Diagnosis and management of pericardial effusion

A case report of systemic lupus erythematosus with severe pulmonary hypertension presenting as large pericardial effusion with early signs of cardiac tamponade: a diagnostic and therapeutic challenge

Background

Pulmonary hypertension is defined as resting arterial pressure >20 mmHg. Cardiac tamponade is a medical emergency where fluids accumulate in the pericardial sac compressing the heart pericardium leading to heart failure. Pericardiocentesis is challenging in patients with cardiac tamponade and severe pulmonary hypertension due to the risk of catastrophic haemodynamic collapse.

Case Summary

An 18-year-old female who was recently diagnosed to have systemic lupus erythematosus (SLE) presented to the emergency department with shortness of breath, chest pain, fever, and fatigue. The physical examination revealed tachycardia, muffled heart sounds, and distended jugular venous pulse. Chest X-ray showed cardiomegaly, and transthoracic echocardiography showed a large circumferential pericardial effusion with signs of cardiac tamponade. There was severe pulmonary hypertension along with a dilated right ventricle with systolic dysfunction. The right ventricular systolic pressure was around 100 mmHg. The multidisciplinary team of cardiologists and pulmonologists decided to avoid pericardiocentesis due to the high risk of haemodynamic collapse. Aggressive medical therapy targeting pulmonary hypertension and SLE was started, which resulted in complete resolution of the pericardial effusion and normalization of pulmonary artery pressure.

Discussion

A conservative approach can be an alternative strategy to manage patients with large pericardial effusion and impending pericardial tamponade in the presence of severe pulmonary arterial hypertension as pericardiocentesis carries a high risk of haemodynamic collapse.

A Case Report of Methicillin-Resistant Staphylococcus aureus-Related Pericardial Empyema: A Deadly Cardiac Risk

Pericardial empyema, a rare but often fatal condition, is frequently diagnosed postmortem. Staphylococcus aureus is the most common causative organism. This case involves a 73-year-old male with diabetes and hypothyroidism who presented with chills, fever, and a persistent skin infection. Cultures revealed Methicillin-resistant Staphylococcus aureus (MRSA), and he was treated with intravenous Vancomycin. On the third day, the patient experienced sudden chest pain, and examination revealed muffled heart sounds, jugular venous distension, sinus tachycardia, and diffuse ST elevation. Transthoracic echocardiography (TTE) showed a large pericardial effusion. An emergent pericardiocentesis was performed, followed by a pericardial window, but the patient later developed a clot, leading to the removal of 1000 ml of the bloody fluid. He subsequently became dyspneic and experienced pulseless electrical activity, resulting in death from cardiopulmonary collapse. MRSA was confirmed in the pericardial fluid. This case underscores the critical need for prompt diagnosis and treatment of pericardial empyema due to its high mortality risk and often ambiguous clinical presentation.

Coronary microvascular dysfunction in childhood: An emerging pathological entity and its clinical implications

Coronary microvascular dysfunction (CMD) encompasses a spectrum of structural and functional alterations in coronary microvasculature resulting in impaired coronary blood flow and consequent myocardial ischemia without obstruction in epicardial coronary artery. The pathogenesis of CMD is complex involving both functional and structural alteration in the coronary microcirculation. In adults, CMD is predominantly discussed in context with anginal chest pain or existing ischemic heart disease and its risk factors. The presence of CMD suggests increased risk of adverse cardiovascular events independent of coronary atherosclerosis. Coronary microvascular dysfunction is also known in children but is rarely recognized due to paucity of concommitent coronary artery disease. Thus, its clinical presentation, underlying mechanism of impaired microcirculation, and prognostic significance are poorly understood. In this review article, we will overview variable CMD reported in children and delineate its emerging clinical significance.

Idiopathic Pericardial Effusions in Children: Workup and Final Diagnoses

Pediatric idiopathic pericardial effusions are common and often have a prolonged clinical course. We hypothesized that these effusions have no standardized diagnostic workup, and ultimately have a final etiology not initially appreciated. To test these hypotheses, a hospital system-wide retrospective (1/1/1990-10/1/2019) cohort study of pericardial effusions in children (< 18 years) was conducted. Effusions were grouped by etiology and patients receiving an initial idiopathic diagnosis were further analyzed. Effusion size, diagnostic workup, final diagnosis, and time to resolution were abstracted. In total, 42/366 effusions were initially diagnosed as idiopathic. Workup was not standardized and included up to six laboratory tests including pericardial fluid analysis and infectious, metabolic, rheumatologic and thyroid workups. Treatment course involved 1 readmission in 24%, and > 1 readmission in 12%. Resolution of effusion occurred in 83% of patients within a median of 1 admission (range 1-4). Of those effusions initially deemed idiopathic, 12/42 (29%) were later found to have an underlying etiologic diagnosis including: autoimmune (7, 58%), neoplastic (2, 16%), infectious (2, 16%), and renal (1, 8%). Children initially diagnosed with idiopathic pericardial effusions have an underlying etiologic diagnosis 29% of the time, and a standardized workup may prevent delays in definitive diagnosis and treatment.

Malignant Pericardial Effusion Presenting as a Sequela of Lung Adenocarcinoma

Pericardial effusion is a collection of fluid in the pericardial sac that can result in symptoms such as shortness of breath, pleuritic chest pain, and/or hemodynamic instability. Malignant pleural effusions are seen in a few cancer patients and are associated with poor prognosis. Here, we present the case of a 65-year-old female with a large malignant pericardial effusion in the setting of advanced-stage lung adenocarcinoma.

Cardiac Arrest Following Retrieval of Inferior Vena Cava Filter: A Case Report and Literature Review of Pericardial Effusion and Cardiac Tamponade

This report presents the clinical details and management of a 58-year-old Caucasian male with pericardial effusion and cardiac tamponade following outpatient inferior vena cava (IVC) filter removal. The patient was unresponsive and experienced cardiac arrest minutes after the procedure, requiring cardiopulmonary resuscitation. After return of spontaneous circulation he displayed somnolence, confusion and chest discomfort. Investigations revealed a large pericardial effusion, and an echocardiography confirmed cardiac tamponade. Prompt intervention involved pericardiocentesis, resulting in haemodynamic stabilisation and reduction in effusion size. The patient responded favourably with treatment. Differential diagnoses were considered and treatment options were discussed, highlighting the importance of timely recognition and appropriate intervention in managing pericardial effusion and cardiac tamponade. This report adds to the limited literature on pericardial effusion and cardiac tamponade following a scheduled outpatient IVC filter removal, emphasising the unique clinical presentation and successful management of this rare phenomenon.

