Cytokine Activation in Pericardial Fluids in Different Forms of Pericarditis

There are many caused of pericardial effusion and it is useful to classify them etiologically, since this disorder is the most common pathologic process involving the pericardium. This report details our experience with pericardioscopy and epicardial biopsy in 101 patients with pericardial effusions in whom pericardioscopy was performed. By means of clinical data and polymerase chain reaction we tried to elucidate the etiology of the pericardial effusion which were classified as follows: we found 41 effusions to be induced by primary malignant tumors or tumors metastatic to the pericardium. Specific diagnosis of viral and bacterial pericarditis was established in 17 patients by examination of the pericardial effusion with PCR, where we found 3 patients positive for adenovirus, 5 patients positive for cytomegalovirus, 2 patients positive for enterovirus-RNA and 5 patients positive for borrelia Burgdorferi-DNA. Additionally, idiopathic effusions (lymphocytic and autoreactive) were seen in 35 patients. In summary immunological and molecular biology investigations seem to provide an additional tool in the diagnostic of pericardial effusion with unknown etiology. If we focus on the ELISA results, there is some evidence, that the demonstration of activation markers and soluble mediators of inflammation such as Il-6, Il-8 and IFN-gamma in pericardial effusion and the simultaneously lack of these mediators in sera of the patients first may be helpful in the discrimination of autoreactive and lymphocytic effusion. Second, this cytokine pattern or distribution indicates a possible local inflammatory process, where these cytokines were all released from activated T lymphocytes present in lymphocytic effusion. In the future, this may have therapeutic implications. Zusammenfassung Die Ursachen für eine Perikarditis mit Ergussbildung sind unterschiedlich, sodass es sinnvoll ist, diese nach ihren Ätiologien zu unterscheiden. In diese Untersuchung wurden 101 Patienten mit Perikarditis und Ergussbildung unterschiedlicher Ätiologie eingeschlossen, wobei jeweils eine Perikardioskopie mit Punktion des Ergussen und Perikard- bzw. Epikardbiopsie durchgeführt wurde. Neben den klinischen wurden labordiagnostische Untersuchungen zur Klärung der Ursache der Ergussbildung durchgeführt. Hierzu gehörte der Nachweis von Infektionserregern über Polymerasekettenreaktion (PCR) aus dem Erguss der Patienten ebenso wie zytologische Untersuchungen. Die Patienten konnten so in folgende Gruppen eingeteilt werden: 41 Ergüsse wurden durch maligne Tumoren oder Tumormetastasen hervorgerufen. Die spezifische Diagnose einer viralen oder bakteriellen Perikarditis konnte durch PCR aus der Perikardflüssigkeit bei 17 Patienten nachgewiesen werden. Idiopathische Ergüsse (lymphozytär/autoreaktiv) wurden bei 35 Patienten gefunden. Um mögliche Hinweise auf autoreaktive Mechanismen zu erhalten, wurden im Vergleich zum Serum Zytokine (Interferon gamma, Interleukin 6 und 8) mittels ELISA nachgewiesen. Die Ergebnisse weisen darauf hin, dass der Nachweis von Aktivierungsmarkern und löslichen Mediatoren der Entzündungsreaktion wie Il-6, Il-8 und IFN-gamma im Perikarderguss und das gleichzeitige Fehlen dieser Mediatoren im Serum der Patienten zunächst einmal zur Unterscheidung zwischen lymphozytären und autoreaktiven Perikardergüssen hilfreich sein kann. Zweitens deutet diese Zytokinverteilung auf einen lokalen entzündlichen Prozess mit Freisetzung der Zytokine aus aktivierten T-Zellen hin, der möglicherweise in Zukunft therapeutische Konsequenzen haben könnte.     

