Hemodynamic Effects of Volume Expansion in Patients With Cardiac Tamponade

The physiology of cardiac tamponade and implications for patient management

Exceeding the limit of pericardial stretch, intrapericardial collections exert compression on the right heart and decrease preload. Compensatory mechanisms ensue to maintain hemodynamics in the face of a depressed stroke volume but are outstripped as disease progresses. When constrained within a pressurized pericardial space, the right and left ventricles exhibit differential filling mediated by changes in intrathoracic pressure. Invasive hemodynamics and echocardiographic findings inform on the physiologic effects. In this review, we describe tamponade physiology and implications for supportive care and effusion drainage.

Acute cardiac tamponade during atrial flutter ablation: improved hemodynamics after positive pressure ventilation: a case report

INTRODUCTION

Acute cardiac tamponade is a rare event during any type of interventional or surgical procedure. It can occur during electrophysiology procedures due to radiofrequency ablation, lead or catheter manipulation, transseptal puncture, laser lead extractions, or left atrial appendage occlusion device positioning. Cardiac tamponade is difficult to study in a prospective manner, and case reports and case series are important contributions to understanding the best options for patient care. An 87-year-old Caucasian male patient breathing spontaneously developed acute tamponade during an atrial flutter ablation. Pericardial drain insertion was difficult, and hypotension failed to respond to epinephrine boluses. The patient became hypoxemic and hypercarbic, requiring intubation. Unexpectedly, the blood pressure markedly increased postintubation and remained in a normal range until the pericardium was drained.

CONCLUSION

Spontaneous ventilation is considered important to maintain venous return to the right heart during cardiac tamponade. However, spontaneous ventilation reduces venous return to the left heart and worsens the paradoxical pulse in tamponade. Intravenous vasopressors are thought to be ineffective during cardiac tamponade. Our patient maintained pulmonary blood flow as indicated by end-tidal carbon dioxide measurements but had no measurable systemic blood pressure during spontaneous ventilation. Our case demonstrates that tracheal intubation and positive pressure ventilation can transiently improve left heart venous return, systemic perfusion, and drug delivery to the systemic circulation.

Cardiac arrest in the perioperative period: a consensus guideline for identification, treatment, and prevention from the European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery

INTRODUCTION

Cardiac arrest in the operating room is a rare but potentially life-threatening event with mortality rates of more than 50%. Contributing factors are often known, and the event is recognised rapidly as patients are usually under full monitoring. This guideline covers the perioperative period and is complementary to the European Resuscitation Council guidelines.

MATERIAL AND METHODS

The European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery jointly nominated a panel of experts to develop guidelines for the recognition, treatment, and prevention of cardiac arrest in the perioperative period. A literature search was conducted in MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials. All searches were restricted to publications from 1980 to 2019 inclusive and to the English, French, Italian and Spanish languages. The authors also contributed individual, independent literature searches.

RESULTS

This guideline contains background information and recommendation for the treatment of cardiac arrest in the operating room environment, and addresses controversial topics such as open chest cardiac massage, resuscitative endovascular balloon occlusion and resuscitative thoracotomy, pericardiocentesis, needle decompression, and thoracostomy.

CONCLUSIONS

Successful prevention and management of cardiac arrest during anaesthesia and surgery requires anticipation, early recognition, and a clear treatment plan. The ready availability of expert staff and equipment must also be taken into consideration. Success not only depends on medical knowledge, technical skills and a well-organised team using crew resource management, but also on an institutional safety culture embedded in everyday practice through continuous education, training, and multidisciplinary co-operation.

Cardiac arrest in the perioperative period: a consensus guideline for identification, treatment, and prevention from the European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery

INTRODUCTION

Cardiac arrest in the operating room is a rare but potentially life-threatening event with mortality rates of more than 50%. Contributing factors are often known, and the event is recognised rapidly as patients are usually under full monitoring. This guideline covers the perioperative period and is complementary to the European Resuscitation Council (ERC) guidelines.

MATERIAL AND METHODS

The European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery jointly nominated a panel of experts to develop guidelines for the recognition, treatment and prevention of cardiac arrest in the perioperative period. A literature search was conducted in MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials. All searches were restricted to publications from 1980 to 2019 inclusive and to the English, French, Italian and Spanish languages. The authors also contributed individual, independent literature searches.

