[Cardiac Tamponade by Chest Compression at Cardiopulmonary Resuscitation;Report of a Case]

We report a case of right ventricular rupture caused by sternal bone fracture following chest compression at cardiopulmonary resuscitation (CPR). A 68-year-old man presented with syncope and was referred to our hospital in an ambulance. Ventricular fibrillation was confirmed by electrocardiography(ECG), and CPR was performed with chest compression. He was resuscitated and his ECG showed ST elevation. He immediately underwent percutaneous coronary intervention to the right coronary #1 which was subtotally occluded. Thereafter, massive cardiac tamponade was noted by echocardiography, and coronary injury or left ventricle( LV) rupture was suspected. Emergency exploratory surgery was performed through median sternotomy. Laceration of the right ventricle corresponding to the sternal bone fracture was found intraoperatively. We repaired the injury and he was discharged without complication. The possibility of iatrogenic cardiac tamponade should be considered when a resuscitated patient by chest compression develops hypotension.

Acute primary purulent pericarditis in an adult patient with unknown X-linked agammaglobulinemia

X-linked agammaglobulinemia (XLA) is a rare form of inherited immunodeficiency due to an impairment in B-lymphocyte differentiation and maturation. In the majority of cases XLA is diagnosed in childhood, particularly among males affected by recurrent infections and with a family history of immunodeficiency. Infections of respiratory tract, gastrointestinal apparatus, eyes, nose and ears are frequent in XLA patients; on the contrary, infections of myocardium, cardiac valves and pericardium are rarely described in XLA. A 34-year-old man with unknown XLA was hospitalized because of syncope, due to pericardial tamponade, caused by acute primary purulent pericarditis. Immediate pericardiocentesis was effective in improving hemodynamics, and empiric antibiotic therapy was successful in controlling the infection. Purulent pericarditis is a rare disease with high mortality rate: it is usually caused by hematogenous bacterial propagation, direct infection of pericardial space by chest wounds or thoracic surgery, or extension of infection from adjacent tissues. However, this patient had no recent local or systemic infections. Because of unusual clinical picture during hospitalization he underwent further clinical and laboratory evaluations, that showed low immunoglobulin levels. After exclusion of acquired immunodeficiency, genetic tests were performed: they detected deletion of exons 8-9-10 of Bruton Tyrosine Kinase gene on X chromosome, leading to the diagnosis of XLA. Acute purulent primary pericarditis may also occur in adult XLA patients as first clinical manifestation. According to this case report, a primary immunodeficiency syndrome should be considered in patients with atypical cardiac infections and no predisposing conditions, regardless of age.

[Pericardiocentesis and Pericardial Drainage]

Peicardiocentesis and surgical pericardial drainage are essential treatment and diagnostic modality for pericardial effusion. Though it theoretically is a simple therapeutic method, accurate diagnosis, correct decision, and safe procedure are not always easy. Thoracic and cardiovascular surgeons are required to have high level of expertise in pericardial drainage as surgeons who specialize this anatomical part of the body. The presence of pericardial effusion does not always require drainage. Accurate diagnosis is essential to determine correct indication. Echocardiography and computed tomography are useful tools for accurate diagnosis. The percutaneous drainage has become much safer in these 2 decades with the aid of imaging technology, especially echocardiography and fluoroscopy. Surgical pericardial window still has its role and is considered one of the standard treatment methods with minimal chance to require repeat procedure compared to percutaneous drainage.

[Iatrogenic clinically cardiac arrest after administration of nitroglycerin]

This case report highlights the importance of preload in cardiac tamponade, as cardiac arrest with pulseless electrical activity was unintentionally induced after sublingual administration of nitroglycerin in an 83-year-old woman with unrecognised haemopericardium. Cardiac tamponade is a life-threatening condition, as accumulation of fluids in the pericardial sac diminishes preload which can ultimately lead to cardiac arrest. Primary elements in the development of critical haemodynamic tamponade are rate of fluid-accumulation and compensatory mechanisms, mainly tachycardia and vasoconstriction.

Acute and recurrent pericarditis

Pericardial diseases have been until recently relatively neglected entity; however, there has been a markedly increased interest in these disorders in the last decade due to new diagnostic as well as therapeutic options. Various clinical manifestations of pericardial diseases may be generally grouped into pericardial syndromes including pericarditis, pericardial effusion, cardiac tamponade and constrictive pericarditis. In this review, the comprehensive analysis of acute and recurrent pericarditis is presented. Acute and recurrent pericarditis represent the most common pericardial disorders in clinical practice, in which major changes in therapeutic procedures occurred based on recently published trials, particularly the introduction of colchicine therapy.

Cardiac and Vascular Injuries Sustained During Transvenous Lead Extraction

The rise in indications for cardiac implantable electronic devices has necessitated the development of tools for removal of the electrodes that connect the heart to these externally located pacemakers and defibrillators. After implant of a cardiac electrode, variable but progressive fibrous adhesion occurs. Removal of these adhesions can cause devastating complications with high risk of mortality if not treated surgically in a highly expeditious and appropriate manner. This article describes the incidence, risk factors, and diagnosis of these injuries followed by discussion of recent evidence for use of superior vena cava balloon occlusion, and conventional surgical repair of these injuries.

