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Adrian RJ, Alerhand S, Liteplo A, Shokoohi H. Is pulmonary hypertension protective against cardiac tamponade? A systematic review. Intern Emerg Med 2024:10.1007/s11739-024-03566-y. [PMID: 38622465 DOI: 10.1007/s11739-024-03566-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 02/14/2024] [Indexed: 04/17/2024]
Abstract
The presence of pulmonary hypertension (PH) may affect whether cardiac tamponade physiology develops from a pericardial effusion. Specifically, the increased intracardiac pressure and right ventricular hypertrophy associated with PH would seemingly increase the intrapericardial pressure threshold at which the right-sided chambers collapse. In this systematic review, we examined the impact of PH on the incidence, in-hospital and long-term mortality, and echocardiographic findings of patients with cardiac tamponade. Using the PRISMA guideline, a systematic search was conducted in PubMed, Academic Search Premier, Web of Science, Google Scholar, and the Cochrane Database for studies investigating PH and cardiac tamponade. The Newcastle-Ottawa Scale was used to analyze the quality of returned studies. Primary outcomes included the incidence of cardiac tamponade, as well as in-hospital and long-term mortality rates. Secondary outcomes were the presence or absence of echocardiographic findings of cardiac tamponade in patients with PH. Forty-three studies (9 cohort studies and 34 case reports) with 1054 patients were included. The incidence of cardiac tamponade was significantly higher in patients with PH compared to those without PH, 2.0% (95% CI 1.2-3.2%) vs. 0.05% (95% CI 0.05-0.05%), p < 0.0001, OR 40.76 (95% CI 24.8-66.9). The incidence of tamponade in patients with a known pericardial effusion was similar in those with and without PH, 20.3% (95% CI 12.0-32.3%) and 20.9% (95% CI 18.0-24.1%), p = 0.9267, OR 0.97 (95% CI 0.50-1.87). In patients with tamponade, those with PH demonstrated a significantly higher in-hospital mortality than those without PH, 38.8% (95% CI 26.4-52.8%) vs. 14.4% (95% CI 14.2-14.6%), p < 0.0001, OR 3.77 (95% CI 2.12-6.70). Long-term mortality in patients with tamponade was significantly lower in those with PH than in those without PH, 45.5% (95% CI 33.0-58.5%) vs. 59.1% (95% CI 54.7-63.4%), p = 0.0258, OR 0.576 (95% CI 0.33-1.01). However, after stratifying by non-malignant etiologies, the long-term mortality benefit for those with PH disappeared. In the studies that described specific echocardiographic findings of cardiac tamponade, only 10.5% of patients with PH and tamponade showed right atrial and right ventricular collapse. When evaluating patients with pericardial effusions, physicians must recognize the effects of underlying PH on the incidence, in-hospital and long-term mortality rates, and potentially atypical echocardiographic presentation of cardiac tamponade.
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Affiliation(s)
- Robert James Adrian
- Department of Emergency Medicine, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA.
- Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA.
| | - Stephen Alerhand
- Department of Emergency Medicine, Rutgers New Jersey Medical School, 185 S. Orange Ave, Newark, NJ, 07103, USA
| | - Andrew Liteplo
- Department of Emergency Medicine, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
| | - Hamid Shokoohi
- Department of Emergency Medicine, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
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Sami F, Sami SA, Tanveer S, Sami H. Hemorrhagic Cardiac Tamponade as a Complication of Limited Cutaneous Systemic Sclerosis. Cureus 2023; 15:e39947. [PMID: 37283596 PMCID: PMC10239686 DOI: 10.7759/cureus.39947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2023] [Indexed: 06/08/2023] Open
Abstract
Cardiac tamponade is an uncommon complication of systemic sclerosis (SSc) with a high mortality rate. Here, we report a case of a 58-year-old patient with limited cutaneous systemic sclerosis (lcSSc), gastroesophageal reflux disease (GERD), diabetes mellitus, pulmonary hypertension (PHTN), and COVID-19 infection, which occurred one month ago, presenting with a large hemorrhagic pericardial effusion and early cardiac tamponade. The patient had an acute onset of progressive dyspnea and anasarca. On examination, she was tachypneic, tachycardic, desaturating on room air, and hypotensive. Pitting edema up to thighs and bilateral basilar crackles were also appreciated. Labs were remarkable for negative troponin, chest X-ray with pulmonary congestion, D-dimer at 6.01, CT angiogram negative, brain natriuretic peptide level at 73 pg/mL, C-reactive protein level at 7.64 mg/dL, normal complement levels, and negative COVID-19 test results. Echocardiography showed early tamponade and a large circumferential effusion with chamber collapse. Right heart catheterization was performed finding PHTN at 54 mmHg. Pericardiocentesis drained 500 mL of the hemorrhagic effusion. Fluid analysis showed RBC at 220,000/uL, WBC at 5000/uL, protein 4.8 g/dL, lactate dehydrogenase level of 1275 U/L, and negative cytology. The patient was treated for serositis from lcSSc flare with mycophenolate mofetil and steroids, and responded very well. Hemorrhagic cardiac tamponade is a very rare phenomenon in limited scleroderma. A recent COVID-19 infection could have served as a trigger factor for our patient's lcSSc in long remission to flare up. Clinicians should maintain a high index of suspicion and a low threshold for intervention when lcSSc patients have an acute onset of cardiac compromise, especially with a history of a recent COVID-19 infection.
