Malignant pleural/pericardial effusion with tamponade and life-threatening reversible myocardial depression in a case of an initial presentation of lung adenocarcinoma

We present a case of a middle-aged woman in cardiac tamponade. Following pericardiocentesis that removed 1,500 ml of hemorrhagic fluid, the patient exhibited cardiogenic shock; LVEF, at its nadir, on inotrope, was less than 20%. Ventricular function slowly improved, with inotropic support, to the normal range by the 25th day of hospitalization. Cardiac failure in malignancy has often been attributed to multi-system failure; this case showed a hereto unrecognized clinical phenomenon - 'malignancy-associated myopericarditis'. While the direct link of cause and effect cannot be made with certainty, the case should be instructive to other clinicians who encounter similar life-threatening presentations of cardiac decompensation in malignancy.

Left Ventricular Cardiac Tamponade in the Setting of Cor Pulmonale and Circumferential Pericardial Effusion

Circumferential pericardial effusion typically results in biventricular tamponade and equalization of intracardiac and pericardial pressure during diastole. However, tamponade may involve the right or left ventricle. While isolated left ventricular cardiac tamponade (LVCT) can occur as a postoperative complication from localized posterior pericardial effusions, circumferential pericardial effusions leading to LVCT are rare. We report a case of a patient with severe pulmonary hypertension, a large nonloculated pericardial effusion, and LVCT, which was probably due to a chronic undifferentiated connective tissue disorder. This case illustrates that when evaluating patients with circumferential pericardial effusions and associated pulmonary hypertension, the typical findings of cardiac tamponade (pulsus paradoxus, right ventricular diastolic compression and hypotension) may be masked. The echocardiogram must be reviewed carefully as it may reveal left ventricular diastolic compression, the hallmark of LVCT, which may significantly compromise left ventricular filling and cardiac output.

Cardiac tamponade

Cardiac tamponade is a common cardiac emergency requiring prompt diagnosis and intervention. A thorough understanding of the spectrum of clinical and hemodynamic changes in patients with pericardial effusion is vital for interventional cardiologists. This review discusses pathophysiology of cardiac tamponade with emphasis on hemodynamic aberrations. Specific clinical situations that lead to atypical hemodynamic presentations of cardiac tamponade are emphasized with a review of various diagnostic and therapeutic procedures.

Hepatosplanchnic blood flow control and oxygen extraction are modified by the underlying mechanism of impaired perfusion

OBJECTIVE

To assess the effects of low hepatosplanchnic blood flow on regional blood flow control and oxygenation.

DESIGN

Three randomized, controlled animal experiments.

SETTING

Two university experimental research laboratories.

SUBJECTS

Pigs of either gender.

INTERVENTIONS

Isolated abdominal blood flow reduction: An extracorporeal shunt with reservoir and roller pump was inserted between proximal and distal aorta in 11 pigs. Abdominal aortic blood flow was reduced by 50% by activating the shunt. Mesenteric ischemia: In seven pigs, superior mesenteric arterial flow was reduced to 4 mL.kg.min for 4 hrs. Cardiac tamponade: In 12 pigs, aortic blood flow was reduced by cardiac tamponade to 50 mL (moderate tamponade) and further to 30 mL.kg.min (severe tamponade) for 1 hr each. In each experimental condition, the same number of control animals was used.

MEASUREMENTS AND MAIN RESULTS

Abdominal blood flow reduction, acute mesenteric ischemia, and moderate tamponade resulted in a portal venous flow (QPV) reduction to 51 +/- 23%, 52 +/- 18%, and 61 +/- 25% (mean +/- sd) of baseline flow, respectively. During abdominal blood flow reduction, QPV and hepatic arterial flow (QHA) decreased proportionally, whereas in moderate tamponade and acute mesenteric ischemia QPV reduction was associated with an increase in QHA of 30 +/- 39% and 102 +/- 108%, respectively (p = .001 and .018). Prolonged mesenteric ischemia restored total hepatic blood flow (Qliver) completely. During all conditions, decreasing mesenteric oxygen consumption was partly prevented by increased mesenteric oxygen extraction (p < .001 for all conditions). In contrast, decreasing hepatic oxygen delivery was associated with increased oxygen extraction in tamponade (p = .009) but not in abdominal blood flow reduction.

