Echocardiography in the diagnosis and management of pericardial disease

Ultrasound Assessment in a Pregnant Woman? Not just for the Fetus

Pericarditis is a relatively common diagnosis worldwide; however, there are few data published on the frequency, diagnosis, and management of pericardial diseases in pregnant women. Ultrasonography has established its utmost importance and is worldwide recognized in pregnancy and fetal evaluation. Moreover, point-of-care ultrasonography of pregnant women, guided by clinical examination and history, can play an equally fundamental role. We present a case of a 37-year-old pregnant woman who presented at the emergency department with pleuritic chest pain, fever, and cough. Bedside point-of-care ultrasonography confirmed pericarditis revealing an organized pericardial effusion, leading to patient hospitalization and initiation of therapy. The importance and acknowledgment of portable and hand-held ultrasonography devices are growing since it enables physicians not only to make a fast and accurate diagnosis but also to access evolution in inpatient and outpatient settings.

Pericarditis caused by Proteus mirabilis in sheep

Pericarditis means inflammation in the pericardial sac. Pericarditis is divided into three categories based on morphology, including fibrinous, purulent, and constrictive. In the present study, a 7-month-old male Ghezel breed sheep was examined for low weighting rate for three months. Tachypnea, tachycardia, heart friction sound, absence of fever and normal appetite were recorded in the clinical examination. In the patient's history, there was a history of perforated chest trauma behind the left scapula about three months ago. After the echocardiography examination and bacteriology procedures, purulent pericarditis caused by Proteus mirabilis was diagnosed. The bacterium was analysed using genome sequencing and new strain called Abhar114 was diagnosed. This is the first report of pericarditis caused by Proteus mirabilis in sheep.

Impaired Myocardial Function Is Prognostic for Severe Respiratory Failure in the Course of COVID-19 Infection

COVID-19 may lead to severe acute respiratory distress syndrome (ARDS) resulting in increased morbidity and mortality. Heart failure and/or pre-existing cardiovascular disease may correlate with poor outcomes and thus require special attention from treating physicians. The present study sought to investigate a possible impact of impaired myocardial function as well as myocardial distress markers on mortality or ARDS with need for mechanical ventilation in 157 consecutive patients with confirmed SARS-CoV-2 infection. All patients were admitted and treated at the University Hospital of Tübingen, Germany, during the first wave of the pandemic. Electrocardiography, echocardiography, and routine blood sampling were performed at hospital admission. Impaired left-ventricular and right-ventricular function, tricuspid regurgitation > grade 1, and elevated RV-pressure as well as thrombotic and myocardial distress markers (D-dimers, NT-pro-BNP, and troponin-I) were associated with mechanical ventilation and/or all-cause mortality. Impaired cardiac function is more frequent amidst ARDS, leading to subsequent need for mechanical ventilation, and thus denotes a poor outcome in COVID-19. Since a causal treatment for SARS-CoV-2 infection is still lacking, guideline-compliant cardiovascular evaluation and treatment remains the best approach to improve outcomes in COVID-19 patients with cardiovascular comorbidities.

Urgent Surgical Treatment of Blunt Chest Trauma Followed by Cardiac and Pericardial Injuries

Introduction

Widespread opinion that penetrating chest injuries are more urgent, in terms of treatment and care, contributed to underestimation of the urgency of blunt chest trauma, which in most cases is treated conservatively. It remains an open question frequency when the injuries of the heart and pericardium are not timely diagnosed and surgically treated.

Aim

To demonstrate the importance of well-timed surgical treatment of blunt chest trauma, when coupled with cardiac and pericardial injuries.

Methods

At the Thoracic Surgery Clinic of the University Clinical Centre Banja Luka, Bosnia and Herzego vina, during period of 10 years (01.01. 2008 - 31.01.2018.), the total of 66 patients were treated for urgent thoracotomy due to clinically and radiologically unclear findings after blunt chest trauma. In general, diagnostic examinations, apart from laboratory analysis, included radiological imaging and Multi Slice Computed Tomography (MSCT) of the chest, followed by an ultrasound of the heart in cases when sternum was injured or when pericardial tamponade was suspected. Results presented in the study where obtained from the retrospective analysis of patients data. This work presents a retrospective observational cross-sectional study, which results in the assessment of the correctness of a particular diagnostic test.