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Affiliation(s)
- Faria Sami
- Internal Medicine, Allama Iqbal Medical College, Lahore, PAK
| | | | - Saman Tanveer
- Internal Medicine, Army Medical College, National University of Medical Sciences (NUMS), Rawalpindi, PAK
| | - Hania Sami
- Anatomy, Physiology, and Biochemistry, Shalamar Medical and Dental College, Lahore, PAK
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Glynn P, Hale S, Hussain T, Freed BH. Cardiovascular Imaging for Systemic Sclerosis Monitoring and Management. Front Cardiovasc Med 2022; 9:846213. [PMID: 35433887 PMCID: PMC9008238 DOI: 10.3389/fcvm.2022.846213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 03/08/2022] [Indexed: 11/23/2022] Open
Abstract
Systemic sclerosis (SSc) is a complex connective tissue disease with multiple clinical and subclinical cardiac manifestations. SSc can affect most structural components of the heart, including the pericardium, myocardium, valves, and conduction system through a damaging cycle of inflammation, ischemia, and fibrosis. While cardiac involvement is the second leading SSc-related cause of death, it is frequently clinically silent in early disease and often missed with routine screening. To facilitate identification of cardiac disease in this susceptible population, we present here a review of cardiac imaging modalities and potential uses in the SSc patient population. We describe well-characterized techniques including electrocardiography and 2D echocardiography with Doppler, but also discuss more advanced imaging approaches, such as speckle-tracking echocardiography, cardiovascular magnetic resonance imaging (CMR), and stress imaging, among others. We also suggest an algorithm for the appropriate application of these modalities in the workup and management of patients with SSc. Finally, we discuss future opportunities for cardiac imaging in SSc research to achieve early detection and to optimize treatment.
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Affiliation(s)
- Peter Glynn
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Sarah Hale
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Tasmeen Hussain
- Division of Hospital Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Benjamin H. Freed
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
- *Correspondence: Benjamin H. Freed,
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Ansari Aval Z, Mirhosseini SM, Jafari Naeini S. Atypical presentation of cardiac tamponade in pulmonary hypertension: A case report and review of the literature. Clin Case Rep 2021; 9:e05218. [PMID: 34938566 PMCID: PMC8667288 DOI: 10.1002/ccr3.5218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 11/01/2021] [Accepted: 12/03/2021] [Indexed: 11/07/2022] Open
Abstract
A young woman with systemic sclerosis, hypothyroidism, and pulmonary hypertension was admitted to our center with massive pericardial effusion and left ventricular collapse. Despite undergoing successful pericardiocentesis, she passed away a month later. The best therapeutic approach in this situation remains to be determined.
