The production of acute pericardial effusion: the effects of various degrees of interference with venous blood and lymph drainage from the heart muscle in the dog

Incidence and prognostic significance of pleural effusions in pulmonary arterial hypertension

It has been suggested pleural effusions may develop in right heart failure in the absence of left heart disease. The incidence and prognostic significance of pleural effusions in pulmonary arterial hypertension is uncertain. Patients with pulmonary arterial hypertension followed at our tertiary care center were reviewed. Survival was examined based on the subsequent development of a pleural effusion. A total of 191 patients with pulmonary arterial hypertension met the inclusion criteria. The prevalence of pleural effusions on initial assessment was 7.3%. Among patients without a pleural effusion on initial imaging and at least one follow-up computerized tomography (N = 142), pleural effusion developed in 27.5% (N = 39) of patients. No alternative etiology of the effusion was identified in 19 (48.7%) cases and effusions deemed related to pulmonary arterial hypertension occurred at an incident rate of 38.6 cases per 1000 person-years. Of these, 14 (73.7%) were bilateral, 3 (15.8%) were right-sided, and 2 (10.5%) were left-sided. Effusion size was trace or small in 18 patients (94.7%). Development of a new pleural effusion was associated with attenuated survival in unadjusted survival analysis (HR: 3.80; 95% CI: 1.55–9.31), multivariate analysis (HR: 5.13; 95% CI: 1.86–14.16), and after the multivariate model was adjusted for concomitant pericardial effusion (HR: 4.86; 95% CI: 1.51–15.71). Negative impact on survival remained unchanged when effusions more likely related to an alternative cause were removed from analysis. In conclusion, pleural effusions can complicate pulmonary arterial hypertension in the absence of left heart disease. These effusions are frequently small in size, bilateral in location, and their presence is associated with decreased survival. Attenuated survival appears independent of the risk associated with a new pericardial effusion.

Rare case of right ventricular dilatation associated with anomalous pulmonary venous drainage, sinus venosus atrial septal defect and persistent left superior vena cava

A 34-year-old woman was seen in the emergency department for shortness of breath and chest pain. During a pandemic, it is easy to 'think horses and not zebras', and with a patient presenting with the classic coronavirus symptoms it would have been easy to jump to that as her diagnosis. After a careful history and examination, it became clear that there was another underlying diagnosis. Chest X-ray, echocardiogram and CT scan revealed marked right ventricular dilatation and pulmonary hypertension, alongside a persistent left superior vena cava (PLSVC). Further investigation with cardiac MRI and coronary angiography at a tertiary centre demonstrated that she not only have a PLSVC but also a partial anomalous pulmonary venous drainage and sinus venosus atrial septal defect. This case highlights the importance of considering all differentials and approaching investigations in a logical manner.

Which prognostic factors should be used in pulmonary arterial hypertension in elderly patients?

In recent times, the prevalence of pulmonary arterial hypertension (PAH) is more commonly seen among elderly populations. The increased prevalence of hypertension, diabetes, obesity, arterial stiffness, as well as diastolic dysfunction, may cause endothelial dysfunction and affect pulmonary vasculature. Furthermore, older patients have certain differences in clinical characteristics and outcomes. In this article, the special characteristics of aging in PAH patients have been reviewed, while the risk predictors of elderly patients are also discussed.

Prognostic factors in pulmonary arterial hypertension with Dana Point group 1

AIMS

To clarify the prognosis and prognostic factors in pulmonary arterial hypertension (PAH) patients in real-world medical practice in the Tokai area in Japan.

MAIN METHODS

We conducted a retrospective, multicenter observational study. The data of 81 patients diagnosed with Dana Point group 1 or 1' PAH was collected from January 2005 to January 2013. The primary outcome was all-cause death.

KEY FINDINGS

The patients consisted of 34 cases of idiopathic PAH (IPAH), 28 of connective tissue-associated PAH (CTD-PAH), 16 of congenital heart disease-associated PAH (CHD-PAH) and others. Mean age was 51 years and mean observation period was 46 months. The systolic blood pressure (BPs) was 117±23 mm Hg. Pericardial effusion was observed in 27.0% of patients. The mean right atrial pressure (mRAP) was 10.2±7.3 mm Hg. In the univariate Cox regression analysis, WHO-FCS III & IV, a cardiac index (CI)<2.5 L/min/m(2), and the presence of pericardial effusion at baseline were significantly associated with all-cause death. In the multivariate analysis, the pericardial effusion (HR 3.3, 95% CI 1.03-10.63, p=0.04) and mRAP (HR 3.2, 95% CI 1.03-9.83, p=0.04) or CI<2.5 L/min/m(2) (HR 3.89, 95% CI 1.05-14.45, p=0.04) were the independent predictors of mortality.

SIGNIFICANCE

The presence of pericardial effusion and mRAP or CI<2.5 L/min/m(2) at diagnosis indicated high mortality.