CONCLUSIONS

Blood flow redistribution can restore Qliver totally when mesenteric blood flow is reduced selectively, partially when cardiac output is reduced, and not at all during abdominal blood flow reduction. Since hepatic oxygen extraction does not increase in abdominal blood flow reduction, hepatic oxygenation is at risk in this condition.

Cardiac tamponade, constrictive pericarditis, and restrictive cardiomyopathy

The pericardium envelopes the cardiac chambers and under physiological conditions exerts subtle functions, including mechanical effects that enhance normal ventricular interactions that contribute to balancing left and right cardiac outputs. Because the pericardium is non-compliant, conditions that cause intrapericardial crowding elevate intrapericardial pressure, which may be the mediator of adverse cardiac compressive effects. Elevated intrapericardial pressure may result from primary disease of the pericardium itself (tamponade or constriction) or from abrupt chamber dilatation (eg, right ventricular infarction). Regardless of the mechanism leading to increased intrapericardial pressure, the resultant pericardial constraint exerts adverse effects on cardiac filling and output. Constriction and restrictive cardiomyopathy share common pathophysiological and clinical features; their differentiation can be quite challenging. This review will consider the physiology of the normal pericardium and its dynamic interactions with the heart and review in detail the pathophysiology and clinical manifestations of cardiac tamponade, constrictive pericarditis, and restrictive cardiomyopathy.

Atypical hemodynamic manifestations of cardiac tamponade

Clinical examination and transthoracic echocardiography play a vital role in the management of patients with pericardial effusion and cardiac tamponade physiology. We report patients in advanced phase 3 cardiac tamponade with variant clinical and hemodynamic presentations. These atypical cardiac tamponade cases include: A patient with severe aortic valve regurgitation who lacked pulsus paradoxus; a patient with systemic sclerosis without hypotension; and a patient with pulmonary hypertension lacking right heart collapse on echocardiography. Recognition of these atypical clinical and hemodynamic manifestations of cardiac tamponade will avoid undue delay in the treatment.

Prolonged right ventricular failure after relief of cardiac tamponade

PURPOSE

To report a case of severe and fatal cardiac complication following pericardiotomy to relieve a malignant tamponade. Right ventricular (RV) failure was responsible for major hypoxemia and for a persistent shunt through a patent foramen ovale. In the absence of pulmonary embolism and coronary occlusion, possible pathophysiologic mechanisms are discussed.

CLINICAL FEATURES

This 53-yr-old patient presented with oropharyngeal carcinoma previously treated by chemotherapy. One month later, he showed clinical and echocardiographic signs of cardiac tamponade. He had a circumferential pericardial effusion with complete end-diastolic collapse of the right cavities. After an emergent pericardiotomy, he rapidly presented severe hypoxemia. Transesophageal echocardiography showed an akinetic and dilated right ventricle, paradoxical septal wall motion and a normal left ventricular function. A contrast study revealed a right-to-left shunt. No residual pericardial effusion was detectable. Pulmonary angiography excluded a pulmonary embolism and the coronary angiogram was normal. Troponin Ic was elevated postoperatively and peaked on day two (3.78 micro g x L(-1)). The patient died of refractory shock with persistent intracardiac shunt and RV akinesia on day nine.

CONCLUSION

Although pulmonary embolism or thrombus of a coronary vessel are the most common causes of prolonged RV failure after pericardiotomy, other mechanisms may be invoked. The possibility is raised that a rapid increase in RV tension may induce the development of muscular injury and impair coronary blood flow, despite a normal coronary angiogram. These could result in a stunned myocardium and opening of a patent foramen ovale. We hypothesize that gradual decompression of a chronic pericardial effusion might be beneficial in patients at risk.

Unique features of early diastolic mitral annulus velocity in constrictive pericarditis

BACKGROUND

In most primary myocardial diseases, early diastolic mitral annulus velocity (E') decreases with disease progression. To our knowledge, constrictive pericarditis (CP) is the only condition without this phenomenon.