Intrapericardial treatment of autoreactive myocarditis with triamcinolon. Successful administration in patients with minimal pericardial effusion

A major clinical drawback in the treatment of autoreactive pericarditis is its inherent feature to relapse. Intrapericardial treatment with triamcinolone was reported to be efficient in patients with large, symptomatic autoreactive pericardial effusions, avoiding side effects of systemic treatment as well as compliance problems. Intrapericardial treatment with 300 mg/m2 triamcinolone was for the first time performed in patients with autoreactive myopericarditis and minimal pericardial effusions (75 to 110 ml). After 12 months of follow-up both patients are asymptomatic and there were no further recurrences of pericardial effusion. Pericardiocentesis in these patients was performed with the application of the PerDUCER device, guided by pericardioscopy. This device has a hemispherical cavity at the top of the instrument connected with a vacuum-producing syringe. In this cavity the pericardium is captured by vacuum and tangentially punctured by the introducer needle. Pericardium that can be captured, must be up to 2 mm thin to fit into the hemispherical cavity. Pericardioscopy performed from the anterior mediastinum significantly contributed to the success of the procedures enabling visualization of the portions of the pericardium free of adipose tissue or adhesions, suitable for puncture with the PerDUCER. In conclusion, intrapericardial treatment of symptomatic autoreactive myopericarditis with minimal pericardial effusion was safely and efficiently performed in 2 patients. Pericardiocentesis was enabled by means of the PerDUCER device, facilitated by pericardioscopy.     

Pericardioscopy and epi- and pericardial biopsy—a new window to the heart improving etiological diagnoses and permitting targeted intrapericardial therapy

The etiology of pericardial effusions remains unresolved in many cases because not the full spectrum of diagnostic methods including cytology, histology, immunohistology and PCR on cardiotropic agents, which are currently available, used in many institutions. After comprehensive clinical workup and use of imaging methods, such as echocardiography and cardiac MRI, pericardiocentesis and epicardial and pericardial biopsy were carried out under pericardioscopical control of the biopsy site. Biopsies and fluid were evaluated by cytological, histological, immunological and molecular (PCR) methods in 259 patients of our tertiary referral center following an identical clinical pathway, diagnostic and therapeutic algorithm in all cases. A standard clinical pathway and the same diagnostic and therapeutic algorithms were used in all cases. When all methods are applied to patients with pericardial effusions, “idiopathic” pericardial effusion is no longer a relevant diagnosis. Autoreactive and lymphocytic pericardial effusions are the leading diagnosis in 35 % of patients in the prospective Marburg registry, followed by malignant effusions in 28 % of cases. Viral genome was assessed in fluid and epi- as well as pericardial biopsies in 12 %, followed by post-traumatic/iatrogenic effusions in 15 % and purulent/bacterial effusions in only 2 %. Pericardioscopy permits the macroscopic inspection of the pulsating heart and its disease-associated macroscopic alterations. It also permits safe and targeted biopsy for further investigations of the tissue. Therapy, tailored to the individual etiology, can be selected such as intrapericardial instillation in autoreactive effusions with triamcinolone and with cisplatin or thiotepa in neoplastic effusions. With this approach the recurrence of pericardial effusion can be avoided effectively. A comprehensive approach to the diagnosis of pericardial effusions in conjunction with pericardioscopy for targeted tissue sampling is the prerequisite for an etiologically based intrapericardial and systemic treatment, which improves outcome and prognosis.     

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.     