Pericardial effusion in pulmonary arterial hypertension

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.

Right side of heart failure

The function of the right ventricle (RV) in heart failure (HF) has been mostly ignored until recently. A 2006 report of the National Heart, Lung, and Blood Institute identified a gap between RV research efforts and its clinical importance compared with that of the left ventricle. This recent shift in paradigm is fueled by the prognostic value ascribed to RV failure in HF and morbidity/mortality after myocardial infarction and surgery. In this review, we examine the significance of RV failure in the HF setting, its clinical presentation and pathophysiology, and ways to evaluate RV function using echocardiographic measurements. Furthermore, we discuss the medical management of RV failure including traditional therapies like beta-blockers and newer options like nitric oxide, phosphodiesterase inhibitors, and calcium sensitizers. Mechanical support is also examined. Finally, this review places an emphasis on RV failure in the setting of left ventricular assist devices and heart transplantation.

An unusual presentation of lymphoma: chylotamponade

Chylopericardium is an uncommon but potentially life-threatening clinic entity. Here we reported a case with chylopericardium causing tamponade and shock as an unusual presentation of lymphoma. The patient was managed by immediate pericardiocentesis. Further analysis of the pericardial fluid revealed immature T-cells compatible with precursor T-lymphoblastic lymphoma.

Myocardial microvascular permeability, interstitial oedema, and compromised cardiac function

The heart, perhaps more than any other organ, is exquisitely sensitive to increases in microvascular permeability and the accumulation of myocardial interstitial oedema fluid. Whereas some organs can cope with profound increases in the interstitial fluid volume or oedema formation without a compromise in function, heart function is significantly compromised with only a few percent increase in the interstitial fluid volume. This would be of little consequence if myocardial oedema were an uncommon pathology. On the contrary, myocardial oedema forms in response to many disease states as well as clinical interventions such as cardiopulmonary bypass and cardioplegic arrest common to many cardiothoracic surgical procedures. The heart's inability to function effectively in the presence of myocardial oedema is further confounded by the perplexing fact that the resolution of myocardial oedema does not restore normal cardiac function. We will attempt to provide some insight as to how microvascular permeability and myocardial oedema formation compromise cardiac function and discuss the acute changes that might take place in the myocardium to perpetuate compromised cardiac function following oedema resolution. We will also discuss compensatory changes in the interstitial matrix of the heart in response to chronic myocardial oedema and the role they play to optimize myocardial function during chronic oedemagenic disease.

Asymptomatic pericardial effusion in patients with systemic lupus erythematosus

To determine the frequency and clinical correlates of asymptomatic pericardial effusion (PE) in patients with systemic lupus erythematosus (SLE), echocardiography and electrocardiography were performed in 50 consecutive patients with SLE. Among 50 patients with SLE, 12 patients (24%) had PE and 17 patients (34%) had hypoalbuminaemia. Patients with PE had a significantly lower serum albumin (P < 0.001), higher incidence of proteinuria (P = 0.003), higher C-reactive protein (P = 0.036) and pulmonary artery systolic pressure (P = 0.011) and tended to have a higher incidence of PR-segment depression (P = 0.082) compared with those without PE. When four variables (PR-segment depression, C-reactive protein, serum albumin and pulmonary artery systolic pressure) were used in the multivariate analysis, serum albumin (P = 0.005, odds ratio = 0.016) and pulmonary artery systolic pressure (P = 0.010, odds ratio = 1.106) emerged as significant variables related to the occurrence of asymptomatic PE. Thus, an increase in hydrostatic pressure of the right heart cavities and a decrease in colloid osmotic pressure were important factors associated with the presence of asymptomatic PE in patients with SLE.

Clinical differences between idiopathic and scleroderma-related pulmonary hypertension

OBJECTIVE

Pulmonary arterial hypertension related to scleroderma (PAH-Scl) is associated with high morbidity and mortality as well as poorer response to therapy and worse outcomes compared with the idiopathic form of PAH (IPAH). Scleroderma is an autoimmune disease that can affect left and right heart function directly through inflammation and fibrosis and indirectly through systemic and pulmonary hypertension. This study tested the hypothesis that an increased prevalence of left heart disease might explain the higher mortality in patients with PAH-Scl compared with patients with IPAH.

METHODS

The study was designed as a retrospective cohort study comparing the baseline clinical data from 91 consecutive patients (41 with IPAH and 50 with PAH-Scl). Cox proportional hazards models were used to predict the effect of clinical covariates on patient survival.

