Cardiac tamponade in medical patients

Complication rates in real-time ultrasound-guided vs static echocardiography-guided pericardiocentesis: a cohort study

BACKGROUND

Static echocardiography-guided pericardiocentesis, the current standard of care, uses a phased-array probe to locate the largest fluid pocket, marking the safest entry site and needle trajectory. Nevertheless, real-time needle visualization throughout the procedure would potentially increase success and decrease complications. The aim of this study was to assess the complication rates of the real-time in-plane ultrasound-guided technique compared to the traditional static echocardiography-guided pericardiocentesis.

METHODS

All adult patients who underwent pericardiocentesis in a tertiary care hospital from January 2011 to June 2024 were identified. The incidence of total complications of the real-time, in-plane, US-guided pericardiocentesis versus the static echocardiography-guided technique was compared using a regression model with overlap weighting, based on propensity scores, to adjust for confounding factors.

RESULTS

A total of 220 pericardiocentesis were identified, 91 with real-time, in-plane US-guided technique and 129 with a static echo-guided approach. The overall rate of total complications was 5.5%, with no significant difference between both techniques (IRR 1.06 [95% CI 0.98 to 1.16, p = 0.163]). Only one major complication was reported with the in-plane technique (pulmonary edema) compared to four major complications in the echo-assisted approach (three cardiac injuries and one injury to thoracic vessels), all of which required emergency surgery. The success rate was higher in the real-time in-plane US-guided procedures (97%) compared to the static echo-guided approach (93%).

CONCLUSIONS

In this single-center retrospective cohort study, real-time in-plane, US-guided pericardiocentesis technique was safe, and the rate of total complications was not significantly different from a static echo-guided approach. The low rate of major complications and high success rate underscores the potential use of this technique in emergency situations by well-trained physicians. Future studies are warranted to thoroughly assess the potential benefits of the real-time approach.

Performance of Cardiovascular Physical Exam Skills by Internal Medicine Residents

BACKGROUND

Few studies have assessed the ability of internal medicine residents to perform a cardiovascular physical examination using real patients.

METHODS

First year internal medicine interns from 2 large academic medical centers in Maryland examined the same patient with aortic insufficiency as part of the Assessment of Physical Examination and Communication Skills (APECS). Interns were assessed on 5 clinical domains: physical exam technique, identifying physical signs, generating a differential diagnosis, clinical judgment, and maintaining patient welfare. Spearman's correlation test was used to describe associations between clinical domains. Preceptor comments were examined to identify common errors in physical exam technique and identifying physical signs.

RESULTS

One hundred nine interns examined the same patient with aortic insufficiency across 14 APECS sessions. Only 58 interns (53.2%) correctly identified the presence of a diastolic murmur, and only 52 interns (47.7%) included aortic insufficiency on their differential diagnosis. There was a significant and positive correlation between physical exam technique and identification of the correct physical findings (r = 0.42, P < .001). Both technique (r = 0.34, P = .003) and identifying findings (r = 0.42, P < .001) were significantly associated with generating an appropriate differential diagnosis. Common errors in technique included auscultating over the gown, timing the cardiac cycle with the radial pulse, and failing to palpate for the apical impulse.

CONCLUSIONS

Internal medicine interns had variable skills in performing and interpreting the cardiovascular physical exam. Improving cardiovascular exam skills would likely lead to increased identification of relevant cardiovascular findings, inform clinical decision making and improve overall patient care.

Pericardial effusion in oncological patients: current knowledge and principles of management

BACKGROUND

This article provides an up-to-date overview of pericardial effusion in oncological practice and a guidance on its management. Furthermore, it addresses the question of when malignancy should be suspected in case of newly diagnosed pericardial effusion.

MAIN BODY

Cancer-related pericardial effusion is commonly the result of localization of lung and breast cancer, melanoma, or lymphoma to the pericardium via direct invasion, lymphatic dissemination, or hematogenous spread. Several cancer therapies may also cause pericardial effusion, most often during or shortly after administration. Pericardial effusion following radiation therapy may instead develop after years. Other diseases, such as infections, and, rarely, primary tumors of the pericardium complete the spectrum of the possible etiologies of pericardial effusion in oncological patients. The diagnosis of cancer-related pericardial effusion is usually incidental, but cancer accounts for approximately one third of all cardiac tamponades. Drainage, which is mainly attained by pericardiocentesis, is needed when cancer or cancer treatment-related pericardial effusion leads to hemodynamic impairment. Placement of a pericardial catheter for 2-5 days is advised after pericardial fluid removal. In contrast, even a large pericardial effusion should be conservatively managed when the patient is stable, although the best frequency and timing of monitoring by echocardiography in this context are yet to be established. Pericardial effusion secondary to immune checkpoint inhibitors typically responds to corticosteroid therapy. Pericardiocentesis may also be considered to confirm the presence of neoplastic cells in the pericardial fluid, but the yield of cytological examination is low. In case of newly found pericardial effusion in individuals without active cancer and/or recent cancer treatment, a history of malignancy, unremitting or recurrent course, large effusion or presentation with cardiac tamponade, incomplete response to empirical therapy with nonsteroidal anti-inflammatory, and hemorrhagic fluid at pericardiocentesis suggest a neoplastic etiology.