Flexible percutaneous pericardioscopy: inherent drawbacks and recent advances

Pericardioscopy enables endoscopic inspection and aimed biopsy of the parietal and visceral pericardium. To elucidate possible technical modifications contributing to the feasibility, diagnostic value and safety of the procedure, pericardioscopy with an Olympus HYF-1T flexible endoscope was performed in 32 patients (53.1% males, mean age 46.2 +/- 13.1 years) with pericardial effusions. In all patients, the initial step of the procedure was subxiphoid fluoroscopically controlled pericardiocentesis and drainage of the pericardial effusion. An Olympus FB-41ST biopsy forceps was applied for endoscopically guided pericardial biopsies. Standard sampling was used in 22/32 patients (3 to 6 samples/patient) and extensive sampling in 10/32 patients (18 to 20 samples/patient). In additional 12 patients pericardial biopsy was performed without pericardioscopy, under fluoroscopic control. Endoscopic visualization was clearly superior when pericardial effusion was partially replaced with 100 to 300 ml of air (29/32 procedures) in comparison to 3/32 procedures in which the pericardial effusion was replaced with warm normal saline (37 degrees C). In patients with hemorrhagic effusion (12/32), we either repeatedly injected and removed 100 to 150 ml volumes of normal saline (37 degrees C), or postponed pericardioscopy for 2 to 3 days of active drainage. The specificity of endoscopic findings is low and not decisive for the diagnosis. However, pericardioscopy is significantly contributing to the diagnostic value of pericardial biopsy, especially regarding establishing the new diagnosis and etiology of the pericardial disease. Sampling efficiency was also significantly higher for procedures using aimed pericardial biopsy with standard and extensive sampling compared to procedures performed under fluoroscopy: 86.2%, 87.3%, and 43.7%, respectively. No major complications directly related to the procedure were encountered. Minor complications included: short-run ventricular tachycardia (6.3%), pain at the sheath entry site (75%) and transient fever (37.5%). In conclusion, pericardioscopy with Olympus HYF-1T, after air instillation, is a technically complex, but safe procedure that enables excellent visualization and extensive pericardial sampling with improved diagnostic value of pericardial biopsies.     

Neue Möglichkeiten der Diagnostik und Therapie der Perikarditis

Pericarditis is an inflammatory disorder of the pericardium with or without an associated pericardial effusion. The diagnosis is based on the clinical manifestations and typical ECG changes. Echocardiography is essential to reveal the size of the pericardial effusion and to determine its hemodynamic significance. The precise etiology of pericarditis may be established by pericardiocentesis, pericardioscopy and targeted biopsy and consecutive pericardial fluid and biopsy analysis by molecular biology, cytology, microbiology and immunological techniques. Non steroidal anti-inflammatory drugs and/or colchicine are the mainstay of anti-inflammatory treatment of pericarditis. Systemic corticoid treatment should be restricted to patients with associated autoimmune disorder, relapsing pericarditis and as a complementary therapy in tuberculous pericarditis. In autoreactive pericarditis intrapericardial instillation of triamcinolone is effective with few side effects. In malignant pericarditis the intrapericardial administration of cisplatin prevents early recurrences.     

Malignant pericardial effusions: usefulness of pericardioscopy.

In cases of malignant pericardial effusion, surgical subxiphoid biopsy sometimes fails to prove malignancy. To assess the usefulness of pericardioscopy, which allows an endoscopic investigation of the pericardial cavity, this technique was systematically performed during surgical drainage procedures that were performed on 40 patients who had pericardial effusions of suspected malignant origin. Twenty-six patients had a history of neoplasm, 10 had a history of hematologic malignancy, and four had recent tumors or lymphadenopathies that were suspected to be of malignant origin. Classical tests that are usually performed during a conventional surgical drainage procedure (fluid studies and subxiphoid biopsy) were combined with direct visualization of the pericardial surfaces and guided biopsies of suspicious areas. The follow-up period after pericardioscopy was at least 12 months. Two early deaths occurred after pericardioscopy, but no death was directly related to the endoscopy. According to all of the tests that were performed, diagnoses were malignant pericardial effusion in 15 of 40 patients (group I, 37%) and nonmalignant pericardial effusion in 25 of 40 patients (group II, 73%). In 3 of 13 patients (23%) in group I, the diagnosis was obtained only by pericardioscopy (results of cytologic studies and subxiphoid biopsy were negative). In two patients in group I, pericardioscopy could not be completed, but the diagnosis of malignant pericardial effusion was obtained by pericardiocentesis. In group II, effusion was considered to be postradiation pericarditis in five cases, infectious pericarditis in three cases (bacterial in one and tuberculous in two), hemopericardium induced by coagulation disturbances in three cases, and idiopathic pericarditis in 14 cases.(ABSTRACT TRUNCATED AT 250 WORDS)     

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.     