LEARNING POINTS

Understanding the link between pericardial effusion and cardiac tamponade following IVC filter removal.Recognising and differentiating cardiac tamponade from other emergencies using clinical and diagnostic tools.Learning the immediate management of cardiac tamponade, emphasising the role of pericardiocentesis.

Comparing Outcomes of CT-Guided Percutaneous Pericardial Drainage with Surgical Pericardial Window in Patients with Symptomatic Pericardial Effusions

RATIONALE AND OBJECTIVES

To compare short-term outcomes of CT-guided percutaneous pericardial drainage (PPD) versus subxiphoid surgical pericardial window (PW) drainage and analyze the risk factors associated with their outcomes.

MATERIALS AND METHODS

A retrospective chart review of patients who underwent either percutaneous drainage with drainage catheter placement or PW with surgical drain placement for symptomatic pericardial effusion between January 1, 2006 and August 31, 2016 was performed after institutional review board approval (decision number 16-783). The primary objective was to test for associations between the short-term (≤30 days post procedure) complication and recurrence rates in patients with symptomatic pericardial effusions. The secondary objectives were to test for associations between short-term complications with changes in vital signs.

RESULTS

Of the 257 procedures included in the final analysis, 142 were in the percutaneous drainage group. Short-term complication rate was significantly greater (p < 0.001) in patients undergoing PW, 17% (19/114), as compared with PPD, 2% (3/142). The estimated odds of having complications in the PW cohort was 9 times greater than the percutaneous drainage cohort (OR = 9.3, 95% CI:  2.7-32.3). No significant difference was observed between whether or not a patient experienced a short-term recurrence and any of the explanatory variables (patient demographics, imaging, and vital signs).

CONCLUSION

CT-guided PPD is a safer alternative to surgical PW as it leads to fewer complications without a significant difference in recurrence rate of pericardial effusion.

Development and validation of a deep learning pipeline to measure pericardial effusion in echocardiography

Objectives

The aim of this study was to develop a deep-learning pipeline for the measurement of pericardial effusion (PE) based on raw echocardiography clips, as current methods for PE measurement can be operator-dependent and present challenges in certain situations.

Methods

The proposed pipeline consisted of three distinct steps: moving window view selection (MWVS), automated segmentation, and width calculation from a segmented mask. The MWVS model utilized the ResNet architecture to classify each frame of the extracted raw echocardiography files into selected view types. The automated segmentation step then generated a mask for the PE area from the extracted echocardiography clip, and a computer vision technique was used to calculate the largest width of the PE from the segmented mask. The pipeline was applied to a total of 995 echocardiographic examinations.

Results

The proposed deep-learning pipeline exhibited high performance, as evidenced by intraclass correlation coefficient (ICC) values of 0.867 for internal validation and 0.801 for external validation. The pipeline demonstrated a high level of accuracy in detecting PE, with an area under the receiving operating characteristic curve (AUC) of 0.926 (95% CI: 0.902-0.951) for internal validation and 0.842 (95% CI: 0.794-0.889) for external validation.

Conclusion

The machine-learning pipeline developed in this study can automatically calculate the width of PE from raw ultrasound clips. The novel concepts of moving window view selection for image quality control and computer vision techniques for maximal PE width calculation seem useful in the field of ultrasound. This pipeline could potentially provide a standardized and objective approach to the measurement of PE, reducing operator-dependency and improving accuracy.

Continuous drainage for the treatment of gastric cancer with pericardial metastasis and cardiac tamponade: A case report

Key Clinical Message

Signet-ring cell gastric carcinomas presenting as pericardial effusion early in diagnosis are rare and associated with high mortality and a poor prognosis. There are two interesting aspects of this case: primary gastric carcinoma presenting as cardiac tamponade and the metastatic behavior of gastric signet-ring cell carcinoma.

Abstract

This report describes an 83-year-old man diagnosed to have cardiac tamponade due to massive pericardial effusion. A cytological analysis of the pericardial effusion disclosed adenocarcinoma. The patient was treated with continuous pericardial drainage and the amount of pericardial effusion decreased.

Incidental finding of asymptomatic non-traumatic pericardial effusion in a trauma patient: a case report

Pericardial effusion can either be an incidental finding or a manifestation of systemic or cardiac disease. It has a wide range of presentations, from asymptomatic small effusion to rapidly progressive fatal tamponade. In a trauma setting, pericardial effusion is usually attributed to hematoma collection, with the concern of clinical evidence of tamponade that can lead to cardiopulmonary collapse. The Focused Assessment with Sonography for Trauma (FAST) is a widely used tool to diagnose pericardial effusion in trauma patients. We published this case report to emphasize that the presence of pericardial effusion alone in a trauma patient does not indicate the presence of tamponade. This case concerns a 39 years old male patient who presented to ER as a trauma case after a fall from two meters height and landing on his feet. ATLS protocol was followed, and FAST showed an incidental finding of massive pericardial fluid. The trauma team was consulted, and the patient was hemodynamically stable without clinical evidence of tamponade. Echocardiography showed mitral valve stenosis and large pericardial effusion. The close observation did not suggest the presence of cardiac tamponade. The pericardial catheter was inserted during admission with drainage of 900cc of serous fluid. The presence of pericardial fluid in a trauma setting does not confirm the diagnosis of tamponade. The mechanism of injury, clinical presentation, and the patient's stability are essential factors in determining further management of such patients.

The ebb and flow of cardiac lymphatics: a tidal wave of new discoveries

The heart is imbued with a vast lymphatic network that is responsible for fluid homeostasis and immune cell trafficking. Disturbances in the forces that regulate microvascular fluid movement can result in myocardial edema, which has profibrotic and proinflammatory consequences and contributes to cardiovascular dysfunction. This review explores the complex relationship between cardiac lymphatics, myocardial edema, and cardiac disease. It covers the revised paradigm of microvascular forces and fluid movement around the capillary as well as the arsenal of preclinical tools and animal models used to model myocardial edema and cardiac disease. Clinical studies of myocardial edema and their prognostic significance are examined in parallel to the recent elegant animal studies discerning the pathophysiological role and therapeutic potential of cardiac lymphatics in different cardiovascular disease models. This review highlights the outstanding questions of interest to both basic scientists and clinicians regarding the roles of cardiac lymphatics in health and disease.

