Pericarditis, pericardial effusion, cardiac tamponade, and constriction

Critical care aspects of pericardial disease are covered, including diagnosis and differential diagnosis of acute pericarditis, pericardial effusion with and without cardiac tamponade, constrictive pericarditis and effusive-constrictive pericarditis. Emphasis is placed on clinical signs and the important invasive and noninvasive diagnostic procedures, particularly various imaging methods (emphasis on echocardiography), electrocardiography, and cardiac catheterization. Medical and surgical therapies are reviewed, and the technique of pericardiocentesis is presented.     

Uremic pericarditis in patients with End Stage Renal Disease: Prevalence,symptoms and outcome in 2017

The prevalence of uremic pericarditis (UP) used to range from 3% to 41%. More recently, it has decreased to about 5%–20% and to < 5% in the last decades, as hemodialysis techniques have become widely used and dialysis quality improved. The objective of this work is to determine the initial clinical picture and the prognosis of patients presenting End Stage Renal Disease (ESRD) with UP. Materials: This is a retrospective study (May 2015–September 2017). Inclusion criteria targeted patients who had uremic pericarditis defined as pericarditis occurring in a patient with ESRD before initiation of renal replacement therapy, or within eight weeks of its initiation. Results: 16 patients met the inclusion criteria. The median age of patients was 54 [24, 71] years and 56.2% were male. Pericardial effusion was small, moderate and large in 31.2%, 37.6% and 31.2% of cases respectively. One pericardiocentesis was performed in view of a clinical picture of impending cardiac tamponade and three pericardial drainages were performed given presentation of tamponade. Hemodialysis was initiated for all the patients and continued for 2 to 3 weeks until complete regression of the pericardial effusion. The mean number of dialysis sessions was 11 ± 3.5. One patient died of septic shock that developed three weeks after diagnosis of uremic pericarditis. Conclusion: UP is considered a rare but fatal complication of ESRD because of the risk of tamponade and its prognosis remains dependent on early diagnosis and adequate treatment of ESRD.     

Spectrum of pericardial disease: part II

Pericardial disease is a common disorder seen in varying clinical settings, and may be the first manifestation of an underlying systemic disease. In part I, we focused on the current knowledge and management of the more common pericardial diseases: acute pericarditis, pericardial effusion, cardiac tamponade, chronic pericarditis and relapsing pericarditis. In part II, we will focus on the knowledge and management of pericardial involvement in chylous pericardial effusion cholesterol pericarditis, radiation pericarditis, pericardial involvement in systemic inflammatory diseases, autoreactive pericarditis, pericarditis in renal failure, pericardial constriction and effusive constrictive pericarditis.     

Pericardial disease: a clinical review

Pericardial disease is infrequently encountered in cardiovascular practice, but can lead to significant morbidity and mortality. Clinical data and practice guidelines are relatively sparse. Early recognition and prompt treatment of pericardial diseases are critical to optimize patient outcomes. In this review we provide a concise summary of acute pericarditis, constrictive pericarditis and pericardial effusion/tamponade.     

快速进展型结核性心包炎的临床治疗

目的探讨不同治疗方案对于快速进展为缩窄性心包炎的结核性心包炎（快速进展型结核性心包炎）治疗效果、并发症、死亡率、患者预后的影响,以期对结核性心包炎的治疗获得更好的效果。 方法回顾性分析2014年6月至2019年5月成都市第三人民医院心脏大血管外科对38例快速进展型结核性心包炎的治疗方式、外科手术干预时机、手术方式及疗效、并发症、死亡率和随访情况等,治疗方式包括药物治疗、心包穿刺引流术、心包开窗术、心包剥脱术等。同期观察对慢性缩窄性心包炎行外科手术治疗患者115例。 结果对于快速进展型结核性心包炎采用不同的治疗方案,随访1~5年。所有患者均采用抗结核药物治疗,其中单纯药物治疗5例,全部进展为缩窄性心包炎;早期行心包穿刺引流术12例,治愈1例,其余11例进展为慢性缩窄性心包炎;早期行心包开窗术10例,进展为慢性缩窄性心包炎1例,治愈9例;早期行心包剥脱术11例,无进展为慢性缩窄性心包炎病例。全组无围术期死亡病例。与同期行慢性缩窄性心包炎外科手术治疗患者相比,快速进展型结核性心包炎外科手术治疗患者低心排综合征发生率较低（4.8% vs 24.3%,P＜0.05）,患者心功能改善情况较好（100.0% vs 80.7%,P＜0.05）,术后5年随访生存率较高（100% vs 78%,P＜0.05）。 结论快速进展型结核性心包炎单纯采用药物治疗和心包穿刺术治疗,有很高比例的患者会进展为缩窄性心包炎,从而严重影响患者的预后。早期外科干预能显著降低快速进展型结核性心包炎进展为缩窄性心包炎的概率,从而改善患者总体预后,改善患者生存质量,减轻社会负担。     

