Acute pulmonary edema following pericardiocentesis for cardiac tamponade

Pericardial Decompression Syndrome: A Comprehensive Review of a Controversial Entity

Pericardial decompression syndrome is an ambiguous clinical entity which has generated controversy regarding its existence. Following pericardial decompression, patients experienced clinical deterioration ranging in complications from pulmonary edema to death that could not be attributed to any other distinct clinical pathology. Multiple theories have suggested the pathophysiology behind pericardial decompression syndrome is related to preload-afterload mismatch following pericardial decompression, coronary microvascular ischemia, and stress from high adrenergic state. Our review aims to describe this syndrome by analyzing demographics, etiology of pericardial effusion, method of drainage, volume of pericardial fluid removed, time to decompensation, and clinical outcomes. A systematic review of MEDLINE/PubMed and Google Scholar literature databases were queried for case reports, case series, review articles, and abstracts published in English journals between 1983 and December 2022. Each author's interpretation of echocardiographic and/or pulmonary arterial catheterization data provided in the case reports was used to characterize ventricular dysfunction. Based on our inclusion criteria, 72 cases of pericardial decompression syndrome were included in our review. Our results showed that phenotypic heterogeneity was present based on echocardiographic findings of right/left or biventricular failure with similar proportions in each type of ventricular dysfunction. Time to decompensation was similar between immediate, subacute, and acute cases with presentation varying between hypoxic respiratory failure and shock. This review article highlights theories behind the pathophysiology, clinical outcomes, and therapeutic options in this high mortality condition.

Comprehensive Management of the Patient With Traumatic Cardiac Injury

Cardiac injuries are rare but potentially life-threatening, with a significant proportion of victims dying before arrival at the hospital. The in-hospital mortality among patients who arrive in-hospital alive also remains significantly high, despite major advancements in trauma care including the continuous updating of the Advanced Trauma Life Support (ATLS) program. Stab and gunshot wounds due to assault or self-inflicted injuries are the common causes of penetrating cardiac injuries, while motor vehicular accidents and fall from height are attributable causes of blunt cardiac injury. Rapid transport of victim to trauma care facility, prompt recognition of cardiac trauma by clinical evaluation and focused assessment with sonography for trauma (FAST) examination, quick decision-making to perform emergency department thoracotomy, and/or shifting the patient expeditiously to the operating room for operative intervention with ongoing resuscitation are the key components for a successful outcome in cardiac injury victims with cardiac tamponade or exsanguinating hemorrhage. Blunt cardiac injury with arrhythmias, myocardial dysfunction, or cardiac failure may need continuous cardiac monitoring or anesthetic care for operative procedure of other associated injuries. This mandates a multidisciplinary approach working in concert with agreed local protocols and shared goals. An anesthesiologist has a pivotal role to play as a team leader or member in the trauma pathway of severely injured patients. They are not only involved in in-hospital care as a perioperative physician but also participate in the organizational aspects of prehospital trauma systems and training of prehospital care providers/paramedics. There is sparse literature available on the anesthetic management of cardiac injury (penetrating as well as blunt) patients. This narrative review discusses the comprehensive management of cardiac injury patients, focusing on the anesthetic concerns and is guided by our experience in managing cardiac injury cases at Jai Prakash Narayan Apex Trauma Center (JPNATC), All India Institute of Medical Sciences, New Delhi. JPNATC is the only level 1 trauma center in north India, providing services to a population of approximately 30 million with around 9000 operations being performed annually.

Pericardial Decompression Syndrome After Drainage of Chronic Pericardial Effusions

Pericardial decompression syndrome (PDS) is a potentially fatal disorder of left ventricular function that sometimes occurs after drainage of a pericardial effusion for cardiac tamponade. Patients at risk for PDS are difficult to identify. Here, we report 2 cases where PDS developed after drainage of effusions that had been present for years, suggesting that patients with chronic effusions are at higher risk for PDS. (Level of Difficulty: Advanced.).

Malignant cardiac tamponade: safety and efficacy of intrapericardial bleomycin instillation

BACKGROUND

Malignant cardiac tamponade is a life-threatening condition that requires prompt treatment and effective management to prevent recurrence. This paper describes safety and efficacy outcomes after intrapericardial instillation of bleomycin as well as possible predictors of survival.

METHODS

We performed a 10-year retrospective, single-center study to evaluate the safety and efficacy of intrapericardial instillation of bleomycin in patients with suspected malignant cardiac tamponade.