Cardiac tamponade

Cardiac tamponade is a medical emergency caused by the progressive accumulation of pericardial fluid (effusion), blood, pus or air in the pericardium, compressing the heart chambers and leading to haemodynamic compromise, circulatory shock, cardiac arrest and death. Pericardial diseases of any aetiology as well as complications of interventional and surgical procedures or chest trauma can cause cardiac tamponade. Tamponade can be precipitated in patients with pericardial effusion by dehydration or exposure to certain medications, particularly vasodilators or intravenous diuretics. Key clinical findings in patients with cardiac tamponade are hypotension, increased jugular venous pressure and distant heart sounds (Beck triad). Dyspnoea can progress to orthopnoea (with no rales on lung auscultation) accompanied by weakness, fatigue, tachycardia and oliguria. In tamponade caused by acute pericarditis, the patient can experience fever and typical chest pain increasing on inspiration and radiating to the trapezius ridge. Generally, cardiac tamponade is a clinical diagnosis that can be confirmed using various imaging modalities, principally echocardiography. Cardiac tamponade is preferably resolved by echocardiography-guided pericardiocentesis. In patients who have recently undergone cardiac surgery and in those with neoplastic infiltration, effusive-constrictive pericarditis, or loculated effusions, fluoroscopic guidance can increase the feasibility and safety of the procedure. Surgical management is indicated in patients with aortic dissection, chest trauma, bleeding or purulent infection that cannot be controlled percutaneously. After pericardiocentesis or pericardiotomy, NSAIDs and colchicine can be considered to prevent recurrence and effusive-constrictive pericarditis.

Pericardial Tamponade and Berger's Disease: An Unusual Association

Cardiac tamponade is considered a medical emergency because a patient can deteriorate easily and die of cardiac arrest if the fluid is not drained immediately. The most common etiologies are the same as pericarditis as fluid accumulates due to pericardial inflammation, including infection, malignancy, trauma, iatrogenic, autoimmune, post-myocardial infarction, radiation, and renal failure. Although the treatment is pericardiocentesis or pericardial window, finding the etiology responsible for the development of pericardial effusion is important. Here, we describe the case of a 40-year-old female who presented to the emergency department with a chief complaint of severe epigastric pain of a two-day duration that was associated with multiple episodes of nausea, vomiting, dysphagia, and severe shortness of breath (New York Heart Association III). The patient was eventually diagnosed with cardiac tamponade as a cause of her dyspnea, as a two-dimensional cardiac echocardiogram detected a large pericardial effusion (>2 cm) with echocardiographic indications for cardiac tamponade with severe pulmonary hypertension. The patient underwent a therapeutic pericardial window with drainage of 250 mL of pericardial fluid. Ultrasound of the abdomen focusing on the kidneys showed an atrophic and echogenic right kidney with a bidirectional flow in the hepatic veins, suggestive of right heart failure. Subsequently, she underwent a kidney biopsy that showed diffuse mesangial proliferative glomerulonephritis with segmental sclerosing features consistent with IgA nephropathy, associated with tubular atrophy, interstitial fibrosis, interstitial inflammation, and moderate arteriosclerosis. The patient was diagnosed with stage V chronic kidney disease secondary to IgA nephropathy. IgA nephropathy is usually common in Caucasian or Asian males in their teens and late 30s, with hematuria as a usual presentation. This case is unique as cardiac tamponade with renal failure is rarely the presenting symptom of IgA nephropathy.

Diagnosis, treatment, and management of pericardial effusion- review

The hemodynamic stability of the heart and pericardium are maintained by the pericardial fluid of volume ∼10–50 ml. Pericardial effusion is associated with the abnormal accumulation of pericardial fluid in the pericardial cavity. Numerous imaging techniques are utilized to evaluate pericardial effusion including chest X-ray, electrocardiogram, transthoracic echocardiography, computed tomography scan, cardiac magnetic resonance imaging, and pericardiocentesis. Once diagnosed, there are numerous treatment options available for the management of patients with pericardial effusion. These include various invasive and non-invasive strategies such as pericardiocentesis, pericardial window, and sclerosing therapies. In recent times, few studies have been conducted to evaluate the safety and efficacy of each approach in routine clinical practice. In this review, we review the role of different modalities in the diagnosis of pericardial effusion while highlighting existing therapies aimed at the management and treatment of pericardial effusion.

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Numerous imaging techniques are utilized to evaluate pericardial effusion (PE) including chest X-ray, electrocardiogram, transthoracic echocardiography, CT scan, cardiac MRI, and pericardiocentesis.

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Multiple treatment options are available for the management of patients with PE including pericardiocentesis, pericardial window, and sclerosing therapies.

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Recent studies have evaluated the safety and efficacy of various diagnostic and management techniques in routine clinical practice.

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Further research is needed to investigate the optimal diagnostic and treatment options for patients with PE.

