New two-dimensional, echocardiographically directed pericardiocentesis in cardiac tamponade

Seventeen patients with cardiac tamponade were treated by pericardiocentesis guided by two-dimensional (2-D) echocardiography and a needle guide. The needle guide used in the present study was designed so that the needle path lies within the center of the scan thickness. Before actual puncture, the mask method was performed in a water bath so that the needle progress avoided injury. The needle progress was monitored continuously in real time on the display throughout the procedure. Immediate relief from acute cardiac tamponade was obtained in all except one patient, who was treated by pericardiotomy because of insufficient drainage. In two patients, second drainage was performed because of reaccumulation of the pericardial effusion. There were no major complications. Nine patients recovered and the other patients died of underlying disease. Accurate and efficient visualization of the needle might allow a safer procedure. We conclude that pericardiocentesis guided by 2-D echocardiography using a needle guide may be a safe and easily applied technique for the management of 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.     

New therapeutic approach to aortic dissection complicated by cardiac tamponade

The management of aortic dissection with cardiac tamponade may result in increased blood pressure and thereby itself make the aortic dissection worse. Nevertheless, it is important to prevent cardiac failure caused by cardiac tamponade. We describe a case of aortic dissection with cardiac tamponade. Echocardiography and aortography showed DeBakey IIIb-type aortic dissection with retrograde dissection, complicated by cardiac tamponade and aortic insufficiency. To treat this condition, a new therapeutic approach was undertaken. A vasodilator was administered, then pericardiocentesis guided by echocardiography was performed. To prevent abrupt elevation of blood pressure in response to the relief of cardiac tamponade, the pericardial aspiration was carried out slowly--it took four hours for the complete drainage of 415 ml of blood--and a vasodilator, sodium nitroprusside, was administered. After drainage, cardiac function was reversed fully, and the systolic pressure was controlled under 140 mmHg. Then, using extra-corporeal circulation, the surgical procedure was performed successfully. We conclude that it is useful to treat cardiac tamponade by controlling blood pressure with slow drainage and use of a vasodilator in preparation for performing the surgical procedure.     

Large pericardial effusion after cardiac surgery: role of echocardiography in diagnosis and management

We performed M-mode and two-dimensional (2-D) echocardiograms prospectively in 140 patients an average of eight days after open heart surgery. Large pericardial effusions occurred in 13 patients; three had complete circumcardiac pericardial effusion, four had local anterior adhesions, five had extensive anterior adhesions (posterior loculated effusion), and one had a large loculated pericardial effusion contiguous to the right atrium. In five patients with tamponade, the effusion was drained, with immediate reversal of symptoms and signs of tamponade. In the other eight patients, who had no deterioration in cardiovascular status, the effusion was not drained; instead, these patients were treated medically with indomethacin and observed with serial echocardiograms, and the effusions eventually disappeared. The most consistent echocardiographic differences between the five patients with and the eight patients without tamponade were that patients with tamponade had larger posterior pericardial effusions, more severe left atrial compression, and more indentation of the right atrial wall. Echocardiography plays an essential role in diagnosis and management of large pericardial effusions after open heart surgery. Patients with large pericardial effusions who are clinically stable need only medical management, including serial echocardiograms, but drainage is indicated if the cardiovascular or respiratory status worsens. Certain echocardiographic findings indicate a high probability of tamponade.     

Percutaneous balloon pericardiostomy for non-surgical management of recurrent pericardial tamponade: A case report

We report the case of a 26-year-old male with recurrent hemorrhagic cardiac tamponade occurring after initial management by needle pericardiocentesis and pigtail catheter drainage. As an alternative to open surgical pericardial fenestration, a percutaneous balloon pericardiostomy was performed with an 18 mm balloon catheter and over-the-wire insertion of a 16 F chest tube for 72 h of pericardial drainage. This non-surgical approach resulted in successful resolution of recurrent cardiac tamponade.     

