Relationship between pericardial pressure and lymphatic pericardial fluid transport in sheep

We investigated the relationship between pericardial pressure and the volumetric lymphatic clearance rate of pericardial fluid in sheep. A single catheter perfusion system was established to deliver tracer to the pericardial cavity and control pericardial pressure. In addition, catheters were placed into the thoracic duct and into the jugular vein at the base of the neck. (125)I-human serum albumin (HSA) was administered into the pericardial perfusate to serve as the lymph flow marker and its concentration monitored in the effluent from the outflow end of the perfusion system. (131)I-HSA was injected intravenously to permit calculation of plasma tracer loss and tracer recirculation into lymphatics. From mass balance equations, estimates of total pericardial clearance into lymphatics increased significantly as pericardial pressures were elevated in 2. 5 cm H(2)O increments from 2.5 to 12.5 cm H(2)O (P = 0.018). Pericardial lymph transport ranged from 0.89 +/- 0.10 to 3.09 +/- 0. 66 ml/h at 2.5 and 12.5 cm H(2)O pericardial pressure, respectively. The majority of transport occurred through mediastinal vessels with a small proportion (10.3 to 23.9%) being cleared into lymphatics leading to the thoracic duct. We conclude that lymphatic pericardial fluid transport increases approximately 3.5-fold over a pericardial pressure range that encompasses the transition between the shallow and steep portions of the pericardial pressure-volume relationship.     

Scleroderma pericardial disease presented with a large pericardial effusion--a case report

Scleroderma pericardial disease is usually silent and benign. The incidence of pericardial involvement in scleroderma is about 50% according to autopsy results, but symptomatic pericarditis manifests in about 16% of patients with diffuse scleroderma and in about 30% of patients with limited scleroderma. The clinically evident pericardial effusion is rare in scleroderma, although it can be detected in about 41% of patients with echocardiography. In majority of the patients, the pericardial effusion is small and not associated with symptoms. The pericardial effusion manifests usually after the manifestation of the other clinical and serologic features of scleroderma. A case of scleroderma is reported that presented with a large pericardial effusion, which antedated the other clinical and serologic features of scleroderma. The pericardial involvement in scleroderma is reviewed.     

Recurrent pericardial effusion and pericardial tamponade in a patient with limited systemic sclerosis

We describe a patient with limited systemic sclerosis who presented with a large pericardial effusion with tamponade on echocardiogram, requiring pericardiocentesis to drain 1.2 l of fluid. She had a rapid re-accumulation of pericardial fluid and subsequently required a pericardial window. Although small pericardial effusions are common in patients with systemic sclerosis it is rare to have hemodynamic compromise. Previously reported large pericardial effusions have been seen in patients with pulmonary hypertension and renal failure however these were absent in our patient.     

Primary malignant pericardial sarcoma

We describe the case of a 91-year-old man who presented with a large pericardial effusion and an intrapericardial mass. Primary malignant pericardial sarcoma was diagnosed by percutaneous pericardial tumor biopsy. The patient died of multiple organ failure three months later. We also review the epidemiology, clinical presentation, pathology and treatment of cardiac tumors. The prognosis of primary malignant pericardial sarcoma is very poor especially in old people.     

心包腔容积—压力关系的临床研究

１６ 例中到大量心包积液患者在Ｘ线下使用Ｓｅｌｄｉｎｇｅｒ法,经剑突下穿刺心包放置７Ｆ导鞘,心包造影,定量抽液及压力测定。资料完整的１５ 例患者显示:心包腔内压力与心包积液量无相关性。有心包填塞症状者,当抽液量达到１５０ ｍ ｌ时,心包内压力下降曲线最为陡峭:幅度最大,而以后随积液量减少,压力下降徐缓。当抽液到２５０ ｍ ｌ时心包腔舒张压在０．４０ ｋＰａ～－ １．４６ ｋＰａ 之间,大多数低于文献报道的右房舒张压。在积液基本抽完时,１２ 例心包腔平均压在０～－ １．３３ ｋＰａ之间,最低可达－ ２．０ ｋＰａ,与胸膜腔压近似。１ 例有肺气肿的老年患者和２ 例有胸腔积液者压力在０．１３ ｋＰａ～０．５３ ｋＰａ之间     

Echocardiographic interpretation of pericardial effusion

Echocardiography has proved to be quite useful in the detection of pericardial effusion. As little as 15 ml of fluid within the pericardial space can be detected. Specific signs of pericardial effusion, such as electrical alternans and paradoxical pulse, have become better understood by echocardiographic study. Yet, with all the benefits of echocardiography, the detection of pericardial effusion still may be quite difficult if careful attention is not given to technique. False-positive diagnosis of anterior pericardial effusion can be seen with epicardial fat pad, pericardial cyst, or foramen of Morgagni hernia. False-positive posterior pericardial effusion can be seen in large left pleural effusion, calcified mitral anulus, or excessively medial transducer angulation. New "switched-gain" circuits have helped detection of pericardial effusion by enhancement of pericardial echoes.     