Clinical significance of 12 lead ECG changes in patients undergoing pericardiocentesis for cardiac tamponade

INTRODUCTION

The electrocardiogram (ECG) is one of the initial tests done in patients suspected of having a cardiac Tamponade. Historically the emphasis has been on low QRS voltage and electrical alternans, which lacks specificity and sensitivity respectively. Majority of these studies included patients with pericardial effusions without tamponade. Moreover, the influence of different therapeutic interventions such as pericardiocentesis on ECG variables has not been elucidated.

OBJECTIVE

To determine the clinical significance of 12 lead ECG changes in patients undergoing pericardiocentesis for cardiac tamponade.

METHODS

144 patients underwent Echo guided pericardiocentesis for cardiac tamponade at a tertiary care hospital over a period of 7 years. We compared 19 EKG variables pre and post procedure.

RESULTS

Low voltage was detected in only 31 patients (29%) with 19 (18%) patients having persistent low voltage (p value = 0.0047) after the pericardiocentesis. Electrical alternans was only observed in 25 patients (23%), and persisted in 10 patients (10%) following pericardiocentesis. None of the other EKG variables measured changed reliably post procedure.

CONCLUSION

We found that although electrical alternans and low voltage were associated with cardiac tamponade, none of the ECG variables were highly sensitive or specific for the diagnosis, reproducibly changed after drainage or predicted recurrent effusion post-pericardiocentesis.

The Use of Point-of-Care Ultrasound to Evaluate Pulsus Paradoxus in Children With Asthma

Pulsus paradoxus (PP) is defined as a fall of systolic blood pressure of greater than 10 mm Hg during the inspiratory phase of respiration. Measurement of PP is recommended by national and international asthma guidelines as an objective measure of asthma severity but is rarely used in clinical practice. Cardiac point-of-care ultrasound with pulsed wave Doppler imaging measuring respiratory-phasic changes of mitral valve inflow velocities is well described in cardiac tamponade as "sonographic" PP. We present 10 cases of acute asthma presenting to an emergency department showing the finding of sonographic determined PP in the apical 4-chamber view of the heart on pulsed wave Doppler imaging.

Recurrent pericardial effusion with pericardial amyloid deposition: a case report and literature review

Pericardial amyloidosis is a rare cause of pericardial effusion. Here, we report a case of recurrent pericardial effusion because of pericardial amyloid deposition. The patient was a man in his 40s admitted for pulmonary embolism. During hospitalization, arterial fibrillation and cardiac tamponade were observed, and an initial pericardial puncture was performed. Thereafter, pericardial puncture was repeated nine times over the next two years. Cytological examination of the pericardial effusion suggested malignant mesothelioma. Afterward, pericardial fenestration and partial resection were performed. Intraoperatively, a thickened pericardium and hemorrhagic pericardial effusion were noted. Histologically, the surface of the pericardium was covered by an eosinophilic amorphous material. Congo red and DYLON stains, electron microscopy, and immunohistochemical findings revealed localized amyloidosis composed of an immunoglobulin lambda light chain. Although the patient did not receive further treatment for 5 years postoperatively, his renal and cardiac functions remained within normal limits. Based on these findings, the patient was diagnosed with localized amyloidosis. So far, hemorrhagic pericardial effusion has been reported in few cases with systemic amyloidosis. Because localized immunoglobulin light-chain-derived (AL) amyloidosis may progress to systemic disease (although it is a very rare occurrence), long-term follow-up is necessary to detect recurrence or progression to a systemic form.

Pericardial diseases in patients with hypothyroidism

Hypothyroidism is a well-known cause of pericardial effusion (with an incidence of 3%-37%) and can cause cardiac tamponade in severe cases. In this review, we present the current knowledge on the epidemiology of hypothyroid-induced pericardial diseases, the mechanism through which low thyroid hormone levels affect the pericardium, the associated clinical manifestations, diagnostic tests and management options. Hypothyroidism causes pericardial effusion through increased permeability of the epicardial vessels and decreased lymphatic drainage of albumin, resulting in accumulation of fluid in the pericardial space. Interestingly, autoimmunity does not seem to play a major role in the pathophysiology, and a majority of effusions are asymptomatic due to slow fluid accumulation. The diagnosis is generally made when the pericardial disease is associated with an elevated thyroid-stimulating hormone level, and other secondary causes are excluded. Management consists of thyroid replacement therapy, along with pericardial drainage in case of tamponade.In conclusion, hypothyroidism-induced pericardial diseases are underdiagnosed. Initiating treatment early in the disease process and preventing complications relies on early diagnosis through systematic screening per guidelines.