Statistical methods used

descriptive statistics, counting measures (frequencies and percentages), central tendency measures (arithmetic mean), variability measures (standard deviation).

Results

Sixty six patients were treated with urgent thoracotomy after a blunt trauma of the chest due to the unclear clinical and radiological finding. In the case of 11 patients (10 men and 1 woman), presenting 16.6% of the total sample, pericardial and cardiac injuries were detected and treated intraoperatively. Further, in the case of the one patient, pericardiotomy and suturing of the right heart chamber where performed, with the creation of a pericardial window. Transthoracic echocardiogram was not used as the primary screening module, but rather as a diagnostic test for patients who had unexplained hypotension and arrhythmia. Radiographs of the chest showed cardiomegaly with or without epicardial fat pad sign suggesting a pericardial effusion.

Conclusion

Blunt cardiac and pericardial injuries represent a serious therapeutic problem, which, if not treated properly, result in a high mortality rate. Echocardiography is the primary diagnostic method for initial detection of pericardial effusion. Pericardial fluid first accumulates posterior to the heart, when the patient is examined in the supine position. As the effusion increases, it extends laterally and with large effusions the echo-free space expands to surround the entire heart. The size of the effusion may be graded as small ( echo free spaces in diastole <10 mm, corresponding to approxymately 300 ml), moderate (10-20 mm, corresponding to 500 ml), and large ( >20 mm, corresponding to >700 ml). When the ability of the pericardium to stretch is exceeded by rapid or massive accumulation of fluid, any additional fluid causes the pressure with the pericardial sac. Early recognition, pericardiotomy with pericardial window creation and/or ventricular rupture suture remain the "gold standard" in the treatment of blunt cardiac and pericardial injuries.

A Case of Profound Hypothyroidism Presenting with Hypertensive Emergency and Large Amount of Pericardial Effusion

Patient: Female, 45-year-old

Final Diagnosis: Hypothyroidism

Symptoms: Dysarthria • dyspnea

Medication:—

Clinical Procedure: Pericardial drainage

Specialty: Cardiology

Does Colchicine Substitute Corticosteroids in Treatment of Idiopathic and Viral Pediatric Pericarditis?

Background and Objectives: Recurrence of pericarditis (ROP) is an important complication of the acute pericarditis. The aim of this study was to analyse the influence of aetiology, clinical findings and treatment on the outcome of acute pericarditis. Methods: Data were retrospectively collected from medical records of patients treated from 2011 to 2019 at a tertiary referent heart paediatric center. Results: Our investigation included 56 children with idiopathic and viral pericarditis. Relapse was registered in 8/56 patients, 2/29 (7.41%) treated with nonsteroidal anti-inflammatory drugs (NSAID) and 6/27 (28.57%) treated with corticosteroids (CS) and NSAID. Independent risk factors for ROP were viral pericarditis (p = 0.01, OR 31.46), lack of myocardial affection (p = 0.03, OR 29.15), CS use (p = 0.02, OR 29.02) and ESR ≥ 50 mm/h (p = 0.03, OR 25.23). In 4/8 patients the first recurrence was treated with NSAID and colchicine, while treatment of 4/8 patients included CS. Children with ROP treated with CS had higher median number of recurrence (5, IQR: 2–15) than those treated with colchicine (0, IQR: 0–0.75). Conclusions: Independent risk factors for recurrence are CS treatment, viral aetiology, pericarditis only and ESR ≥ 50 mm/h. Acute pericarditis should be treated with NSAID. Colchicine and NSAID might be recommended in children with the first ROP.