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Affiliation(s)
- Zahra Ansari Aval
- Cardiovascular Research CenterDepartment of Cardiovascular SurgeryShahid Beheshti University of Medical SciencesTehranIran
| | - Seyed Mohsen Mirhosseini
- Cardiovascular Research CenterDepartment of Cardiovascular SurgeryShahid Beheshti University of Medical SciencesTehranIran
| | - Sepideh Jafari Naeini
- Cardiovascular Research CenterShahid Beheshti University of Medical SciencesTehranIran
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Swan-Ganz and Pericardial Pressure-guided Pericardiocentesis in Pulmonary Arterial Hypertension-associated Cardiac Tamponade. Ann Am Thorac Soc 2020; 16:1189-1191. [PMID: 31469306 DOI: 10.1513/annalsats.201902-127cc] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Abstract
PURPOSE OF REVIEW We review the epidemiology, pathophysiology, and management of pericarditis most commonly complicating autoimmune and autoinflammatory conditions. RECENT FINDINGS Typically, pericarditis occurs in the context of a systemic flare of the underlying disease but infrequently, it is the presenting manifestation requiring a high index of suspicion to unravel the indolent cause. Pericardial involvement in rheumatic diseases encompasses a clinical spectrum to include acute, recurrent and incessant pericarditis, constrictive pericarditis, asymptomatic pericardial effusion, and pericardial tamponade. Direct evidence on the pathophysiology of pericarditis in the context of rheumatic diseases is scant. It is theorized that immune perturbations within pericardial tissue result from the underlying central immunopathology of the respective autoimmune or autoinflammatory disease. Pericarditis management depends on acuity, the underlying cause and epidemiological features such as patient's immune status and geographic prevalence of infections such as tuberculosis. Immunosuppressive medications including biologics such as interleukin 1 blockers emerge as possible steroid sparing agents for pericarditis treatment.
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Affiliation(s)
- Apostolos Kontzias
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Stony Brook University School of Medicine, Stony Brook, NY, USA.
| | - Amir Barkhodari
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Stony Brook University School of Medicine, Stony Brook, NY, USA
| | - QingPing Yao
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Stony Brook University School of Medicine, Stony Brook, NY, USA
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Nie LY, Wang XD, Zhang T, Xue J. Cardiac complications in systemic sclerosis: early diagnosis and treatment. Chin Med J (Engl) 2019; 132:2865-2871. [PMID: 31856059 PMCID: PMC6940066 DOI: 10.1097/cm9.0000000000000535] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Systemic sclerosis (SSc) is a remarkably systemic heterogeneous connective tissue disease with many organs involved. The heart is one of the major organs involved, carrying the threat of sudden cardiac death, especially in diffuse cutaneous SSc. This review summarizes the pathophysiology, types, new diagnostic approaches, and imaging and novel therapies of primary cardiac complications while underlining the effects of recently developed non-contrast cardiovascular magnetic resonance (CMR) in early diagnosis. DATA SOURCES Medline and Embase were searched for articles published up to July 2019. A combination of Medical Subject Headings (MeSH) terms and keywords pertaining to SSc ("Scleroderma, Systemic" OR "Systemic sclerosis" OR' SSc"), AND cardiology ("cardiology" OR "heart" OR "cardiac") were applied to the search strategies. STUDY SELECTION Literature was mainly printed in English and Chinese about cardiac complications in systemic sclerosis. After selected simply on the title and abstract, the articles were included for the full text. Article type was not limited. RESULTS Relevant cardiac manifestations are complex, including arrhythmias, pericardial effusion, myocardial dysfunction, and valvular diseases. Even though the symptoms of cardiac complications are well known, unfortunately, they appear to be poor prognostic factors. As systemic sclerosis with cardiac complications has a high mortality rate and patients might have a poor quality of life, it is essential to promote early diagnosis and treatment. With the advent of non-invasive imaging techniques, such as CMR, early diagnosis of cardiac complications in SSc is becoming more effective. CONCLUSIONS Cardiac complications play an essential role in SSc and carry the threat of sudden cardiac death. More basic and clinical studies are warranted to develop better management of cardiac involvement in patients with SSc.