Constrictive pericarditis complicating endovascular pacemaker implantation

A patient is described who has 6 months of progressive dyspnea and peripheral edema for 4 years following implantation of an endovascular pacemaker, which was complicated by a large hemorrhagic pericardial effusion. Evaluation was consistent with constrictive pericarditis, which is an extremely unusual complication of pacemaker implantation.     

The Postcardiotomy Syndrome Following Transvenous Pacemaker Insertion

We describe a syndrome of fever, pericarditis, and symptomatic pericardial effusion beginning 2 months after transvenous insertion of a permanent pacemaker in a 75-year-old woman. The syndrome improved dramalicaily following pericardiocentesis and resolved after subsequent administration of indomethacin. Although right ventricuiar perforation during pacemaker insertion was not recognized, inadvertent perforation leading to the postcardiotomy syndrome is postulated.     

New approaches to the management and treatment of malignant pericardial effusion

The purpose of this study was the evaluation of the effectiveness of intrapericardial administration of tetracycline, 5-fluorouracil and cisplatin in patients with recurrent malignant pericardial effusion. In 33 cases with malignant pericardial effusion 46 pericardiocenteses under two-dimensional echo-cardiography were performed. No complications were observed after this procedure. Pericardiocentesis was followed by catheterization of the pericardial space for a mean period of 15 days (range 1–64). In 4 cases bacterial pericarditis was observed during catheterization. The mean volume of the pericardial fluid was 2.4 l (range 0.4–13 l). In cases with bloody pericardial fluid thePO₂,PCO₂ and pH of the fluid were estimated and the results compared with the values for venous blood obtained from the upper limbs. Highly statistically significant differences were documented. Twenty cases of malignant pericardial effusion were treated with direct pericardial administration of cisplatin, 3 with 5-fluorouracil and 2 with tetracycline. Good results (no fluid reaccumulation) were observed only after cisplatin therapy. We conclude that pericardiocentesis performed under two-dimensional echo cardiography, followed by pericardial catheterization and direct pericardial treatment with cisplatin are the methods of choice in cases with malignant pericardial effusion. In cases with bloody pericardial fluidPO₂,PCO₂ and pH analysis can be useful to differentiate the source of the bloody fluid (blood or bloody fluid).     

MR imaging findings in 76 consecutive surgically proven cases of pericardial disease with CT and pathologic correlation

To describe findings of patients with surgically confirmed pericardial disease on state of the art MR sequences. Retrospective review was performed for patients who underwent pericardiectomy and preoperative MR over a 5 year period ending in 2009. Patients' records were reviewed to confirm the diagnosis of chronic recurrent pericarditis, constrictive pericarditis, or pericardial tumor. MR imaging findings of pericardial thickness, IVC diameter, presence or absence of pericardial or pleural effusion, pericardial edema, pericardial enhancement, and septal "bounce" were recorded. Patients with constriction had a larger IVC diameter (3.1 ± 0.4 cm) than patients with recurrent pain and no constriction (2.0 ± 0.4 cm). Mean pericardial thickness for the 16 patients with chronic recurrent pericarditis but no evidence of constriction was 4.8 ± 2.9 mm. Mean pericardial thickness for patients with constriction was 9.2 ± 7.0 cm with calcification, and 4.6 ± 2.1 cm without calcification. 94% of patients with chronic recurrent pericarditis had gadolinium enhancement of the pericardium, while 76% of patients with constriction had pericardial enhancement. Septal "bounce" was present in 19% of chronic recurrent pericarditis cases and 86% of constriction cases. 5 patients had a pericardial neoplasm, 1 of which was not identified preoperatively. State of the art MR techniques can identify significant and distinct findings in patients with chronic recurrent pericarditis, constrictive pericarditis, and pericardial tumors.     