OBJECTIVE

This study was performed to evaluate the diagnostic and pathophysiologic role of mitral annulus velocity in patients with CP.

METHODS

In all, 17 patients with CP (9 men; mean age 46.5 +/- 14.3 years), 8 patients with cardiac tamponade (Tamp) (2 men; mean age 44.5 +/- 15.0 years), and age- and sex-matched control subjects for CP and Tamp were recruited for the study. Early mitral inflow velocity and E' were obtained while simultaneously recording respiration. In 8 patients with CP and in all patients with Tamp, these measurements were repeated after the relief of constrictive physiology or after pericardiocentesis.

RESULTS

In patients with CP, E' was significantly higher than it was for control subjects (12.9 +/- 3.0 cm/s vs 9.8 +/- 2.4 cm/s, P <.01). An E' of 2 cm/s higher than the predicted normal E' could differentiate patients with CP from control subjects with a sensitivity of 76% and specificity of 82%. In 12 of 17 patients (71%), inspiratory E' was higher than expiratory E'-the opposite of mitral inflow variation. In 8 patients, E' decreased significantly after the relief of constrictive physiology (13.8 +/- 2.5 cm/s vs 9.3 +/- 3.1 cm/s, P <.05). In contrast, E' in the Tamp group was significantly lower than in the control group (6.8 +/- 1.6 cm/s vs 10.2 +/- 2.5 cm/s, P <.01), did not show significant respiratory variation, and increased significantly after pericardiocentesis (6.8 +/- 1.6 cm/s vs 9.5 +/- 3.0 cm/s, P <.05).

CONCLUSION

E' is exaggerated in CP, which is helpful for diagnosis. The opposite phenomenon was noted in Tamp, a dissimilarity that might contribute to different hemodynamics.

Haemodynamic effects of volume resuscitation by hypertonic saline-dextran (HSD) in porcine acute cardiac tamponade

BACKGROUND

Hypertonic saline-dextran (HSD) has been utilized for small-volume resuscitation in acute circulatory shock. However, HSD has also been reported to induce myocardial depression. The aim of this study was to examine the effects of HSD on cardiac performance and splanchnic perfusion in a low cardiac output model based on experimental cardiac tamponade.

METHODS

Seven anaesthetized, mechanically ventilated pigs of both sexes (weight 24 +/- 2 kg, mean +/- SEM) completed a randomized, cross-over protocol. A low cardiac output state was established by intrapericardial infusion of dextran. Animals were resuscitated by bolus infusions (4 ml kg(-1) in 2 min) of either 7.5% hypertonic saline-dextran or Ringer's acetated solution (RAc) and then observed during tamponade (20 min) and following its release (40 min). Central haemodynamics, portal venous (QPV) and renal arterial (QRA) flows were measured together with gastric, jejunal, hepatic and renal laser-Doppler flowmetry.

RESULTS

Resuscitation using HSD in a low cardiac output state completely restored QPV and improved gastric, jejunal, hepatic and renal microcirculation as assessed by laser-Doppler flowmetry while no significant effect was observed in QRA. No such beneficial effects could be observed when animals were resuscitated using RAc. The improved haemodynamic state by HSD was maintained following release of cardiac tamponade while perfusion in RAc resuscitated animals returned to baseline or even remained depressed (hepatic and renal microcirculation). No signs of cardiodepression by HSD were observed.

CONCLUSION

Resuscitation using HSD in a low cardiac output state restored splanchnic perfusion and microcirculation without any signs of cardiodepression.

Echocardiographic tamponade in severe left ventricular dysfunction: the impact of small pericardial effusion and the absence of pulsus paradoxicus

Cardiac tamponade is a commonly encountered clinical entity. It is a clinical syndrome characterized by elevated filling pressures, pulsus paradoxicus, and eventually, hypotension. It occurs as intrapericardial pressure exceeds intracardiac pressures altering ventricular filling. Generally tamponade occurs with moderate or large accumulations of pericardial fluid that result in an increase in pericardial pressure. It is well known that rapid accumulation of relatively small volumes of fluid can cause tamponade pathophysiology. We report a less well-recognized phenomenon. In the setting of severe left ventricular dysfunction, small volumes of pericardial fluid can result in excessive intrapericardial pressure and echocardiographic tamponade in the absence of a significant pulsus paradoxicus.

