In seven, purulent pericarditis was the result of contiguous spread of infection from a pleural, mediastinal or pulmonary focus in nonsurgical patients. In five patients, it was the result of direct spread to the pericardium from an intracardiac infection. In the remaining six patients, purulent pericarditis developed as the result of a systemic bactermia. Immunosuppressive therapy, extensive thermal burns, lymphoproliferative disease and other systemic processes affecting host resistance were present in at least half the patients. Staphylococcus aureus was the etiologic agent in the largest number of patients (8 of 26 in this report). However, in contrast to previous studies, in a significant number of the patients (five), purulent pericarditis was the result of fungal infection (in three patients subjected to thoracic surgery and in two immunosuppressed patients). This report confirms that purulent pericarditis is an acute disease with a fulminant course. The diagnosis is easily missed since classic signs of pericarditis (including chest pain, friction rub and diagnostic electrocardiographic abnormalities) may be absent. The echocardiogram shows considerable promise in allowing earlier diagnosis of the pericardial effusion which accompanies purulent pericarditis. Optimal therapy consists of prolonged antibiotic therapy and aggressive drainage of the pericardium. In this series, there were 6 survivors among the 11 patients (55 per cent) who received appropriate therapy.     

Purulent pneumococcal pericarditis. A continuing problem in the antibiotic era

The clinical findings in five patients with purulent pneumococcal pericarditis are presented. Predisposing factors were untreated pneumococcal pneumonia and empyema in three patients and congenital hypogammaglobulinemia in one patient. The three patients, in whom the diagnosis was established by pericardiocentesis, recovered without sequelae after surgical drainage of the pericardium and systemic antibiotic therapy. The two remaining patients had unsuspected purulent pericarditis demonstrated postmortem.A review of 113 cases of purulent pneumococcal pericarditis since 1900 was made. A preceding pneumonia was present in 93.1 per cent of the patients; 66.6 per cent had pneumonia with empyema. Signs frequently associated with pericarditis such as a pericardial friction rub, pulsus paradoxus and an enlarged cardiac silhouette may be absent although circulatory embarrassment exists. Pericardiocentesis is mandatory to establish the diagnosis of purulent pneumococcal pericarditis. Although mortality in untreated patients was 100 per cent, the 10 patients treated with both systemic antibiotics and surgical drainage survived.     

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.     

Aortic valve replacement in the elderly

In order to determine the risk of aortic valve replacement in the elderly, 77 patients over the age of 60 who had undergone this procedure were reviewed. Hypothermic-hyperkalemic cardioplegia was used in all patients. In 55 patients with isolated aortic valve replacement there were three deaths (5.5 per cent). In the entire series of 77 patients there were 13 deaths (13 per cent). In seven patients of an organ other than the heart. In only two patients did the operative death have a myocardial cause. Ninety-two per cent of the patients were in functional class I or II following surgery. Patients should come to surgery before reaching class IV. Aortic valve replacement can be carried out safely in the elderly, and the indications should be the same as for younger patients.     

Tuberculous pericarditis

Twenty-seven patients with tuberculous pericarditis (TBP) presenting between 1969 and 1978 are reported. Twenty-four patients received standard forms of chemotherapy, of whom two (eight per cent) died. Three (13 per cent) patients developed constrictive pericarditis (CP), all within the first three months of diagnosis and while on treatment. Two of the latter required pericardiectomy of whom one died, the other patient remaining well 11 years after surgery. Pericardial constriction in the third patient is mild and has not progressed. The remaining 21 patients who have been followed up for between one and 11 years remain well and show no evidence of any late effects including pericardial constriction. Three patients were diagnosed only at post mortem examination. The prognosis of TBP is good provided the diagnosis is made and chemotherapy commenced, promptly.     

Ischemic myocardial injury during coronary artery surgery

ECG's and serum levels of SGOT, LDH, and CPK were examined during the postoperative period in 50 patients with angina pectoris who had myocardial revascularization procedures. ECG signs of acute myocardial infarction appeared in 34 per cent and changes compatible with acute ischemic injury were seen in 10 per cent. Elevation of SGOT exceeding 90 units occurred in 32 per cent of 50 patients, and LDH levels over 900 units occurred in 24 per cent. In patients with ECG evidence of post-operative infarction or ischemia, 50 per cent had abnormal SGOT levels and 55 per cent had abnormal LDH levels. In 16 patients with SGOT levels exceeding 90 units, 69 per cent had ECG evidence of acute infarction or ischemia. Two patients died following surgery and acute myocardial infarction was demonstrated in both at autopsy. Relief of angina occurred in one patient who developed a myocardial infarct following internal mammary implantation. A follow-up angiogram revealed no effective communication of the implant with myocardial vessels. Acute myocardial infarction is a frequent complication of coronary artery surgery as determined by serial ECG's. In this study, approximately 50 per cent of these patients had diagnostic elevations of SGOT or LDH.     