Management of tuberculous constrictive pericarditis and tuberculous pericardial effusion in Transkei: results at 10 years follow-up

BACKGROUND: Tuberculous pericarditis is common in Transkei (Eastern Cape). Two randomized trials showed benefits at two years for prednisolone in patients with constrictive pericarditis, and open drainage plus prednisolone in patients with pericardial effusion. AIM: To see whether the advantages of prednisolone and open drainage were maintained up to 10 years. DESIGN: Follow-up of randomized, double-blind, placebo-controlled trials. METHODS: All 383 patients (143 constriction, 240 effusion) received the same anti-tuberculosis chemotherapy. They were randomized to prednisolone or placebo for the first 11 weeks, and were followed-up over 10 years. Among the 240 with effusion, 122 were also randomized to immediate open surgical drainage of pericardial fluid versus pericardiocentesis as required. Adverse outcomes were: death from pericarditis, pericardiectomy, repeat pericardiocentesis, and subsequent open drainage. RESULTS: The 10-year follow-up rate was 96%. In constriction patients, adverse outcomes occurred in 19/70 (27%) prednisolone vs. 28/73 (38%) placebo (p = 0.15), deaths from pericarditis being 2 (3%) vs. 8 (11%), respectively (p = 0.098, Fisher's exact test). In effusion patients, adverse outcomes occurred in 14/27 (52%) with neither drainage nor prednisolone, vs. 4/29 (14%) drainage and prednisolone, 4/35 (11%) drainage and placebo, and 6/31 (19%) prednisolone and no drainage (p = 0.08 for interaction). Drainage eliminated the need for repeat pericardiocentesis. In the 176 with effusion and no drainage, adverse outcomes occurred in 17/88 (19%) prednisolone vs. 35/88 (40%) placebo patients (p = 0.003), with repeat pericardiocentesis 20 (23%) placebo vs. 9 (10%) prednisolone (p = 0.025). In a multivariate survival analysis (stratified by type of pericarditis), prednisolone reduced the overall death rate after adjusting for age and sex (p = 0.044), and substantially reduced the risk of death from pericarditis (p = 0.004). At 10 years, the great majority of surviving patients in all treatment groups were either fully active or out and about, even if activity was restricted. DISCUSSION: In the absence of a clear contraindication, a corticosteroid should be used in addition to antituberculosis chemotherapy in the management of patients with tuberculous pericarditis.     

An Unusual Cause of Dysphagia: Pericardial Effusion after Implantable Cardioverter-Defibrillator Placement

Background

Dysphagia is a known complication of pericardial effusions. Most cases of pericardial effusions are idiopathic, infectious, and neoplastic, but can also occur after cardiac procedures.

Objective

To report the case of a patient who developed dysphagia from a sub-acute pericardial effusion caused by the placement of an implantable cardioverter-defibrillator (ICD).

Case Report

A 62-year-old woman presented to the Emergency Department (ED) with a 2-day history of dysphagia. Imaging revealed a large pericardial effusion compressing the esophagus from the mid-thoracic level to the gastroesophageal junction. Ten days prior, a dual-chamber ICD with small-diameter active fixation leads was placed in the patient. There had been no apparent complications from the procedure, however, over this 10-day period she developed a sub-acute pericardial effusion from an incidental perforation during ICD lead placement that led to the extrinsic compression of the esophagus and her presenting symptom of dysphagia. The patient underwent pericardiocentesis for the pericardial effusion and she was discharged in stable condition.

Conclusion

This case report highlights the importance of recognizing a non-cardiac complaint such as dysphagia as the primary symptom of a critical cardiac condition. With an increase in cardiac procedures anticipated, clinicians should consider the possibility of a pericardial effusion as a cause of dysphagia, especially for those patients with recent cardiac procedures.     

AMOEBIC PERICARDITIS

Twenty-five patients with amoebic pericarditis were studiedand the clinical findings described. Two types were recognized,one with a serous effusion associated with a left lobe liverabscess and the other with a purulent effusion resulting fromrupture of a liver abscess into the pericardium. These havebeen termed presuppurative and suppurative amoebic pericarditisrespectively. The first type may progress to the second. Five patients suffered from the presuppurative variety of pericarditisand all recovered following treatment of the liver abscess. Of the 20 patients with suppurative pericarditis 12 recoveredand had no residual disability. In the eight patients who succumbed,death was due to cardiac tamponade (usually when the correctdiagnosis had not been made) or to constrictive pericarditisin which surgery was unsuccessful. It appears from this series that if suppurative amoebio pericarditisis treated by pericardial aspiration to relieve tamponade, andby the anti-amoebic drugs emetine hydrochloride and chloroquine,a proportion of patients recover fully without developing constriction.When constrictive pericarditis develops, conservative treatmentshould be continued as resolution often occurs. Pericardectomyshould be reserved for cases in which death seems inevitableunless constriction is relieved. ² The Amoebiasis Research Unit is sponsored by the followingbodies: The South African Council for Scientific and IndustrialResearch, University of Natal, Natal Pro vincial Administration,United States Public Health Service (Grant E-1592).     