Right-sided infective mural endocarditis complicated by septic pulmonary embolism and cardiac tamponade caused by MSSA

The appearance of right-sided mural infective endocarditis has rarely been reported. Here, we report the case of a 40-year-old male with a history of alcoholic liver disease who presented with a partial loss of consciousness and fever. Chest computed tomography scans showed multiple pulmonary infiltration sites and cavities. A repeat transthoracic echocardiogram detected a vegetation on the right ventricular surface of the interventricular septum middle segment, as well as pericardial effusion. Blood, pericardial fluid, sputum, and scalp effusion cultures were positive for methicillin-sensitive Staphylococcus aureus. We diagnosed the patient with infective mural endocarditis complicated by septic pulmonary embolism, pericardial effusion, and cardiac tamponade. The patient was successfully treated with pericardiocentesis and appropriate antibiotics. Right-sided mural endocarditis complicated by pericardial effusion and cardiac tamponade is an uncommon condition in clinical practice. This case confirms the usefulness of transthoracic echocardiography in the early recognition of primary mural endocarditis and its associated complications.

Bedside Ultrasound in the Diagnosis and Treatment of Children with Respiratory Difficulty Following Cardiac Surgery

Many children frequently fail extubation or require a prolonged period of positive pressure ventilation support after cardiac surgery. Pediatric cardiac Intensive Care Unit (PCICU) ultrasound (US) stands as a simple, basic bedside tool that can be performed by trained intensivists for the diagnosis with immediate implication on therapeutic decisions in multiple scenarios that physicians may face in PCICU. Bedside US is widely available, convenient, and inexpensive. This educational article based mainly on our own experience is highlighting the role of US in detecting the most common causes of respiratory weaning difficulties and extubation failure in postoperative cardiac children through proposed illustration and algorithm.

Life-Threatening Hemopericardium Associated with Rivaroxaban

Rivaroxaban is a novel oral anticoagulant used in the treatment of venous thromboembolism. The use of this medication has expanded over the recent years with resultant expansion of side effect profile. We present a case of a 56-year-old female who presented with shortness of breath and chest pain 12 weeks after starting rivaroxaban for left upper extremity deep vein thrombosis. She was later diagnosed with spontaneous hemopericardium requiring pericardial fluid drainage. Rarer side effects like this will be encountered more often with the increasing use of novel oral anticoagulants. The clinicians should be cognizant of this entity among patients with shortness of breath and chest pain for timely diagnosis and intervention.

Echocardiographic Assessment of Pericardial Effusion

Echocardiography is routinely used to evaluate diseases of the pericardium, including effusion, tamponade, and, to a lesser extent, constriction. Doppler evaluation provides information regarding the attendant alterations of cardiac filling. This review details the role of echocardiography in the diagnosis and management of common abnormalities of the pericardium.

M.mode.ify: A Free Online Tool to Generate Post Hoc M-Mode Images From Any Ultrasound Clip

We present a software tool designed to generate an M-mode image post hoc from any B-mode ultrasound clip, along any possible axis. M.mode.ify works by breaking down an ultrasound clip into individual frames. It then rotates and crops these frames by using a user-selected M-mode line. The post hoc M-mode image is created by splicing these frames together. Users can measure time and distance after proper calibration through the M.mode.ify interface. This tool opens up new possibilities for clinical application, quality assurance, and research. It is available free for public use at http://www.ultrasoundoftheweek.com/M.mode.ify/.

The preventive role of the posterior pericardial window in the development of late cardiac tamponade following heart valve surgery

OBJECTIVES

It is reported that creating a window from the posterior pericardium into the left pleural cavity during coronary bypass surgeries reduces postoperative late cardiac tamponades. Although late tamponades are more common after heart valve surgeries, this procedure is not generally performed. The present study investigated whether creating a window has a preventive effect on the formation of late cardiac tamponade after heart valve surgeries.

METHODS

The study was conducted on all patients (n = 262) in whom one or more valves were replaced and who fulfilled the study criteria between January 2010 and October 2014 in one centre. We began to create a posterior pericardial window in all valvular patients from March 2012. One hundred and thirty-five patients operated on before this date (Non-Window Group) and 127 patients after this date (Window Group) were compared for the development of late cardiac tamponade.