Outcomes of primary and secondary treatment of pericardial effusion in patients with malignancy

OBJECTIVE: To evaluate the treatment strategies for primary and secondary management of malignancy-related pericardial effusions. PATIENTS AND METHODS: Retrospective review of Mayo Clinic Rochester charts and external records of patients with pericardial effusion associated with malignant disease who required treatment between February 1979 and June 1998 was performed. Telephone interviews with patients, their families, or their physicians were conducted to determine the outcomes of treatment. Recurrence of pericardial effusion and survival were the main outcome measures. RESULTS: Of 1002 consecutive pericardiocenteses performed during the period under study, 341 were performed in 275 patients with confirmed malignant disease. Patients were followed up for a minimum of 190 days, unless death occurred first. Of 275 patients, recurrence of pericardial effusion or persistent drainage necessitated secondary management in 59 (43 of 118 simple pericardiocenteses, 16 of 139 pericardiocenteses with extended catheter drainage, and 0 of 18 pericardial surgery following temporizing pericardiocentesis). Recurrence was strongly and independently predicted by absence of pericardial catheter for extended drainage, large effusion size, and emergency procedures. Recurrence after secondary management occurred in 12 patients: 11 underwent successful pericardiocentesis with extended catheter drainage, and 1 had pericardial surgery. Median survival of the cohort was 135 days, and 26% survived the first year after diagnosis of pericardial effusion. Male sex, positive fluid cytology for malignant cells, lung cancer, and clinical presentation of tamponade or hemodynamic collapse were independently associated with poor survival. CONCLUSION: Echocardiographically guided pericardiocentesis with extended catheter drainage appears to be safe and effective for both primary and secondary management of pericardial effusion in patients with malignancy.     

体外循环心内直视术后并发急性心包填塞的观察与护理

目的探讨体外循环心内直视术后并发急性心包填塞的观察与护理要点。方法回顾性分析本院2006年7月～2011年7月实施体外循环心内直视术后出现心包填塞15例患者的临床资料,并总结术后观察和护理要点。结果15例患者经过及时对症治疗和护理后,血流动力学恢复稳定,无1例死亡。结论心内直视术后心包填塞的主要原因是术后纵膈出血过多,可伴有心包液引流不畅,而积极的观察和及时正确做好纵膈引流管护理是防治急性心包填塞的关键。     

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。     

Pericardiocentesis.

Cardiac tamponade is a life-threatening condition resulting from compression of the cardiac chambers by a pericardial effusion. The principal cause of pericardial effusion is malignant disease of the pericardium, but infectious causes and cardiac trauma are common as well. The patient with cardiac tamponade demonstrates an abnormal pulsus paradoxus, and clinical signs of shock and impending cardiovascular collapse occur with very severe cardiac compression. Relief of the increased intrapericardial pressure is mandatory to establish adequate cardiac output. The definitive treatment of cardiac tamponade is emergent removal of enough pericardial fluid to acutely lower intrapericardial pressure. Echocardiographic guidance may be used if immediately available, but is not required to perform pericardiocentesis in a critical situation. Placement of a pulmonary artery catheter prior to pericardiocentesis is not indicated in cardiac tamponade. Once cardiac output and tissue perfusion have been restored, further drainage procedures such as pericardial catheter placement or surgical drainage are indicated. Therapeutic measures to address the underlying disease process should be initiated after pericardial drainage is accomplished.     

超声监测经皮心包内多部位活检,引流和灌洗治疗

本文介绍应用介入性超声技术在原因不明的心包积液诊断和治疗取得显著效果。３７例患者经心包多部位活检明确病因诊断章取义务兵例，病理论断率８６．３％，比以往常规心包穿刺术诊断率提高了６０％以上；２１例急慢性心包填塞的患者经过导管引流得到完全缓解；根据病因在超声控制引流完全后给予心包腔内灌洗治疗，使数月、数年不能治愈的心包积液变为３－－１０天完成治疗，全部病例复查随访三个月无一例复发。本文详细描述了操作方     

Tamponade due to hemopericardium after streptokinase therapy for pulmonary embolism

A 67-year-old man was given intravenous heparin and then streptokinase for an acute severe pulmonary embolism. The next day a large pericardial effusion developed, with tamponade. Aspiration of blood (500 ml) from the pericardial sac produced prompt relief. The possibility of hemopericardium causing tamponade should be considered on unexplained worsening of cardiac status in a patient who has recently received streptokinase for pulmonary embolism or myocardial infarction.     