RESULTS

Patients with PAH-Scl had a lower mean pulmonary artery pressure (46.6 mm Hg versus 54.4 mm Hg in patients with IPAH; P = 0.002) despite similar levels of cardiac dysfunction (cardiac index 2.2 and 2.1 liters/minute/m(2), respectively; P = 0.19). Echocardiography revealed similar degrees of right ventricular dysfunction in the 2 groups, whereas a predominance of left heart dysfunction was observed in patients with PAH-Scl. One- and three-year survival estimates were 87.8% and 48.9%, respectively, in patients with PAH-Scl and 95.1% and 83.6%, respectively, in those with IPAH. Patients with PAH-Scl were 3.06 times more likely to die than were patients with IPAH, after controlling for the presence of pericardial effusion; there was no significant change in increased risk of death in PAH-Scl after controlling for left heart disease.

CONCLUSION

The results confirm that there are significant clinical and survival differences between IPAH and PAH-Scl. The presence of left heart disease, although more common in PAH-Scl, was not predictive of the higher mortality in these patients.

Clinical factors associated with persistent pericardial effusion after successful primary coronary angioplasty

STUDY OBJECTIVE

To evaluate the incidence and clinical factors related to the persistence of infarct-associated pericardial effusion (PE) after primary angioplasty.

DESIGN

Consecutive case-series analysis.

SETTING

Coronary care unit in a university hospital.

PATIENTS

Three hundred ninety-one consecutive patients with acute myocardial infarction (AMI) who underwent successful primary percutaneous transluminal coronary angioplasty (PTCA) at hospital admission.

INTERVENTIONS

Coronary angiography and primary PTCA on hospital admission and serial echocardiography.

MEASUREMENTS AND RESULTS

The status of coronary flow before and after primary PTCA was evaluated by coronary angiography at hospital admission, while PE was studied by echocardiography within 24 h of admission and 1 month after the onset of AMI. PE was present in the acute phase in 76 patients (19%), and patients with PE had a significantly higher incidence of in-hospital death than those without PE (11% vs 2%, p < 0.001). Among 68 patients who had PE in the acute phase and underwent echocardiography 1 month later, PE persisted to 1 month after the onset of AMI (persistent PE) in 26 patients (38%). Patients with persistent PE had a significantly higher incidence of pericardial rub (p = 0.010), Killip class > 1 (p = 0.025), no reflow after PTCA (p = 0.026), lower incidence of collaterals (p = 0.024), and tended to have higher peak creatine kinase (CK) [p = 0.05] levels than those with transient PE. When five variables (peak CK, collaterals, no reflow, pericardial rub, and Killip class > 1) were used in the multivariate analysis, pericardial rub (p = 0.023; odds ratio [OR], 5.45), absence of collaterals (p = 0.011; OR, 0.16), and Killip class > 1 (p = 0.027; OR, 3.80) were the significant variables related to persistent PE.

CONCLUSIONS

PE remains a relatively common complication of AMI even in the era of reperfusion therapy and is associated with increased mortality. Furthermore, the presence of a pericardial rub, Killip class > 1, and absence of collateral flow in the early phase of the infarct are associated with persistence of the PE to 1 month after the onset of AMI.

Clinical significance of low voltage in asymptomatic patients with pericardial effusion free of heart disease

STUDY OBJECTIVE

The purpose of this study was to evaluate the diagnostic value of low voltage with PR-segment and ST-T wave changes in determining the amount of clinically silent pericardial effusion detected in a routine echocardiography.

DESIGN

Consecutive case series analysis.

SETTING

Noninvasive cardiology department of a university hospital.

PATIENTS

Among 8,041 consecutive patients referred to our echocardiography laboratory, 121 asymptomatic patients with pericardial effusion free of heart disease were studied.

INTERVENTIONS

Echocardiography and ECG.

MEASUREMENTS AND RESULTS

The amount (small or moderate/large) of pericardial effusion was correlated with ECG. Among 121 patients with pericardial effusion, low voltage was detected in 32 patients (26%), while widespread PR-segment depression was observed in 32 patients (26%) and widespread ST-segment elevation in 8 patients (7%). Although there was a significantly higher incidence of low voltage in patients with moderate/large pericardial effusion compared to that of small pericardial effusion, 13 of 32 patients (41%) with low voltage had a small pericardial effusion. In patients with a small pericardial effusion, 7 of 13 patients (54%) with low voltage had PR-segment depression, while 15 of 85 patients (18%) without low voltage had PR-segment depression; the difference was significant (p = 0.011). In patients with moderate/large pericardial effusions, there was no significant difference in the incidence of PR-segment depression between patients with and without low voltage (47% vs 25%, respectively; p = 0.791).

CONCLUSIONS

In the presence of PR-segment depression, even a small pericardial effusion may cause low voltage in the surface ECG.

Clinical correlates of PR-segment depression in asymptomatic patients with pericardial effusion

OBJECTIVES

The purpose of this study was to determine the clinical correlates of PR-segment depression among consecutive asymptomatic patients with pericardial effusion (PE) detected by routine echocardiography.

BACKGROUND

Pericardial effusion is a relatively common finding in clinical practice, but not many studies have evaluated electrocardiographic (ECG) changes associated with the occurrence of PE.