RESULTS

There were no differences between the groups in terms of preoperative and intraoperative characteristics. Late pericardial tamponade was not observed in any patients from the Window Group, whereas it occurred in 7 (5.2%) patients from the Non-Window Group (P = 0.015). Three patients died in total; all 3 were from the Non-Window Group. One of the mortalities was associated with tamponade.

CONCLUSIONS

Creating a pericardial window may reduce late cardiac tamponade events/episodes, which may be a fatal complication in valve patients. We recommend performing this procedure by allocating some time during the surgical procedure in order to avoid tamponade.

The use of the diaphragmatico-hepatic (DH) views of the abdominal and thoracic focused assessment with sonography for triage (AFAST/TFAST) examinations for the detection of pericardial effusion in 24 dogs (2011-2012)

OBJECTIVE

To evaluate the clinical usefulness of the diaphragmatico-hepatic (DH) view of the abdominal and thoracic focused assessment with sonography for triage (AFAST/TFAST) in detecting pericardial effusion (PE) in dogs.

DESIGN

Retrospective case series from 2011 to 2012.

SETTING

Private practice emergency and critical care hospital.

ANIMALS

Twenty-four dogs with PE diagnosed by FAST.

INTERVENTIONS

None.

MEASUREMENT AND MAIN RESULTS

Fifty-two medical records from October 1, 2011 through September 30, 2012 had the terms "PE" within the medical record. Twenty-four dogs were diagnosed with PE by FAST with entries for the DH view. Of the 24 dogs, 7 had abdominal FAST, 6 had thoracic FAST (TFAST), and 11 had both exams performed. PE was noted on the DH view in 20 of 24 (83%) cases. Subjective PE volume assessment ranged from trivial (<5 mm) to severe. Of the 4 cases in which PE was absent via the DH view, PE was seen during the same exam at the TFAST pericardial views (n = 2) or detected on serial exam at the DH view (n = 2). The PE volume that was missed via the DH view was characterized as trivial (<5 mm; n = 1), mild (n = 1), and moderate (n = 2).

CONCLUSIONS

The DH view of FAST was found to be clinically helpful for the detection of PE. Veterinarians should make it routine practice and part of FAST training to look into the thorax via the DH view during both abdominal FAST and TFAST exams.

Prolonged pericardial drainage using a soft drain reduces pericardial effusion and need for additional pericardial drainage following orthotopic heart transplantation

OBJECTIVES

Pericardial effusion can cause haemodynamic compromise after heart transplantation. We identified the effects of soft drains on the development of pericardial effusion.

METHODS

We enrolled 250 patients ≥17 years of age who underwent heart transplantation between July 1999 and April 2012 and received two conventional tubes (n = 96; 32 French), or two tubes with a soft drain (n = 154; 4.8 mm wide). The development of significant pericardial effusion or the need for drainage procedure during 1 month after heart transplantation was compared with the use of the propensity score matching method to adjust for selection bias.

RESULTS

At 1 month after transplantation, 69 patients (27.6%) developed significant pericardial effusion. Among these, 13 patients (5.2%) underwent pericardial drainage. According to multivariate analysis, history of previous cardiac surgery [odds ratio (OR) = 0.162; 95% confidence interval (CI) = 0.046-0.565; P = 0.004] and placement of a soft drain (OR = 0.186; 95% CI = 0.100-0.346; P < 0.001) were significant factors that prevented pericardial effusion or the need for drainage during the early postoperative period. For the 82 propensity score matched pairs, patients receiving an additional soft drain were at a lower risk of the development of significant pericardial effusion or the need for a pericardial drainage procedure during 1 month (OR = 0.148; 95% CI = 0.068-0.318; P < 0.001) compared with those receiving only two conventional tubes.

CONCLUSIONS

Pericardial soft drainage is a simple and safe procedure that reduces pericardial effusion and decreases the need for pericardial drainage after heart transplantation.

Role of a 12-lead electrocardiogram in the diagnosis of cardiac tamponade as diagnosed by transthoracic echocardiography in patients with malignant pericardial effusion

BACKGROUND

Few studies have looked at the utility of the 12-lead electrocardiogram (ECG) in diagnosing cardiac tamponade in malignant pericardial effusion (PE). The aim of this study was to determine the sensitivity (Se), specificity (Sp), positive predictive value (PPV), and negative predictive value (NPV) of 12-lead ECG in diagnosing cardiac tamponade in PE.