L’embolie pulmonaire au secours de la tamponnade cardiaque

The association of cardiac tamponade and pulmonary embolism has not previously been described. We report the case of a patient, who presented with such an association, due to an underlying pulmonary carcinoma. When a major pericardial effusion is associated with pulmonary hypertension, some echocardiographic signs of tamponade may appear, such as a moderate right ventricular collapse, or the absence of a paradoxical septum. The presence of pulmonary hypertension in this context of tamponade may have paradoxically saved the life of this patient.

Respiratory changes in transvalvular flow velocities versus two-dimensional echocardiographic findings in the diagnosis of cardiac tamponade

BACKGROUND

The purpose of this study was to compare the sensitivity, specificity and positive predictive value of the respiratory changes in the transvalvular flow velocities to those of right atrial collapse and right ventricular collapse in the diagnosis of cardiac tamponade.

METHODS

Standard two-dimensional and Doppler echocardiography were performed with respiratory monitoring in 56 consecutive patients with mild to severe pericardial effusion. Sixteen patients met the clinical criteria for cardiac tamponade and underwent pericardiocentesis or surgical drainage. Forty patients were found to have no tamponade and were followed up for at least 2 weeks and none of them showed clinical worsening.

RESULTS

The sensitivity, specificity and predictive value were, respectively, 77, 80 and 62% for an inspiratory decrease > 22% in the peak velocity of the early mitral flow; 75, 89 and 73% for an inspiratory reduction > 20% in the peak velocity of the aortic flow; 50, 69 and 36% for an inspiratory increase > 30% in the peak velocity of the early tricuspid flow; 87, 85 and 64% for an inspiratory increase > 25% in the peak velocity of the pulmonary flow. Right atrial collapse and right ventricular collapse had a sensitivity of 100 and 75%, a specificity of 33 and 85%, and a predictive value of 37 and 66%, respectively.

CONCLUSIONS

In the diagnosis of cardiac tamponade: 1) right atrial collapse is the most sensitive sign but lacks any specificity; 2) except for the tricuspid valve, the respiratory variations in the transvalvular flow velocities have a reliability and a predictive value comparable with those of right ventricular collapse; 3) the predictive value is not very high, indicating that at both techniques false positive results are not negligible.

Effects of positive-pressure ventilation, pericardial effusion, and cardiac tamponade on respiratory variation in transmitral flow velocities

OBJECTIVE

To determine the effects of positive-pressure ventilation and experimentally induced pericardial effusion and tamponade on transmitral flow velocities in dogs.

DESIGN

Descriptive.

SETTING

University laboratory.

PARTICIPANTS

Eleven tracheally intubated and mechanically ventilated dogs.

INTERVENTIONS

Experimental pericardial effusion and cardiac tamponade were created by pericardial injection of warm saline.

MEASUREMENTS AND MAIN RESULTS

Hemodynamic parameters and pericardial pressures were monitored in the 11 dogs. Pulsed-wave Doppler tracings of mitral valve flow were obtained at the leaflet tips along with hemodynamic measurements at 4 stages: control, effusion (no decrease in mean arterial pressure), tamponade (>or=40% decrease in mean arterial pressure), and tamponade relief (after evacuation of pericardial fluid). Maximal variation (36%) in transmitral flow velocity over the respiratory cycle during positive-pressure ventilation was seen in the control stage. In the effusion and tamponade stages, variation in transmitral flow velocity decreased progressively to 29% (p = 0.1804, not significant) and 16% (p < 0.0001), respectively.

CONCLUSION

Intrathoracic pressure and lung volume changes caused by positive-pressure ventilation influence transmitral flow velocity patterns. Respiratory variation in transvalvular flow is pronounced during standard positive-pressure mechanical ventilation, decreases in the presence of pericardial effusion, and becomes almost nonexistent when cardiac tamponade is present. These findings show that the echocardiographic criteria used to diagnose cardiac tamponade based on mitral valve inflow patterns are different during positive-pressure ventilation from spontaneously breathing subjects.