Usefulness of Oximetry Paradoxus to Diagnose Cardiac Tamponade

Although echocardiography is usually diagnostic of cardiac tamponade, it may not be readily available at the point-of-care. We sought to develop and validate a measurement of respirophasic variation in the amplitude of pulse oximetry plethysmographic waveforms as a diagnostic tool for cardiac tamponade. Pulse oximetry plethysmographic waveforms were recorded, and the ratio of maximum-to-minimum measured amplitude of these waveforms from one respiratory cycle was calculated by blinded observers. Ratios from 3 consecutive respiratory cycles were then averaged to derive an "oximetry paradoxus" ratio. Cardiac tamponade was independently confirmed or excluded according to a "blinded" objective interpretation of echocardiography or right heart catheterization. Seventy four subjects were enrolled (51% men; mean age 54 ± 15 years); 19 of whom had cardiac tamponade. Oximetry paradoxus area under the curve for diagnosis of cardiac tamponade was 0.90 (95% confidence interval, 0.84 to 0.97); its diagnostic performance was superior to sphygmomanometer-measured pulsus paradoxus (area under the curve difference = 0.16, p = 0.022). In a derivation cohort (n = 37; tamponade, 9 cases), 3 diagnostic oximetry paradoxus thresholds were identified and validated in an independent validation cohort (n = 37; tamponade, 10 cases): 1.2 (100% sensitivity, 44% specificity), 1.5 (80% sensitivity, 81% specificity), and 1.7 (80% sensitivity, 89% specificity). Furthermore, oximetry paradoxus was significantly reduced after draining pericardial fluid. In conclusion, we defined and validated oximetry paradoxus as a simple and ubiquitous point-of-care test to diagnose cardiac tamponade using respirophasic changes in pulse plethysmography waveforms. This test can aid in identifying patients with cardiac tamponade, thus expediting confirmatory testing and life-saving treatment.

Evolution of the pericardiocentesis technique

: Pericardiocentesis is a valuable technique for the diagnosis and treatment of patients with pericardial effusion and cardiac tamponade, although it may be associated with potentially serious complications. Through the years, many different imaging approaches have been described to reduce the complication rate of the procedure. This systematic review provides a focused overview of the different techniques developed in recent years to reduce the procedural complications and to increase the related success rate.

Pulsus paradoxus

OBJECTIVES

Reviewed the etiologies, pathophysiologic mechanisms, detection and clinical significance of pulsus paradoxus in various conditions.

DATA SOURCE

We searched PubMed, EMBASE, and the CINAHL from inception to June 2017. We used the following search terms: Pulsus paradoxus, pericardial effusion, acute asthma, ventricular interdependence and so forth. All types of study were chosen.

RESULTS AND CONCLUSION

Legendary physician Sir William Osler truly said that "Medicine is learned by the bedside and not in the classroom." Bedside history taking and physical examination should be an integral component of clinical teaching curriculum imparted to medical students. Pulsus paradoxus is a valuable physical sign seen in many clinical conditions. Pulsus paradoxus is defined by an inspiratory fall in systolic blood pressure of greater than 10 mm Hg. Two prototype examples of pulsus paradoxus are cardiac tamponade and acute asthma. Exaggerated swings of intrapleural pressure, bi-ventricular interactions and increase afterload of the left ventricle are few of the pathophysiological mechanisms involved in the causation of pulsus paradoxus. The sensitivity of pulsus paradoxus in the diagnosis of cardiac tamponade is very high. In acute asthma, it also correlates with the severity of airflow obstruction.

Comprehensive review of cardiovascular toxicity of drugs and related agents

Cardiovascular diseases are a leading cause of morbidity and mortality in most developed countries of the world. Pharmaceuticals, illicit drugs, and toxins can significantly contribute to the overall cardiovascular burden and thus deserve attention. The present article is a systematic overview of drugs that may induce distinct cardiovascular toxicity. The compounds are classified into agents that have significant effects on the heart, blood vessels, or both. The mechanism(s) of toxic action are discussed and treatment modalities are briefly mentioned in relevant cases. Due to the large number of clinically relevant compounds discussed, this article could be of interest to a broad audience including pharmacologists and toxicologists, pharmacists, physicians, and medicinal chemists. Particular emphasis is given to clinically relevant topics including the cardiovascular toxicity of illicit sympathomimetic drugs (e.g., cocaine, amphetamines, cathinones), drugs that prolong the QT interval, antidysrhythmic drugs, digoxin and other cardioactive steroids, beta-blockers, calcium channel blockers, female hormones, nonsteroidal anti-inflammatory, and anticancer compounds encompassing anthracyclines and novel targeted therapy interfering with the HER2 or the vascular endothelial growth factor pathway.

Oncologic Mechanical Emergencies

Prevalence of cancer and its various related complications continues to rise. Increasingly these life-threatening complications are initially managed in the emergency department, making a prompt and accurate diagnosis crucial to effectively institute the proper treatment and establish goals of care. The following oncologic emergencies are reviewed in this article: pericardial tamponade, superior vena cava syndrome, brain metastasis, malignant spinal cord compression, and hyperviscosity syndrome.

Emergency department point-of-care ultrasonography improves time to pericardiocentesis for clinically significant effusions

Objective

Our objective was to determine the utility of point-of-care ultrasound (POCUS) to identify and guide treatment of tamponade or clinically significant pericardial effusions in the emergency department (ED).

Methods

This was a retrospective cohort study of non-trauma patients who were diagnosed with large pericardial effusions or tamponade by the ED physician using POCUS. The control group was composed of those patients later diagnosed on the medical wards or incidentally in the ED by other means such as a computed tomography. The following data were abstracted from the patient’s file: demographics, medical background, electrocardiogram results, chest radiograph readings, echocardiogram results, and patient outcomes.