HYPOTHESIS

Abnormalities on a 12 lead ECG can be used to diagnose or exclude cardiac tamponade in patients with malignant PE.

METHODS

Using echocardiography as the gold standard for diagnosis of cardiac tamponade, we determined the Se, Sp, PPV, and NPV for individual and combinations of the 3 ECG abnormalities (low-voltage complexes, electrical alternans, and sinus tachycardia).

RESULTS

For PEs of all sizes, the Se, Sp, PPV, and NPV for detecting cardiac tamponade were: low-voltage complexes (56%, 74%, 81%, 46%), electrical alternans (23%, 98%, 95%, 39%), and sinus tachycardia (76%, 60%, 79%, 56%), respectively. Presence of all 3 and any of the 3 ECG abnormalities had a Se, Sp, PPV, and NPV of 8%, 100%, 100%, 36% and 89%, 47%, 77%, 69%, respectively, for cardiac tamponade. The odds ratios for cardiac tamponade in PE were 3.7 (95% confidence interval [CI]: 1.65-8.30) for low-voltage complexes, 12.3 (95% CI: 1.58-95.17) for electrical alternans, and 4.9 (95% CI: 2.22-10.80) for sinus tachycardia. Presence of any of 3 ECG abnormalities had an odds ratio of 7.3 (95% CI: 2.9-18.1) for cardiac tamponade.

CONCLUSIONS

In malignant PE, combination of ECG abnormalities can supplement clinical examination in the diagnosis of echocardiographic cardiac tamponade. Due to its low NPV, 12-lead ECG cannot be used as a screening tool to exclude cardiac tamponade with malignant PE.

The use of echocardiography in acute cardiovascular care: Recommendations of the European Association of Cardiovascular Imaging and the Acute Cardiovascular Care Association

Echocardiography is one of the most powerful diagnostic and monitoring tools available to the modern emergency/critical care practitioner. Currently, there is a lack of specific European Association of Cardiovascular Imaging/Acute Cardiovascular Care Association recommendations for the use of echocardiography in acute cardiovascular care. In this document, we describe the practical applications of echocardiography in patients with acute cardiac conditions, in particular with acute chest pain, acute heart failure, suspected cardiac tamponade, complications of myocardial infarction, acute valvular heart disease including endocarditis, acute disease of the ascending aorta and post-intervention complications. Specific issues regarding echocardiography in other acute cardiovascular care scenarios are also described.

The use of echocardiography in acute cardiovascular care: recommendations of the European Association of Cardiovascular Imaging and the Acute Cardiovascular Care Association

Echocardiography is one of the most powerful diagnostic and monitoring tools available to the modern emergency/ critical care practitioner. Currently, there is a lack of specific European Association of Cardiovascular Imaging/Acute Cardiovascular Care Association recommendations for the use of echocardiography in acute cardiovascular care. In this document, we describe the practical applications of echocardiography in patients with acute cardiac conditions, in particular with acute chest pain, acute heart failure, suspected cardiac tamponade, complications of myocardial infarction, acute valvular heart disease including endocarditis, acute disease of the ascending aorta and post-intervention complications. Specific issues regarding echocardiography in other acute cardiovascular care scenarios are also described.

[Analysis of clinical, echocardiographic, microbiological and cytopathological characteristics of pericardial effusions in a tertiary hospital care]

OBJECTIVE

To determine the prevalence, etiology, clinical, echocardiographic, microbiological and cytopathological characteristics of patients with pericardial effusion.

METHODS

Observational, retrospective, cross-sectional analytical study. We reviewed medical records of patients undergoing pericardiocentesis for a 5 years period. We used descriptive statistics, measures of central tendency and dispersion for analysis.