Echocardiography-Guided Pericardiocentesis Using a Central Venous Catheter in Rural Area

Large pericardial effusion may possess potential risks of hemodynamic consequences and may progress into cardiac tamponade unexpectedly. Pericardiocentesis is advisable in asymptomatic large pericardial effusion when there are signs of hemodynamic collapse on echocardiography. However, in a limited setting, the ideal equipment is rarely available. Thus, we present a case of echocardiography-guided pericardiocentesis using a central venous catheter (CVC) in a large pericardial effusion with massive pleural effusion in a rural area.

Cardiac Tamponade-Associated Dense Deposit Disease: A Case Report and Review of the Literature

Pericardial effusion is an abnormal accumulation of fluid in the pericardial cavity. It can be associated with various cardiac and non-cardiac disorders. Dense deposit disease (DDD) is a rare kidney disease caused by uncontrolled activation of the alternative complement pathway. We are reporting a seven-year-old male child who was diagnosed to have DDD approved by renal biopsy and presented with shortness of breath, cough, and fever. Chest X-ray displayed cardiomegaly. Thereafter, echocardiography showed massive pericardial effusion and left ventricle compression with a risk for cardiac tamponade. He subsequently underwent pericardiocentesis with the removal of 450 ml of pericardial fluid. The patient's edema was not correlated with the described amount of drained pericardial fluid. To the best of our knowledge, this is the first reported case of significant pericardial effusion carrying the risk of cardiac tamponade associated with DDD. With this report, we would like to highlight the importance of cardiac assessment in patients with DDD, in particular those with nephrotic range proteinuria who present with cardiac symptoms and cardiomegaly.

Malignant pericardial effusions: A retrospective look at etiology and prognosis in a tertiary oncological center

PURPOSE

Cancer and the associated treatments are important causes of pericardial effusion. However, the natural history of malignant pericardial effusion is largely unknown, especially in the context of newer cancer treatments. We investigated the causes of pericardial effusions in a tertiary oncology center, with particular focus on the prognosis of malignant effusions in the era of contemporary oncological therapies.

METHOD

We obtained data from electronic medical records. Survival analyses were performed utilizing the Kaplan-Meier method. We performed Cox regression to explore the potential clinical factors associated with survival.

RESULTS

Forty-four patients had pericardial effusion treated with pericardiocentesis during the study period. The mean age was 62-years, and 55% were female. Sixty-eight percent of these patients also had cancer, with approximately half (47%) receiving prior chemotherapy, and a quarter (27%) having had chest radiotherapy. Seventy percent of the patients with active cancer had malignant cells on cytology of pericardial fluid. The median survival of the cohort was 227 days, with malignant effusions having a median survival of 62-days compared to nonmalignant effusions with 1408 days (Logrank statistic 7.4, p-value .007). Malignant cytology was significantly associated with mortality on univariable analysis (HR 2.5, 95% CI 1.2-5.3). Complication rates were low, with no deaths as a direct complication of pericardiocentesis.

CONCLUSION

Malignancy is the most common cause of pericardial effusion in this tertiary medical and oncological center. Abnormal cytology with malignant cells has a poor median survival, despite advances in oncological treatment over the last decade. Pericardiocentesis is a safe procedure for these patients.

Cardiovascular manifestation of end-stage liver disease and perioperative echocardiography for liver transplantation: anesthesiologist’s view

Liver transplantation (LT) is the curative therapy for decompensated cirrhosis. However, anesthesiologists can find it challenging to manage patients undergoing LT due to the underlying pathologic conditions of patients with end-stage liver disease and the high invasiveness of the procedure, which is frequently accompanied by massive blood loss. Echocardiography is a non-invasive or semi-invasive imaging tool that provides real-time information about the structural and functional status of the heart and is considered to be able to improve outcomes by enabling accurate and detailed assessments. This article reviews the pathophysiologic changes of the heart accompanied by cirrhosis that mainly affect hemodynamics. We also present a comparative review of the diagnostic criteria for cirrhotic cardiomyopathy published by the World Congress of Gastroenterology in 2005 and the Cirrhotic Cardiomyopathy Consortium in 2019. This article discusses the conditions that could affect hemodynamic stability and postoperative outcomes, such as coronary artery disease, left ventricular outflow tract obstruction, portopulmonary hypertension, hepatopulmonary syndrome, pericardial effusion, cardiac tamponade, patent foramen ovale, and ascites. Finally, we cover a number of intraoperative factors that should be considered, including intraoperative blood loss, rapid reaccumulation of ascites, manipulation of the inferior vena cava, post-reperfusion syndrome, and adverse effects of excessive fluid infusion and transfusion. This article aimed to summarize the cardiovascular manifestations of cirrhosis that can affect hemodynamics and can be evaluated using perioperative echocardiography. We hope that this article will provide information about the hemodynamic characteristics of LT recipients and stimulate more active use of perioperative echocardiography.

An unusual cause of pericardial effusion: A case report of a hepatic abscess following foreign body migration and duodenal perforation

INTRODUCTION AND IMPORTANCE

Although foreign bodies are a rare cause of gastrointestinal tract perforation, they may serve as a nidus for hepatic abscess. Abdominal pain is the most common presenting symptom. We present a case of an ingested pen causing duodenal perforation and hepatic abscess several months after initially presenting with a pericardial effusion.

CASE PRESENTATION

A 59-year-old female living in an intensive tertiary mental health facility was noted to have an incidental pericardial effusion during work-up for hyponatremia. Seven months later, she developed a new fever and was noted to have interval increase in the pericardial effusion size. This prompted further investigation which finally revealed that an ingested pen had perforated through the first part of the duodenum and caused an abscess in the left lobe of the liver. The pericardial effusion was presumed secondary to local inflammation. Upon discovery of the abscess, the patient underwent successful operative management including abscess drainage, foreign body extraction, and duodenal repair.

CLINICAL DISCUSSION

Reports of hepatic abscess from foreign body causing duodenal perforation are rare, with bone fragments and toothpicks the most common foreign bodies implicated. There is one other previously reported case of an ingested pen. Abdominal pain is present in up to 85% of cases, but fever may be the only presenting symptom.

CONCLUSION

Foreign body migration causing a hepatic abscess may present non-specifically with unexplained fever or even pericardial effusion. Psychiatric comorbidities may contribute to delays in diagnosis due to difficulties recalling the episode of ingestion.