Acute pericarditis complicated with pericardial effusion as first presentation of COVID‐19 in an adult sudanese patient: A case report

Acute pericarditis is an uncommon presentation of COVID‐19. Here, we described a case of a 50‐year‐old male patient who presented with chest pain without fever or cough and diagnosed with acute pericarditis complicated by pericardial effusion due to COVID‐19 after exclusion of other causes and received supportive treatment and improved over two weeks.     

“Ghost imaging” in pericardial cavity: Disappeared “tumor-like” masses in tuberculous pericarditis

A 66-year-old woman was admitted to our hospital due to chest distress and shortness of breath during 1 week. Transthoracic echocardiography (TTE) revealed massive pericardial effusion and multiple, irregular and high-density echo “tumor-like” masses on the heart, with the largest one on the apex. However, there were no masses found by computed tomography (CT) scan, except for increased lipids around the coronary artery. We performed emergency pericardiocentesis and drainage to relieve symptoms. The positron emission tomography/CT (PET/CT) also showed several ununiformly high accumulations in pericardial cavity. However, the high-density echo “tumor-like” masses cannot be seen by TTE after pericardiocentesis, and also cannot be detected when surgery. Pericardiotomy was performed due to severe pericardial adhesion. The diagnosis of tuberculosis (TB) was confirmed by pericardiotomy and pericardial biopsy.     

Multimodality imaging for the diagnosis and treatment of constrictive pericarditis

ABSTRACT

Introduction: Constrictive pericarditis can result in debilitating congestive right heart failure and has been considered an important cause of morbidity and mortality in patients with cardiovascular disease. Multimodality imaging continues to play a fundamental role in the individual approach to diagnosis, management, and prognosis of patients with this clinical syndrome.

Areas covered: This article gives an overview of the clinical spectrum of constrictive pericardial diseases and the role of multimodality imaging in the diagnosis of constrictive pericarditis. There is a focus on the emerging role of cardiac magnetic resonance (CMR) for the diagnosis, management, and prognostication of patients with constrictive pericarditis based on more recent case series, retrospective and prospective studies, which have helped to define the role of CMR.

Expert opinion: Advanced multimodality imaging assists with identification of both overt and subclinical pericardial inflammation. This allows the pericardiologist to recognize patients with potentially reversible disease, trial medical therapy, and thereby avoid mechanical removal of the pericardium. Further, pericardial characterization by CMR has provided novel information about the natural history of these pericardial conditions, which can help tailor therapy and improve prognosis.     

Acute pericarditis

Although acute pericarditis is most often associated with viral infection, it may also be caused by many diseases, drugs, invasive cardiothoracic procedures, and chest trauma. Diagnosing acute pericarditis is often a process of exclusion. A history of abrupt-onset chest pain, the presence of a pericardial friction rub, and changes on electrocardiography suggest acute pericarditis, as do PR-segment depression and upwardly concave ST-segment elevation. Although highly specific for pericarditis, the pericardial friction rub is often absent or transient. Auscultation during end expiration with the patient sitting up and leaning forward increases the likelihood of observing this physical finding. Echocardiography is recommended for most patients to confirm the diagnosis and to exclude tamponade. Outpatient management of select patients with acute pericarditis is an option. Complications may include pericardial effusion with tamponade, recurrence, and chronic constrictive pericarditis. Use of colchicine as an adjunct to conventional nonsteroidal anti-inflammatory drug therapy for acute viral pericarditis may hasten symptom resolution and reduce recurrences.     

Intrapericardial fibrinolysis: a useful treatment in the management of purulent pericarditis

Since the introduction of antibiotics into clinical practice, purulent pericarditis has become a rare disease. The major complication of the standard management for this condition is constrictive pericarditis. We report two cases of purulent pericarditis in which intrapericardial fibrinolysis was performed in order to minimize this complication. The first case was a 38-year-old man admitted to our intensive care unit (ICU) for management of constrictive pericarditis complicating purulent pericarditis diagnosed 17 days previously. The patient was treated with four intrapericardial injections of streptokinase (250000 IU each). Fluid drainage and cardiac output were improved. No change in clotting parameters was noted. Pericardiectomy and esophagectomy were then performed for a diagnosis of esophageal neoplasm. The postoperative course was uneventful. The second case was a 16-year-old boy admitted with loss of consciousness due to cardiac tamponade. Percutaneous pericardiocentesis drained 900 ml of cloudy fluid. Two intrapericardial injections were performed (day 1 and day 5) without any complication. Pericardial drainage was withdrawn on day 13 and the patient was discharged from ICU on the same day. Six months later, there was no evidence of constrictive pericarditis. Intrapericardial fibrinolysis appears to be safe and effective when prescribed rapidly in the course of purulent pericarditis. Received: 19 June 1996 Accepted: 15 September 1996     

Sex-based differences in prevalence and clinical presentation among pericarditis and myopericarditis patients

Background

Sex differences in heart diseases, including acute coronary syndrome, congestive heart failure, and atrial fibrillation, have been studied extensively. However, data are lacking regarding sex differences in pericarditis and myopericarditis patients.