Getting to the heart of hypopituitarism

A 53-year-old woman was diagnosed with hypopituitarism following an acute presentation with cardiac tamponade and hyponatraemia, having recently been investigated for a pericardial effusion. Secondary hypothyroidism is a rare cause of pericardial effusion and tamponade, but an important differential to consider. Management requires appropriate hormone replacement and, critically, a low threshold for commencing stress dose steroids. Clinical signs classically associated with cardiac tamponade are frequently absent in cases of tamponade due to primary and secondary hypothyroidism, and the relatively volume deplete state of secondary hypoadrenalism in hypopituitarism may further mask an evolving tamponade, as the rise in right atrial pressure is less marked even in the presence of large effusion. Our case demonstrates the importance of a high index of suspicion for cardiac tamponade in this patient cohort, even in the absence of clinical signs, and for measuring both thyroid-stimulating hormone and thyroxine levels when evaluating a pericardial effusion.

Acute fatal pericardial effusion induced by accidental ingestion of cigarette butts in a dog

A dog was referred for collapse and tachypnea after ingesting cigarette butts. Thoracic radiography and echocardiography indicated pericardial effusion, and an electrocardiogram showed tachycardia, variable QRS complexes, and ventricular premature complexes. This is the first description of fatal pericardial effusion associated with cigarette butt ingestion in a veterinary patient.

Interplay of co-inherited diseases can turn benign syndromes in a deadly combination: haemoglobinopathy and bilirubin transport disorder

We present a case about a 25-year-old male patient suffering from a rare genetic disorder called Mizuho haemoglobin. He was admitted to the Intensive Care Unit with acute liver and renal failure. During admission he also developed a cardiac tamponade twice. Finally he received a liver transplantation. Hereafter the patient stabilised and his liver and renal functions improved. His symptoms could not be explained solely by his known disease. After searching the literature, similarities between his symptoms and a rare complication of sickle cell disease were found. Molecular diagnostics showed that the patient also suffered from Gilbert's syndrome. Due to his chronic haemolysis, symptoms of this other disease were masked. This stresses the importance of always looking for other causes if symptoms or changes cannot be explained by a known rare disorder.

Lesson of the month 1: Pericardial mass and cardiac tamponade associated with Mycoplasma pneumoniae

Mycoplasma pneumoniae primarily causes respiratory tract infections. Extrapulmonary manifestations are seen in 20-25% of cases. Cardiac involvement is rarely reported. We present a unique case of a pericardial mass and cardiac tamponade associated with a Mycoplasma pneumoniae pneumonia. This required emergency pericardial fenestration. The patient improved dramatically postoperatively on antibiotics and there was no recurrence of the pericardial effusion on follow up. This case highlights the often forgotten invasive properties of a common respiratory tract pathogen and emphasises the need to consider this easily treatable entity in the differential diagnosis of idiopathic pericardial effusions.

Percutaneous balloon pericardiotomy in a patient with end stage renal disease with recurrent pericardial effusion & pericardial tamponade

A case report of 37-year-old female with end stage renal disease presented with recurrent pericardial effusion and cardiac tamponade, who underwent percutaneous balloon pericardiotomy using an Inoue balloon dilating catheter, to create a non-surgical pericardial window. The procedure of non-surgical pericardial window is safe and effective alternative to conventional more invasive surgical pericardial window. It is concluded that percutaneous balloon pericardiotomy is helpful in the management of massive pericardial effusions particularly in patients with chronic renal failure and poor clinical condition.

Pericarditis as a presenting sign of infective endocarditis: two case reports and review of the literature

Pericarditis as a presenting sign of infective endocarditis is rare. Here we describe 2 cases and an additional 19 cases of pericarditis as a presenting sign of infective endocarditis reported during the last 40 y. 71% of patients were young males (mean age 43.2 y). The most commonly reported underlying conditions were diabetes mellitus type 2 (5 patients, 24%), and substance or alcohol abuse (4 patients, 19%). The native aortic valve was the most frequently involved valve. The most common symptoms were fever, cough or dyspnoea, and chest pain. Overt tamponade was diagnosed in 47% of the patients. However, pulsus paradoxus and pericardial friction rub were rare. A heart murmur was heard in 12 patients (57%). Staphylococcus aureus was the most commonly isolated pathogen concomitantly from blood and pericardial fluid. 16 patients (76%) were operated. Six underwent a pericardial procedure, 5 underwent valve replacement, 4 both, and 1 patient was operated for pseudoaneurysm. Mortality rates were 60% and 31% of patients treated with antibiotics alone versus antibiotics and surgical intervention, respectively. In patients presenting with pericarditis with or without cardiac tamponade, the possibility of infective endocarditis should be considered. Optimal therapy should consist of antibiotics and surgical intervention.