RESULTS

This guideline contains background information and recommendation for the treatment of cardiac arrest in the operating room environment, and addresses controversial topics such as open chest cardiac massage (OCCM), resuscitative endovascular balloon occlusion (REBOA) and resuscitative thoracotomy, pericardiocentesis, needle decompression and thoracostomy.

CONCLUSION

Successful prevention and management of cardiac arrest during anaesthesia and surgery requires anticipation, early recognition and a clear treatment plan. The ready availability of expert staff and equipment must also be taken into consideration. Success not only depends on medical knowledge, technical skills and a well organised team using crew resource management but also on an institutional safety culture embedded in everyday practice through continuous education, training and multidisciplinary co-operation.

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.

Treatment of acute cardiac tamponade: A retrospective analysis of classical intermittent versus continuous pericardial drainage

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Acute cardiac tamponade is a highly relevant complication in modern cardiology.

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Continuous pericardial drainage is safe and does not increase total drainage volume.

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Continuous drainage associates with lower rates of open-heart surgical interventions.

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Continuous drainage associates with reduced re-tamponades and mortality on day 5.

Background

Acute cardiac tamponade is a life-threatening pathology in modern cardiology as catheter-based interventions become increasingly relevant. Pericardiocentesis is usually the primary treatment of choice. However, protocols for handling of draining pigtail catheters are very variable due to limit data and require further investigation.

Methods

We retrospectively analyzed 52 patients with acute cardiac tamponade requiring immediate pericardiocentesis from January 2017 to August 2020. Patients were treated with a classical approach of intermittent manual aspiration or continuous pericardial drainage using a redon drainage system.

Results

Mean age of patients was 74 years in both groups. Most common causes for cardiac tamponade were percutaneous coronary interventions in about 50% and transaortic valve implantations in 25% of all cases. 28 patients were treated with classic intermittent drainage from 2017 to 2020. 24 patients were treated with continuous drainage from December 2018–2020. Compared to classical intermittent drainage treatment, continuous drainage was associated with a lower rate of a surgical intervention or cardiac re-tamponade and a lower mortality at 5 days (HR 0.2, 95% CI 0.1–0.9, log-rank p = 0.03). Despite a longer total drainage time under continuous suction, drainage volumes were comparable in both groups.

Conclusion

Acute cardiac tamponade can be efficiently treated by pericardiocentesis with subsequent continuous negative pressure drainage via a pigtail catheter. Our retrospective analysis shows a significantly lower mortality, a decreased rate of interventions and lower rates of cardiac re-tamponade without any relevant side effects when compared to classical intermittent manual drainage. These findings require further investigations in larger, randomized trials.

A rare case of cardiac tamponade masquerading as acute abdomen

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Acute abdomen is any acute abdominal condition requiring a quick response.

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The abdominal discomfort associated with extra-abdominal pathologies could mimic acute abdomen.

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Cardiac tamponade is a medical emergency.

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The differential diagnosis could be kept in mind to avoid a delayed treatment.

Introduction

Acute abdomen is any acute abdominal condition requiring a quick response. The incidence varies according to age and disease aetiology. The abdominal discomfort associated with extra-abdominal pathophysiology and thoracic conditions could mimic acute abdomen. In this case we report a rare case of a young patient with cardiac tamponade masquerading as acute abdomen.

Presentation of case

A 25-years-old African man presented to the Emergency Department with abdominal pain. An EKG was performed, which revealed sinus tachycardia, with electrical alternans and borderline reduced voltage. At the time of the admission to our unit, he had a clinical worsening and a CT scan of abdomen was performed, which demonstrated hepatomegaly, abundant pericardial effusion and thin right pleural effusion at the lung bases. An echocardiogram confirmed a circumferential pericardial effusion with initial collapse of the right ventricular free wall. It was decided to immediately transport the patient to the Cardiosurgery Unit of another hospital to undergo pericardiocentesis.

Discussion

Our experience with this case underlines the important point that patients with a large pericardial effusion may present with the clinical features of acute abdomen and peritonitis. Abdominal pain was the primary symptom that prompted this patient to seek medical attention.