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Affiliation(s)
- Liu-Yan Nie
- Department of Rheumatology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310009, China
| | - Xiao-Dong Wang
- Department of Rheumatology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310009, China
- Department of Rheumatology, People's Hospital of Lishui, Lishui, Zhejiang 323000, China
| | - Ting Zhang
- Department of Rheumatology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310009, China
| | - Jing Xue
- Department of Rheumatology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310009, China
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Clinically Symptomatic Pericardial Effusions in Hospitalized Systemic Sclerosis Patients: Demographics and Management. BIOMED RESEARCH INTERNATIONAL 2018; 2018:6812082. [PMID: 29967777 PMCID: PMC6008774 DOI: 10.1155/2018/6812082] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 03/28/2018] [Accepted: 04/04/2018] [Indexed: 11/24/2022]
Abstract
Background Pericardial effusions in systemic sclerosis (SSc) may present as acute or chronic with or without clinical symptoms. Best treatment is unknown and whether patients receive medical therapy or a surgical procedure is clinician-dependent. Objective To describe the clinical characteristics, treatment, and outcomes of patients with SSc and clinically symptomatic pericardial effusions treated in the inpatient setting. Methods We evaluated all SSc admissions over a 10-year period to a tertiary care hospital which has a dedicated SSc clinic. Patients who had a clinically symptomatic pericardial effusion were evaluated based on their demographics, disease pattern, and medical or surgical management. Results From January 2005 till October 2015, there were 462 SSc admissions with 32 (6.9%) of them being for a clinically symptomatic pericardial effusion in 23 unique patients. Eleven (47%) of these patients had right heart failure, seventeen (74%) had pulmonary arterial hypertension (PAH), and 4 (17%) had tamponade physiology. Five (22%) patients were treated by a surgical procedure, while eighteen (78%) patients had medical therapy. Patients who received medical therapy tended to be older, have a lower serum Cr level, and more likely have right heart failure. Conclusion Clinically symptomatic pericardial effusion is a rare cause for hospital admissions in SSc, with a high percentage of these patients having PAH. Medical therapy tends to be reserved for older patients with right heart failure, while surgical therapy was more likely in patients with higher serum Cr levels.
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Bournia VK, Tountas C, Protogerou AD, Panopoulos S, Mavrogeni S, Sfikakis PP. Update on assessment and management of primary cardiac involvement in systemic sclerosis. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2018; 3:53-65. [PMID: 35382127 PMCID: PMC8892878 DOI: 10.1177/2397198317747441] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2017] [Indexed: 09/26/2023]
Abstract
Primary cardiac involvement is a common and severe complication of systemic sclerosis, which may affect all of the hearts' structural components, including pericardium, myocardium, endocardium, cardiac valves, and conduction system. While cardiac disease can be clinically silent and only diagnosed in autopsy, new imaging modalities such as speckle-tracking echocardiography and cardiovascular magnetic resonance may reveal various abnormal findings in the majority of patients. Cardiovascular magnetic resonance evaluation should include assessment of left and right ventricular function, inflammation (STIR T2-weighted sequences (T2-W) for edema detection), and fibrosis (T1-weighted sequences 15 min after Gd-DTPA contrast medium injection (late-gadolinium enhancement). Notably, cardiac disease is responsible for about one-fourth of systemic sclerosis-related deaths. Systematic studies for the assessment and therapy of systemic sclerosis-related cardiac complications, as well as relevant guidelines from the European League Against Rheumatism and the American College of Rheumatology, are currently lacking. However, research advances reviewed herein allow for a better understanding of the mechanisms that alter cardiac function. Implementation of such knowledge should reduce cardiac morbidity and mortality in systemic sclerosis patients.
