Pericardiocentesis with cisplatin for malignant pericardial effusion and tamponade

AIM:To evaluate the role and outcome of pericardiocentesis with intrapericardial cisplatin instillation for malignant pericardial effusion resulting from esophageal cancer. METHODS:We retrospectively studied 7 patients who underwent pericardiocentesis with intrapericardial cisplatin instillation for malignant pericardial effusion resulting from esophageal cancer.After pericardiocentesis,we performed catheterization of the pericardial space under ultrasonogram guidance.Malignant etiology of the pericardial fluid was confirmed by cytological examination.Subsequently,cisplatin(10 mg in 20 mL normal saline) was instilled into the pericardial space. RESULTS:The mean total volume of the aspirated effusion fluid was 782±264 mL(range,400-1200 mL) . The drainage catheter was successfully removed in all patients,and the mean duration of pericardial drainagewas 7.7±2.7 d(range,5-13 d) .No fluid reaccumulation was observed.Mean survival time was 120±71 d(range,68-268 d) . CONCLUSION:Pericardiocentesis along with catheter drainage appears to be a safe and effective for pericardial malignant effusion and tamponade,and cisplatin instillation prevents recurrence.

What is the ideal approach for emergent pericardiocentesis using point-of-care ultrasound guidance?

BACKGROUND:Traditionally performed using a subxiphoid approach,the increasing use of point-of-care ultrasound in the emergency department has made other approaches(parasternal and apical)for pericardiocentesis viable.The aim of this study is to identify the ideal approach for emergency-physician-performed ultrasound-guided pericardiocentesis as determined by ultrasound image quality,distance from surface to pericardial fl uid,and likely obstructions or complications.METHODS:A retrospective review of point-of-care cardiac ultrasound examinations was performed in two urban academic emergency departments for the presence of pericardial eff usions.The images were reviewed for technical quality,distance of eff usion from skin surface,and predicted complications.RESULTS:A total of 166 pericardial effusions were identified during the study period.The mean skin-to-pericardial fl uid distance was 5.6 cm(95%confi dence interval[95%CI]5.2-6.0 cm)for the subxiphoid views,which was signifi cantly greater than that for the parasternal(2.7 cm[95%CI 2.5-2.8 cm],P<0.001)and apical(2.5 cm[95%CI 2.3-2.7 cm],P<0.001)views.The subxiphoid view had the highest predicted complication rate at 79.7%(95%CI 71.5%-86.4%),which was signifi cantly greater than the apical(31.9%;95%CI 21.4%-44.0%,P<0.001)and parasternal(20.2%;95%CI 12.8%-29.5%,P<0.001)views.CONCLUSIONS:Our results suggest that complication rates with pericardiocentesis will be lower via the parasternal or apical approach compared to the subxiphoid approach.The distance from skin to fl uid collection is the least in both of these views.

Peritonitis and pneumoperitoneum after successful emergency pericardiocentesis in the case of a Chilaiditi syndrome

Pericardiocentesis is a common therapeutic procedure for pericardial tamponade due to pericardial effusion as well as a diagnostic procedure to obtain fluid for cytopathologic examination.Standard methods include ultrasound or fluoroscopic guidance,which generally result in high success rates(over 95%).[1,2].The complication rate of pericardiocentesis is low with reported incidences of l%-2%.[3]In the past,the most common indications for pericardiocentesis include uremia,tuberculous pericarditis or malignant pericardial effusions.However,with the increasing number of catheter-based interventional cardiac procedures,iatrogenic pericardial effusions are becoming more frequent[4-6].

Right ventricular tear mimicking myocardial infarction following pericardiocentesis

A 72-year-old female was admitted to the CCU with a recent onset of progressive breathlessness for bedside pericardial drainage for chronic pericardial effusion. After an uncomplicated drainage procedure, initially a serous straw coloured fluid was aspired with subsequent hemorrhagic aspiration with haemoglobin value similar to the peripheral blood. The patient showed initially transient improvement followed by rapid deterioration into severe shock and death. Signs of infero-posterior myocardial infarction (MI) were seen on the ECG. Before death, further interventions were refused by her and her family but a permission was given for autopsy. At autopsy, right ventricular rupture was seen with a 0.6 cm tear with a large amount of 800 cc bloody fluid with clots. The result of histopathologic study of the tear was resembling three-days old MI. The drain was found to be properly localized in the pericardial space, was not blocked and caused no harm to the myocardium. Furthermore, histopathologic examination revealed pulmonary adenocarcinoma of the left upper lobe, pleuritis and lymphangitis carcinomatosa and enlarged mediastinal lymph nodes. A case of fatal complication is reported following bedside pericardial drainage. Postmortal, right ventricular tear mimicked myocardial infarction.