RESULTS

Intrapericardial instillation of bleomycin was performed in 31 cancer patients (9 men, 22 women) presenting with cardiac tamponade. Non-fatal complications occurred in 3 patients and relapse occurred in 1 patient. Overall survival was less than 10% at the end of the study. Median survival was 104 days (95% CI, 0-251 days). Survival was compared between different groups (defined by primary tumor, type of tumor, TNM stage and results of cytological analysis) with median survival being considerably higher when oncologic therapy was altered afterwards.

CONCLUSIONS

The use of intrapericardial bleomycin instillation following pericardiocentesis for malignant cardiac tamponade is a safe procedure with a high success rate. Survival rates depend on further oncological treatment options available.

A Comprehensive Systemic Literature Review of Pericardial Decompression Syndrome: Often Unrecognized and Potentially Fatal Syndrome

BACKGROUND

Pericardial Decompression Syndrome (PDS) is defined as paradoxical hemodynamic deterioration and/or pulmonary edema, commonly associated with ventricular dysfunction. This phenomenon was first described by Vandyke in 1983. PDS is a rare but formidable complication of pericardiocentesis, which, if not managed appropriately, is fatal. PDS, as an entity, has discrete literature; this review is to understand its epidemiology, presentation, and management.

METHODOLOGY

Medline, Science Direct and Google Scholar databases were utilized to do a systemic literature search. PRISMA protocol was employed. Abstracts, case reports, case series and clinical studies were identified from 1983 to 2019. A total of 6508 articles were reviewed, out of which, 210 were short-listed, and after removal of duplicates, 49 manuscripts were included in this review. For statistical analysis, patient data was tabulated in SPSS version 20. Cases were divided into two categories surgical and percutaneous groups. t-test was conducted for continuous variable and chi-square test was conducted for categorical data used for analysis.

RESULTS

A total of 42 full-length case reports, 2 poster abstracts, 3 case series of 2 patients, 1 case series of 4 patients and 1 case series of 5 patients were included in the study. A total of 59 cases were included in this manuscript. Our data had 45.8% (n=27) males and 54.2% (n=32) females. The mean age of patients was 48.04 ± 17 years. Pericardiocentesis was performed in 52.5% (n=31) cases, and pericardiostomy was performed in 45.8% (n=27). The most common identifiable cause of pericardial effusion was found to be malignancy in 35.6% (n=21). Twenty-three 23 cases reported pre-procedural ejection fraction, which ranged from 20%-75% with a mean of 55.8 ± 14.6%, while 26 cases reported post-procedural ejection fraction which ranged from 10%-65% with a mean of 30% ± 15.1%. Data was further divided into two categories, namely, pericardiocentesis and pericardiostomy. The outcome as death was significant in the pericardiostomy arm with a p-value of < 0.00. The use of inotropic agents for the treatment of PDS was more common in needle pericardiocentesis with a p-value of 0.04. Lastly, the computed recovery time did not yield any significance with a p-value of 0.275.

CONCLUSION

Pericardial decompression syndrome is a rare condition with high mortality. Operators performing pericardial drainage should be aware of this complication following drainage of cardiac tamponade, since early recognition and expeditious supportive care are the only therapeutic modalities available for adequate management of this complication.

Management of a patient with pericardial decompression syndrome and HOCM

A 44-year-old man, with a history of arterial hypertension, was referred with increasing shortness of breath due to a large pericardial effusion and imminent tamponade. Emergency ultrasound-guided pericardiocentesis resulted in the rapid withdrawal of 2760 cc of serous fluid. 3 hours later, the patient developed acute pulmonary oedema, which was successfully treated. Hypertrophic obstructive cardiomyopathy was later diagnosed and malignancy was excluded as a cause of the effusion. Clinicians performing pericardiocentesis need to be aware of pericardial decompression syndrome (PDS), a rare but serious complication. Although the underlying mechanisms causing PDS are not fully understood, patients with high left ventricular (LV) filling pressures are at particular risk. In other words: diastolic dysfunction of the LV is a risk factor for the occurrence of PDS.