Cardiac tamponade as a presentation of primary adrenal insufficiency

Cardiac tamponade is an important and severe consequence of pericardial effusion. Patients with haemodynamically significant pericardial effusions present with signs and symptoms relating to the degree of their impaired cardiac function. Although autoimmune disease is a recognised cause of pericardial effusion, cardiac tamponade as a clinical presentation of primary adrenal insufficiency (PAI) is infrequently reported. We present a case of a woman, in her early 50s, who was admitted to the coronary care unit with cardiac tamponade caused by an acute adrenal crisis from unrecognised PAI. We hope to raise clinicians' awareness of PAI as a rare but important cause of cardiac tamponade.

Frequency of Electrocardiographic Alterations and Pericardial Effusion in Patients With Uncomplicated Malaria

Studies have proposed that malaria may lead to electrocardiographic (ECG) changes and pericardial inflammation. We aimed to investigate the frequency of ECG alterations, determined by ECG and Holter monitoring, and pericardial effusion in patients with malaria infection. We performed a prospective observational study of adult patients with uncomplicated malaria in Amazonas, Brazil. Peripheral blood smears, ECG, and bedside echocardiography were conducted before antimalarial treatment and repeated at follow-up after completed treatment. We evaluated the diagnostic value of PR-segment depression, PR-segment elevation, and Spodick's sign for detecting pericardial effusion. A subset of patients underwent Holter monitoring at baseline. Among 98 cases of uncomplicated malaria (55% men; mean age 40 years; median parasite density 1,774/µl), 75 had Plasmodium vivax, 22 Plasmodium falciparum, and 1 had mixed infection. At baseline, 17% (n = 17) had PR-segment depression, 12% (n = 12) PR-segment elevation, 3% (n = 2) Spodick's sign, and the prevalence of pericardial effusion was 9% (n = 9). ECG alterations had sensitivities of 22% to 89% and specificities of 88% to 100% for detecting pericardial effusion at baseline. PR-segment depression had the best accuracy (sensitivity 89%, specificity 90%). Of the 25 patients, 4 patients who did not have pericardial effusion, displayed nonsustained ventricular tachycardia, determined by Holter monitoring (median duration 43 hours). Follow-up examination data were obtained for 71 patients (median 31 days), for whom PR-segment depression, elevation, and pericardial effusion had reduced significantly (p <0.05). In conclusion, our findings suggest that ECG alterations may be useful to detect pericardial effusion in malaria and that these findings decrease after completed antimalarial treatment.

Massive Pericardial Effusion in a 14-Year-Old Girl with Mild Fatigue and Neck Pain

Pericardial effusion is rare in pediatric patients and is characterized by a variable clinical presentation. Mild symptoms may be present despite severe effusion. We here report the case of a patient with massive pericardial effusion with mild clinical presentation. Our case points out the need not to exclude this diagnosis in patients with mild general impairment. This clinical suspicion can be lifesaving.

A, Tanami S, Nambiar R. A Case Report of Olmesartan-Induced Enteropathy

Chronic olmesartan use can cause a drug-induced enteropathy as a rare side effect leading to diarrhea, significant weight loss, and reduced quality of life. The mechanism of this enteropathy is poorly understood and requires further investigation. We present a case of olmesartan-induced enteropathy resulting in recurrent hospitalizations for intractable diarrhea. Significant enteropathy is more commonly related to infectious or autoimmune causes making the diagnosis of drug-induced enteropathy a challenge. In this case, the lack of significant findings on labs or imaging resulted in a thorough diagnostic work-up revealing olmesartan-induced enteropathy. We present this case to inform providers of the possibility of olmesartan-induced enteropathy and characteristics to identify in other similar cases.

Significance of medical intervention for non-traumatic hemorrhagic cardiac tamponade

BACKGROUND

The outcomes of patients with cardiac arrest induced by non-traumatic hemorrhagic cardiac tamponade are poor.

PURPOSE

We retrospectively investigated the significance of medical intervention with pericardiocentesis and/or pericardiotomy for non-traumatic hemorrhagic cardiac tamponade.

METHODS

From January 2013 to April 2021, we retrospectively reviewed the medical charts of all patients with cardiac arrest in a prehospital setting or emergency room due to cardiac tamponade confirmed by an ultrasound examination with or without an invasive procedure (pericardiocentesis and/or pericardiotomy) and computed tomography findings, including those obtained at autopsy imaging. The subjects were divided into two groups: the Intervention (+) group, which included subjects who underwent pericardiocentesis or pericardiotomy, and the Intervention (-) group, which included subjects who did not undergo pericardiocentesis or pericardiotomy. Variables were then compared between the two groups.

RESULTS

There were 68 patients with non-traumatic cardiac tamponade. All three survival cases had witnessed collapse, and the initial rhythm was pulseless electrical activity (PEA).There were no statistically significant differences in the sex, age, means of transportation, bystander chest compression, electric shock, or adrenalineor FDP levels between the two groups.However, the number with witnessed collapse, PEA, rupture of the heart;the ratio of obtaining return of spontaneous circulation; and the survival ratio were significantly greater in the Intervention (+) group than in the Intervention (-) group.

CONCLUSION

Based on the results of preliminary study, we hypothesized that invasive medical intervention for patients with cardiac arrest induced by non-traumatic hemorrhagic cardiac tamponade might be useful for obtaining return of spontaneous circulation and a survival outcome, especially for patients with witnessed collapse with PEA as the initial rhythm.

Established and Emerging Techniques for Pericardial Imaging with Cardiac Magnetic Resonance

PURPOSE OF REVIEW

Pericardial diseases include a wide range of pathologies and their diagnosis can often be challenging. The goal of this review is to describe the established and emerging CMR imaging techniques used in the assessment of common pericardial diseases and explain the role of pericardial characterization in their diagnosis and management.

RECENT FINDINGS

CMR is indicated in cases of diagnostic uncertainty and for a comprehensive evaluation of the pericardium and its impact on the heart. This includes assessment of pericardial anatomy and associated cardiac hemodynamics, quantification and characterization of an effusion, disease staging, tissue characterization, guiding management, and even prognostication in some diseases of the pericardium. An emerging technique, pericardial characterization, utilizes various sequences to diagnose and stage pericardial inflammation, act as a biomarker in recurrent pericarditis, and guide management in inflammatory pericardial conditions. Beyond imaging, it has ushered in an era of tailored therapy for patients with pericardial diseases. Future directions should aim at exploring the role of tissue characterization in various pericardial diseases.