METHODS

Among 4,061 consecutive patients referred to our echocardiography laboratory, 176 asymptomatic patients had PE correlated with their clinical history and ECG findings.

RESULTS

PR-segment depression was detected in 40 patients (23%). There were no significant differences in age, gender distribution or heart rate between patients with and without PR-segment depression. Fifteen post-pericardiotomy patients (33%), 19 patients (40%) with malignant disease and 6 patients (46%) with connective tissue disease had PR-segment depression, whereas no patient with heart disease (dilated cardiomyopathy, hypertensive heart disease, old myocardial infarction, valvular heart disease), renal disease or hypothyroidism had PR-segment depression, nor widespread ST-segment elevation. Among 40 patients with PR-segment depression, 8 had ST-segment elevation in the leads of epicardial derivation, 8 had upright T waves, 20 had low to inverted T waves with an isoelectric ST-segment and 4 had ST-T-wave changes due to bundle branch block.

CONCLUSIONS

PR-segment depression was a relatively common ECG sign associated with clinically silent PE, and it was an ECG indicator of inflammatory pericardial involvement.

Echocardiographic predictors of adverse outcomes in primary pulmonary hypertension

OBJECTIVES

The aim of this study was to evaluate the relationships between echocardiographic findings and clinical outcomes in patients with severe primary pulmonary hypertension (PPH).

BACKGROUND

Primary pulmonary hypertension is associated with abnormalities of right heart structure and function that contribute to the poor prognosis of the disease. Echocardiographic abnormalities associated with PPH have been described, but the prognostic significance of these findings remains poorly characterized.

METHODS

Echocardiographic studies, invasive hemodynamic measurements and 6-min walk tests were performed and outcomes prospectively followed in 81 patients with severe PPH. Subjects were participants in a 12-week randomized trial examining the effects of prostacyclin plus conventional therapy compared with conventional therapy alone.

RESULTS

During the mean follow-up period of 36.9 +/- 15.4 months, 20 patients died and 21 patients underwent transplantation. Pericardial effusion (p = 0.003) and indexed right atrial area (p = 0.005) were predictors of mortality. Pericardial effusion (p = 0.017), indexed right atrial area (p = 0.012) and the degree of septal shift in diastole (p = 0.004) were predictors of a composite end point of death or transplantation. In multivariable analyses incorporating clinical, hemodynamic and echocardiographic variables, pericardial effusion and an enlarged right atrium remained predictors of adverse outcomes. Six-minute walk results, mixed venous oxygen saturation and initial treatment randomization were also independently associated with a poor prognosis.

CONCLUSIONS

Pericardial effusion, right atrial enlargement and septal displacement are echocardiographic abnormalities that reflect the severity of right heart failure and predict adverse outcomes in patients with severe PPH. These characteristics may help identify patients appropriate for more intensive medical therapy or earlier transplantation.

Protein washdown as a defense mechanism against myocardial edema

Myocardial edema occurs in many pathological conditions. We hypothesized that protein washdown at the myocardial microvascular exchange barrier would change the distribution of interstitial proteins from large to small molecules and diminish the effect of washdown on the colloid osmotic pressure (COP) of interstitial fluid and lymph. Dogs were instrumented with coronary sinus balloon-tipped catheters and myocardial lymphatic cannulas to manipulate myocardial lymph flow and to collect lymph. Myocardial venous pressure was elevated by balloon inflation to increase transmicrovascular fluid flux and myocardial lymph flow. COP of lymph was measured directly and was also calculated from protein concentration. Decreases occurred in both protein concentration and COP of lymph. The proportion of lymph protein accounted for by albumin increased significantly, whereas that accounted for by beta-lipoprotein decreased significantly. The change in the calculated plasma-to-lymph COP gradient was significantly greater than the change in the measured COP gradient. We conclude that the change in the distribution of interstitial fluid protein species decreases the effect of protein washdown on interstitial fluid COP and limits its effectiveness as a defense mechanism against myocardial edema formation.

Pericardial and pleural effusions in decompensated chronic heart failure

BACKGROUND

In decompensated chronic heart failure, there is controversy regarding the incidence and amount of pericardial fluid. Moreover, the relation of pericardial effusion to pleural effusion has not yet been clarified. The current study examined the incidence and amount of pericardial effusion in patients with decompensated chronic heart failure as a function of the volume of pleural effusion.

METHODS AND RESULTS

The study subjects were 60 consecutive patients with chronic heart failure requiring diuresis to improve the symptoms and signs of congestion. Pericardial effusion was semiquantified on the basis of M-mode echocardiographic findings and the volume of thoracic effusion drawn from computed tomographic images of the chest with Simpson's method. Causes of decompensated chronic heart failure in the 60 patients included cardiac valve disease (n = 26), arterial hypertension (n = 12), chronic ischemic heart disease (n = 9), and others (n = 13). As many as 52 (87%) of the 60 patients had pleural effusion; of these, 45 had bilateral effusion, 5 had right-sided effusion only, and 2 had left-sided effusion only. In contrast, only 12 (20%) patients had small (n = 9) or moderate (n = 3) pericardial effusion. There was no significant association between the amount of pleural effusion and the semiquantified pericardial effusion (chi-square 3.27, P =.775).