Results

There were 18 patients in the POCUS arm and 55 in the control group. The POCUS arm had a decreased time to pericardiocentesis (11.3 vs. 70.2 hours, P=0.055) as well as a shorter length of stay (5.1 vs. 7.0 days, P=0.222). A decreased volume of pericardial fluid was drained (661 vs. 826 mL, P=0.139) in the group diagnosed by POCUS.

Conclusion

This study suggests that POCUS may effectively identify pericardial effusions and guide appropriate treatment, leading to a decreased time to pericardiocentesis and decreased length of hospital stay. Pericardial tamponade or a large pericardial effusion should be considered in all patients presenting to the ED with clinical, radiographic, or electrocardiographic signs of cardiovascular compromise.

Cardiovascular Oncologic Emergencies

Oncologic emergencies can present either as a progression of a known cancer or as the initial presentation of a previously undiagnosed cancer. In most of these situations, a very high degree of suspicion is required to allow prompt assessment, diagnosis, and treatment. In this article, we review the presentation and management of cardiovascular oncologic emergencies from primary and metastatic tumors of the heart and complications such as pericardial tamponade, superior vena cava syndrome, and hyperviscosity syndrome. We have included the cardiovascular complications from radiation therapy, chemotherapeutic agents, and biologic agents used in modern cancer treatment.

Getting to the heart of hypopituitarism

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

Predictors of tamponade and constriction in patients with pericardial disease undergoing interventional and surgical treatment

OBJECTIVE

The aim of our study was to define predictors of cardiac compression development including clinical, electrocardiographic, echocardiographic, chest-X-ray and perioperative parameters and their diagnostic value.

METHODS

Overall 243 patients with pericardial disease, among them 123 with compression (tamponade, constriction) and 120 without signs of compression were included in the study. Clinical, laboratory, electrocardiographic, chest-X-Ray, echocardiographic and perioperative data were included in the logistic regression analysis to define predictors of tamponade/constriction development.

RESULTS

Logistic regression analysis demonstrated large effusion (> 20 mm) (OR 5.393, 95%CI 1.202-24.199, p = 0.028), cardiac chamber collapse (OR 31.426, 95%CI 1.609-613-914, p = 0.023) and NYHA class > 3 (OR 8.671, 95%CI 1.730-43.451, p = 0.009) were multivariable predictors of compression development. The model including these three variables allowed predicting compression in 91.7% of cases. ROC analyses demonstrated that all three variables had significant diagnostic value with sensitivity of 75.6% and specificity of 74.2% for large effusion, low sensitivity and high specificity for cardiac chamber collapse (35% and 92%) and NYHA class (32.5% and 94.2%).

CONCLUSION

The independent predictors of compression development are presence of large effusion > 20 mm, cardiac chamber collapse and high NYHA class. The model including all three parameters allows correctly predicting compression in 91.4% of cases. The diagnostic accuracy of each parameter is characterized by high sensitivity and specificity of large effusion, high specificity of cardiac chamber collapse and NYHA class.

Ultrasound Guidance for Pericardiocentesis

Sonographic guidance with 41 punctures and 38 catheterizations was employed in 68 patients. The approach was either intercostal or subxiphoid. Most punctures were performed with a 1.4-mm-thick plastic-sheathed cannula after local anesthesia. Complications were observed in 7 patients. In one patient a catheter introduced with a movable core-type guidewire pierced the right ventricle wall with uneventful recovery after surgery. Intercostal drainage caused pleural pain in 2 patients, and in 2, leakage to the pleural space. Two patients with heart transplants had severe bradycardia and drop of blood pressure, one after needle drainage and the other during guidewire manipulation. Direct monitoring generally ensures a correct position of the instruments and hazards to adjacent organs can be avoided. In small effusions a simple needle aspiration with a plastic-sheathed cannula is safer than catheter drainage.

Complications of Percutaneous Pericardiocentesis under Fluoroscopic Guidance

Complications in 352 cases of fluoroscopy-guided percutaneous pericardiocentesis accomplished through an indwelling catheter were reviewed following surgery and non-surgery. Thirteen major complications were found, namely 3 cardiac perforations, 2 cardiac arrhythmias, 4 cases of arterial bleeding, 2 cases of pneumothorax in children, one infection, and one major vagal reaction. No significant difference in complications was found between pericardiocenteses for pericardial effusions after cardiac surgery (n = 208) and those for effusions of non-surgical (n = 144) origin. Fluoroscopy-guided pericardiocentesis by the subxiphoid approach with placement of an indwelling catheter is a safe method for achieving pericardial drainage in both surgical and non-surgical effusions. Accidental cardiac perforation with a fine needle is a minor complication as long as the needle is directed towards the anterior diaphragmatic border of the right ventricle and drainage is achieved with a reliable indwelling catheter.

Pericardial Disease in the Intensive Care Setting

Pericardial disease commonly occurs in the intensive care setting, but its timely diagnosis may be missed. The normal pericardium serves as a lubricated sac within which the heart may beat with minimal friction. The effect of the pericardium on cardiac filling at normal diastolic pressures is not clear; however, it may limit cardiac dilation in states of acute volume overload such as mitral regurgitation and right ventricular infarction.