RESULTS

The prevalence of pericardial effusion was 1.1%. Predominant in women (60.4%) and there was a mean age of 49 years. The main causes were neoplastic 32.1%, idiopathic 27.4% and rheumatological 10.4%. A percentage of 27.1 had cardiac tamponade whereas dyspnea and muffled heart sounds were the most common clinical data. The right atrial and ventricular collapse occurred in 84.9 and 75.5%, respectively. The pericardial fluid cytology yielded better in neoplastic causes a sensitivity of 54%, specificity 95%, positive predictive value 85% and negative predictive value 81%.

CONCLUSIONS

The prevalence of pericardial effusion in a tertiary care hospital was 1.1%, the main cause was neoplastic. In the evaluation of moderate or severe pericardial effusion we found that right atrial and ventricular collapses were the most common echocardiographic findings. The cytopathological study had a high specificity for the diagnosis of neoplasia.

Regional Pericarditis Mimicking Inferior Myocardial Infarction following Abdominal Surgery

Acute pericarditis is common but illusive, often mimicking acute coronary syndrome in its clinical and electrocardiographic presentation. Regional pericarditis, though rare, presents further challenge with a paucity of published diagnostic criteria. We present a case of postoperative regional pericarditis and discuss helpful electrocardiographic findings. A 66-year-old male with history of open drainage of a liver abscess presented with abdominal pain and tenderness. CT of the abdomen was concerning for pneumatosis intestinalis of the distal descending colon. He underwent lysis of liver adhesions; exploration revealed only severe colonic impaction, for which he had manual disimpaction and peritoneal irrigation. Postoperatively, he developed sharp chest pain. Electrocardiogram revealed inferior ST elevation. Echocardiogram revealed normal left and right ventricular dimensions and systolic function without wall motion abnormalities. Emergent coronary angiography did not identify a culprit lesion, and left ventriculogram showed normal systolic function without wall motion abnormalities. He received no intervention, and the diagnosis of regional pericarditis was entertained. His cardiac troponin was 0.04 ng/dL and remained unchanged, with resolution of the ECG abnormalities in the following morning. Review of his preangiography ECG revealed PR depression, downsloping baseline between QRS complexes, and reciprocal changes in the anterior leads, suggestive of regional pericarditis.

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.

Pericardial effusion and pericardiocentesis: role of echocardiography

Pericardial effusion can develop from any pericardial disease, including pericarditis and several systemic disorders, such as malignancies, pulmonary tuberculosis, chronic renal failure, thyroid diseases, and autoimmune diseases. The causes of large pericardial effusion requiring invasive pericardiocentesis may vary according to the time, country, and hospital. Transthoracic echocardiography is the most important tool for diagnosis, grading, the pericardiocentesis procedure, and follow up of pericardial effusion. Cardiac tamponade is a kind of cardiogenic shock and medical emergency. Clinicians should understand the tamponade physiology, especially because it can develop without large pericardial effusion. In addition, clinicians should correlate the echocardiographic findings of tamponade, such as right ventricular collapse, right atrial collapse, and respiratory variation of mitral and tricuspid flow, with clinical signs of clinical tamponade, such as hypotension or pulsus paradoxus. Percutaneous pericardiocentesis has been the most useful procedure in many cases of large pericardial effusion, cardiac tamponade, or pericardial effusion of unknown etiology. The procedure should be performed with the guidance of echocardiography.

A systematic approach to evaluation of pericardial effusion and cardiac tamponade

Pericardial disease leading to pericardial effusion (PEF) is a common condition encountered by the clinician in day-to-day practice. If the PEF becomes large enough, it can cause hemodynamic compromise, resulting in a cardiogenic shock state known as cardiac tamponade. There are many clinical and echocardiographic signs that a clinician can use to assess whether a large PEF is hemodynamically significant. However, these signs can be either conflicting or even absent. The purpose of this review is to first, describe the physiology of the pericardium in health and how it changes with disease; second, outline the pathophysiology of pericardial tamponade and discuss how it is responsible for the physical and echocardiographic findings of cardiac tamponade; and third, suggest an approach to applying these findings in a systematic order to ensure a correct diagnosis.