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Affiliation(s)
- Vasiliki-Kalliopi Bournia
- First Department of Propaedeutic
and Internal Medicine and Joined Rheumatology Program, Medical School,
National and Kapodistrian University of Athens, Laikon Hospital, Athens -
Greece
| | - Christos Tountas
- First Department of Propaedeutic
and Internal Medicine and Joined Rheumatology Program, Medical School,
National and Kapodistrian University of Athens, Laikon Hospital, Athens -
Greece
| | - Athanase D. Protogerou
- Cardiovascular Prevention and
Research Unit, Department of Pathophysiology, Medical School, National and
Kapodistrian University of Athens, Athens - Greece
| | - Stylianos Panopoulos
- First Department of Propaedeutic
and Internal Medicine and Joined Rheumatology Program, Medical School,
National and Kapodistrian University of Athens, Laikon Hospital, Athens -
Greece
| | | | - Petros P. Sfikakis
- First Department of Propaedeutic
and Internal Medicine and Joined Rheumatology Program, Medical School,
National and Kapodistrian University of Athens, Laikon Hospital, Athens -
Greece
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Fernández Morales A, Iniesta N, Fernández-Codina A, Vaz de Cunha J, Pérez Romero T, Hurtado García R, Simeón-Aznar CP, Fonollosa V, Cervera R, Espinosa G. Cardiac tamponade and severe pericardial effusion in systemic sclerosis: report of nine patients and review of the literature. Int J Rheum Dis 2016; 20:1582-1592. [PMID: 27943614 DOI: 10.1111/1756-185x.12952] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
AIM To describe the clinical characteristics, treatment and outcome of patients with systemic sclerosis (SSc) developing severe pericardial effusion or cardiac tamponade. METHODS SSc patients with severe pericardial effusion or cardiac tamponade from three Spanish hospitals were collected. In addition, a computer-assisted (PubMed, MEDLINE) search of the literature to identify all cases of cardiac tamponade or severe pericardial effusion associated with SSc reported in English, French and Spanish from 1987 through September 2015 was performed. RESULTS We included 40 patients (nine cases from the Spanish hospitals and 31 cases from the literature review). Most patients (87%) were female with a mean age at pericardial involvement of 49.3 ± 15.2 years (range: 18-80 years), and 22 (55%) patients had the diffuse cutaneous subtype. Twenty-five (63%) patients presented with cardiac tamponade and the remaining 15 (37%) as severe or massive pericardial effusion. Pericardial involvement was previous or simultaneous to SSc diagnosis in 13 (32.5%) cases. In most cases (88.9%) pericardial fluid analysis disclosed an exudate. Half the patients received steroids and 35% needed surgical treatment. Five (12.5%) patients died due to cardiac tamponade, three of them during the acute phase and the remaining two, 2 and 9 months later, respectively. CONCLUSIONS Although cardiac tamponade or severe pericardial effusion is an infrequent complication in SSc patients, it can be the first manifestation of disease associated with the diffuse cutaneous subset. No specific treatment for this complication is known.
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Affiliation(s)
| | - Nerea Iniesta
- Department of Autoimmune Diseases, Hospital Clinic, Barcelona, Spain
| | | | | | | | | | | | - Vicent Fonollosa
- Department of Internal Medicine, Hospital Vall d'Hebron, Barcelona, Catalonia, Spain
| | - Ricard Cervera
- Department of Autoimmune Diseases, Hospital Clinic, Barcelona, Spain
| | - Gerard Espinosa
- Department of Autoimmune Diseases, Hospital Clinic, Barcelona, Spain
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Immunological and inflammatory processes in systemic autoimmune disease may not only cause pericardium inflammation, but may also cause mitral valve deterioration and left ventricular wall thickening. Int J Cardiol 2016; 215:466-71. [PMID: 27131766 DOI: 10.1016/j.ijcard.2016.04.126] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 04/12/2016] [Accepted: 04/13/2016] [Indexed: 11/22/2022]
Abstract
PURPOSE Systemic autoimmune disease (SAD) frequently affects the pericardium, and pathology is characterized by both immunological and inflammatory processes. We hypothesized that these processes simultaneously influence mitral-valve (MV) deterioration and left-ventricular (LV) wall thickening in SAD subjects. METHODS 101 SAD subjects were selected (76 female; 53±17years; systemic-lupus-erythematosus, 26%; vasculitis, 20%; scleroderma, 14%; polymyositis/dermatomyositis complex, 10%; mixed connective tissue disease, 11% and rheumatoid-arthritis, 2%). MV anterior-mitral-leaflet (AML) length, AML thickness index, AML doming height and LV mass index (LVMI) were measured using transthoracic-echocardiography (TTE) and the presence of MV calcification, MV sub-valvular thickening and pericardial effusion (PE) were estimated. AML thickness index was calculated as the ratio of AML thickness to aortic posterior wall thickness. The correlation between LVMI and ECG V1S+V5R voltage was used to assess the etiology of LV wall thickening. RESULTS 19 subjects (19%) had significant PE. PE subjects had a significantly greater AML thickness index (1.55±0.48 vs. 1.14±0.32, P<0.001), AML doming height (1.26±1.54mm vs. 0.03±0.91mm, P<0.001), more frequent MV sub-valvular thickening (26% vs. 5%, P=0.003) and greater LVMI (104.7±34.6g/m2 vs. 80.6±21.0g/m2, P=0.002). Significant correlation was observed between LVMI and ECG V1S+V5R voltage in 79 subjects without PE (R=0.39, P<0.001). However, in 18 subjects with PE, no such correlation was observed (R=0.30, P=0.23). CONCLUSIONS MV, MV sub-valvular deterioration and increased LVMI, unrelated to high voltage ECG criteria, were frequently detected in SAD subjects with PE. Immunological and inflammatory processes in SAD may not only cause pericardium inflammation, but may also cause MV deterioration and LV wall thickening.