Pericardial disease may be divided into two catego ries : those cases that result from inflammation of the pericardium (pericarditis), and those cases in which a pericardial effusion or the thickened pericardium itself causes hemodynamic changes (tamponade and constric tion). Simple pericarditis should not lead to any hemo dynamic alteration other than tachycardia. In both tam ponade and constriction, the jugular venous pressure is elevated with low forward cardiac output; tamponade typically shows pulsus paradoxus, whereas constric tion more frequently shows Kussmaul's sign.

The electrocardiogram may show diffuse ST segment elevation with PR segment depression in pericarditis; a large pericardial effusion, even with early tamponade, may not by itself cause any changes in the electrocar diogram. The echocardiogram is invaluable in diagnos ing the presence of a pericardial effusion and recogniz ing tamponade physiology (diastolic collapse of the right ventricular outflow tract and invagination of the right atrium).

In selected patients, simple pericarditis may be managed outside of the hospital. Anyone suspected of having a hemodynamically significant pericardial effu sion should be hospitalized, usually in an intensive care unit. Pericardiocentesis should be performed under op timal monitoring conditions, although in an emergency, blind pericardiocentesis may be attempted. Recognition of the cause of the pericardial process will guide its treatment. Management of selected pericardial syn dromes is discussed later in this review.

The evaluation of cardiac tamponade risk in patients with pericardial effusion detected by non-gated chest CT

BACKGROUND

Although pericardial effusion is often identified using non-gated chest computed tomography (CT), findings predictive of cardiac tamponade have not been adequately established.

PURPOSE

To determine the findings predictive of clinical cardiac tamponade in patients with moderate to large pericardial effusion using non-gated chest CT.

MATERIAL AND METHODS

We performed a retrospective analysis of 134 patients with moderate to large pericardial effusion who were identified from among 4581 patients who underwent non-gated chest CT. Cardiac structural changes, including right ventricular outflow tract (RVOT), were qualitatively evaluated. The inferior vena cava ratio with hepatic (IVCupp) and renal portions (IVClow) and effusion size were measured. The diagnostic performance of each structural change was calculated, and multivariate analysis was used to determine the predictors of cardiac tamponade.

RESULTS

Of the 134 patients (mean age, 70.3 years; 64 men), 37 (28%) had cardiac tamponade. The sensitivity and specificity were 76% and 74% for RVOT compression; 87% and 84% for an IVClow ratio ≥0.77; and 60% and 77% for an effusion size ≥25.5 mm, respectively. Multivariate logistic regression analysis demonstrated that RVOT compression, an IVClow ratio ≥0.77, and an effusion size ≥25.5 mm were independent predictors of cardiac tamponade. The combination of these three CT findings had a sensitivity, specificity, and accuracy of 81%, 95%, and 91%, respectively.

CONCLUSION

In patients with moderate to large pericardial effusion, non-gated chest CT provides additional information for predicting cardiac tamponade.

Pericardial disease: a clinical review

Pericardial disease is infrequently encountered in cardiovascular practice, but can lead to significant morbidity and mortality. Clinical data and practice guidelines are relatively sparse. Early recognition and prompt treatment of pericardial diseases are critical to optimize patient outcomes. In this review we provide a concise summary of acute pericarditis, constrictive pericarditis and pericardial effusion/tamponade.

Percutaneous Pericardial Effusion Drainage under Ultrasonographic and Fluoroscopic Guidance for Symptomatic Pericardial Effusion: A Single-Center Experience in 93 Consecutive Patients

PURPOSE

To evaluate the safety and efficacy of ultrasound-guided and fluoroscopically guided percutaneous pericardial effusion drainage as performed by interventional radiologists in patients with symptomatic pericardial effusion.

MATERIALS AND METHODS

From July 2002 to December 2013, 93 patients were treated with percutaneous pericardial effusion drainage. Pericardial effusion drainage was performed via 3 routes: apical, subxiphoid, and transhepatic routes. After puncturing the pericardial sac with a 22-gauge needle under ultrasound guidance, a drainage catheter was inserted under fluoroscopic guidance. Pericardial effusion was categorized according to its distribution in the pericardial cavity: "circumferential even," "circumferential uneven" (predominant site specified), and "loculated." Technical success, recurrence, and complication rates were assessed.

RESULTS

The technical success rate was 99%. Pericardial effusion drainage was performed via the subxiphoid approach in 54 procedures, transhepatic approach in 30 procedures, and apical approach in 13 procedures. The transhepatic approach was mainly performed in cases where the effusion was distributed posteriorly to the heart (80%). One patient died of uncontrolled hypotension without evidence of hemopericardium.

CONCLUSIONS

Ultrasound-guided and fluoroscopically guided pericardial effusion drainage is a safe and effective procedure for patients with symptomatic pericardial effusion. The transhepatic approach may be preferable for posteriorly distributed pericardial effusion that would otherwise be inaccessible by a traditional subxiphoid or apical approach.