Ascending aorta-pulmonary artery anastomosis for cyanotic congenital heart disease.

The course and prognosis of 208 patients with an ascending aorta to pulmonary artery anastomosis is reviewed. Mortality rate during, or within one month, of surgery was 24 per cent (50/208) and late mortality rate, prior to repair, was 10 per cent (21/208). An additional 5 per cent (10/208) died during subsequent intracardiac repair. Congestive heart failure developed in 25 per cent (53/208), pulmonary artery hypertension in 17 per cent (12/72), and pulmonary vascular obstruction in 6 per cent (4/72). An increase in orifice size of the stoma with time was documented in eight patients. Additional subsequent palliative surgery was required in 22 per cent (45/208). Mortality rate was directly related to age at operation and was highest in neonates less than one week of age. In infants with tetralogy of Fallot, a preliminary comparison of mortality rate between palliative surgery and primary repair clearly suggests that the latter is the preferred method of treatment.     

Aggressive chemotherapy for diffuse histiocytic lymphoma in the elderly: increased complications with advancing age

Twenty patients greater than or equal to 70 years of age were included in a study of the treatment of diffuse histiocytic lymphoma utilizing cyclophosphamide, adriamycin, vincristine, and prednisone. These patients ranged in age from 70 to 94 years (median 75 years). There were also 55 younger patients (age range 33 to 69 years) in the treatment trial. There were no dose adjustments for age. The complete remission rate in the elderly patients (45 per cent) was not different from that in the younger patients (53 per cent). The overall survival in the elderly patients (median 13 months) was somewhat shorter than that in the younger patients (medians 22 months for patients 56-69 years of age and 41 months for patients 33-55 years of age), but not significantly different. Death during the first two treatment cycles from causes other than lymphoma occurred in 25 per cent of the patients greater than or equal to 70 years of age versus 2 per cent of younger patients (P less than 0.01). In addition, three other patients aged 79, 65, and 59 years died in the fourth or fifth cycles of treatment from causes other than lymphoma. Thus, 30 per cent of patients greater than or equal to 70 years of age died during therapy from causes other than lymphoma, versus 5 per cent of younger patients (P less than 0.01). Whether this altered ability to tolerate therapy in the older patients reflected decreased marrow function, altered drug metabolism, other effects of aging, or a combination of these factors is not clear. It might be appropriate to alter drug doses when treating elderly patients, and particular attention to supportive measures seems appropriate.     

Management of admitted malaria cases in four major hospitals of Delhi: a case study.

A hospital-based retrospective case study of admitted patients was undertaken in four major hospitals of Delhi during 1991, with a view to assessing (i) recording and reporting system of malaria cases, (ii) diagnostic criteria being followed, (iii) management of complicated and severe malaria cases, and (iv) availability of life-saving antimalarials. The study showed that none of the hospitals either followed the international coding system for recording or adopted the National Malaria Eradication Programme guidelines for diagnostic criteria malaria, i.e. by blood smear examination. Diagnosis of malaria in three out of four hospitals was not preceded by blood examination in all cases. Only 55% of the 283 clinically suspected malaria cases were screened for malaria parasite with overall positivity of 20.14 per cent and of 38.25 per cent in examined cases. Age and sex break-up indicated that males suffered more and 65 per cent of the patients belonged to 16-40 years' age groups as compared to 38.4 per cent population falling in this age group according to 1981 census. Out of 263 recovered study cases, 13 per cent came from adjoining states while this percentage went up to 35 per cent (7 out of 20 cases) in the case of malaria deaths. Over 80 per cent of the clinically suspected cases presented with signs and symptoms of fever or fever with rigour, chills or vomiting. In 38 per cent of the cases there was a definite time lag in reporting of the cases to hospitals but most of the cases (91 per cent) were administered antimalarials within 24 h of admission.(ABSTRACT TRUNCATED AT 250 WORDS)     