Tumormarker im Perikarderguss bei malignen und nichtmalignen Perikarderg��ssen

Background

The differential diagnosis of pericardial effusion is often challenging because different etiologies can be discussed. Of particular therapeutic and prognostic importance is the definitive differentiation of malignant pericardial effusion from benign effusions. The definitive diagnosis of malignant pericardial effusion is established by a positive cytological examination of the pericardial fluid. However, pericardial fluid cytology, although specific has variable sensitivity. Tumor markers are often investigated after pericardiocentesis but their utility as an aid for the diagnosis of malignant pericardial effusion is not well established. The aim of this study was to measure the concentrations of the tumor markers CEA, CA?19-9, CA?72-4, SCC and NSE in malignant and non-malignant pericardial effusions and to assess their diagnostic utility in differentiating malignant from benign pericardial effusion.

Methods

We investigated the pericardial fluid of 29?patients with proven malignant pericardial effusion and 25?patients with non-malignant pericardial effusion. The etiology of the pericardial effusion was defined by pericardial cytology, epicardial histology and PCR for cardiotropic viruses from pericardial and epicardial tissue acquired by pericardioscopy. The group with non-malignant pericardial effusion comprised 15?patients with autoreactive effusion and 10?patients with viral pericardial effusion. We analyzed the following tumor markers in the pericardial fluid: carcinoembryonic antigen (CEA), carbohydrate antigen (CA)?19-9, carbohydrate antigen (CA)?72-4, squamous cell carcinoma (SCC) antigen and neuron-specific enolase (NSE).

Results

Of the tumor markers tested the mean concentrations of the CEA, CA?72-4 and CA?19-9 were significantly higher in malignant pericardial effusions than in non-malignant effusions (CEA 450.66 ±1620.58???g/l vs. 0.72 ±1.49???g/l, p<0.001; CA?19-9 1331.31 ±3420.87?kU/l vs. 58.85 ±17.53?kU/l, p=0.04; CA?72-4 707.90 ±2397.55?kU/l vs. 0.48 ±2.40?kU/l, p<0.001). ROC curve analysis showed that pericardial fluid CA?72-4 yielded an area under the curve (AUC) of 0.85 (95% confidence interval 0.74?C0.95), followed by CEA with 0.80 (95% confidence interval 0.68?C0.92). Pericardial fluid CA?72-4 levels >1.0?kU/l had 72% sensitivity (95% confidence interval 53%?C87%) and 96% specificity (95% confidence interval 80%?C99.9%) and CA?72-4 levels >2.5?kU/l had 69% sensitivity (95% confidence interval 49%?C85%) and 96% specificity (95% confidence interval 80%?C99.9%) in differentiating malignant pericardial effusions from effusions due to benign conditions.

Conclusion

Malignant pericardial effusions are associated with significantly higher pericardial concentrations of the tumor markers CEA, CA?72-4 and CA?19-9. Of the tested tumor markers, measurement of CA?72-4 levels in pericardial fluid offered the best diagnostic accuracy. Based on our data evaluation of every patient with unexplained pericardial effusion and negative pericardial fluid cytology should include the measurement of pericardial fluid CA?72-4 levels. Under these circumstances the elevation of pericardial fluid CA?72-4 levels should include malignancy as a probable diagnosis.     

Echocardiographic mimicry of pericardial effusion

Echocardiography is a sensitive technique for the detection of pericardial effusion, but the abnormal echocardiographic patterns seen with effusions are not, however, entirely specific for that diagnosis. This study describes four patients in whom anatomic structures, a coronary artery to coronary sinus fistula (one case) and tumors metastatic to pericardium (three cases), produced posterior and, in two cases, anterior spaces compatible with pericardial fluid. Echocardiographic patterns mimicking pericardial effusion have previously been reported in patients with anatomic abnormalities such as mitral anular calcification, pleural effusions, left atrial enlargement, anterior mediastinal or pericardial tumors, foramen of Morgagni hernia and pseudoaneurysm of the left ventricle. It appears that structures of fluid or tissue density, interposed between the heart and the airfilled lung, can produce echocardiographic patterns simulating pericardial effusion.     