CONCLUSIONS

In this series of patients with congestive heart failure, small pericardial effusion was sometimes observed, but moderate to large effusion was uncommon, and there was no significant association between a given amount of pleural effusion and the volume of pericardial effusion.

Pericardial effusion after primary percutaneous transluminal coronary angioplasty in first Q-wave acute myocardial infarction

To evaluate the incidence and clinical significance of infarction-associated pericardial effusion in patients with successful primary percutaneous transluminal coronary angioplasty, we studied 214 consecutive patients with a first Q-wave acute myocardial infarction. Based on 9 clinical variables, multivariate analysis was performed to determine the important variables related to the occurrence of pericardial effusion. Pericardial effusion was detected by echocardiography in 45 patients (21%); pericardial rub (p <0.001), number of advanced asynergic segments (p <0.001), ventricular aneurysmal motion (p = 0.03), and pulmonary capillary wedge pressure (p = 0.04) were found to be the important variables related to pericardial effusion. Among 45 patients with pericardial effusion, 29 patients with no pericardial rub had significantly higher pulmonary capillary wedge pressure than those with pericardial rub, whereas 16 patients with pericardial rub had a higher incidence of angiographic no reflow and ventricular aneurysmal motion than those without pericardial rub. Patients with pericardial effusion and a pericardial rub had a higher mortality rate than those without pericardial effusion (19% vs 3%; p = 0.02). Thus, pericardial effusion is still a relatively common clinical finding after primary percutaneous transluminal coronary angioplasty, and those with pericardial effusion and a pericardial rub were associated with more severe transmural myocardial damage and higher in-hospital mortality.

Malignancy-related pericardial effusion. 127 cases from the Roswell Park Cancer Institute

BACKGROUND

Malignancy-related pericardial effusions may represent a terminal event in patients with therapeutically unresponsive disease. However, select patients with malignancies sensitive to available therapies may achieve significant improvement in palliation and long term survival with prompt recognition and appropriate intervention.

METHODS

From 1968 to 1994, 150 invasive procedures were performed for the treatment or diagnosis of pericardial effusion in 127 patients with underlying malignancies. These cases were reviewed retrospectively to best identify the clinical features, appropriate diagnostic workup, and optimal therapy for this complication of malignancy.

RESULTS

Dyspnea (81%) and an abnormal pulsus paradoxus (32%) were the most common symptoms. Echocardiography had a 96% diagnostic accuracy. Cytology and pericardial biopsy had sensitivities of 90% and 56%, respectively. Fifty-five percent of all effusions were malignant comprising 71% of adenocarcinomas of the lung, breast, esophagus, and unknown primary site. In 57 patients, a malignant effusion could not be determined, and no definitive etiology could be established for 74% of these effusions. Radiation-induced, infectious, and hemorrhagic pericarditis each were identified in fewer than 5% of cases.

CONCLUSIONS

Subxyphoid pericardiotomy proved to be a safe and effective intervention that successfully relieved pericardial effusions in 99% of cases with recurrence and reoperation rates of 9% and 7%, respectively. Survival most closely was related to the extent of disease and its inherent chemo-/radiosensitivity, with 72% of the patients who survived longer than 1 year having breast cancer, leukemia, or lymphoma.

Infectious pericardial effusion in five dogs

The medical records of five dogs diagnosed with infectious pericardial effusion were reviewed. Clinical signs included anorexia, depression, respiratory distress, abdominal distension, collapse, coughing, and vomiting. Anemia and leukocytosis were present in three dogs. Grass awn migration was confirmed as the cause of the pericardial effusion in two dogs and suspected in the other three. Surgery, followed by continuous chest drainage, and appropriate antibiotic therapy was the treatment in four dogs. Chest drains were removed within 4 days of surgery. One dog did not have chest drainage after surgery. Antibiotic treatment was continued for up to 6 months. The dogs were monitored postsurgically for a period ranging from 3 to 24 months. All dogs recovered well without apparent complications.

Clinical significance of pericardial effusion in Q-wave inferior wall acute myocardial infarction

To assess the clinical significance of pericardial effusion in Q-wave inferior wall acute myocardial infarction, 185 consecutive patients were examined by means of electrocardiogram, echocardiogram and hemodynamic monitoring. A pericardial effusion was present in 44 patients and was absent in 141 patients. Electrocardiographic right ventricular infarction (> or = 1 mm of ST-segment elevation and Q wave in V4R) was detected in 54 patients, with 20 patients having pericardial effusion. Patients with pericardial effusion had significantly more left ventricular segments with advanced asynergy, lower cardiac output, higher pulmonary artery wedge pressure and higher incidence of right ventricular infarction than those without pericardial effusion. There were 17 in-hospital deaths. Although there was no significant difference in the mortality rate between patients with and without right ventricular infarction, a significantly higher hospital mortality rate was observed in patients with pericardial effusion compared to those without it (23 vs 5%). Pericardial effusion was selected with age and pulmonary artery wedge pressure as important variables associated with hospital mortality by the discriminant analysis. Patients who developed pericardial effusion, regardless of right ventricular infarction, had more extensive myocardial damage, and hence, pericardial effusion was one of the predictors of increased hospital mortality.