心脏直视术后纵隔感染及急性心包填塞的预防与胸腔引流的体会

本文报告460例心脏直视手术经胸腔引流替代纵隔及心包引流的体会。全组无纵隔感染及急性心包填塞并发症。作者认为经胸腔引流对预防心脏直视术后纵隔感染及急性心包填塞有重要意义，对于大心脏和瓣膜替换病人、复杂先天性心脏病纠治、体外循环时间长、肝功能差的病例可常规采用。     

Épanchement péricardique en réanimation — critères cliniques et échographiques diagnostiques de tamponnade — indications de drainage en urgence

Cardiac tamponade, defined by acute circulatory failure secondary to compression of the heart chambers by pericardial effusion, causes obstructive shock requiring intensive care. The incidence of cardiac tamponade in the intensive care unit (ICU) is poorly documented, but pericardial effusion seems to be associated with increased mortality. Pericardial effusion may be caused by infectious, malignant, or autoimmune diseases, and occurs frequently after cardiac surgery. It may be suspected in any patient with shock and signs of right heart failure and polypnea, but echocardiography is crucial in the diagnosis as it visualizes pericardial effusion and detects poor hemodynamic tolerance with diastolic collapse of the right chambers and respiratory variation of right and left Doppler flows. Pericardial drainage, by pericardiocentesis or pericardiotomy, remains the only effective treatment in an emergency situation. Symptomatic treatments are mandatory before drainage to improve venous return despite pericardial obstruction: cautious volume expansion in documented hypovolemia, or norepinephrine, while minimizing the use of mechanical ventilation and sedation as these may increase circulatory failure and lead to cardiac arrest.     

Short-term Minoxidil Use Associated With Pericardial Effusion and Cardiac Tamponade: An Uncommon Presentation

A 48-year-old man presented with complaints of shortness of breath and lower extremity swelling. His medical history was significant for hypertension on minoxidil and recent intracerebellar hemorrhage. Electrocardiography showed sinus tachycardia with left ventricular hypertrophy, and cardiomegaly was noted in the chest x-ray. The patient was hypertensive and tachypneic on admission. An echocardiogram taken immediately showed a large pericardial effusion with evidence of cardiac tamponade. He underwent immediate pericardiocentesis with drainage of 900 mL of pericardial fluid with significant improvement in the symptoms. Analysis of the pericardial fluid proved to be nondiagnostic. Infectious and rheumatologic causes were ruled out. After an extensive battery of tests, not yielding any diagnostic results, the pericardial effusion was attributed to minoxidil therapy. Closer monitoring is needed to prevent potentially fatal complications such as cardiac tamponade as in our patient.     

Pericardial Tamponade Associated with Pacemaker Catheter Manipulation

Three patients developed cardiac tamponade following postpacemaker catheter manipulation. Although regarded as a rare complication, this entity has to be recognized immediately on clinical grounds and confirmed by echocardiography. Prompt recognition and urgent pericardial drainage is lifesaving in this acute cardiac emergency.     

Hypothyroidism presenting as acute cardiac tamponade with viral pericarditis

This report describes the case of a young woman who presented to an emergency department with severe abdominal pain and shock. The patient was found to have pericardial tamponade due to a massive pericardial effusion. On further evaluation, the etiology of this effusion was considered to be secondary to hypothyroidism with concominant acute viral pericarditis leading to a fulminant tamponade. The presentation, differential diagnosis, and management of pericardial effusion and tamponade secondary to hypothyroidism and viral pericarditis are discussed. The diagnosis of hypothyroidism in conjunction with acute viral pericarditis should be considered in patients presenting with unexplained pericardial effusion and tamponade.     