Effectiveness of Intrapericardial Administration of Streptokinase in Purulent Pericarditis

BACKGROUND AND PURPOSE: Purulent pericarditis is very rare. However, among patients suffering from this disease the mortality rate is very high. The aim of this study was to evaluate the effectiveness and side effects of intrapericardial streptokinase administration in patients with confirmed purulent pericarditis. PATIENTS AND METHODS: Three patients, one 50-year-old man and two women aged 64 and 40 years, who were admitted to the intensive care unit (ICU) due to purulent pericarditis, entered the study. In all three cases a subxiphoid pericardiotomy followed by insertion of a drainage line into the pericardial space was performed. Antibiotic therapy was started immediately on admission to the hospital. Despite continued antibiotic therapy in all three patients, daily drainage from the pericardium--during several days after surgery--staggered between 50-200 ml/day. Due to considerable purulent pericardial drainage loculations and/or fibrin deposits confirmed by echocardiography, streptokinase (500,000 IU dissolved in 50 ml of normal saline) was administered into the pericardial space over 10 min, using the previously inserted drainage catheter. This regimen was repeated after 12 and 24 h. The total dose of streptokinase was 1,500,000 IU. RESULTS: The clinical effect of intrapericardial streptokinase administration was excellent. Several days after intrapericardial administration of streptokinase, drainage of purulent pericardial fluid stopped. No complications associated with intrapericardial streptokinase administration were observed. In the follow-up echocardiography (in two patients repeated 6 and 9 months after delivery of streptokinase), pericardial fluid and echocardiographic signs of pericardial constriction were not observed. CONCLUSION: Intrapericardial administration of streptokinase in purulent pericarditis is effective and safe.     

Status of the coronary arteries in the nephrotic syndrome: Analysis of 20 necropsy patients aged 15 to 35 years to determine if coronary atherosclerosis is accelerated

This report describes the status of the major extramural (epicardial) coronary arteries in 20 patients (average age = 24 years) with the nephrotic syndrome (from systemic lupus erythematosus in 13 patients, diabetes mellitus in four and chronic idiopathic glomerulonephritis in three), and compares the clinical and morphologic observations to those in 14 control subjects (average age = 29 years). Both patients with the nephrotic syndrome and control subjects ranged in age from 15 to 39 years. The 20 patients with the nephrotic syndrome had significantly more coronary luminal narrowing by atherosclerotic plaques than did the control subjects. The lumens of one or more of the four major coronary arteries were narrowed >75 per cent in cross-sectional area in eight (40 per cent) of the 20 nephrotic patients and in none of the 14 control subjects. This difference in degree of coronary disease was even more striking when the per cent of narrowing in the entire coronary tree was examined: of the 290.5 cm of coronary artery examined in the 20 nephrotic patients, the lumen in 88 cm (30 per cent) was >50 per cent narrowed in cross-sectional area, whereas of 288 cm of coronary artery examined in the 14 control subjects, the lumen in only 5.5 cm (2 per cent) was narrowed to this degree.     

Endoscopy in the elderly

The endoscopic experience involving the study of 114 patients in the geriatric age group (65-89 years) in a district general hospital is described. The cases examined were mainly patients with dyspepsia, gastrointestinal blood loss, suspected upper alimentary tract carcinoma or those who had undergone gastric surgery. The procedure was well tolerated and safe. Useful information was obtained in the majority of patients (93 per cent). When the endoscopic and radiological findings were compared the endoscopist and radiologist were in agreement in 55 per cent of the cases examined by both techniques. In the others endoscopy played an essential role in establishing the presence of radiologically undetected or undetectable disease, and in confirming or excluding radiologically doubtful disease.     

Purulent Pericarditis in Sickle Cell Disease Due to Streptococcus agalactiae; a Unique Case Report and Literature Review

Purulent pericarditis is a localized infection with a thick, fibrinous hypercellular exudate and is historically associated with a high mortality. We describe a case of purulent pericarditis due to Streptococcus agalactiae (S. agalactiae) in a 30-year-old woman with sickle cell disease who presented with fever, dyspnea, and S. agalactiae septicemia. Despite timely initiation of antibiotics, she developed a large purulent pericardial effusion requiring surgical pericardiocentesis followed by a pericardial window. At 14?months follow-up, she has remained asymptomatic without sequelae. A review of the literature contained only four patients with purulent pericarditis in sickle cell patients. We discuss the unique aspects of this case in the context of purulent pericarditis in the age of modern antibiotics and hypothesize on the pathogenesis of delayed pericardial effusion after pericarditis.     