Indicators of Poor Prognosis of Acute Pericarditis

Background— The clinical search for indicators of poor prognosis of acute pericarditis may be useful for clinical triage of patients at high risk of specific causal conditions or complications. The aim of the present article is to assess the relationship between clinical features at presentation and specific causes or complications.

Methods and Results— A total of 453 patients aged 17 to 90 years (mean age 52±18 years, 245 men) with acute pericarditis (post–myocardial infarction pericarditis was excluded) were prospectively evaluated from January 1996 to August 2004. A specific cause was found in 76 of 453 patients (16.8%): autoimmune in 33 patients (7.3%), neoplastic in 23 patients (5.1%), tuberculous in 17 patients (3.8%), and purulent in 3 patients (0.7%). In multivariable analysis, women (hazard ratio [HR] 1.67, 95% confidence interval [CI] 1.03 to 2.70; P =0.036) and patients with fever >38°C (HR 3.56, 95% CI 1.82 to 6.95; P <0.001), subacute course (HR 3.97, 95% CI 1.66 to 9.50; P =0.002), large effusion or tamponade (HR 2.15, 95% CI 1.09 to 4.23; P =0.026), and failure of aspirin or of nonsteroidal anti-inflammatory drugs (HR 2.50, 95% CI 1.28 to 4.91; P =0.008) were at increased risk of specific causal conditions. After a mean follow-up of 31 months, complications were detected in 95 patients (21.0%): recurrences in 83 patients (18.3%), tamponade in 14 patients (3.1%), and constriction in 7 patients (1.5%). In multivariable analysis, women (HR 1.65, 95% CI 1.08 to 2.52; P =0.020) and patients with large effusion or tamponade (HR 2.51, 95% CI 1.37 to 4.61; P =0.003) and failure of aspirin or of nonsteroidal anti-inflammatory drugs (HR 5.50, 95% CI 3.56 to 8.51; P <0.001) were at increased risk of complications.

Conclusions— Specific clinical features (fever >38°C, subacute course, large effusion or tamponade, and aspirin or NSAID failure) may be useful to identify higher risk of specific causal conditions and complications.

Incidence and significance of upper body cyanosis in nontraumatic cardiac arrest

OBJECTIVE

Upper body cyanosis is a physical finding sometimes noted at the time of cardiac resuscitation. We attempted to determine the incidence and significance of upper body cyanosis in cases of nontraumatic cardiac arrest.

METHODS

This was a retrospective case-control study. We reviewed all nontraumatic cardiac arrests evaluated by King County, Washington emergency medical system (EMS) personnel during 2000-2004 and identified patients with upper body or nipple-line cyanosis. Those patients who were autopsied comprised the cases for our study. Cases were age and sex matched with controls who also had cardiac arrest with an autopsy but no mention of cyanosis.

RESULTS

EMS personnel treated 3,526 patients, age 18 and older, for nontraumatic out-of-hospital cardiac arrest. One hundred eight (3.1%) had specific mention of upper chest or nipple-line cyanosis, of whom 38 had autopsy. Among the 38 autopsy cases, 6 were died of hemopericardium compared to none in age-and sex-matched controls.

CONCLUSION

Cardiac arrest with upper chest or nipple-line cyanosis had a higher incidence of hemopericardium or dissecting thoracic aortic aneurysm than patients without mention of cyanosis.

Heart embolization with the Kirschner wire without cardiac tamponade

The case of the heart embolization with the Kirschner wire that was used for shoulder trauma fixation, 2 years previously in a 67-year-old female, is reported. This case is unique; although embolization of foreign bodies to the heart is not a novel occurrence, heart embolization with non-broken Kirschner wire with a total length of 13.5 cm without cardiac tamponade was not described in medical literature so far.

[Diagnosis and management of acute pericardial syndromes]

Essentially, acute pericardial syndromes include acute pericarditis and cardiac tamponade. This article focuses on the diagnosis and management of acute pericarditis. In Spain, most cases of acute pericarditis whose etiology is not apparent at initial clinical presentation are either idiopathic or viral pericarditis, which follow a benign or self-limiting clinical course (although tamponade may develop in some patients). Knowledge of this basic epidemiologic fact is essential for the development of a rational management protocol that, on the one hand, avoids the unnecessary use of invasive pericardial diagnostic procedures in patients with idiopathic pericarditis and that, on the other hand, correctly identifies most cases of specific pericarditis, which mainly comprise purulent, tuberculous or neoplastic pericarditis. In accordance with this rationale and on the basis of our own experience, we have proposed a protocol for the management of acute pericardial disease that differs markedly from the "Guidelines on the Diagnosis and Management of Pericardial Disease" recently produced by the European Society of Cardiology. In addition, we have made some comments on the cardiac tamponade and the acute and subacute constrictive pericarditis that can occur during the resolution of acute pericarditis.