Shock

Critically ill patients with undifferentiated shock are complex and challenging cases in the ED. A systematic approach to assessment and management is essential to prevent unnecessary morbidity and mortality. The simplified, systematic approach described in this article focuses on determining the presence of problems with cardiac function (the pump), intravascular volume (the tank), or systemic vascular resistance (the pipes). With this approach, the emergency physician can detect life-threatening conditions and implement time-sensitive therapy.

Case report: cardiac tamponade resembling an acute myocardial infarction as the initial manifestation of metastatic pericardial adenocarcinoma

Pericardial malignancies are uncommon, usually metastatic, linked to terminal oncology patients, and rarely diagnosed premortem. A very small number of patients will develop signs and symptoms of malignant pericardial effusion as initial clinical manifestation of neoplastic disease. Among these patients, a minority will progress to a life-threatening cardiac tamponade. It is exceedingly rare for a cardiac tamponade to be the unveiling clinical manifestation of an unknown malignancy, either primary or metastatic to pericardium. We present the case of a 50-year-old male who was admitted to the emergency department with an acute myocardial infarction diagnosis that turned out to be a cardiac tamponade of unknown etiology. Further studies revealed a metastatic pericardial adenocarcinoma with secondary cardiac tamponade. We encourage considering malignancies metastatic to pericardium as probable etiology for large pericardial effusions and cardiac tamponade of unknown etiology.

Oncologic mechanical emergencies

Prevalence of cancer and its various related complications continues to rise. Increasingly these life-threatening complications are initially managed in the emergency department, making a prompt and accurate diagnosis crucial to effectively institute the proper treatment and establish goals of care. The following oncologic emergencies are reviewed in this article: pericardial tamponade, superior vena cava syndrome, brain metastasis, malignant spinal cord compression, and hyperviscosity syndrome.

Etiology and characteristics of large symptomatic pericardial effusion in a community hospital in the contemporary era

BACKGROUND

The etiology and laboratory characteristics of large symptomatic pericardial effusion (LSPE) in the Western world have evolved over the years, and vary between regions, community and tertiary hospitals.

METHODS

We reviewed data of 86 consecutive patients who underwent pericardiocentesis or pericardial window due to LSPE in a community hospital from 2001 to 2010. The characteristics of the PE including chemistry, hematology, bacteriology, serology and cytology have been analyzed. We correlated the etiologies of PE with age, gender and clinical presentation.

RESULTS

The most frequent etiology of LSPE was idiopathic [36% (77% with a clinical diagnosis of pericarditis)], followed by malignancy (31.4%), ischemic heart disease (16.3%), renal failure (4.6%), trauma (4.6%) and autoimmune disease (4.6%). The average age of all the etiological groups excluding trauma was over 50 years. Laboratory tests did not modify the pre-procedure diagnosis in any of the patients. The most frequent presenting symptom was dyspnea (76.6%). Chest pain was mostly common in patients with idiopathic etiology (58.06%). The most frequent medical condition associated with LSPE was the use of anticoagulant or antiplatelet drugs (31.40%), especially aspirin, and in those, the PE tended to be bloody (73%, P = 0.11). Most of the effusions were exudates (70.9%). PE due to renal failure was the largest (1467 ± 1387 ml).

CONCLUSION

The spectrum of etiologies of LSPE in a community hospital in the Western world in the contemporary era is continuously evolving. The most frequent etiology is now idiopathic, followed by malignancy. Routine laboratory testing still rarely modifies the pre-procedure diagnosis.

Point of care cardiac ultrasound applications in the emergency department and intensive care unit--a review

The use of point of care echocardiography by non-cardiologist in acute care settings such as the emergency department (ED) or the intensive care unit (ICU) is very common. Unlike diagnostic echocardiography, the scope of such point of care exams is often restricted to address the clinical questions raised by the patient's differential diagnosis or chief complaint in order to inform immediate management decisions. In this article, an overview of the most common applications of this focused echocardiography in the ED and ICU is provided. This includes but is not limited to the evaluation of patients experiencing hypotension, cardiac arrest, cardiac trauma, chest pain and patients after cardiac surgery.

Echocardiography-guided or "sided" pericardiocentesis

Echocardiography-guided pericardiocentesis is the first choice method for relieving cardiac tamponade, but the exact role of the echocardiography at the moment of the puncture is still controversial. In this report, detailed echocardiographic evaluation was performed in 21 consecutive patients with cardiac tamponade just before the pericardiocentesis. Appropriate needle position was determined according to the probe position using imaginary x, y, and z axes. Pericardiocentesis was performed successfully using this technique without simultaneous echocardiography and no complications were observed. We concluded that bedside echocardiography with detailed evaluation of the puncture site and angle is enough for pericardiocentesis instead of real time guiding.