Safety, Efficacy, and Complications of Pericardiocentesis by Real-Time Echo-Monitored Procedure

Pericardiocentesis is useful in the diagnosis and treatment of pericardial effusive disease. To date, a number of methods have been developed to reduce complications and increase the success rate of the procedure. The aim of the present study was to evaluate the efficacy and the safety of echocardiography-guided pericardiocentesis under continuous echocardiographic monitoring in the management of pericardial effusion. We prospectively performed 161 pericardiocentesis procedures in 141 patients admitted from 1993 to 2015 in 3 centers. This procedure was performed for tamponade or large pericardial effusion in 157 cases and for diagnosis in 4 cases. A percutaneous puncture was performed where the largest amount of fluid was detected. To perform a real-time echo-guided procedure, a multi-angle bracket was mounted on the echocardiographic probe to support the needle and enable its continuous visualization during the puncture. The procedure was successful in 160 of 161 cases (99%). Two major complications occurred (1.2%): 1 mediastinal hematoma that required surgical drainage in a patient on anticoagulant therapy and 1 pleuropericardial shunt requiring thoracentesis. Seven minor complications occurred (4.3%): 1 pleuropericardial shunt, 1 case of transient AV type III block, 3 vasovagal reactions (1 with syncope), and 2 cases of acute pulmonary edema managed with medical therapy. No punctures of any cardiac chamber occurred, and emergency surgical drainage was not required in any case. In conclusion, echocardiography-guided pericardiocentesis under continuous visualization is effective, safe, and easy to perform, even in hospitals with low volumes of procedures with or without cardiac surgery.

Complications of pericardiocentesis: A clinical synopsis

Pericardiocentesis (PC) is both a diagnostic and a potentially life-saving therapeutic procedure. Currently echocardiography-guided pericardiocentesis is considered the standard clinical practice in the treatment of large pericardial effusions and cardiac tamponade. Although considered relatively safe, this invasive procedure may be associated with certain risks and potentially serious complications. This review provides a summary of pericardiocentesis and a focused overview of the potential complications of this procedure.

An unusual complication following pericardiocentesis: reversible left ventricular dysfunction

We report a case of a 78-year-old woman admitted to hospital due to cardiac tamponade 3 months after surgical mitral valve repair. The patient developed an early left ventricular dysfunction after removal of the pericardial effusion, with complete recovery within 10 days. Transient ventricular dysfunction after pericardiocentesis is a very rare complication, we present a review of the different mechanisms suggested in the literature to explain the pathophysiology of this rare phenomenon.

Transient acute left ventricular dysfunction post-pericardiocentesis for cardiac tamponade

A rare but serious complication of pericardiocentesis is the development of transient left ventricular dysfunction. In this report, we present a case of a 65-year-old male patient with cardiac tamponade who suffered from acute left ventricular heart failure post-pericardiocentesis. <Learning objective: Acute left ventricular dysfunction is a rare but serious complication of pericardiocentesis. However, there is lack of existing guidelines on pericardial fluid drainage and monitoring post-pericardiocentesis. To minimize the risk of the development of acute left ventricular dysfunction, the authors propose that every pericardiocentesis should be guided by predetermined parameters, e.g. rate of drainage, while taking into account each patient's physical profile.>.

A case report of ventricular dysfunction post pericardiocentesis: stress cardiomyopathy or pericardial decompression syndrome?

We report a case of transient biventricular dysfunction post therapeutic pericardiocentesis, with classic features of stress cardiomyopathy (SCM). In our patient, the clinical and echocardiographic features were more in keeping with Takotsubo-type SCM than pericardial decompression syndrome (PDS). Our case is instructive in challenging our understanding of the aetiology of LV dysfunction complicating pericardiocentesis, and in highlighting the importance of careful clinical evaluation (altered heart rate and dyspnoea) in suspecting acute LV dysfunction after initial clinical improvement with pericardial aspiration.

Rare post-operative complications of large mediastinal tumor resection

BACKGROUND

There are some reports in the literature, which suggest that cardiac tamponade drainage may transiently affect systolic function and also cause acute respiratory distress syndrome (ARDS). We did not find any reports of acute ventricular failure and ARDS secondary to mediastinal tumor resection without tamponade.

CASE REPORT

Here we report a 48-year-old woman presenting with massive pericardial effusion without tamponade in whom tumor was resected through median sternotomy using cardiopulmonary bypass. ARDS and acute heart failure were two rare complications that happened at the end of the operation secondary to a sudden decompression of the heart from tumor pressure.

CONCLUSION

ARDS and acute heart failure are two rare complications, which can happen after large mediastinal tumor resection.

Patient characteristics and predictors of mortality associated with pericardial decompression syndrome: a comprehensive analysis of published cases

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.