Malignant Müllerian Adenocarcinoma Manifesting With Cardiac Tamponade and Pleural Effusion

A 54-year-old woman with a past medical history of untreated stage IV Müllerian adenocarcinoma presented for dyspnea. She was found to have a large right-sided pleural effusion through basic radiology and clinically improved after a CT-guided therapeutic thoracocentesis. However, the patient rapidly deteriorated shortly afterward. A broader workup that included echocardiography revealed a large pericardial effusion with tamponade physiology. The patient underwent an emergent pericardiocentesis, which briefly improved hemodynamics, but her clinical status kept declining until she eventually expired. Subsequent cytology of the pleural and pericardial fluid revealed malignant cells of Müllerian origin.

Coil embolization for ruptured coronary pseudoaneurysm causing haemopericardium: a case report

Background

Coronary artery pseudoaneurysm is a rare disease that can rupture and cause haemopericardium. It can occur principally as a complication after coronary artery instrumentation, but it can also result from trauma.

Case summary

A 15-year-old male patient with a history of spontaneous pneumothoraces treated twice with video-assisted thoracoscopic thoracic surgery presented with pericarditis and increasing haemopericardium. During the hospitalization, he had developed cardiogenic shock and he underwent emergent pericardiocentesis. Coronary angiography revealed a small right coronary artery pseudoaneurysm. We successfully coil embolized the pseudoaneurysm.

Discussion

This is a rare case of a ruptured coronary artery pseudoaneurysm associated with prior tube thoracostomy. The treatments for a coronary pseudoaneurysm should be tailored based on the pathologic and anatomical characteristics.

Prospective evaluation of pericardial catheter placement versus needle pericardiocentesis in the management of canine pericardial effusion

OBJECTIVE

To compare the safety and efficacy of pericardial catheter placement with needle pericardiocentesis in dogs with pericardial effusion (PE) DESIGN: Prospective, randomized clinical trial.

SETTING

University teaching hospital.

ANIMALS

Thirty client-owned dogs requiring pericardiocentesis between January 2017 and August 2019.

INTERVENTIONS

Dogs were randomized to undergo PE drainage via indwelling pericardial catheter placement (catheter group) followed by elective drainage every 4-6 hours or needle pericardiocentesis (needle group) repeated as necessary.

MEASUREMENTS AND MAIN RESULTS

Fifteen dogs were allocated to the catheter group and 15 to the needle group. Data collected included signalment, cause of effusion, occurrence of arrhythmias pre-, during, and post-pericardiocentesis, procedural length, and details of repeated drainages. There was no significant difference between mean procedural times for pericardial catheter placement (17.7 min [±11.8]) and needle pericardiocentesis (12.1 min [±8.6]) (P = 0.192) or the rate of new arrhythmias in the catheter (36%) and needle (64%) groups (P = 0.24). Pericardial catheters were kept in situ for a median of 21 hours (range, 14-85). Three of 15 (20%) dogs in the needle group required repeated pericardiocentesis within 24 hours of initial pericardiocentesis. Pericardial catheters enabled repeated large volume PE drainage in 4 cases (median, 10.6 mL/kg; range, 8-5-10.6).

CONCLUSIONS

Pericardial catheters appear to offer a safe alternative to needle pericardiocentesis. Minimal sedation is required for placement, and they can be placed quickly. Their indwelling nature and use was not associated with a higher rate of arrhythmia compared to that of needle pericardiocentesis alone, and may be beneficial in the event that clinically significant PE recurs.

Rare complication after pericardial window: symptomatic diaphragmatic hernia containing bowel and liver

A 37-year-old woman presented to her local district general hospital with a cough, pleuritic chest pain and intermittent cyanosis. Eight months prior, she underwent a successful pericardial window for recurrent, symptomatic pericardial effusions. On presentation she was hypoxic but haemodynamically stable. Her chest radiograph raised the suspicion of a diaphragmatic hernia, confirmed by CT imaging. This identified herniation through the diaphragm of the transverse colon and left lobe of the liver resulting in cardiac compression and right ventricular dysfunction. She continued to deteriorate and required emergency intubation to allow safe transfer to a tertiary upper gastrointestinal unit. She underwent a laparotomy and repair of the diaphragmatic hernia with an uneventful inpatient recovery. In the literature, diaphragmatic liver herniation is a recognised complication secondary to trauma or congenital defects, however, to our knowledge, there are currently no cases described following pericardial windowing.

Pericardiocentesis Indications and Complications: A Retrospective Observational Study in a Tertiary Care Hospital in Karachi, Pakistan

INTRODUCTION

Pericardiocentesis is crucial for the diagnosis and management of diseases responsible for significant pericardial effusions. Pericardiocentesis was performed the first time by Riolanus for cardiac tamponade. He described the process of trephination of the sternum to remove the abnormally accumulated fluid from the pericardial space. However, with the advancement of expertise in echocardiography assisted procedures, echocardiography-guided diagnostic and therapeutic pericardiocentesis is now considered standard clinical practice in the treatment of pericardial effusions.

OBJECTIVES

We aim to study different causes of pericardial effusion and indications of pericardiocentesis as well as complications associated with it in our population.

METHODS

This is a retrospective observational study done at Aga Khan University Hospital, Karachi. We reviewed hospital record files of 66 patients admitted to Aga Khan University Hospital from January 2010 to December 2019 who underwent pericardiocentesis.

RESULTS

Out of 66 patients, 43 (65.2%) were male. The mean age of the study population was 48.59±18.9 years and 41 (62.1%) of them had underlying active malignancy with hematological malignancies being most common followed by lung carcinoma. In the majority of patients (71.2%), pericardiocentesis was performed at the bedside, and the rest of them (28.8%) underwent pericardiocentesis in the cardiac catheterization laboratory. Of all the patients, 46 (69.7%) underwent pericardiocentesis under echocardiography guidance and 18 (27.3%) required fluoroscopy. Successful pericardiocentesis was performed in 65 (98.5%) of the patients, two (3%) patients developed access site infection and only one (1.5%) patient became hemodynamically unstable while undergoing pericardiocentesis Conclusion: Malignancy, predominantly lymphoma, is the most common cause of pericardial effusion requiring pericardiocentesis. Dyspnea is the most common symptom of presentation with cardiac tamponade. Echocardiography is the commonly used imaging modality for pericardiocentesis. Bedside setting is the most common setting used for pericardiocentesis. Imaging guided pericardiocentesis has a very high success and low complication rate.