Usefulness of pericardial effusion as new diagnostic criterion for noninvasive detection of myocarditis

Cardiovascular magnetic resonance (CMR) imaging holds promise for diagnosing myocarditis in vivo. The CMR diagnosis of myocarditis is determined by the ventricular morphology/function, late gadolinium enhancement, and T(2)-weighted imaging for myocardial edema. However, in routine clinical practice, we encounter patients with suspected myocarditis in the absence of left ventricular dysfunction, myocardial edema, or late gadolinium enhancement. In the present study, we sought to determine whether the presence of pericardial effusion could serve as a new diagnostic criterion and improve the sensitivity of CMR imaging to detect myocarditis. A total of 35 consecutive patients with biopsy proven virus-associated myocarditis, onset of clinical symptoms within the past 3 months, and normal left ventricular function were enrolled in the present study. All patients underwent echocardiography, CMR imaging, and endomyocardial biopsy for workup of myocarditis. Late gadolinium enhancement was present in 16 patients (46%). Myocardial edema on T(2)-weighted imaging was present in 4 patients, but in just 1, it was the only abnormal finding. Pericardial effusion was present in 14 patients (40%). In 7 patients with myocarditis (20%), pericardial effusion was the only abnormal finding. Pericardial effusion, used as an additional diagnostic criterion, improved the sensitivity of CMR imaging for myocarditis from 46% to 66% (p = 0.023). In conclusion, pericardial effusion detected by CMR imaging might serve as a new diagnostic criterion for the noninvasive diagnosis of myocarditis in patients with recent onset of clinical symptoms and normal left ventricular function.

Focused Transthoracic Echocardiography in the Perioperative Period

Ultrasound applications in perioperative medicine have expanded enormously over the past decade. Transoesophageal echocardiography has been performed by anaesthetists during cardiac surgery for over 20 years. With the increasing availability of portable ultrasound systems, the use of ultrasound to assist in vascular cannulation and regional anaesthesia has been well described. Portable ultrasound systems come with a range of probes for different applications, including transthoracic echocardiography. While transthoracic echocardiography has traditionally been the domain of cardiologists, its use has been increasing in critical care, the emergency room and, recently, by anaesthetists in the perioperative period. Unlike formal cardiology-based transthoracic echocardiography, focused, goal-directed transthoracic echocardiography is often more appropriate in the perioperative period to address a particular question and can be performed in just a few minutes. Transthoracic echocardiography allows rapid, noninvasive, point-of-care assessment of ventricular function, valvular integrity, volume status and fluid responsiveness. It can help distinguish undifferentiated systolic murmurs preoperatively, give valuable information on the aetiology of unexplained hypotension and cardiovascular collapse and assess response to therapeutic interventions such as vasoactive drugs and volume resuscitation. Focused transthoracic echocardiography should include qualitative assessment of left and right ventricular function, an estimate of aortic valve gradient, right ventricular systolic pressure and intravascular volume status as minimum requirements. Transthoracic echocardiography is a valuable tool in the perioperative period and ideally the equipment and expertise should be available in all operating rooms.

Has the clinical presentation and clinician's index of suspicion of cardiac tamponade changed over the past decade?

It remains unclear whether advances in the understanding of the pathophysiology and improvements in cardiovascular imaging over the years have impacted the clinician's recognition of cardiac tamponade (CT). We sought to evaluate signs and symptoms of CT in a present-day population and compare it to a similar group from a decade prior. We performed a retrospective analysis of two cohorts of patients presenting to a tertiary hospital with CT, all of whom underwent pericardial drainage (PD). Group 1 (Gp1) included subjects presenting from 1988 to 1991 and Group 2 (Gp2) included subjects from 2002 to 2005. Fifty-five patients comprised each group, with an average age of 55 years. Seventy-one percent of patients in Gp1 had identifiable cardiovascular symptoms 1 week prior to presentation, compared to 33% in Gp2. Dyspnea was the most common symptom in both groups, and was less frequent in Gp2. Compared with Gp1, chest pain, cough, and lethargy were also less frequent in Gp2. One day prior to PD, tachypnea and pulsus paradoxus were detected more frequently in Gp1 compared to Gp2. Large, circumferential pericardial effusions were the most frequent echocardiographic findings in both groups and the most common etiology of CT was malignancy in Gp1and postoperative bleeding in Gp2. Thus, the recognition of symptoms and physical signs in patients presenting with CT has changed over the past decade, as has etiology of pericardial effusions. However, the diagnosis of CT still remains delayed, and the present data emphasize the need for a heightened index of suspicion for recognizing this hemodynamically-important process.