Inflammatory activation after experimental cardiac tamponade

BACKGROUND/PURPOSE

Cardiac tamponade is a medical emergency situation associated with a high rate of life-threatening complications, even after immediate interventions. Our aim was to characterize the acute inflammatory consequences of this event in a clinically relevant large animal model.

METHODS

Cardiac tamponade was induced for 60 min in anesthetized, ventilated and thoracotomized minipigs by intrapericardial fluid administration, the mean arterial pressure (MAP) being maintained in the interval of 40-45 mm Hg (n = 8). A further group (n = 7) served as sham-operated control. The global macrohemodynamics, including the right- and left-heart end-diastolic volumes (RHEDV and LHEDV), the pulmonary vascular resistance index (PVRI) and the superior mesenteric artery (SMA) flow, were monitored for 240 min, and the intestinal microcirculatory changes (pCO2 gap) were evaluated by indirect tonometry. Blood samples were taken for the determination of cardiac troponin T and vasoactive inflammatory mediators, including histamine, nitrite/nitrate, big-endothelin, superoxide and high-mobility group box protein-1 levels in association with intestinal leukocyte and complement activation.

RESULTS

The cardiac tamponade induced significant decreases in MAP, cardiac output, LHEDV and SMA flow, while the PVRI and the pCO2 gap increased significantly. After the removal of fluid from the pericardial sac, the MAP and the LHEDV were decreased, while the PVRI and the pCO2 gap remained elevated when compared with those in the sham-operated group. In the posttamponade period, the abrupt release of inflammatory mediators was accompanied by a significant splanchnic leukocyte accumulation and complement activation.

CONCLUSIONS

The macrocirculatory and splanchnic microcirculatory disturbances were accompanied by a significant proinflammatory reaction; endothelin and the complement system may be significant components of the inflammatory cascade that is activated in this porcine model of pericardial tamponade.

High-volume hemofiltration as adjuvant therapy for refractory shock after pericardiocentesis

BACKGROUND

Pericardiocentesis for the treatment of chronic cardiac tamponade can occasionally result in acute pulmonary edema or biventricular failure. A sudden increase in heart filling pressures and right-to-left ventricular-output mismatch have been proposed underlying mechanisms.

CASE REPORT

We report the case of 16-year-old patient who underwent pericardiocentesis for chronic cardiac tamponade 6 weeks after undergoing a Bentall procedure. The patient developed circulatory shock 6 hours after pericardiocentesis. High-volume hemofiltration was used as a rescue therapy after treatment with positive inotropic drugs proved ineffective. An improvement in circulatory function observed after commencement of the hemofiltration treatment was followed by hemodynamic deterioration when the hemofiltration procedure was ceased.

DISCUSSION

The mechanism of the observed hemodynamic improvement is unclear. Hemodynamic recovery related in time to high-volume hemofiltration treatment indicates the possible removal of inflammatory mediators. Visceral vasoconstriction resulting from cardiac tamponade and subsequent improvement in gut perfusion after pericardiocentesis that led to washout of inflammatory mediators might have contributed to the development of acute heart failure. Cytokine removal by high-volume hemofiltration and the procedure's relationship to hemodynamic improvement have previously been demonstrated in clinical and experimental studies of septic shock.

CONCLUSIONS

We conclude that high-volume hemofiltration can be helpful as an adjuvant treatment for refractory shock after pericardiocentesis for chronic cardiac tamponade. The mechanism of the observed hemodynamic improvement remains to be investigated.

Reversible severe biventricular dysfunction postpericardiocentesis for tuberculous pericardial tamponade

Transient severe biventricular systolic dysfunction is a rare phenomenon postpericardiocentesis. Here, the authors report the clinical scenario of a young male who presented with pericardial tamponade that was tuberculous in origin. Soon postpericardiocentesis, he had biventricular dysfunction that recovered spontaneously. The authors discuss the clinical presentation, investigations and pathogenesis of this complication.

The intraoperative management of patients with pericardial tamponade

The anesthetic management of patients with pericardial tamponade is challenging, as they present with not only the cardiovascular compromise that defines pericardial tamponade, but often have comorbid conditions that increase the complexity of their management. This review describes the pathophysiology, etiology, clinical presentation, and anesthetic management of patients with pericardial tamponade, with an emphasis on the intraoperative period and the management of pericardial window procedures, the most common clinical scenario where anesthesiologists will encounter pericardial tamponade.