Cardiac Tamponade Caused by Cutibacterium acnes: An Updated and Comprehensive Review of the Literature

Bacterial pericarditis is a critical diagnosis caused by a wide range of organisms including Streptococcus pneumoniae and other anaerobic organisms like Cutibacterium acnes which has been gaining more importance as a causative organism. Cutibacterium species are Gram-positive microaerophilic rods that constitute part of the normal flora of skin and mucosal membranes. The incidence of pericarditis caused by this organism is underreported as it is often dismissed as a skin flora contaminant. However, if left untreated, Cutibacterium acnes can cause pericarditis with serious complications. In this paper, we present a comprehensive review of the literature regarding pericarditis caused by Cutibacterium acnes along with a case presentation from our institution. In our institution, a 20-year-old man with history of atrial septal defect presented with chest pain radiating to the back along with symptoms of upper respiratory tract infection including headaches and myalgia. Electrocardiogram was remarkable for diffuse low-voltage waves. Echocardiography revealed a large pericardial effusion with tamponade features. Pericardiocentesis drained 1.2 L of milky fluid. Pericardial fluid analysis grew Cutibacterium acnes after being cultured for 8 days. The patient received 3 weeks of IV penicillin followed by 3 weeks of oral amoxicillin along with nonsteroidal anti-inflammatory agents and colchicine with no recurrence. Pericarditis caused by Cutibacterium acnes requires a high clinical suspicion since isolation of this organism can be dismissed as a skin flora contaminant. Literature review reveals that this infection may be underdiagnosed and underreported. Prompt diagnosis may lead to timely initiation of antibiotics which can help prevent devastating complications like constrictive pericarditis. Prospective studies are needed to evaluate the true incidence and prevalence of this disease.

Atypical Cardiac Tamponade Manifesting as Left Ventricular Diastolic Collapse: A Case Report

Cardiac tamponade is a medical emergency, the diagnosis of which is predominantly clinical with supportive echocardiographic findings. Echocardiographic findings highly suggestive of cardiac tamponade include chamber collapse, inferior vena cava (IVC) plethora, and respiratory volume/flow variations. The right-sided cardiac chambers are a low-pressure system and are the first to show signs of collapse with high specificity for tamponade. We report the case of a 35-year-old woman who demonstrated left ventricular (LV) diastolic collapse on echocardiogram following a tricuspid valve replacement. Although left-sided chamber collapse with tamponade has been reported with localized pericardial effusions postoperatively, our patient had a large circumferential pericardial effusion. Selective chamber compression can be a presenting sign of postoperative tamponade after cardiac surgery. Our case highlights the importance of recognizing atypical forms of cardiac tamponade to help in early identification and emergent management in such patients.

Acquired Immunity Is Not Essential for Radiation-Induced Heart Dysfunction but Exerts a Complex Impact on Injury

While radiation therapy (RT) can improve cancer outcomes, it can lead to radiation-induced heart dysfunction (RIHD) in patients with thoracic tumors. This study examines the role of adaptive immune cells in RIHD. In Salt-Sensitive (SS) rats, image-guided whole-heart RT increased cardiac T-cell infiltration. We analyzed the functional requirement for these cells in RIHD using a genetic model of T- and B-cell deficiency (interleukin-2 receptor gamma chain knockout (IL2RG-/-)) and observed a complex role for these cells. Surprisingly, while IL2RG deficiency conferred protection from cardiac hypertrophy, it worsened heart function via echocardiogram three months after a large single RT dose, including increased end-systolic volume (ESV) and reduced ejection fraction (EF) and fractional shortening (FS) (p < 0.05). Fractionated RT, however, did not yield similarly increased injury. Our results indicate that T cells are not uniformly required for RIHD in this model, nor do they account for our previously reported differences in cardiac RT sensitivity between SS and SS.BN3 rats. The increasing use of immunotherapies in conjunction with traditional cancer treatments demands better models to study the interactions between immunity and RT for effective therapy. We present a model that reveals complex roles for adaptive immune cells in cardiac injury that vary depending on clinically relevant factors, including RT dose/fractionation, sex, and genetic background.

Pericardial effusion with tamponade: bedside ultrasonography saves another life

In these video clinical images, the authors present the cause for an elderly gentleman’s shortness of breath. It was presumed to be an exacerbation of chronic obstructive pulmonary disease, a condition for which he was in the process of being evaluated. However, bedside ultrasonography revealed a large pericardial effusion with tamponade. This timely diagnosis resulted in the patient being taken expeditiously to the operating room and saving his life.

Etiology of Pericardial Effusion and Outcomes Post Pericardiocentesis in the Western Region of Saudi Arabia: A Single-center Experience

Background Pericardial effusion is the accumulation of blood or excess fluid in the cavity between the heart and the pericardium sac. Pericardial effusion can be caused by several etiologies, including malignant and non-malignant causes. Pericardiocentesis is the gold standard assessment method for pericardial effusion etiology. The aim of this study was to identify the long-term outcome of patients who presented with massive pericardial effusion and underwent pericardiocentesis at King Abdulaziz Medical City, Jeddah, a large tertiary hospital in the western part of Saudi Arabia. Methods This is a single-center retrospective cross-sectional study conducted at King Abdulaziz Medical City Jeddah, Saudi Arabia, between January 2013 to December 2018. Data were collected from patient's charts; the clinical and echocardiographic findings, alongside with pericardial fluid analysis, were collected. Procedure and patients outcomes were obtained and reported. Results Of the 107 patients with pericardial effusion, 39 patients had moderate to severe pericardial effusion requiring pericardiocentesis. The mean age was 52 years, and 56.4% were females. The most common chronic disease was hypertension and the presence of metastasis. The most common cause of pericardial effusion was a malignancy. A majority of patients had severe pericardial effusion. Many patients had tamponade (69.6%). Patients with malignant pericardial effusion had a median survival of 54 days. Conclusion Etiologies of pericardial effusion requiring drainage depend on the population studied. Patients with malignant effusions have worse outcomes than non-malignant effusion. Pericardiocentesis is required to ascertain the cause and risk-stratify patients.

Steroids as a possible effective therapy in the management of large isolated chylopericardium following open heart surgery

BACKGROUND

Chylopericardium is the collection of lymph fluid inside the pericardial cavity. The incidence of chylopericardium is very low, as this diagnosis is rarely reported following cardiac procedures in children. While some reports were published worldwide on isolated chylopericardium after cardiac surgeries for diverse reasons, it has never been reported after repair for partial anomalous pulmonary venous return. In addition, management of this diagnosis ends up being surgical with minimal concentration on medical treatment which proved unsuccessful. We present a medical approach with corticosteroids as an effective method to treat isolated chylopericardium.