The importance of transesophageal echocardiography in diagnosis of pericardial tamponade after cardiac surgery

BACKGROUND AND AIM OF THE STUDY

Despite the fact that there is a simple and effective treatment for pericardial tamponade (PCT), delayed diagnosis can cause serious morbidities or even mortality. In this study, we discuss the management and the diagnostic procedures of PCT.

MATERIALS AND METHODS

Sixty-two patients with suspected PCT were initially evaluated with transthoracic echocardiography (TTE) and then with transesophageal echocardiography (TEE). Forty-nine (79%) patients were chosen for surgery after TEE displayed a suspected PCT diagnosis. Patients with suspected PCT were divided into two groups: Early-phase PCT (symptoms developed within 72 hours) and late-phase PCT (symptoms developed after 72 hours).

RESULTS

Thirty-five (56%) patients were in the early phase and 27 (44%) patients were in the late phase. In 13 out of 22 (59%) cases, from both early and late phases, TTE findings showed no PCT, but TEE findings showed a positive PCT diagnosis. All 13 of the cases where TEE was positive after a negative TTE were confirmed by surgery. Overall, the PCT diagnoses in 48 out of 49 patients were confirmed during surgery.

DISCUSSION

The role of echocardiography in PCT diagnosis is shown to be extremely important in some clinical cases, such as in patients during the postoperative period after cardiac surgery. Furthermore, particularly when TTE does not provide complete imaging of the pericardial sac, TEE should be mandatory. We recommend that even patients with a negative diagnosis of PCT from TTE should undergo further evaluation with TEE.

Postoperative complications of coronary artery bypass grafting surgery

Coronary artery bypass grafting (CABG) surgery continues to be an effective and well-used intervention for coronary artery disease. Older patients and those with sicker hearts will become the norm. In spite of increased risk for patients undergoing CABG, overall mortality rates have decreased. Nursing contributions to these improved outcomes cannot be overestimated. Continued understanding and appreciation of these complications will be necessary to effectively care for patients and create optimal outcomes.

Cancer therapy and cardiotoxicity: the need of serial Doppler echocardiography

Cancer therapy has shown terrific progress leading to important reduction of morbidity and mortality of several kinds of cancer. The therapeutic management of oncologic patients includes combinations of drugs, radiation therapy and surgery. Many of these therapies produce adverse cardiovascular complications which may negatively affect both the quality of life and the prognosis. For several years the most common noninvasive method of monitoring cardiotoxicity has been represented by radionuclide ventriculography while other tests as effort EKG and stress myocardial perfusion imaging may detect ischemic complications, and 24-hour Holter monitoring unmask suspected arrhythmias. Also biomarkers such as troponine I and T and B-type natriuretic peptide may be useful for early detection of cardiotoxicity. Today, the widely used non-invasive method of monitoring cardiotoxicity of cancer therapy is, however, represented by Doppler-echocardiography which allows to identify the main forms of cardiac complications of cancer therapy: left ventricular (systolic and diastolic) dysfunction, valve heart disease, pericarditis and pericardial effusion, carotid artery lesions. Advanced ultrasound tools, as Integrated Backscatter and Tissue Doppler, but also simple ultrasound detection of "lung comet" on the anterior and lateral chest can be helpful for early, subclinical diagnosis of cardiac involvement. Serial Doppler echocardiographic evaluation has to be encouraged in the oncologic patients, before, during and even late after therapy completion. This is crucial when using anthracyclines, which have early but, most importantly, late, cumulative cardiac toxicity. The echocardiographic monitoring appears even indispensable after radiation therapy, whose detrimental effects may appear several years after the end of irradiation.