Conclusion

Acute abdomen is any acute abdominal condition requiring a rapid, often surgical, treatment. Cardiac tamponade is a medical emergency. The differential diagnosis could be kept in mind by any emergency physician, surgeon and anaesthesiologist, because an incorrect diagnosis and therefore an incorrect treatment or a delay in pericardial evacuation can be life-threatening.

Identification and Management of Acute Cardiac Tamponade

Although incidence is rare, acute cardiac tamponade (CT) is a cardiovascular condition often resulting in a high mortality rate. In acute CT, rapid accumulation of fluid occurs in the pericardial sac and prevents the heart's chambers from adequately filling with blood, leading to reduced diastolic filling, diminished stroke volumes, and subsequent hemodynamic instability. Health care providers should be aware of at-risk patients and the earliest signs and symptoms because an acute CT is considered a medical emergency.

Chest Pain in the Setting of Altered Mental Status

We report on a young adult female presenting with altered mental status and chest pain. Timely review of her electronic medical record revealed a history of panhypopituitarism with poor medication adherence, although this was unknown at the time of her initial evaluation.The patient required hormone replacement and significant fluid resuscitation, followed by definitive treatment with a pericardiocentesis. She was discharged home on hospital day 4, with normalization of her diminished left ventricular ejection fraction at her 1-month follow-up.Although panhypopituitarism and cardiac tamponade are rare diagnoses, we highlight the management of severe hypothyroidism, the importance of early administration of hydrocortisone for panhypopituitarism, and the need for aggressive volume expansion to maintain preload in cardiac tamponade.

Echocardiographic approach to cardiac tamponade in critically ill patients

Cardiac tamponade should be considered in a critically ill patient in whom the cause of haemodynamic shock is unclear. When considering tamponade, transthoracic echocardiography plays an essential role and is the initial investigation of choice. Diagnostic sensitivity of transthoracic echocardiography is dependent on image quality, and in some cases a transoesophageal approach may be required to confirm the diagnosis. Knowledge of the pathophysiology and echocardiographic features of cardiac tamponade are essential for the practicing Intensivist. This review presents an approach to the recognition, diagnosis, and treatment of cardiac tamponade in critically ill patients.

Dynamic Variables Fail to Predict Fluid Responsiveness in an Animal Model With Pericardial Effusion

OBJECTIVES

The reliability of dynamic and volumetric variables of fluid responsiveness in the presence of pericardial effusion is still elusive. The aim of the present study was to investigate their predictive power in a porcine model with hemodynamic relevant pericardial effusion.

DESIGN

A single-center animal investigation.

PARTICIPANTS

Twelve German domestic pigs.

INTERVENTIONS

Pigs were studied before and during pericardial effusion. Instrumentation included a pulmonary artery catheter and a transpulmonary thermodilution catheter in the femoral artery. Hemodynamic variables like cardiac output (COPAC) and stroke volume (SVPAC) derived from pulmonary artery catheter, global end-diastolic volume (GEDV), stroke volume variation (SVV), and pulse-pressure variation (PPV) were obtained.

MEASUREMENTS AND MAIN RESULTS

At baseline, SVV, PPV, GEDV, COPAC, and SVPAC reliably predicted fluid responsiveness (area under the curve 0.81 [p = 0.02], 0.82 [p = 0.02], 0.74 [p = 0.07], 0.74 [p = 0.07], 0.82 [p = 0.02]). After establishment of pericardial effusion the predictive power of dynamic variables was impaired and only COPAC and SVPAC and GEDV allowed significant prediction of fluid responsiveness (area under the curve 0.77 [p = 0.04], 0.76 [p = 0.05], 0.83 [p = 0.01]) with clinically relevant changes in threshold values.

CONCLUSIONS

In this porcine model, hemodynamic relevant pericardial effusion abolished the ability of dynamic variables to predict fluid responsiveness. COPAC, SVPAC, and GEDV enabled prediction, but their threshold values were significantly changed.

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.