CASE PRESENTATION

In this manuscript, we present an approach to treat isolated post-operative chylopericardium in a child following repair of partial anomalous pulmonary venous return. Chylous drainage responded to corticosteroids and completely ceased. There was no need for surgical intervention.

CONCLUSION

Until now, isolated chylopericardium has never been reported to occur with partial anomalous pulmonary venous return repair. A review of the literature showed that most patients follow a conservative approach consisting of diuretics and non-steroidal anti-inflammatory agents with some of them undergoing surgical re-intervention. With future research on the topic still needed, we hope that this will encourage physicians worldwide to consider administering a trial of corticosteroids as an option to treat chylopericardium.

Retrospective evaluation of pericardial catheter placement in the management of pericardial effusion in dogs (2007-2015):18 cases

OBJECTIVE

To describe the use of pericardial catheters in dogs with pericardial effusion (PE), and detail any associated adverse events.

DESIGN

Retrospective study.

SETTING

University teaching hospital.

ANIMALS

Eighteen client-owned dogs that had pericardial catheters placed for pericardial fluid drainage between May 2007 and January 2015.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

All pericardial catheters were placed within 5 hours of presentation, usually within 1 hour (median 72.5 min, range 45-300 min). Ten of 18 cases were sedated with butorphanol, and 4 with additional midazolam. Four had pericardial catheters positioned for single drainage only and were immediately removed. The other 14 pericardial catheters remained in situ for a median of 18 hours (range 2-88 h). Ten of the remaining 14 cases were redrained after pericardial catheter placement. The main adverse events reported were new arrhythmias in 6/18 cases, with 4 of these 6 patients being administered anti-arrhythmic therapy. No infectious or functional complications were reported. Ten patients were discharged, 1 died and 7 were euthanized.

CONCLUSIONS

Thoracic drainage catheters inserted into the pericardial space via a modified-Seldinger technique can be positioned in dogs to aid management of PEs. The main associated adverse event is arrhythmia. Minimal sedation is required for placement, and dogs tend not to require postprocedural analgesia. Catheters can remain in situ for repeated drainage, potentially decreasing staffing time requirement and repeat sedation. Their use is associated with a rate of arrhythmia requiring treatment of 22%, compared to that of needle pericardiocentesis alone at 13%. They are easy to position using equipment available in many facilities.

Acute Influenza Infection Presenting with Cardiac Tamponade: A Case Report and Review of Literature

INTRODUCTION

Cardiac complications associated with influenza infection can occur either via a direct effect of the virus on the heart or through exacerbation of preexisting cardiovascular disease. We present a case of a 57-year-old man with acute influenza infection complicated by pericardial effusion and cardiac tamponade.

CASE PRESENTATION

A 57-year-old white man presented to the Emergency Department with sudden onset of severe, nonexertional, retrosternal, pressure-like chest pain for a few hours and with fever and muscle aches for 2 days. The patient was initially admitted because of suspected acute coronary syndrome. The next morning, he complained of acute-onset shortness of breath and had hypotension and tachycardia. On examination, his peripheral extremities were cold and heart sounds were distant. Pulsus paradoxus was 20 mmHg. The electrocardiogram showed low-voltage QRS complex with electrical alternans. An urgently performed bedside echocardiogram showed moderate pericardial effusion with a small right ventricular cavity with diastolic collapse. Emergent pericardiocentesis was performed, with removal of 250 mL of fluid from the pericardial space. The patient's hemodynamic status immediately improved. Analyses of pericardial fluid demonstrated no bacteria, acid-fast bacilli, or malignant cells. The result of a rapid influenza diagnostic test with polymerase chain reaction was positive for influenza A virus, with other viral panels yielding normal results. The patient was treated with oseltamivir for 5 days.

DISCUSSION

Pericardial involvement is a rare and perhaps underreported complication of influenza infection. Early recognition of cardiac symptoms and appropriate diagnostic workup in a patient presenting with influenza-like symptoms is important to avoid life-threatening complications.

Serum BNP levels are associated with malignant pericardial effusion

Introduction

The development of malignant pericardial effusion indicates a poor prognosis and is the leading cause of cardiac tamponade. The objectives of the study were to examine the levels of BNP in traumatic, malignant and non-malignant pericardial effusion etiologies, and to assess the value of serum and pericardial fluid BNP levels in the prognosis of malignant pericardial effusion.

Methods

A of 56 patients with clinical and echocardiographic diagnosis of pre-tamponade or tamponade who required pericardiocentesis were included in the study. BNP levels were assessed in the serum and within the pericardial fluid. The diagnostic value of BNP levels in discriminating between malignant and non- malignant etiology of pericardial effusion was examined using a receiver-operating characteristic (ROC).

Results

Pericardial fluid BNP levels were similar across all etiology groups. In patients with malignant etiology, the amount of pericardial fluid was high and their serum BNP levels were relatively low. BNP levels were strong predictors of malignant pericardial effusion, and the cut-off point of BNP ≤ 250 pg/ml demonstrated the highest sensitivity (90.0%) for malignant etiology.

Conclusions

Low serum BNP levels were significantly associated with malignancy in patients undergoing pericardiocentesis for pericardial effusions. Serum BNP levels <250 pg/ml may trigger more extensive diagnostic testing for malignant pericardial effusion in patients with small pericardial effusion who are not considered for pericardiocentesis due to small effusion, in whom the etiology is unclear.

Comparison between optical microscopy and automation for cytometric analysis of pericardial fluids in a cohort of adult subjects undergoing cardiac surgery

Aims

Limited information is available on number and type of cells present in the pericardial fluid (PF). Current evidence and has been garnered with inaccurate application of guidelines for analysis of body fluids. This study was aimed at investigating the performance of automate cytometric analysis of PF in adult subjects.

Methods

Seventy-four consecutive PF samples were analysed with Sysmex XN with a module for body fluid analysis (XN-BF) and optical microscopy (OM). The study also encompassed the assessment of limit of blank, limit of detection and limit of quantitation (LoQ), imprecision, carryover and linearity of XN-BF module.

Results

XN-BF parameters were compared with OM for the following cell classes: total cells (TC), leucocytes (white blood cell [WBC]), polymorphonuclear (PMN) and mononuclear (MN) cells. The relative bias were −4.5%, 71.2%, 108.2% and −47.7%, respectively. Passing and Bablok regression yielded slope comprised between 0.06 for MN and 5.8 for PMN, and intercept between 0.7 for PMN and 220.3 for MN. LoQ was comprised between 3.8×106 and 6.0×106 cells/L for WBC and PMN. Linearity was acceptable and carryover negligible.