Clinical significance of pericardial effusion associated with pericarditis in acute Q-wave anterior myocardial infarction

To elucidate the incidence and clinical factors related to the occurrence of pericardial effusion in infarction-associated pericarditis, 303 consecutive patients with their first Q-wave anterior myocardial infarction were examined carefully by means of auscultation, echocardiography, chest radiography, and hemodynamic monitoring. During the first 3 days, a pericardial rub was detected in 65 patients and was absent in 238 patients. Among the 65 patients with pericardial rub, pericardial effusion was present in 27 patients (group 1) and was absent in 38 patients (group 2). Although there were no significant differences in cardiac output, pulmonary artery wedge pressure and right atrial pressure between the two groups, patients in group 1 had significantly more left ventricular segments with advanced asynergy and higher radiographic scores (diffuse interstitial infiltrate or alveolar infiltrate) compared with those in group 2. Thus, pericardial effusion and increased extravascular lung water in infarction-associated pericarditis were not caused by left ventricular failure but by other mechanisms reflecting a larger infarct.

Disturbance of pulmonary gas exchange in patients with acute myocardial infarction-associated pericardial effusion

To elucidate the effect of pericardial effusion on pulmonary gas exchange in patients with infarction-associated pericardial effusion, 294 consecutive patients with their first Q-wave anterior wall acute myocardial infarction were examined carefully by echocardiography, chest radiography and hemodynamic monitoring. A pericardial effusion was detected in 77 patients and was absent in 217 (group 1). Of the 77 patients with pericardial effusion, it was mild in 57 (group 2) and moderate in 20 (group 3). Patients with pericardial effusion (groups 2 and 3) had significantly greater pulmonary artery wedge pressure and more left ventricular segments with advanced asynergy than did those in group 1. Although there were no significant differences in pulmonary artery wedge pressure and number of left ventricular segments with advanced asynergy between groups 2 and 3, group 3 had significantly greater right atrial pressure, alveolar arterial oxygen difference and incidence of high radiographic score. Thus, accumulation of pericardial effusion to a moderate amount may contribute to the greater incidence of increase in extravascular lung water, and disturbance of pulmonary gas exchange.

Pericardial effusion and cardiac hemangioma in the neonate

In the absence of hydrops or sepsis, a pericardial effusion is a rare occurrence in the neonate. We report a case of a neonate with a pericardial effusion in which there was an associated intracardiac hemangioma. Our literature review found 32 cases of pericardial effusion without hydrops in infants under 3 months of age; twelve of these cases were associated with intracardiac and pericardial tumors; 20 others were discovered to be randomly associated with other problems.

Subxiphoid pericardiotomy in the diagnosis and management of large pericardial effusions associated with malignancy

To determine the safety, diagnostic value, and clinical outcome of patients with malignancy undergoing subxiphoid pericardiotomy for large pericardial effusions, we prospectively studied 25 consecutive patients with malignancy and new, large pericardial effusions diagnosed by echocardiography. Twenty-two of the 25 operations were done under local anesthesia, and no patient died at surgery. Pericardial fluid cytology revealed malignant cells in 11 patients (44 percent), while tumor was seen in only five (45 percent) of these 11 patients on pathologic examination. The remaining 14 patients showed no evidence of pericardial invasion with tumor. Evidence of intrathoracic disease by CT or MRI scanning, tamponade, a sanguineous pericardial fluid character, and an elevated serum and pericardial fluid lactate dehydrogenase level all were suggestive of malignant invasion of the pericardium. All 25 patients were followed at least 12 months postoperatively. Effusions recurred in three patients (12 percent), and one patient required reoperation. Overall mortality was 72 percent with a 91 percent (10 of 11) mortality for those with malignant effusions and a 57 percent (8 of 14) mortality for those with nonmalignant effusions. Diagnostically, subxiphoid pericardiotomy has little advantage over examination of pericardial fluid alone in this group of patients. Therapeutically, however, it is a low morbidity procedure which is safe and effective in treating patients with malignancy and large pericardial effusions.