Evaluation of aortocoronary venous bypass grafting for prevention of cardiac arrhythmias.

The influence of ACB on cardiac arrhythmias was examined in 27 patients. Eight-hour Holter monitoring was performed 8 days preoperatively and 100 days postoperatively. Arrhythmias were divided into 3 groups (Class I: NSR +/- occasional APBs; Class II: less than five unifocal VPBs per minute; Class II: more than five VPBs per minute, multifocal VPBs, VPBs in a row or VT). Preoperative classification disclosed that 13 patients (48.1 per cent) were in Class I, six patients (22.2 per cent) were in Class II, and eight patients (29.6 per cent) were in Class III. The corresponding values after surgery were 10 patients (37.0 per cent), 13 patients (48.1 per cent), and four patients (14.8 per cent). These differences were not statistically significant (p less than 0.1). In view of the tendency of arrhythmias of Class III to improve after ACB, we feel that further investigations in this area are needed. At the present time ventricular arrhythmias alone constitute no indication for bypass surgery.     

Detection of coronary disease before valve surgery. Contribution of myocardial scintigraphy with dipyridamole

The detection of coronary disease before valve surgery remains difficult in the absence of coronary arteriography. The contribution of myocardial scintigraphy with dipyridamole (MS-DP) was studied in 34 consecutive patients with valve disease (11 mitral and 23 aortic) with a mean age of 63 +/- 11 years having undergone coronary arteriography before valve surgery. Coronary arteriography was performed because of angina (21 cases) or age (women greater than 50, men greater than 40). Positive criteria of coronary disease were the presence of at least one frank and clearly visible fault of myocardial perfusion (MS-DP positive) and at least one stenosis of greater than 70 per cent by coronary arteriography. Coronary disease existed in 13 patients (38 per cent). Ten patients (29 per cent) had a positive MS-DP. The sensitivity and specificity of MS-DP in detecting coronary disease were 69 per cent and 95 per cent respectively. Its positive predictive value was 90 per cent. MS-DP was negative in all asymptomatic patients (19 per cent of them having coronary disease) and in 11 symptomatic patients (18 per cent of them having coronary disease). The low positive predictive value of angina (52 per cent) increased to 90 per cent when combined with a positive MS-DP. Because of relatively low sensitivity, basing indications for coronary arteriography before valve surgery on the results of MS-DP cannot be advised.     

Perioperative myocardial infarct following aortocoronary bypass. Clinical aspects, causes, consequences

Perioperative infarction is a significant factor of morbidity of coronary bypass surgery. The aim of this study was to review peri-operative infarction and its complications over a 10 year period (1974 to 1984) and to determine its consequences on left ventricular function and life expectancy. The material included 514 patients who underwent coronary bypass surgery. Perioperative infarction was defined as the association of a postoperative Q wave and increase in creatinine phosphokinase after the 24th postoperative hour: this diagnosis was made in 31 cases (Group A), 6 per cent of the series; 483 patients (Group B) had no signs of infarction. The necrosis involved the revascularised zone in 26 cases and other zones in 5 cases. The acute phase of infarction was associated with major complications in 9 patients of Group A. In 22 patients (70 per cent of cases) the initial evolution was uncomplicated. There was no significant difference in the number of patients with unstable angina between Groups A and B (52 per cent vs 67 per cent), with single vessel disease (25 per cent vs 28 per cent), double vessel disease (45 per cent vs 34 per cent) or with triple vessel disease (30 per cent vs 38 per cent). The average number of bypasses was higher in Group A (2.06 per cent vs 1.4 per cent, p less than 0.05), as was the duration of cardiopulmonary bypass (117 min vs 91 min, p less than 0.05) and of aortic clamping (45 min vs 31 min, p. less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)     

Is the prognosis of non-thrombolysed inferior infarction benign?