Pericardial Disease: Diagnosis and Management

Pericardial diseases can present clinically as acute pericarditis, pericardial effusion, cardiac tamponade, and constrictive pericarditis. Patients can subsequently develop chronic or recurrent pericarditis. Structural abnormalities including congenitally absent pericardium and pericardial cysts are usually asymptomatic and are uncommon. Clinicians are often faced with several diagnostic and management questions relating to the various pericardial syndromes: What are the diagnostic criteria for the vast array of pericardial diseases? Which diagnostic tools should be used? Who requires hospitalization and who can be treated as an outpatient? Which medical management strategies have the best evidence base? When should corticosteroids be used? When should surgical pericardiectomy be considered? To identify relevant literature, we searched PubMed and MEDLINE using the keywords diagnosis, treatment, management, acute pericarditis, relapsing or recurrent pericarditis, pericardial effusion, cardiac tamponade, constrictive pericarditis, and restrictive cardiomyopathy. Studies were selected on the basis of clinical relevance and the impact on clinical practice. This review represents the currently available evidence and the experiences from the pericardial clinic at our institution to help guide the clinician in answering difficult diagnostic and management questions on pericardial diseases.CMR = cardiac magnetic resonance imaging; CT = computed tomography; CYP = cytochrome P450; ECG = electrocardiographic; ESC = European Society of Cardiology; IVC = inferior vena cava; LV = left ventricular; NSAID = nonsteroidal anti-inflammatory drug; RA = right atrium; RV = right ventricleThe pericardium is a thin covering that separates the heart from the remaining mediastinal structures and provides structural support while also having a substantial hemodynamic impact on the heart. The pericardium is not essential—normal cardiac function can be maintained in its absence—however, diseased pericardium presenting clinically as acute or chronic recurrent pericarditis, pericardial effusion, cardiac tamponade, and pericardial constriction can be challenging to manage and life-threatening in some cases. The etiology of pericardial disease is often difficult to determine or remains idiopathic. However, microorganisms, including viruses and bacteria; systemic illnesses, including neoplasia, autoimmune disease, and connective tissue disease; renal failure; previous cardiac surgery; previous myocardial infarction; trauma; aortic dissection; radiation; and, rarely, drugs have been associated with pericardial diseases.The diagnosis and management of pericardial diseases remain challenging because of the vast spectrum of manifestations and the lack of clinical data on which to base guidelines by the American College of Cardiology and the American Heart Association. However, the European Society of Cardiology (ESC) published guidelines on pericardial disease in 2004.¹ This review aims to describe the methods of diagnosing and managing major pericardial syndromes on the basis of the literature and the clinical experience of our pericardial clinic. Searches were performed on PubMed and MEDLINE using the keywords diagnosis, treatment, management, acute pericarditis, relapsing or recurrent pericarditis, pericardial effusion, cardiac tamponade, constrictive pericarditis, and restrictive cardiomyopathy. No date limitations were set. Studies were selected on the basis of clinical relevance and the impact on clinical practice.     

Pericardiocentesis: differential aspects of a common procedure

Objective: To evaluate the risk and effectiveness of pericardiocentesis in primary and repeat cardiac tamponade Design: Retrospective analysis. Setting: Intensive care unit in a medical university hospital. Patients: Sixty-three consecutively admitted patients with cardiac tamponade. Interventions: In all patients pericardiocentesis was performed via the subxiphoid pathway after echocardiographic detection of the pericardial effusion. Measurements and results: There was no adverse event in patients undergoing primary pericardiocentesis, which was sufficient to resolve pericardial effusion in 51 of 63 patients (81 %). However, repeat pericardiocentesis necessitated by the recurrence of symptomatic pericardial effusion yielded suboptimal results in 10 of 12 patients (83 %). Conclusion: Pericardiocentesis is the treatment of choice for primary symptomatic pericardial effusion. In recurrent pericardial effusion surgical approaches appear to be preferable. Received: 27 August 1999 Final revision received: 18 January 2000 Accepted: 28 February 2000