Pericardial decompression syndrome: A comprehensive review

Pericardial decompression syndrome(PDS)is an infrequent,life-threatening complication following pericardial drainage for cardiac tamponade physiology.PDS usually develops after initial clinical improvement following pericardiocentesis and is significantly underreported and may be overlooked in the clinical practice.Although the precise mechanisms resulting in PDS are not well understood,this seems to be highly associated with patients who have some underlying ventricular dysfunction.Physicians performing pericardial drainage should be mindful of the risk factors associated with the procedure including the rare potential for the development of PDS.

Cardiac tamponade as the initial manifestation of severe hypothyroidism: A case report

Background: Hypothyroidism is a commonly seen condition. The presence of pericardial effusion with cardiac tamponade as initial manifestation of this endocrinological condition is very unusual. Objectives: In hypothyroidism pericardial fluid accu-mulates slowly, allowing adaptation and stretching of the pericardial sac, sometimes accommodating a large volume. Case Report: A 39 year-old female presented with chest pain, dyspnea and lower extremity edema for 1 day. Bradycardia, muffled heart sounds and severe hypertension were noticed. Chest radiograph showed an enlarged cardiac silhouette. A bedside echocardiogram revealed a cardiac tamponade, later she developed sudden hypotension and bradycardia that resolved after pericardiocentesis of 1 liter of pericardial fluid. The further laboratory evaluation revealed a TSH value of 69.3 miU/L and low T3 and free T4. The patient later developed reaccumulation of pericardial fluid with the need for creation of pericardial window. Conclusion: When the classic Beck’s triad is not present and bradycardia accompanies a cardiac tamponade, hypothyroidism should be strongly suspected. The requirement for thyroid hormone supplement is critical and is well reported. There is a chance of recurrence even after starting levothyroxine supplementation;and the associated hypertension usually requires treatment with more than one drug.

Study of Etiological Profile, Clinical Profile and Short Term Outcome of Patients Presenting with Pericardial Effusion in a Tertiary Care Center, Nepal

Introduction: Pericardial effusion is one of the common cardiac problems in our?part of the world and adds burden to the health and economy of the country, as it is associated with high risk of morbidity and mortality. Our objective of the study was to determine the etiological spectrum of pericardial effusion, their clinical presentations and complications and assessing the usefulness of echocardiographic features of effusion in helping to determine the etiology. Methods: A cross-sectional observational prospective study of 63 patients with diagnosis of pericardial effusion was enrolled in the study. Pericardial effusion was diagnosed by echocardiography and pericardiocentesis was done in the cardiac catheterization room. Patients were followed up 3 monthly for 1 year and reassessed clinically and by echocardiography. Results: Patients presenting with pericardial effusion belonged to the age group of 8 to 88 years. The most common etiology was tuberculosis (36.5%) followed by malignancy (19%) and idiopathic/Viral (12.6%). Among malignancies, carcinoma lung was the most common cause followed by lymphoma. Pericardiocentesis was done in 46 patients (73%) and the approach was subxiphoid. The procedure-related complications were in 4 patients (6.3%) and there was no death as a consequence of the procedure. The total mortality was 12 (19%) with in-hospital death of 6 patients (9.5%). Conclusions: The study showed tuberculosis as the most common cause of pericardial effusion in developing countries like Nepal and as a cause of cardiac tamponade in contrast to the studies from the developed world where malignancy remains the leading cause.

Cardiac tamponade due to group a streptococcal pericarditis in a 10-month-old boy and a review of the literature

Group A streptococcus (GAS) is a rare cause of purulent pericarditis in pediatric patients as only 7 cases have been reported. We present a 10-month-old boy who developed cardiac tamponade from GAS and was successfully treated with subxiphoid tube drainage and 4 weeks of antibiotics at the Children’s Hospital of Philadelphia.