Factors associated with atrial fibrillation in Q wave anterior myocardial infarction

To elucidate the role of inflammatory and hemodynamic factors in the genesis of atrial fibrillation in acute myocardial infarction, 228 patients with a first Q wave anterior myocardial infarction were studied. Forty-nine patients had pericarditis (detection of pericardial rub by careful auscultation), and 36 patients had echocardiographically demonstrated hydropericardium (presence of pericardial effusion without pericardial rub). During the first 3 days after admission, transient episodes of atrial fibrillation were observed in 10 patients (20%) with pericarditis (group 1), 15 patients (42%) with hydropericardium (group 2), and 20 patients (14%) without pericarditis and hydropericardium (group 3). Although there was no significant difference in the incidence of atrial fibrillation between groups 1 and 3, patients in group 2 had a significantly higher incidence of atrial fibrillation than those in groups 1 and 3. Pulmonary capillary wedge pressure and the number of advanced asynergic segments were found to be the important factors discriminating the three groups by multivariate analysis. Therefore atrial fibrillation after acute Q wave anterior infarction was not related to the inflammatory infiltration involving the atria but to the increase in atrial pressure resulting from hemodynamic change caused by more extensive myocardial damage.

Factors associated with pericardial effusion in acute Q wave myocardial infarction

To elucidate the clinical characteristics associated with pericardial effusion in the early phase of myocardial infarction, 330 patients with acute Q wave infarction were studied. According to echocardiography, 83 patients had pericardial effusion on the third day of hospitalization, and careful auscultation revealed that a pericardial rub was absent in 45 patients and was present in 38 patients. Based on seven clinical variables, multivariate analysis was performed to determine the important variables related to the occurrence of pericardial effusion with and without pericardial rub. Pulmonary capillary wedge pressure and left ventricular segments with advanced asynergy were the significant factors related to the occurrence of pericardial effusion without a pericardial rub. The presence of ventricular aneurysmal motion, left ventricular segments with advanced asynergy, and alveolar arterial oxygen difference were related to pericardial effusion with a pericardial rub. Therefore, a hemodynamic factor was the major mechanism associated with the increase in extravascular myocardial fluid and the consequent occurrence of hydropericardia in the absence of a pericardial rub, whereas an increase in the microvascular permeability in the myocardium with excessive fluid exudating through the irritated epicardial surface was the mechanism related to pericardial effusion with a pericardial rub in the early phase of acute myocardial infarction.

Two-dimensional and Doppler-echocardiographic and cardiac catheterization correlates of survival in primary pulmonary hypertension

To determine correlates of survival in primary pulmonary hypertension, we compared 41 echocardiography-Doppler and nine catheterization parameters with outcome in 26 patients. Mean follow-up was 19.7 months in survivors; mean survival was 4.8 months in 16 nonsurvivors. Cox life-table univariate analysis correlated two echocardiographic, three Doppler, and three catheterization variables with poor survival (p less than or equal to 0.05), and chi 2 analysis ensured the best critical values: severity of pericardial effusion, heart rate of more than 87 beats/min, pulmonic flow acceleration time of less than 62 msec, tricuspid early flow deceleration (T-DEC) equal to or less than -300 cm2/sec, mitral early flow-to-atrial flow velocity ratio (M-E/A) equal to or less than 1.0, catheterization cardiac index (CI) equal to or less than 2.3 l/min/m2, mean pulmonary artery pressure of more than 61 mm Hg, and diastolic pulmonary artery pressure of more than 43 mm Hg. Multivariate life-table analysis of noninvasive variables revealed the severity of pericardial effusion to be independently significant (p = 0.006), whereas analysis of catheterization variables revealed cardiac index to be independently significant (p = 0.014). Combined multivariate analysis did not differ from the noninvasive results alone. Categorical modeling of the eight significant variables split at their critical values (present or absent) revealed M-E/A, T-DEC, and CI to be independently significant by multivariate analysis (p = 0.0014). Analysis of the five echocardiography-Doppler variables alone revealed M-E/A, T-DEC, and heart rate to be independently significant (p = 0.0016). In both cases, mortality increased with the number of critical values reached.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute massive (pericardial effusive) pulmonary thromboembolism--pulmonary embolectomy revisited

The most recent patient in a 13-year experience with 14 patients suffering massive pulmonary thromboembolism requiring pulmonary thromboembolectomy is the focus of this report. This 40-year-old woman not only survived life-threatening acute hypoxemia and right heart failure, but was also found to have developed a unique transudative 700 cc pericardial effusion. Pulmonary artery pressure was 90/30 (mean 50 mmHg), accompanied by 17 mm right ventricular alternans. Systemic alternans and tamponade physiology were absent. This unusual natural model for acute right heart failure illustrates a novel mechanism for pericardial effusion physiology.

The postmortem determination of CK isozymes in the pericardial fluid in various causes of death

The authors have studied the CK isozyme pattern in the pericardial fluid of 100 cadavers autopsied in the Anatomic Forensic Institute of Granada. The samples were classified into several groups according to the cause of death: --Multiple trauma with thoracic contusion --Pneumonia and pulmonary embolism --Mechanical asphyxia --Cranio-cerebral trauma --Acute haemorrhage --Myocardial infarction --Others. The results showed that the CK isozyme pattern of pericardial fluid provides useful postmortem information of cardiac "status", adding to the diagnostic potential of CK isozymes.