Penetrating nail-gun injury of the heart managed by adenosine-induced asystole in the absence of a heart-lung machine

During his work, an 18-year-old carpenter-in-training overbalanced and shot himself in the left median thorax with a nail gun. The patient was delivered to our thoracic surgery unit with a tentative diagnosis of penetrating lung trauma. An emergent computed tomogram showed a heart-penetrating nail injury. The patient was taken to the operating room, where he underwent emergency surgery that included sternotomy, pericardiotomy, extraction of the nail, and trauma treatment of the heart injury. The surgery was performed in a unit without a heart-lung machine. For that reason, asystole was chemically induced by the intravenous administration of adenosine. The surgery was successful, and the patient was discharged from the hospital on the 10th postoperative day. In cases of penetrating injuries of the heart, especially those with a foreign body retained in situ, we believe that the intravenous administration of adenosine is an elegant solution for the rapid provocation of asystole. In contrast to other methods, adenosine-induced asystole enables relatively safe myocardial manipulation in the absence of a cardiac surgical unit and a heart-lung machine.

Cardiac tamponade masquerading as gastritis: a case report

INTRODUCTION

Pericardial effusion and cardiac tamponade can develop in patients with virtually any condition that affects the pericardium. A high index of suspicion with proper diagnostic scheme can lessen the concomitant morbidity and mortality. Although cardiac tamponade mimics many medical conditions, internists and primary care physicians should be aware of the physiological and clinical aspects of the disease spectrum.

CASE PRESENTATION

A 31-year-old Caucasian man, with no significant past medical history, presented to our emergency room with acute upper abdominal heaviness of 2 hours' duration after drinking excessive amounts of alcohol in a short period of time (binge drinking). The coexistence of recent alcohol binge drinking and nonspecific abdominal complaints usually presume a diagnosis of gastritis in our daily encounters in the absence of hepatic, biliary or pancreatic derangements. We present a case in which the presenting abdominal pain turned out to be related to cardiac tamponade.

CONCLUSIONS

Cardiac tamponade is a sort of cardiogenic shock and is a medical emergency. Clinicians should understand the cardiac tamponade physiology, especially in cases without large pericardial effusion, and correlate the signs of clinical tamponade together with the echocardiographic findings. Drainage of cardiac tamponade is life-saving. A high index of suspicion with proper diagnostic arcades lessens the concomitant morbidity and mortality.

Advanced ultrasound procedures

Ultrasound guidance has become the standard of care for many bedside procedures, owing to its portability, ease of use, and significant reduction in complications. This article serves as an introduction to the use of ultrasonography in several advanced procedures, including pericardiocentesis, thoracentesis, paracentesis, lumbar puncture, regional anesthesia, and peritonsillar abscess drainage.

Misconceptions and facts about pericardial effusion and tamponade

Several common misconceptions can make the clinical diagnosis of subacute pericardial tamponade challenging. Widely known physical findings of pericardial tamponade lack sensitivity and specificity. Interpretation of echocardiographic signs requires good understanding of pathophysiology. Over-reliance on echocardiography may result in over-utilization of pericardial drainage procedures. Awareness of these misconceptions with an integrative approach to both clinical and imaging data will help clinicians to assess the hemodynamic impact of pericardial effusion and the need for drainage.

Pericardial tamponade caused by massive fluid resuscitation in a patient with pericardial effusion and end-stage renal disease -A case report-

Pericardial tamponade can lead to significant hemodynamic derangement including cardiac arrest. We experienced a case of pericardial tamponade in a patient with end-stage renal disease. Hemodynamic changes occurred by unexpectedly aggravated pericardial effusion during surgery for iatrogenic hemothorax. We quickly administered a large amount of fluids and blood products for massive bleeding and fluid deficit due to hemothorax. Pericardial effusion was worsened by massive fluid resuscitation, and thereby resulted in pericardial tamponade. Hemodynamic parameters improved just after pericardiocentesis, and the patient was transferred to the intensive care unit.

Dynamic and volumetric variables reliably predict fluid responsiveness in a porcine model with pleural effusion

Background

The ability of stroke volume variation (SVV), pulse pressure variation (PPV) and global end-diastolic volume (GEDV) for prediction of fluid responsiveness in presence of pleural effusion is unknown. The aim of the present study was to challenge the ability of SVV, PPV and GEDV to predict fluid responsiveness in a porcine model with pleural effusions.