Conclusions

PF has a specific cellular composition. Overall, automated cell counting can only be suggested for total number of cells, whereas OM seems still the most reliable option for cell differentiation.

Recurrent haemorrhagic pericardial effusion due to idiopathic pericarditis: a case report

BACKGROUND

Haemorrhagic pericardial effusion (PE) has been described in pericarditis due to infection, neoplasm, collagen vascular disease, uraemia, pericardial inflammation after acute myocardial infarction, trauma, irradiation, and idiopathic pericarditis. Patients with large haemorrhagic PE develop recurrence or constrictive pericarditis (CP) frequently as complication without being treated intensively.

CASE SUMMARY

A 22-year-old female patient with a previous episode of pericarditis with severe PE was admitted for acute pericarditis. Three days before, she was evaluated at the emergency department and presented normal laboratory workup and no significant findings in the transthoracic echocardiogram (TTE). A new TTE showed severe PE and laboratory work-up showed low haemoglobin levels. Fifteen days later, due to slow evolution, a left anterior mini-thoracotomy pericardial window procedure was performed finding minimal haemorrhagic PE with clots. We performed a complete work-up for a cause without significant findings and treated intensely to prevent recurrence or CP.

DISCUSSION

This is a case of recurrent haemorrhagic PE due to idiopathic pericarditis. Physicians should perform an intensive workup in order to find the cause because of its clinical implications and possible treatments. An intensive treatment must be initiated as soon as possible to prevent recurrence or CP.

Clinical characteristics and prognosis of cardiac tamponade patients: 5‑year experience at a tertiary center

BACKGROUND

Cardiac tamponade (CT) is characterized by compression of the cardiac chambers due to pericardial fluid accumulation. The etiology and prognosis may vary in different regions, and thus patient series from various regions can be useful for exploring the etiological and prognostic disparities. The aim of this study was to determine the clinical characteristics of patients with imminent CT, to evaluate the diagnostic performance of biochemical, microbiologic, and pathologic laboratory analysis, and to ascertain the prognosis of CT patients.

METHODS

We enrolled all patients with imminent CT who underwent percutaneous pericardiocentesis between July 2012 and December 2017 in this retrospective study. The patients were classified into three etiology groups: (a) malignancy (MRCT); (b) iatrogenic/mechanical complication of myocardial infarction (IMCT); and (c) other causes (OCT). Clinical information, laboratory findings, and survival data were recorded.

RESULTS

In total, 186 pericardiocentesis procedures were performed on 153 consecutive patients with CT. The median follow-up was 137 days (range: 1-1937). The MRCT group had the highest mortality rate (79%) in 12 months, while the OCT group had the lowest rate (27%). We determined that increased age, higher serum urea levels, and malignancy-related CT were independent predictors of mortality. The mortality rates of the MRCT and IMCT groups were similar, with both of them being significantly higher than the rate of the OCT group. In all, 15 patients were diagnosed with a new malignancy via pericardial fluid cytology.

CONCLUSION

Patients in the MRCT and IMCT groups had a poor prognosis. The presence of malignancy was found to be the most powerful predictor of mortality in CT patients.

Outcomes of idiopathic chronic large pericardial effusion

Objective

Aim of this paper is to evaluate the outcomes of ‘idiopathic’ chronic large pericardial effusions without initial evidence of pericarditis.

Methods

All consecutive cases of idiopathic chronic large pericardial effusions evaluated from 2000 to 2015 in three Italian tertiary referral centres for pericardial diseases were enrolled in a prospective cohort study. The term ‘idiopathic’ was applied to cases that performed a complete diagnostic evaluation to exclude a specific aetiology. A clinical and echocardiographic follow-up was performed every 3–6 months.

Results

100 patients were included (mean age 61.3±14.6 years, 54 females, 44 patients were asymptomatic according to clinical evaluation) with a mean follow-up of 50 months. The baseline median size of the effusion (evaluated as the largest end-diastolic echo-free space) was 25 mm (IQR 8) and decreased to a mean value of 7 mm (IQR 19; p<0.0001) with complete regression in 39 patients at the end of follow-up. There were no new aetiological diagnoses. Adverse events were respectively: cardiac tamponade in 8 patients (8.0%), pericardiocentesis in 30 patients (30.0%), pericardial window in 12 cases (12.0%) and pericardiectomy in 3 patients (3.0%). Recurrence-free survival and complications-free survival was better in patients treated without interventions (log rank p=0.0038).

Conclusions

The evolution of ‘idiopathic’ chronic large pericardial effusions is usually benign with reduction of the size of the effusion in the majority of cases, and regression in about 40% of cases. The risk of cardiac tamponade is 2.2%/year and recurrence/complications survival was better in patients treated conservatively without interventions.

Pericardial Disease Associated with Malignancy

PURPOSE OF REVIEW

Pericardial effusion is commonly associated with malignancy. The goals of treatment should include optimizing symptom relief, minimizing repeat interventions, and restoring as much functional status as possible.

RECENT FINDINGS

Pericardiocentesis should be the first intervention but has high recurrence rates (30-60%). For patients with recurrence, repeat pericardiocentesis is indicated in those with limited expected lifespans. Extended pericardial drainage decreases recurrence to 10-20%. The addition of sclerosing agents decreases recurrence slightly but creates significant pain and can lead to pericardial constriction and therefore has fallen out of favor. Most patients with symptomatic pericardial disease have a short median survival time due to their underlying disease. In patients with a longer life expectancy, surgical drainage offers the lowest recurrence rate. Surgical approach is based on effusion location and clinical condition. Subxiphoid and thoracoscopic approaches lead to similar outcomes. Thoracotomy should be avoided as it increases morbidity without improving outcomes.

Pyopericardium presenting with echocardiographic features of pericardial tamponade in an elderly man

A 72-year-old Chinese man presented with mild symptoms of heart failure. Transthoracic echocardiography showed signs of cardiac tamponade though clinically he was relatively well. The option of pericardiocentesis was not carried out due to a narrow window for aspiration with only a thin layer of effusion seen surrounding the apex and right ventricle on subcostal view.Pericardial window was done via a left anterolateral thoracotomy. Intraoperatively, 500 cm³ of purulent fluid was drained. Microbiology screens were all negative. We present the atypical clinical course of this elderly man presenting with a large pyopericardium.