Between 1978 and 1983, 2,970 coronary angiographies were performed at the Cardiology Clinic of Necker Hospital; 220 survivors of an initial Q-wave inferior infarction who had not received thrombolytic therapy were selected. The ejection fraction was 55 +/- 11 per cent, and the indexed end diastolic left ventricular volume was 108 +/- 29 ml/m2. The left anterior descending artery was diseased in 57 per cent of cases. The incidence of multivessel disease was 67 per cent. Two hundred and eleven patients (96%) were followed up for 79 +/- 22 months. The prevalence of cardiovascular events was: cardiac deaths: 22 (10%), recurrent infarction: 20 (9%), angina requiring coronary bypass surgery: 60 (28%), cardiac failure: 22 (10%). The 10 year actuarial survival was significantly lower in patients with an ejection fraction less than 45 per cent (46% vs 91%) and in patients with triple vessel disease (62% vs 92% and 88%). The survival was not lower in patients with stenosis of the left anterior descending artery.     

Prognosis in juvenile rheumatoid arthritis with systemic onset. A follow-up study

Thirty-three patients with systemic onset JRA were followed up for 4 to 24 years (median 10 years). None had positive RF or ANA. Most patients developed polyarthritis. Cardiac involvement occurred in 14 patients (42%). Cardiac prognosis was good for pericarditis but seemed to be worse for myocarditis or perimyocarditis. Three patients contracted renal amyloidosis (9%). Severe growth retardation was observed in 39 per cent. Half of the patients had low activity or were in remission after in average 5.9 years' duration of the disease. Seventy per cent of the patients were in a good functional state. Patients with less than average radiological progression during the first 5 years of disease and those with onset of disease after the age of 5, seemed to have a better functional prognosis.     

Incidence of mitral valve prolapse in subjects with thoracic skeletal abnormalities--a prospective study.

The incidence of mitral valve prolapse (MVP) in 80 patients with various thoracic skeletal abnormalities (TSA) was examined prospectively using compete history and physical examination, chest x-rays, electrocardiography, phonocardiography, and echocardiography. There were 76 males and four females, ranging in age from 18 to 80 years. Thirty-four patients had narrow anteroposterior diameter of the chest (asthenic habitus) (Group 1), 13 had straight back (Group 2), and 33 had pectus excavatum (Group 3). Twenty-five of the 80 patients (31 per cent) had evidence of MVP, 22 by echocardiographic criteria and three by phonocardiographic criteria. The incidence of MVP in this predominantly male population was substantially higher than that reported in the general adult population. Thoracic skeletal abnormality is an important nonauscultatory feature of mitral valve prolapse syndrome. The association between TSA and MVP may be a manifestation of a single connective tissue defect during embryonic development of the bony thoracic cage and the atrioventricular valves. All patients with TSA, even when asymptomatic, should be screened for MVP by noninvasive investigations. The recognition of MVP in patients with TSA may be of potential value in prevention of life-threatening endocarditis and cardiac arrhythmia.     

Primary acute pericardial disease: a prospective series of 231 consecutive patients

A series of 231 patients with "primary" acute pericardial disease (acute pericarditis or tamponade presenting without an apparent cause) were studied according to the following protocol: general clinical and laboratory studies (stage I), pericardiocentesis (stage II), pericardial biopsy (stage III) and blind antituberculous therapy (stage IV). In 32 patients (14%) a specific etiologic diagnosis was obtained (13 with neoplasia, 9 with tuberculosis, 4 with collagen vascular disease, 2 with toxoplasmosis, 2 with purulent pericarditis and 2 with viral pericarditis). "Diagnostic" pericardiocentesis (32 patients) was performed when clinical activity and effusion persisted for longer than 1 week or when purulent pericarditis was suspected, whereas "therapeutic" pericardiocentesis (44 patients) was performed to treat tamponade; their diagnostic yield was 6% and 29%, respectively. "Diagnostic" biopsy (20 patients) was carried out when illness persisted for longer than 3 weeks, whereas "therapeutic" biopsy was performed whenever pericardiocentesis failed to relieve tamponade; their diagnostic yield was 5% and 54%, respectively. The diagnostic yield difference between "diagnostic" and "therapeutic" procedures was significant (p less than 0.001); in contrast, the global diagnostic yield of pericardiocentesis (19%) and biopsy (22%) was similar. At the end of follow-up (1 to 76 months, mean 31 +/- 20), no patient in whom a diagnosis of idiopathic pericarditis had been made showed signs of pericardial disease. It is concluded that a "diagnostic" procedure is not warranted as a routine method, a choice between "therapeutic" pericardiocentesis and biopsy is circumstantial and must be individualized, and only through a systematic approach can a substantial diagnostic yield be reached in primary acute pericardial disease.