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Hurtado García R, Martín Guillén S, Argueta LA, Lorenzo J, Cienfuegos AA. Cardiac tamponade in a patient with systemic sclerosis. Scand J Rheumatol 2015; 45:78-79. [DOI: 10.3109/03009742.2015.1085083] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Pradhan R, Okabe T, Yoshida K, Angouras DC, DeCaro MV, Marhefka GD. Patient characteristics and predictors of mortality associated with pericardial decompression syndrome: a comprehensive analysis of published cases. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2014; 4:113-20. [PMID: 25178691 DOI: 10.1177/2048872614547975] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Pericardial decompression syndrome (PDS) is a rare and potentially fatal complication of pericardial drainage, either by needle pericardiocentesis or surgical pericardiostomy. It manifests with paradoxical hemodynamic deterioration and/or pulmonary edema, commonly associated with ventricular dysfunction. We sought to elucidate factors associated with mortality in PDS. METHODS MEDLINE was systematically searched for PDS case reports and case series published between 1983 and 2013. For this analysis, clinical variables, echocardiographic and hemodynamic variables, details of drainage procedure and clinical outcomes were collected for each case. RESULTS A total of 35 cases (12 male, 23 female) were identified. PDS developed after pericardiocentesis, pericardiostomy, or both, in 18, 16, and one patients, respectively. Cardiac tamponade was the indication in 33 cases (94%). The mean age was 47 ± 17 years. The mean amount of effusion drained was 888 mL. The minimum amount of effusion drained was 450 mL. The onset of PDS after the procedure varied widely, ranging from 'immediate' to 48 hours. Presentations included 10 (29%) with cardiogenic pulmonary edema without shock, 14 (40%) with left ventricular failure, three (9%) with right ventricular failure, seven (20%) with biventricular failure, and one (3%) with non-cardiogenic pulmonary edema. Ten patients (29%) died of PDS. Mortality was associated only with surgical drainage (p<0.001). Severe LV dysfunction normalized in PDS survivors. CONCLUSIONS PDS is a rare complication of pericardial drainage with a high mortality rate. Surgical pericardiostomy was associated with mortality in PDS.
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Affiliation(s)
- Rajesh Pradhan
- Department of Medicine, Division of Cardiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Toshimasa Okabe
- Department of Medicine, Division of Cardiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | | | - Dimitrios C Angouras
- Department of Cardiac Surgery, University of Athens, Faculty of Medicine, Attikon University Hospital, Athens, Greece
| | - Matthew V DeCaro
- Department of Medicine, Division of Cardiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Gregary D Marhefka
- Department of Medicine, Division of Cardiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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Fenstad ER, Le RJ, Sinak LJ, Maradit-Kremers H, Ammash NM, Ayalew AM, Villarraga HR, Oh JK, Frantz RP, McCully RB, McGoon MD, Kane GC. Pericardial effusions in pulmonary arterial hypertension: characteristics, prognosis, and role of drainage. Chest 2014; 144:1530-1538. [PMID: 23949692 DOI: 10.1378/chest.12-3033] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The presence and size of a pericardial effusion in pulmonary arterial hypertension (PAH) and its association with outcome is unclear. METHODS In this single-center cohort study of 577 patients with group 1 PAH seen between January 1, 1995, and December 31, 2005, all patients underwent transthoracic echocardiography and were followed for ≥ 5 years. Echocardiography-guided pericardiocentesis was performed as needed. RESULTS Pericardial effusions on index echocardiography occurred in 150 patients (26%); 128 patients had small and 22 had moderate-sized or larger effusions. Most of the moderate or greater effusions occurred in patients who had connective tissue disease (82%). Mean right atrial pressure was 13.4 ± 4.4 mm Hg (no effusion), 15.1 ± 4.4 mm Hg (small effusion), and 17.0 ± 4.0 mm Hg (moderate or greater effusion) (P < .0001). Median survival for patients with moderate or greater effusion, mild effusion, or no effusion was 11.3 months, 42.3 months, and 76.5 months, respectively. Four of the 22 patients with moderate or greater pericardial effusions eventually required echocardiography-guided pericardiocentesis because of clinical and echocardiographic evidence of hemodynamic impact. When drained, the effusions were large (858 ± 469 mL) and generally serous. All pericardiocenteses were performed cautiously under echocardiographic guidance by a highly experienced echocardiologist, with low immediate morbidity and mortality. CONCLUSIONS Pericardial effusions are relatively common but rarely of hemodynamic significance in patients with PAH. However, even modest degrees of pericardial fluid are associated with a significant increase in mortality and appear to reflect the presence of associated collagen vascular disease and high right atrial pressure.