Emergency echocardiography to detect pericardial effusion in patients in PEA and near-PEA states

OBJECTIVES: Emergency echocardiography (EM echo) has been proposed to assist in decision-making in patients with pulseless electric activity (PEA) or PEA-like states. We observed the value of EM echo by emergency physicians in detecting pericardial effusion in patients in PEA and near PEA states. MATERIALS AND METHODS: Observational, prospective series at a Level 1 urban ED of patients with non-traumatic PEA or near PEA states who had EM echoes performed by emergency physicians during an 18-month period. Outcomes of patients with EM echoes were established by review of clinical course, formal echocardiography, radiography, operation or autopsy. RESULTS: Twenty patients had EM echo for non-traumatic hemodynamic collapse. Eight of 20 patients (40%) were without cardiac ventricular motion and were refractory to ACLS measures. Twelve of 20 (60%) patients had cardiac kinetic motion observed on echo. Eight of the 12 (67%) patients with cardiac motion had a pericardial effusion observed on EM echo. Formal echocardiography or other imaging studies confirmed all pericardial effusion cases. The following diagnoses were subsequently confirmed in patients with pericardial effusion: one aortic aneurysm, two aortic dissections, two metastatic cancers, one post-dialysis effusion, two minimal effusions. Three patients had tamponade with emergency pericardial drainage or surgery. In two of four patients with cardiac activity without pericardial effusion, EM echo was useful by detecting pacer capture and ROSC, respectively. CONCLUSIONS: Emergency echocardiography performed by emergency physicians in patients in PEA or near PEA states can detect pericardial effusions with correctable etiologies versus true PEA with ventricular standstill.     

Echocardiography-guided pericardiocentesis with probe-mounted needle: report of 53 cases.

Fifty-three pericardiocentesis procedures were performed on 48 patients from 1993 to 2000 at our coronary care unit. Percutaneous puncture (anterior thoracic in 43 cases, subxiphoid in 10 cases) was performed at the site closest to the exploring probe, where the largest amount of fluid was detected. A needle carrier supported by a bracket with two fixed angulations was mounted on the probe. The needle was advanced through the tissues and inside the pericardial space under continuous visualization. The procedure was successful in 52 of 53 cases. In 1 case of diagnostic pericardiocentesis, the pericardial space was impossible to reach because of the minimal amount of pericardial fluid. In 1 case of acute tamponade after transcatheter ablation of the atrioventricular node, the pericardial puncture caused a pleural-pericardial shunt with consequent drainage of pericardial fluid into the pleural space and symptom resolution. In 1 case, a transient atrioventricular type III block occurred. Emergency surgical drainage was not required in any of the cases. No puncture of cardiac walls ever occurred in this series of patients. No major complications occurred; the incidence of minor sequelae was lower than the incidence reported by other studies on pericardiocentesis without continuous visualization. Our technique appears to be safe and easy to perform even in the presence of minimal amounts of pericardial fluid.     

A case report of pacemaker lead perforation causing late pericardial effusion and subacute cardiac tamponade

Despite medical therapy, the overall prognosis for heart failure (HF) remains poor with high rates of sudden death and death from progressive HF. Device-based therapies offer considerable promise both for the relief of symptoms and for improving prognosis. Cardiac resynchronization therapy is a relatively new and effective treatment for patients with moderate to severe systolic HF and ventricular dyssynchrony. Clinical trials have demonstrated an improvement in quality of life, improved exercise tolerance, decreased HF hospitalizations, and improved survival. Complication rates for patients receiving cardiac pacemakers are relatively low. Although rare, cardiac tamponade caused by myocardial perforation during pacing lead insertion usually occurs a short time after the procedure. This case study discusses a patient who presented with cardiac tamponade 4 months after pacemaker implant. A small perforation of the right atrial lead caused a slow effusion into the pericardial sac. The patient's unusual presentation, hospital course, pathophysiology, and treatment for cardiac tamponade are discussed.     

A new scoring system for the triage of cardiac tamponade

Prompt recognition of cardiac tamponade is critical since the underlying hemodynamic disorder can lead to death if not resolved by percutaneous or surgical drainage of the pericardium. Nevertheless, the management of cardiac tamponade can be challenging because of the lack of the validated criteria for the risk stratification that should guide clinicians in the decision-making process. The Working Group on Myocardial and Pericardial Diseases issued this position statement in order to reply to specific questions: Which patients need immediate drainage of the pericardial effusion?; Is echocardiography sufficient for guidance of pericardiocentesis or should patient be taken to the cardiac catheterization laboratory?; Who should be transferred to specialized/tertiary institution or surgical service?; What type of medical support is necessary during transportation? Current European guidelines published in 2004 do not cover these issues and no additional guidelines are available from major medical and cardiology societies.