Percutaneous balloon pericardial window for patients with malignant pericardial effusion and tamponade

We performed percutaneous balloon pericardial window (PBPW) in 8 patients (age 40 to 70 yrs; 4 men, 4 women) with malignant pericardial effusion and tamponade. Pericardial window was indicated because they continued to drain >100 ml/day of pericardial fluid through the pigtail catheter for >/3 days. A 0.038 inch guidewire was advanced through the pigtail catheter into the pericardial space and then the catheter was removed. A 20 mm diameter, 3 cm long balloon dilating catheter was advanced to straddle the parietal pericardium. Manual inflations were performed until the waist produced by the pericardium disappeared. All patients tolerated the procedure well with minimal discomfort and with no complications. A left or bilateral pleural effusion occurred in all patients after PBPW. No patient developed recurrent pericardial tamponade at a mean follow-up of 6 ± 2 months. Thus, PBPW is a useful and safe technique to avoid surgery in patients with malignant pericardial effusion and tamponade.     

Video-assisted transportal pericardial window

Pericardial interventions for the diagnosis and treatment of pericardial disease has been evolving since the 17th century. The controversy over opened or closed procedures, the optimal guidance modality, and techniques for the creation of pericardial windows continues to be debated. This report describes two patients who the endoscopic approach to creating a pericardial window. © Wiley-Liss, Inc.     

Echocardiographic quantitation of pericardial effusion

This study was undertaken to test the validity of M-mode echocardiographic quantitation of pericardial effusion. M-mode estimate of the volume of pericardial effusion in 27 patients was compared with the actual volume of pericardial effusion removed during surgical pericardial drainage. The 16 two-dimensional echocardiographic studies in patients with small, moderate, and large pericardial effusions were reviewed to examine the distribution of pericardial fluid around the heart. Although there was good correlation between the echocardiographic estimate and the actual volume removed during surgery (r = 0.78), significant overestimation and underestimation were noted. Our findings suggest that the errors in the estimate could be attributed in part to difficulties in precise measurement of the epicardial and pericardial landmarks and in part to nonuniform distribution of pericardial fluid around the heart.     

Malignant pericardial effusion not diagnosed by pericardial fluid and biopsy: importance of CT scan

A 47-year-old female came to the emergency room due to dyspnea for 1 month. Initial chest X-ray showed enlargement of the cardiac silhouette. Emergent echocardiogram demonstrated large amount of pericardial effusion. Pericardiostomy with pericardial biopsy was performed. The etiology of large amount of hemorrhagic pericardial effusion could not be confirmed even by aggressive analysis of pericardial fluid and pericardial biopsy. CT scan of the mediastinum was performed. Percutaneous fine needle aspiration biopsy demonstrated thymic carcinoma with focal squamous differentiation. When the analysis of pericardial fluid and pericardial biopsy cannot reveal the etiology of hemorrhagic pericardial effusion, CT scan should be performed.     

Pericardial hematoma mimicking pericardial abscess

A 26-year-old man, with human immunodeficiency virus infection, on hemodialysis, was hospitalized due to infective endocarditis. A mechanical prosthetic mitral valve was implanted. During postoperative period, he maintained signs suggestive of infection. The transthoracic echocardiograms (TTE) revealed a pericardial effusion. One week later was visible a circumscribed collection compatible with a pericardial abscess. He was refused for cardiac surgery; however, inflammatory parameters elevation persisted. The TTE showed a periprosthetic mitral leak, and cardiac surgery was performed. The pericardial drainage revealed a hematoma. This case highlights the difficulty on echocardiographic differential diagnosis between a pericardial hematoma and pericardial abscess in clinical practice.     

Nonuniform distribution of normal pericardial fluid

Summary It has been suggested that pericardial fluid functions as a lubricant rather than a means of transmitting pericardial pressure from one region of the heart to another. Since the functional behavior of pericardial fluid depends on fluid thickness, we measured pericardial volume and fluid distribution. In seven animals, we found that the normal canine pericardium contains 0.25±0.15 ml of pericardial fluid per kg of body weight, resulting in an average pericardial fluid thickness of only 0.34±0.27 mm. We next determined the pericardial fluid distribution in eight anesthetized mongrel dogs (17–29 kg). Color video images were recorded, while green dye (0.1 ml) was injected into the pericardial space overlying the ventricular apex to allow visualization of the pericardial fluid distribution. Within 26±17 s (range 15–53 s), dye reached the base of the heart. After 15 min of equilibration, the dye distribution appeared very nonuniform with dye accumulation over the interventricular and atrioventricular grooves. Little or no dye was present over the right and left ventricular free walls.We conclude that pericardial fluid thickness over the interventricular and atrio-ventricular grooves is sufficient to allow fluid motion in these regions. In contrast, pericardial fluid thickness overlying the ventricular free walls is very thin. Thus, in these regions the pericardial fluid functions primarily as a lubricant: and regional variations in pericardial pressure may occur.This study was supported in part by NIH Grant Numbers HL36068 and HL40511.     

