Severe circulatory collapse immediately after pericardiocentesis in a patient with chronic 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.

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.).

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.

Pericardial decompression syndrome: A comprehensive review

Pericardial decompression syndrome (PDS) is an infrequent, life-threatening complication following pericardial drainage for cardiac tamponade physiology. PDS usually develops after initial clinical improvement following pericardiocentesis and is significantly underreported and may be overlooked in the clinical practice. Although the precise mechanisms resulting in PDS are not well understood, this seems to be highly associated with patients who have some underlying ventricular dysfunction. Physicians performing pericardial drainage should be mindful of the risk factors associated with the procedure including the rare potential for the development of PDS.

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.

Predictors of post pericardiotomy low cardiac output syndrome in patients with pericardial effusion

INTRODUCTION

Pathological involvement of pericardium by any disease that resulting in effusion may require decompression and pericardiectomy. The current article describes rare patients with effusion who after pericadiectomy and transient hemodynamic improvement rapidly developed progressive heart failure and subsequent multi organ failure.

METHODS

During periods of five years, 423 patients in our hospital underwent pericardiotomy for decompression of effusion. The clinical characteristics of those patient with postoperative low cardiac output (B group) (14 cases) recorded and compared with other patients without this postoperative complication (A group) by test and X2. Significant variables in invariables (P≤0.1) entered in logistic regression analysis and odd ratio of these significant variables obtained.

RESULTS

Idiopathic pericardial effusion, malignancy, renal failure, connective tissue disease, viral pericarditis was found in 125 patients (27%), 105 patients (25.4%), 65 patients (15.6%), 50 (17.1%) and 10 (2.4%) of patients subsequently. The factors that predict post-operative death in logistic regression analysis were malignancy, radiotherapy, constrictive pericarditis inotropic drug using IABP using, pre-operative EF and pericardial calcification.

CONCLUSION

Certain preoperative variables such as malignancy, radiotherapy, low EF, calcified pericardium and connective tissue disease are associated with POLCOS and post-operative risk of death. This paradoxical response to pericardial decompression may be more frequent than currently appreciated. Its cause may relate to the sudden removal of the chronic external ventricular support from the effusion or thicken pericardium resulting in ventricular dilatation and failure or intra operative myocardial injury due to pericardiectomy of calcified pericardium, radiation and cardiomyopathy.

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.

Pericardial window procedures: Implications on left ventricular function

INTRODUCTION

Pericardial window procedures are generally designed to relieve pericardial fluid pressure on the heart, in cases of cardiac tamponade, and to restore the hemodynamic stability of the patient. Rarely, however, may acute left ventricular failure develop after creation of a pericardial window.

PRESENTATION OF CASE

We describe a patient in whom that complication developed. We are trying to give an insight to the pathophysiology, existence of potential predisposing factors, as well as to propose therapeutic measures.

DISCUSSION

Acute heart failure, developing after pericardiocentesis or surgical creation of a pericardial window is an unusual complication, with several theories developed to explain that paradox.

CONCLUSION

Treatment is supportive, but that complication of pericardial window procedures may carry a high mortality rate.

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.

Acute pulmonary edema following pericardiocentesis for cardiac tamponade

Pericardiocentesis for therapeutic drainage of pericardial fluid may be associated with a variety of complications, including laceration of the right ventricle or coronary artery, arrhythmias, viscus perforation, hypotension, pneumothorax, adult respiratory distress syndrome and death. Hemodynamic derangements such as acute left ventricular failure, pulmonary edema and cardiogenic shock are infrequent and, hence, less well recognized. The present report describes a patient with pericardial effusion and tamponade who developed cardiogenic shock requiring inotropic support shortly following uncomplicated ultrasound-guided pericardial drainage.

A new diagnostic and therapeutic approach to pericardial effusion: transbronchial needle aspiration

Pericardiocentesis was introduced during the 19th century, and reached its current level of development with the introduction of two-dimensional echocardiography. Although there is general agreement that complications are rare with skilled operators, a diagnostic and therapeutic problem often occurs when there is a posterior pericardial effusion, as it is not easy to quantify by echocardiography, and difficult to drain through a percutaneous access; therefore, it is usually treated surgically. We describe a new approach to pericardial effusion by a transbronchial access through the left lower lobe bronchus (which allows both diagnosis and evacuation of abundant amounts of fluid), or through the distal trachea (for diagnostic purpose only, in the presence of pericardial effusions filling the aortic recess of the pericardium). The technique is rather easy for operators skilled in transbronchial needle aspiration, and is safe, economical, and well tolerated.