Methods

Pigs were studied at baseline and after fluid loading with 8 ml kg⁻¹ 6% hydroxyethyl starch. After withdrawal of 8 ml kg⁻¹ blood and induction of pleural effusion up to 50 ml kg⁻¹ on either side, measurements at baseline and after fluid loading were repeated. Cardiac output, stroke volume, central venous pressure (CVP) and pulmonary occlusion pressure (PAOP) were obtained by pulmonary thermodilution, whereas GEDV was determined by transpulmonary thermodilution. SVV and PPV were monitored continuously by pulse contour analysis.

Results

Pleural effusion was associated with significant changes in lung compliance, peak airway pressure and stroke volume in both responders and non-responders. At baseline, SVV, PPV and GEDV reliably predicted fluid responsiveness (area under the curve 0.85 (p<0.001), 0.88 (p<0.001), 0.77 (p = 0.007). After induction of pleural effusion the ability of SVV, PPV and GEDV to predict fluid responsiveness was well preserved and also PAOP was predictive. Threshold values for SVV and PPV increased in presence of pleural effusion.

Conclusions

In this porcine model, bilateral pleural effusion did not affect the ability of SVV, PPV and GEDV to predict fluid responsiveness.

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.

Anesthesia and the patient with pericardial disease

PURPOSE

Pericardial diseases present unique perioperative considerations for the anesthesiologist. The purpose of this review is to provide a summary of the pertinent issues related to the etiology, diagnosis, pathophysiology, and perioperative management of patients presenting for operative treatment of pericardial disease.

SOURCE

A selective search of the anesthesia, cardiology, and cardiothoracic surgical literature was carried out with particular emphasis on acute pericarditis, effusion, tamponade, and constrictive pericarditis.

PRINCIPAL FINDINGS

The anesthesiologist needs to be well versed in the etiology (i.e., differential diagnosis), pathophysiology, and diagnostic modalities in order to best prepare the patient for surgery. Diagnosis and guidance of management requires a working knowledge of the specific associated hemodynamic consequences, particularly of the impaired diastolic function that can occur. Echocardiography is essential in the diagnosis and management of these patients.

CONCLUSIONS

Patients with acute and chronic pericardial diseases often require the need for surgical intervention. Several unique features of acute tamponade and constrictive pericarditis require careful perioperative consideration. With proper preparation and pre-anesthetic optimization, patients with a variety of pericardial diseases can be safely managed before, during, and after their surgical intervention.

Interventional cardiology for the criticalist

OBJECTIVE

To review indications, procedures, and prognosis for common cardiovascular emergencies requiring intervention in small animals.

ETIOLOGY

Pericardial effusion, symptomatic bradycardia, and heartworm-induced caval syndrome are examples of clinical scenarios commonly requiring intervention. Pericardial effusion in small animals occurs most frequently from cardiac neoplasia, idiopathic pericarditis, or congestive heart failure. Indications for temporary pacing include transient bradyarrhythmias, ingestions resulting in chronotropic incompetence, and emergency stabilization of critical bradyarrhythmias. Caval syndrome results from a large dirofilarial worm burden, pulmonary hypertension, and mechanical obstruction of right-sided cardiac output with resultant hemolysis and organ dysfunction.

DIAGNOSIS

The diagnosis of pericardial effusion is suspected from signalment and physical findings and confirmed with cardiac ultrasound. Symptomatic bradycardias often present for syncope and definitive diagnosis derives from an ECG. Caval syndrome is diagnosed upon clinical, hematologic, and ultrasonographic evidence of severe heartworm infestation, cardiovascular compromise, and/or mechanical hemolysis.

THERAPY

Pericardial effusion is alleviated by pericardiocentesis in the emergency setting, though may require further intervention for long-term palliation. Temporary transvenous pacing can be performed emergently to stabilize the symptomatic patient with a bradyarrhythmia. Dirofilariasis leading to caval syndrome requires urgent heartworm extraction.

PROGNOSIS

The prognosis for pericardial effusion is dependent upon the underlying etiology; the prognosis for cardiac pacing is favorable, and the prognosis for caval syndrome is grave if untreated and guarded to fair if heartworm extraction is performed.

Predicting outcome of rethoracotomy for suspected pericardial tamponade following cardio-thoracic surgery in the intensive care unit

Objectives

Pericardial tamponade after cardiac surgery is difficult to diagnose, thereby rendering timing of rethoracotomy hard. We aimed at identifying factors predicting the outcome of surgery for suspected tamponade after cardio-thoracic surgery, in the intensive care unit (ICU).