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Affiliation(s)
- Eric R Fenstad
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Rachel J Le
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Lawrence J Sinak
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Hilal Maradit-Kremers
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Naser M Ammash
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Assefa M Ayalew
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Hector R Villarraga
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Jae K Oh
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Robert P Frantz
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Robert B McCully
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Michael D McGoon
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Garvan C Kane
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, MN.
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16
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Itolikar SM, Salagre S, Phatak S, Itolikar M. Recurrent cardiac tamponade in a young woman. BMJ Case Rep 2013; 2013:bcr-2013-201472. [PMID: 24293539 DOI: 10.1136/bcr-2013-201472] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A young woman presented with recurrent pericardial effusion, she had previously been treated with antitubercular medications. She had clinical features of systemic sclerosis (SSc) which was subsequently confirmed on further workup. She was also found to be profoundly hypothyroid. Cardiac tamponade is uncommon in both SSc as well as hypothyroidism, unlike in our patient who was found to have both of these disorders. In her case, the pericardial involvement probably ante-dated the other features of SSc.
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Affiliation(s)
- Shobha Manish Itolikar
- Department of Medicine, Seth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
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Abstract
Abstract Pulmonary arterial hypertension (PAH) is a serious condition that can lead to right heart failure and death. Pericardial effusion in PAH is associated with significant morbidity and mortality, and its pathogenesis is complex and poorly understood. There are few data on the prevalence of pericardial effusion in PAH, and more importantly, the management of pericardial effusion is controversial. Current literature abounds with case reports, case series, and retrospective studies that have limited value for assessing this association. Hence, we summarize the available evidence on this ominous association and identify areas for future research.
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Affiliation(s)
- Sandeep Sahay
- 1 Division of Pulmonary, Critical Care and Sleep Medicine, University of Texas, Health Science Center at Houston, Houston, Texas, USA
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18
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Li J, Lee A, Cheng Y. A GPS Map for Pulmonary Hypertension: A Review of Imaging Modalities. Curr Hypertens Rep 2013; 15:650-8. [DOI: 10.1007/s11906-013-0392-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Honeycutt GR, Safdar Z. Pulmonary hypertension complicated by pericardial effusion: a single center experience. Ther Adv Respir Dis 2012; 7:151-9. [PMID: 23258502 DOI: 10.1177/1753465812471416] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Pericardial effusion is an independent predictor of mortality in patients with pulmonary arterial hypertension (PAH). However, the management and outcomes of patients with pulmonary hypertension (PH) and pericardial effusion are not well described. METHODS A retrospective, observational study was conducted at Baylor College of Medicine and The Methodist Hospital by screening all patients admitted between 1 June 2005 and 1 June 2010 with the International Classification of Diseases, ninth revision codes for PH and pericardial effusion. A total of 138 patients were identified, and 103 patients were excluded on the basis of valvular heart disease, recent surgery or end-stage renal disease. Thirty-five patients with PH diagnosed by a historical right heart catheterization or echocardiography and with documented pericardial effusion were included in this analysis. Demographic, hemodynamic, laboratory and survival data were collected. RESULTS The mean age was 49.5±36 years (mean ± standard deviation), 31 of 35 patients were women (93%) and pulmonary artery systolic pressure was 77 ± 19 mmHg. Mean follow-up period was 20.5 ± 12.9 months. Fifteen patients had PAH associated with connective tissue disease (50%). The majority of the patients (87%) with pericardial effusion were managed conservatively. Four patients (13%) who were hemodynamically unstable underwent pericardial window placement. One of them was started on epoprostenol, and two patients had the doses of PAH-specific medications uptitrated. Three of four pericardial window patients survived to the conclusion of the follow-up period. The overall survival in our cohort was 60%, with three patients lost to follow-up. CONCLUSIONS Connective tissue disease associated PAH and female sex were predominant in our cohort of patients with pericardial effusion. Seventy-five percent of patients who were treated with pericardial window for hemodynamically unstable pericardial effusion survived until the end of the study period. Pericardial window may be a therapeutic option in patients with unstable PH with pericardial effusion. Further studies are needed to determine the optimal treatment strategy for such patients.