A delayed diagnosis of cardiac tamponade

A 64-year-old female was referred to the on-call surgical team by her general practitioner with a 2-week history of feeling generally unwell; more short of breath with lethargy and myalgia with a 2-day history of right upper quadrant abdominal pain. On initial assessment she was tachycardic and an abdominal examination revealed a soft abdomen with right upper quadrant tenderness. An abdominal ultrasound scan revealed a distended gall bladder with the diameter of the common bile duct at the upper limit of normal. It also revealed free fluid within the abdomen, bilateral pleural effusions and a large left ovarian cyst. The medical team became involved and ordered a CT thorax and abdomen which showed a large pericardial effusion, bilateral pleural effusions, a small amount of ascites and a large left ovary; reported as appearances most consistent with malignancy. On further assessment by a cardiologist the patient showed signs of cardiac tamponade and she underwent urgent pericardiocentesis.

Diagnostic accuracy retrospectively of electrocardiographic findings and cancer history for tamponade in patients determined to have pericardial effusion by transthoracic echocardiogram

Unexpected pericardial effusions are often found by frontline providers who perform computed tomography. To study the hypothesis that electrocardiographic findings and whether cancer is known or suspected importantly change the likelihood of tamponade for such providers, all unique patients with moderate or large pericardial effusions determined by transthoracic echocardiography during a 6-year period were retrospectively identified. Electrocardiograms were evaluated by blinded investigators for electrical alternans (total and QRS), low voltage (limb leads only, precordial leads only, and both), and tachycardia (>100 QRS complexes/min). Medical records were reviewed to determine whether cancer was known or suspected and whether tamponade was diagnosed. Tamponade was present in 66 patients (27% of 241) with moderate or large pericardial effusions. No tachycardia lowered the odds of tamponade the most (likelihood ratio 0.4, 95% confidence interval 0.3 to 0.6) but by a degree less than any single diagnostic element increased it when present. The combined presence of all 3 electrocardiographic findings and cancer increased the odds of tamponade 63-fold (likelihood ratio 63, 95% confidence interval 33 to 150), whereas their combined absence decreased the odds only fivefold (likelihood ratio 0.2, 95% confidence interval 0.2 to 0.3). In conclusion, electrocardiography findings and cancer rule in tamponade better than they rule it out. Combining these diagnostic elements improves their discriminatory power but not sufficiently enough to rule out tamponade in patients with moderate or large pericardial effusions.

Cardiac tamponade as a presenting manifestation of severe hypothyroidism

We report a patient who presented to our hospital with unusual symptoms of non-specific complaints and uncontrolled hypertension. Acute cardiac tamponade was suspected from cardiomegaly on routine chest x-ray and confirmed with an echocardiogram. Analysis of the pericardial fluid and other laboratory data ruled out all the common causes except for hypothyroidism as a cause of cardiac tamponade. Tamponade results from increased intrapericardial pressure caused by the accumulation of pericardial fluid. The rapidity of fluid accumulation is a greater factor in the development of tamponade than absolute volume of the effusion. Hypothyroidism is a well-known cause of pericardial effusion. However, tamponade rarely develops owing to a slow rate of accumulation of pericardial fluid. The treatment of hypothyroidic cardiac tamponade is different from other conditions. Thyroxine supplementation is all that is necessary. Rarely, pericardiocentesis is needed in a severely symptomatic patient.

Critical cardiovascular skills and procedures in the emergency department

The management of cardiovascular emergencies is a fundamental component of the practice of an emergency practitioner. Delays in the evaluations and management can lead to significant morbidity or mortality. It is of vital importance to be familiar with procedures such as pericardiocentesis, cardioversion, defibrillation, temporary pacing, and options for the management of tachyarrhythmias. This article discusses the most common cardiovascular procedures encountered in an emergency setting, including the indications, contraindications, equipment, technique, and complications for each procedure.

Pericarditis, myocarditis, and other cardiomyopathies

An overview of pericarditis, cardiomyopathy, and acute myocarditis is presented. Clinical presentation, causes, physical signs, laboratory testing, and various imaging procedures are discussed. Established pharmacologic and mechanical therapies are reviewed. Short-term and long-term prognoses, when relevant, are discussed.

Simultaneously diagnosed pulmonary thromboembolism and hemopericardium in a man with thoracic spinal cord injury

BACKGROUND

Simultaneous pulmonary thromboembolism (PTE) and hemopericardium is a rare but life-threatening condition. As hemopericardium is a contraindication to anticoagulation treatment, it is challenging to handle both conditions together.

OBJECTIVE

The objective of the study was to report a rare case of a man with thoracic spinal cord injury presenting with simultaneous PTE and hemopericardium.

DESIGN

Case report.

SUBJECT

A 43-year-old man with incomplete T9 paraplegia (American Spinal Injury Association Impairment Scale D) complained of fever one and a half months after spinal cord injury sustained in a fall.

FINDINGS

During evaluation of fever origin, chest computed tomography and transthoracic echocardiogram revealed simultaneous PTE and hemopericardium. After serial echocardiograms over 2 days demonstrated stability, intravenous heparin, and oral warfarin were administered and his medical status was observed closely. Ultimately, both conditions improved without significant complications.

CONCLUSION

We report successful treatment of man with acute spinal cord injury who presented with simultaneously diagnosed PTE and hemopericardium, a rare complication involving two distinct and opposing pathological mechanisms and conflicting treatments.