Methods

Twenty-one consecutive patients undergoing rethoracotomy for suspected pericardial tamponade in the ICU, admitted after primary cardio-thoracic surgery, were identified for this retrospective study. We compared patients with or without a decrease in severe haemodynamic compromise after rethoracotomy, according to the cardiovascular component of the sequential organ failure assessment (SOFA) score.

Results

A favourable haemodynamic response to rethoracotomy was observed in 11 (52%) of patients and characterized by an increase in cardiac output, and less fluid and norepinephrine requirements. Prior to surgery, the absence of treatment by heparin, a minimum cardiac index < 1.0 L/min/m² and a positive fluid balance (> 4,683 mL) were predictive of a beneficial haemodynamic response. During surgery, the evacuation of clots and > 500 mL of pericardial fluid was associated with a beneficial haemodynamic response. Echocardiographic parameters were of limited help in predicting the postoperative course, even though 9 of 13 pericardial clots found at surgery were detected preoperatively.

Conclusion

Clots and fluids in the pericardial space causing regional tamponade and responding to surgical evacuation after primary cardio-thoracic surgery, are difficult to diagnose preoperatively, by clinical, haemodynamic and even echocardiographic evaluation in the ICU. Only absence of heparin treatment, a large positive fluid balance and low cardiac index predicted a favourable haemodynamic response to rethoracotomy. These data might help in deciding and timing of reinterventions after primary cardio-thoracic surgery.

Pericardial disease: diagnosis and management

Pericardial diseases can present clinically as acute pericarditis, pericardial effusion, cardiac tamponade, and constrictive pericarditis. Patients can subsequently develop chronic or recurrent pericarditis. Structural abnormalities including congenitally absent pericardium and pericardial cysts are usually asymptomatic and are uncommon. Clinicians are often faced with several diagnostic and management questions relating to the various pericardial syndromes: What are the diagnostic criteria for the vast array of pericardial diseases? Which diagnostic tools should be used? Who requires hospitalization and who can be treated as an outpatient? Which medical management strategies have the best evidence base? When should corticosteroids be used? When should surgical pericardiectomy be considered? To identify relevant literature, we searched PubMed and MEDLINE using the keywords diagnosis, treatment, management, acute pericarditis, relapsing or recurrent pericarditis, pericardial effusion, cardiac tamponade, constrictive pericarditis, and restrictive cardiomyopathy. Studies were selected on the basis of clinical relevance and the impact on clinical practice. This review represents the currently available evidence and the experiences from the pericardial clinic at our institution to help guide the clinician in answering difficult diagnostic and management questions on pericardial diseases.

Management and clinical outcomes of acute cardiac tamponade complicating electrophysiologic procedures: a single-center case series

BACKGROUND

Cardiac perforation with tamponade is an infrequent occurrence during an electrophysiologic procedure. The customary approach to management includes volume resuscitation followed by pericardiocentesis. Such a procedure, however, is not without its own risk, especially when performed emergently. We hypothesized that some patients experiencing this type of complication can be managed successfully in a conservative fashion, without the need for an additional invasive procedure.

METHODS

We retrospectively analyzed the clinical outcomes and echocardiographic features of 33 consecutive patients who experienced this complication during cardiac electrophysiology (EP) procedures performed at our institution from 1988 to 2007. Nineteen patients (58%) were managed conservatively with intravenous fluids and vasopressors (Group A). Fourteen patients (42%) were managed invasively with pericardiocentesis (Group B).

RESULTS

The mean systolic blood pressure at diagnosis did not differ between the two groups (64 vs 71 mmHg, P = 0.134). The mean lengths of hospitalization (4.7 vs 4.9 days, P = 0.75) and survival to hospital discharge (100% in both groups) were also similar. A large pericardial effusion (>or=2 cm) was seen predominantly among Group B patients. There was a statistically significant temporal trend toward managing this type of complication invasively (P = 0.038).

CONCLUSION

Among patients who experience cardiac perforation as an acute complication of EP procedure, there appears to be a role for conservative management in a subset of patients who do not have echocardiographic evidence of a large effusion and who respond well to initial stabilizing measures consisting of fluids and vasopressors.