2-dimensional echocardiography in the evaluation of pericardial pathology: new prospects for its differential diagnosis

We examined retrospectively the M-mode and two-dimensional echocardiograms performed in our laboratory on 227 patients with pericardial diseases, in order to assess the capabilities and limits of echocardiography in this field. We observed 4 patients with congenital absence of the pericardium, 10 with of constrictive or infiltrative-adhesive pericarditis, 213 pericardial effusions, associated with left pleural effusion in 36 cases and with different kinds of intrapericardial masses in 33 cases. Through qualitative analysis of the echogenicity of such masses some aspects were singled out which may prove useful in identifying intrapericardial fat, as well as tumors. We also suggest new ways of using specific echocardiographic sections to differentiate left pleural effusions from pericardial effusions, and to identify very small pericardial effusions.     

纤维心包镜在中大量心包积液病因诊断中的应用

目的观察纤维心包镜在中大量心包积液诊断中的作用。方法对188例中大量心包积液病因不明患者进行剑突下心包开窗术及纤维心包镜检查,明确心包积液病因及镜下表现。结果癌性心包炎90例,心包积液多为血性,符合镜下特征51例,临床病因诊断符合率56.7%;非特异性心包炎67例,诊断符合率56.7%;结核性心包炎22例,诊断符合率63.6%;化脓性心包炎8例,诊断符合率100%。术中曾出现心率减慢、血压偏低7例,气胸6例,腹膜损伤3例,偶发室性期前收缩30例,减压性肺水肿6例,经相应治疗或自行缓解。结论纤维心包镜对中大量心包积液的病因诊断有较大的实用价值。     

Case Report: Cardiac Tamponade Resembling an Acute Myocardial Infarction as the Initial Manifestation of Metastatic Pericardial Adenocarcinoma

Pericardial malignancies are uncommon, usually metastatic, linked to terminal oncology patients, and rarely diagnosed premortem. A very small number of patients will develop signs and symptoms of malignant pericardial effusion as initial clinical manifestation of neoplastic disease. Among these patients, a minority will progress to a life-threatening cardiac tamponade. It is exceedingly rare for a cardiac tamponade to be the unveiling clinical manifestation of an unknown malignancy, either primary or metastatic to pericardium. We present the case of a 50-year-old male who was admitted to the emergency department with an acute myocardial infarction diagnosis that turned out to be a cardiac tamponade of unknown etiology. Further studies revealed a metastatic pericardial adenocarcinoma with secondary cardiac tamponade. We encourage considering malignancies metastatic to pericardium as probable etiology for large pericardial effusions and cardiac tamponade of unknown etiology.     

以心包积液为主多浆膜腔积液患者的病因学分布和临床特征分析

目的:明确以心包积液为主多浆膜腔积液患者的病因学分布以及恶性积液和非恶性积液患者临床特征的差异.方法:回顾性分析2010年1月至2017年12月于北京大学人民医院住院治疗的326例以心包积液为主多浆膜腔积液患者的临床资料,明确病因分布情况;并根据多浆膜腔积液是否为恶性肿瘤所致,分为恶性积液组和非恶性积液组,分析两组患者...     

Intrapericardial Treatment of Autoreactive Myocarditis with Triamcinolon Successful Administration in Patients with Minimal Pericardial Effusion