Echocardiographic observations regarding pericardial effusions associated with cardiac disease

Cardiac disease associated with congestive heart failure was found to be the most common cause (22 of 76) of pericardial effusion in patients referred for echocardiography. Parameters of left heart function were markedly abnormal in these patients with congestive heart failure and pericardial effusion, but were not significantly different from a group of patients with congestive heart failure without pericardial effusion. Clinical findings consistent with cardiac decompensation also failed to discern between these two groups. Nonetheless, patients with congestive heart failure with pericardial effusion had significantly larger right ventricular internal dimensions than those without effusion. Patients with pericardial effusion related to congestive heart failure (P < .01), heart disease without congestive heart failure (P < 0.001) and those patients post recent myocardial infarction (P < 0.05) had significantly larger right ventricular internal dimensions in diastole than normal subjects. Patients with pericardial effusions related to recent open heart surgery, idiopathic pericarditis or of miscellaneous causes had normal right ventricular internal dimensions. It is likely that right ventricular dilation indicates abnormal volume/pressure relationships of the right heart and that this abnormality, through alterations in venous and lymphatic drainage, underlies the accumulation of pericardial effusion in these patients with heart disease with or without congestive heart failure.

A study of the routes by which protein passes from the pericardial cavity to the blood in rabbits

The routes by which radioiodinated serum albumin placed in the pericardial cavity gains access to the circulation have been investigated in rabbits. 1. Eighty per cent of pericardial cavity protein passes through the parietal pericardium and into the circulation through the thoracic duct. 2. A small amount of protein is drained through the right lymph duct; this is probably derived from protein passing from the pericardial cavity into the pleural cavity. 3. There is no apparent movement of protein directly into blood vessels of the parietal pericardium. For theoretical reasons movement of protein across the visceral pericardium and into the blood vessels of the myocardium is also unlikely. 4. A small amount of protein enters the circulation when both major lymphatics are ligated. It is proposed that lymphatic uptake may continue and secondary lymphovenous junctions will open as a result of raised intralymphatic pressure.

A study of the composition of pericardial fluid, with special reference to the probable mechanism of fluid formation

The composition of pericardial fluid and simultaneously withdrawn plasma have been measured in rabbits and greyhounds. 1. Sodium and chloride distributions were found to be not markedly different from the ratio predicted for a passive distribution. The small deviation found in greyhounds could be largely corrected by the in vitro dialysis of plasma against pericardial fluid. 2. Calcium and magnesium were distributed in a manner expected from a passive ultrafiltrate of plasma. 3. Pericardial fluid was found to contain between one quarter and one third of the protein of plasma. 4. Separation of the protein constituents demonstrated a far higher proportion of albumin to other proteins in the pericardial fluid. 5. The osmolality of plasma was slightly higher than that of pericardial fluid, as would be expected from a plasma ultrafiltrate. 6. The potassium concentration of pericardial fluid was higher than the plasma concentration in all animals studied. This difference could be abolished, and an expected distribution obtained in the samples from greyhounds, by the in vitro dialysis of plasma against pericardial fluid. This observation for potassium cannot be attributed to haemolysis of blood in pericardial fluid samples or to the use of any inappropriate references. It is suggested that the elevated potassium concentration of pericardial fluid may reflect the lability of the cardiac intracellular potassium during cardiac contraction. 7. The results obtained in this study do not support the concept of an active secretion of pericardial fluid as has been claimed by others. The distribution of ions would appear to be passive and to follow the values predicted by the Gibbs-Donnan relationship.

Surgery in acute and chronic pericarditis. Pathophysiology and management

Forty-two cases of surgically treated pericarditis are presented, with comments on the management and pathophysiology of the acute, recurrent, and chronic stages of the disease. The spectrum of aetiological factors has changed within the last few decades in that tuberculosis is now rare, whereas uraemic pericarditis is referred to surgery with increasing frequency. With the advent of haemodialysis and renal transplantation, these cases should be treated vigorously, since they are amenable to surgical cure. Rapid surgical intervention is advocated in impending tamponade, and in all other acute cases which do not respond promptly to conservative management. In recurrent and chronic pericarditis, surgery is also preferable to long-term medical treatment with steroids and diuretics. Chronic pericarditis should not be allowed to progress to an advanced stage of disease with myocardial involvement and impairment of liver function. Early operation carries little hazard and gives lasting relief in the majority of cases. Microscopical examinations and laboratory analyses point towards an abnormal permeability of capillaries and visceral pericardium as an early and major event in the development of pericardial effusions. Destruction or preservation of the mesothelial cell lining is probably an important factor in determining the progression of acute disease towards adhesions and constriction.