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Affiliation(s)
- Gregory R Honeycutt
- Division of Pulmonary, Critical Care, and Sleep Medicine, Baylor College of Medicine, and The Methodist Hospital, Houston, TX, USA
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Abstract
PURPOSE OF REVIEW When present clinically, cardiac involvement in systemic sclerosis (SSc) is a major risk factor for death. It is therefore vitally important to understand the epidemiology, screening, diagnosis, and treatment of the cardiac manifestations of SSc. RECENT FINDINGS The epidemiology of cardiac involvement in SSc has been the subject of several recent studies. Most importantly, the prevalence of overt left ventricular (LV) systolic dysfunction and its associated risk factors have been defined, and patients with diffuse cutaneous SSc appear to be most susceptible to direct cardiac involvement. From a diagnostic and screening standpoint, tissue Doppler echocardiography and natriuretic peptides have provided fresh insight into subclinical cardiac dysfunction in SSc. Newer techniques, such as speckle-tracking echocardiography, diffuse myocardial fibrosis imaging, and absolute myocardial perfusion imaging, are poised to further advance our knowledge. Lastly, there is now consistent observational data to suggest a central role for calcium channel blockers in the treatment of microvascular ischemia and prevention of overt LV systolic dysfunction, although randomized controlled trials are lacking. SUMMARY Recent studies have improved our understanding of cardiac involvement in SSc. Nevertheless, key questions regarding screening, diagnosis, and treatment remain. Novel diagnostic techniques and multicenter studies should yield important new data, which will hopefully ultimately result in improved outcomes.
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Hoeper MM, Granton J. Intensive care unit management of patients with severe pulmonary hypertension and right heart failure. Am J Respir Crit Care Med 2012; 184:1114-24. [PMID: 21700906 DOI: 10.1164/rccm.201104-0662ci] [Citation(s) in RCA: 174] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Despite advances in medical therapies, pulmonary arterial hypertension (PAH) continues to cause significant morbidity and mortality. Although the right ventricle (RV) can adapt to an increase in afterload, progression of the pulmonary vasculopathy that characterizes PAH causes many patients to develop progressive right ventricular failure. Furthermore, acute right ventricular decompensation may develop from disorders that lead to either an acute increase in cardiac demand, such as sepsis, or to an increase in ventricular afterload, including interruptions in medical therapy, arrhythmia, or pulmonary embolism. The poor reserve of the right ventricle, RV ischemia, and adverse right ventricular influence on left ventricular filling may lead to a global reduction in oxygen delivery and multiorgan failure. There is a paucity of data to guide clinicians caring for acute right heart failure in PAH. Treatment recommendations are frequently based on animal models of acute right heart failure or case series in humans with other causes of pulmonary hypertension. Successful treatment often requires that invasive hemodynamics be used to monitor the effect of strategies that are based primarily on biological plausibility. Herein we have developed an approach based on the current understanding of RV failure in PAH and have attempted to develop a treatment paradigm based on physiological principles and available evidence.
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Affiliation(s)
- Marius M Hoeper
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany.
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