A major clinical drawback in the treatment of autoreactive pericarditis is its inherent feature to relapse. Intrapericardial treatment with triamcinolone was reported to be efficient in patients with large, symptomatic autoreactive pericardial effusions, avoiding side effects of systemic treatment as well as compliance problems. Intrapericardial treatment with 300 mg/m² triamcinolone was for the first time performed in patients with autoreactive myopericarditis and minimal pericardial effusions (75 to 110 ml). After 12 months of follow-up both patients are asymptomatic and there were no further recurrences of pericardial effusion. Pericardiocentesis in these patients was performed with the application of the PerDUCER^® device, guided by pericardioscopy. This device has a hemisperical cavity at the top of the instrument connected with a vacuum-producing syringe. In this cavity the pericardium is captured by vacuum and tangentially punctured by the introducer needle. Pericardium that can be captured, must be up to 2 mm thin to fit into the hemispherical cavity. Pericardioscopy performed from the anterior mediastinum significantly contributed to the success of the procedures enabling visualization of the portions of the pericardium free of adipose tissue or adhesions, suitable for puncture with the PerDUCER^®. In conclusion, intrapericardial treatment of symptomatic autoreactive myopericarditis with minimal pericardial effusion was safely and efficiently performed in 2 patients. Pericardiocentesis was enabled by means of the PerDUCER^® device, facilitated by pericardioscopy. Zusammenfassung Die Behandlung von Patienten mit autoreaktiver Perikarditis wird durch die hohe Rezidivrate kompliziert. Bisher erfolgte eine lokale intraperikardiale Behandlung mit Triamcinolon nur bei Patienten mit großen, symptomatischen Perikardergüssen, um die Nebenwirkungen einer systemischen Corticoidtherapie und die tägliche Medikamenteneinnahme zu vermeiden. Hier wird erstmals über die intraperikardiale Therapie mit 300 mg/m² Triamcinolon bei zwei Patienten mit autoreaktiver Myoperikarditis und minimalem Perikarderguss (75 bis 110 ml) berichtet. Nach zwölf Monaten sind beide Patienten asymptomatisch und ohne Perikardergussrezidiv. Bei beiden Patienten wurde die Perikardpunktion mit dem neuen PerDUCER^®-System unter perikardioskopischer Sicht durchgeführt. Dieses System verfügt über einen halbkugelförmigen Hohlraum an der Spitze, der mit einer Vakuumspritze verbunden ist. In dem halbkugelförmigen Hohlraum wurde das parietale Perikard durch das Vakuum angesaugt und fixiert und konnte anschließend durch eine aus dem Hohlkörper auszufahrende Nadel punktiert werden. Die Punktion mit dem PerDUCER^® wetzt voraus, dass die Dicke des Perikards 2 mm unterschreitet. Die mediastinale Perikardioskopie trug bei beiden Patienten wesentlich zum Erfolg der Prozedur bei, weil sie die Auswahl einer Perikardoberfläche ohne Adhäsionen und Fettgewebe erlaubte. Damit konnte erstmals eine intraperikardiale Behandlung mit Triamcinolon bei zwei Patienten mit einer symptomatischen autoreaktiven Myoperikarditis und einem kleinen (< 110 ml) Perikarderguss unter simultaner Verwendung von mediastinaler Perikardioskopie und PerDUCER^®-Punktionssystem dokumentiert werden.     

Pericardial involvement in human immunodeficiency virus infection

STUDY OBJECTIVES: Previous studies have showed that the pericardium is frequently involved in HIV infection. However, the characteristics and etiology of the pericardial abnormalities that have been found remained poorly defined. We analyzed the features of pericardial involvement in these patients and investigated the clinical variables associated with moderate and severe effusions. DESIGN: Prospective, clinical, and echocardiographic study. SETTING: The service of infectious diseases of a university hospital. PATIENTS: 181 consecutive patients at all stages of HIV infection. RESULTS: Only one patient (0.55%) had acute pericarditis. Seventy-five patients (41%) had an asymptomatic pericardial effusion; in 23 patients (13% of all patients), the effusion was either moderate or severe. Ten cases (5.5% of all patients) of moderate or severe effusions resulted in right atrium diastolic compression, and three of these cases (1.6% of all patients) required pericardiocentesis for the management of tamponade. Six patients (3%) presented with echogenic pericardial masses of undetermined etiology. A moderate or severe effusion was present in a greater number of patients with symptomatic HIV infection than was present in asymptomatic HIV-infected patients, respectively: 17 vs 2% (p = 0.015). The following are variables independently associated with moderate or severe pericardial effusions: heart failure (odds ratio, 20.3; p = 0.0001); Kaposi's sarcoma (odds ratio, 8.6; p = 0.01), tuberculosis (TB; odds ratio, 47.2; p = 0.0006); and other pulmonary infections (odds ratio,15.0; p = 0.02). CONCLUSIONS: Most of these moderate or severe effusions are clinically unsuspected, but they can lead to life-threatening tamponade. This fact seems to justify echocardiographic surveillance in HIV-infected patients, especially in those with heart failure, Kaposi's sarcoma, TB, or other pulmonary infections.     