Ultrasonography in pericardial effusion

Four cases of pericardial effusion diagnosed by echocardiography are reported. While one of the four cases was referred for echocardiography with a diagnosis of pericardial effusion, the other three patients were selected for echocardiography on the basis of cardiomegaly demonstrated in plain x-ray chest examination. Real time echocardiography was considered to be most rapid, safe, convenient, accurate and least invasive method of diagnosing pericardial effusion.     

Echocardiographic evaluation of pericardial diseases

This review has attempted to summarize the usefulness of echocardiography in pericardial effusion and other pericardial diseases. As stated before, it is an extremely useful technique for the detection and following of patients with pericardial effusion. The usefulness in other forms of pericardial disease is less well-established.     

Pericardioscopy as adjunct to pericardial window

A technique for pericardioscopy at the time of subxiphoid pericardial window was evaluated in 17 patients undergoing surgery for clinically suspected malignant pericardial effusion. Best results were obtained using a rigid mediastinoscope for inspection of the posterior and lateral pericardial surfaces. No complications ensued, although many patients experienced cardiac arrythmias which always resolved with removal of the scope. Pericardioscopy revealed cancer transgressing the pericardium near the pulmonary veins in one patient, and this would have been missed without pericardioscopy. Pericardioscopy confirmed palpable metastatic deposits on the inferior pericardial surface in two other patients. In 14 patients, pericardioscopy did not reveal malignancy, although four of these patients had both positive fluid cytologic findings and malignant infiltration of the pericardial biopsy. In one patient a palpable but not visible nodule was proved to be an extrinsic hepatic metastasis. Pericardioscopy is a safe intervention chiefly applicable in patients with central tumors and pericardial effusion in whom subxiphoid pericardial window is not clearly diagnostic at the time of surgery.     

Benign pericardial schwannoma with massive pericardial effusion in a Chinese man: A case report

Primary cardiac neoplasms are rare, and the pericardial schwannoma has an even lower occurrence. We report a case of pericardial schwannoma in China, which is the eighth reported case adding to the existing literature on pericardial schwannoma, and this is the first case reported complicated with massive pericardial effusion. Pericardial schwannomas are usually benign, but they can sometimes have a malignant tendency and cause life‐threatening complications. Thus, it should be managed aggressively and completely resected.     

Neoplastic pericardial disease

The spread of metastatic cancer to the pericardium is the most common cause of cardiac tamponade in medical inpatient settings. Lung cancer, breast cancer, and the hematologic malignancies account for some three quarters of the cases. Occasionally, usually in lung cancer, the pericardial involvement is the first clinical presentation of the neoplastic disease. Differential diagnosis includes radiation pericarditis and cardiac toxicity from chemotherapeutic drugs, as well as any of the causes of pericardial disease in patients without neoplasm. Idiopathic nonneoplastic, noninflammatory pericardial effusion is surprisingly common in cancer patients. The initial cardiac tamponade may be managed with either needle tap or subxiphoid pericardiostomy. Pericardiocentesis, performed with echocardiographic guidance and followed by percutaneous catheter drainage for several days, is safe and effective in neoplastic pericardial effusion. It may be the only local therapy that is needed. Further local treatment, for those patients who develop recurrent cardiac tamponade after an initial drainage procedure, may include tetracycline sclerosis of the pericardial space, instillation of cancer chemotherapeutic agents, radiation therapy, and pericardiectomy. No controlled clinical trials of these methods of treatment are available. The choice of therapy is based on various considerations in individual patients, particularly the patient's general condition and the likelihood of a long-term response to treatment of the systemic neoplastic disease.     

Nasopharyngeal carcinoma with pericardial metastasis

Nasopharyngeal carcinoma (NPC) is prevalent in Taiwan and is characterized by a high frequency of nodal metastasis. The most common organs with distal metastases are the bones, lungs, and liver, with extremely rare cases to the pericardium. Herein, we report a rare case with NPC who presented with dyspnea and orthopnea. Serial studies, including pericardial biopsy, revealed NPC with pericardial metastasis and pericardial effusion. The tumor cells of both the original and metastatic tumors were positive for Epstein-Barr virus by in situ hybridization. This is the first histologically confirmed case of NPC with pericardial metastasis.     

Neoplastic pericardial effusion

Neoplastic pericardial effusion is a serious and common clinical disorder encountered by cardiologists, cardiothoracic surgeons, oncologists, and radiation oncologists. It may develop from direct extension or metastatic spread of the underlying malignancy, from an opportunistic infection, or from a complication of radiation therapy or chemotherapeutic toxicity. The clinical presentation varies, and the patient may be hemodynamically unstable in the setting of constrictive pericarditis and cardiac tamponade. The management depends on the patient's prognosis and varies from pericardiocentesis, sclerotherapy, and balloon pericardiotomy to cardiothoracic surgery. Patients with neoplastic pericardial effusion face a grave prognosis, as their malignancy is usually more advanced. This review article discusses the epidemiology and etiology, pathophysiology, clinical presentation, diagnosis, management, and prognosis of neoplastic pericardial effusion.