Low electrocardiographic voltage in pericardial effusion

Although low ECG voltage has been associated with pericardial effusion, its diagnostic usefulness in such patients is unclear. When we examined the relationship between the volume of pericardial effusion and low voltage in 28 patients who underwent pericardial drainage, 14 patients exhibited low voltage (sum of limb lead QRS amplitudes of 30 mm or less). In eight patients, the QRS amplitude was 5 mm or less in each of the standard leads (absolute low voltage). There was no significant correlation between the volume of the effusion and the QRS amplitude (r = -0.30). This correlation did not improve (r = -0.37) when patients with left ventricular hypertrophy were excluded. Following pericardial drainage, the QRS amplitude increased in 21 of 24 patients and decreased in three. Low voltage persisted in nine patients; the pericardium was thickened in seven of the nine. Analysis of the sensitivity and specificity revealed acceptable sensitivity only with large effusions and no left ventricular hypertrophy. Absolute low voltage appeared to be specific in the diagnosis of moderate and large effusions among patients with pericardial effusion selected for this study.     

Value of pericardioscopy in pericardial effusion. Apropos of 20 patients

The value of pericardioscopy in pericardial effusion of uncertain origin was evaluated in 20 patients, aged from 18 to 77 years, whose pericardial effusion had been diagnosed by ultrasonography; 2 patients presented with clinical signs of tamponade. The cause of the pericarditis was unknown, but the clinical context suggested a malignant disease in 13 patients, tuberculosis in 5 patients and another cause in 2 patients. The pericardium was explored by means of a direct vision, cold-light endoscope, usually a mediastinoscope, introduced by the retroxiphoidal route under general of local anaesthesia. This method made it possible to study the pericardial fluid, examine the pericardial serous membrane, perform biopsies at a distance from the orifice of entry and cleanse the pericardium thoroughly in cases with blood or pus collection. Apart from 2 cases where the examination could not be completed because of an anterior mediastinal mass and a pericardial symphysis, valuable information could be obtained in purulent pericarditis (n = 1), chronic radiation induced lesions (n = 2), metastases (n = 2), haemopericardium (n = 2), and biopsies could be performed in tumoral or suspicious areas. These guided biopsies revealed a metastasis in 3 cases where the pericardial window was negative. No sign of tuberculosis was found in the 5 cases where the disease was suspected. The final diagnoses were: neoplastic pericarditis in 4 cases, radiation-induced pericarditis in 2 cases, purulent pericarditis in 2 cases, haemopericardium in 3 cases and idiopathic or reactive pericarditis in 9 cases. The post-operative period was uneventful, with no major complication ascribable to the procedure.(ABSTRACT TRUNCATED AT 250 WORDS)     

Potential pitfalls in quantification of pericardial effusions by echocardiography.

In the echocardiographic assessment of patients with pericardial effusions, the apparent width of the echo-free space between the left ventricular posterior wall and the parietal pericardium is commonly used to estimate the amount of pericardial fluid present. In 4 patients with pericardial effusions, we showed a distinct disparity between the widths of the posterior pericardial space at different levels of the left ventricular posterior wall. In 2 of them, a 'swinging heart' appearance was recorded when the ultrasoound beam was directed caudally, but not when its direction was cephalad or less caudad. It is suggested that the left ventricle should be scanned at all possible sites to minimise potential errors in estimating the amount of a pericardial effusion.     

Pericardioscopy: definition, value and limitation

After thoracoscopy and mediastinoscopy, pericardioscopy now completes the endoscopic techniques available for exploration of the pericardial cavity. During one year, we systematically associated pericardioscopy with pericardial drainage, using a mediastinoscope. Pericardioscopy visualizes the pericardium and guides biopsies. We report here this one-year experience of 12 pericardioscopies, describing the technique and listing its indications.