A Rare Case of Cardiac Tamponade Induced by Chronic Lymphocytic Leukemia

While cardiac tamponade is a commonly recognized complication in solid organ malignancies and acute leukemias, instances of cardiac involvement in the context of chronic hematologic malignancies, such as chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL), are rarely observed. A 66-year-old male, with a history of stage IV CLL/SLL, presented with three weeks of worsening edema, orthopnea, and dyspnea. Two days after admission, an echocardiogram revealed a large circumferential pericardial effusion. Given the concern about early signs of pericardial tamponade, the patient underwent emergent pericardiocentesis with the removal of 700 cc of sanguineous fluid. A pericardial biopsy and flow cytometry of the pericardial fluid confirmed the diagnosis of CLL/SLL with pericardial involvement. There were no signs of large cell lymphoma transformation at that point. This rare case demonstrates the importance of considering cardiac complications in CLL/SLL patients who present with worsening edema, orthopnea, and dyspnea.

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.

Management of Penetrating Cardiac Injuries With Pericardial Window and Drainage in Select Patients

BACKGROUND

Management of penetrating chest injuries with a positive pericardial window (PW) are presumed cardiac injuries and traditionally result in sternotomy. However, there is some evidence in the literature that select patients can be managed with PW, lavage, and drainage (PWLD).

METHODS

All patients with penetrating chest trauma who underwent PW and/or sternotomy over a 5-year period were identified. Patients were stratified by operative intervention [PW + sternotomy vs PWLD] and compared. Multivariable logistic regression (MLR) analysis was performed to determine independent predictors of therapeutic sternotomy.

RESULTS

Of the 146 patients who underwent PW and/or sternotomy included in the study, 126 patients underwent PW, 39 underwent sternotomy, and 10 underwent PWLD. There was no difference in demographics, LOS, ICU LOS, vent days, or mortality in patients who underwent PW + sternotomy, compared to patients who underwent PWLD. In the PWLD group, one patient returned to the OR for recurrent pericardial effusion and no patients required sternotomy. Multivariable logistic regression identified ISS as an independent predictor of therapeutic sternotomy (OR 1.160; 95% CI 1.006-1.338, P = .0616). Interestingly, positive FAST, significant CT findings, and trajectory were not predictors of therapeutic sternotomy. There were 7 patients with a left hemothorax and negative FAST found to have a positive PW and cardiac injury mandating sternotomy and repair.

CONCLUSION

Penetrating cardiac injury can be managed with PWLD in select patients. Positive FAST, significant findings on CT, and trajectory do not mandate sternotomy. A negative FAST in the setting of a hemothorax does not rule out a cardiac injury.

Anesthetic Management of Suspected COVID-19 Vaccination Pericarditis/Myocarditis Scheduled for a Pericardial Window: A Case Report and Literature Review

The unique challenges posed by the COVID vaccination continue to affect multiple healthcare specialties. Although short-term studies have shown that COVID-19 vaccines are both safe and effective, reports of side effects continue to emerge. Cardiovascular side effects such as myo-pericardial inflammation are of particular interest to the fields of cardiology, anesthesiology, and surgery. Myocarditis and pericarditis necessitate diagnostic and therapeutic procedures such as transesophageal echocardiography (TEE) and pericardial window surgery. Intraoperative monitoring of clinical status and heart rhythm and careful adjustments to anesthetic management are required to ensure successful outcomes. This case report follows a 50-year-old male with a known history of pericardial effusion post-COVID vaccination who presented to the emergency department with shortness of breath and chest pain, necessitating further management. We examine the importance of TEE in preventing unnecessary pericardial window procedures and shed light on the importance of careful patient monitoring and management in promoting successful outcomes from an anesthesiology perspective.

Diagnosis and Management of Pembrolizumab-Associated Pericardial Effusion in a Non-small Cell Lung Cancer Patient

The advent of immune checkpoint inhibitors (ICIs) in the field of oncology has improved the outcome response rate for a variety of neoplastic pathologies with improved cellular specificity that lacks the traditional adverse effects associated with chemotherapy. However, ICIs are not without adverse associations, and a growing concern for modern clinicians is the balancing of interests that most occur to minimize these adverse effects while also improving patients' conditions from an oncologic perspective. This case presents a 69-year-old man who developed multiple episodes of significant pericardial effusion while receiving infusions of pembrolizumab for stage III-A adenocarcinoma for which he underwent a pericardiostomy procedure. Given the positive response of this immunotherapy on disease progression, the decision was made to continue the administration of pembrolizumab following the pericardiostomy with the plan of using serial echocardiography studies to monitor for the presence of clinically significant pericardial effusion in the future. In this way, the patient will still be able to receive optimal treatment for his advanced cancer while preserving adequate cardiac function.

Effect of chest ultrasound compared with pericardial window for the diagnosis of occult penetrating cardiac wounds in hemodynamically stable subjects with penetrating thoracic trauma: A meta-analysis

We conducted a meta-analysis to assess the diagnostic performance of chest ultrasound compared with a pericardial window for the detection of occult penetrating cardiac wounds in patients with penetrating thoracic trauma who were hemodynamically stable. A systematic literature search up to December 2022 was performed and 567 related studies were evaluated. The chosen studies comprised 629 penetrating thoracic trauma subjects who participated in the selected studies' baseline. Odds ratio (OR) with 95% confidence intervals (CIs) were calculated to assess the effect of different chest ultrasounds on wound infection after penetrating thoracic trauma by the dichotomous methods with a random or fixed effect model. The chest ultrasound resulted in significantly lower occult penetrating cardiac wounds detection (OR, 0.02; 95% CI, 0.01-0.08, P < 0.001), higher false positive (OR, 33.85; 95% CI, 9.21-124.39, P < 0.001), and higher false negative (OR, 27.31; 95% CI, 7.62-97.86, P < 0.001) compared with the pericardial window in penetrating thoracic trauma. The chest ultrasound resulted in significantly lower occult penetrating cardiac wound detection, higher false positives, and higher false negatives compared with the pericardial window in penetrating thoracic trauma. Although care should be taken when dealing with the results because all of the studies had less than 200 subjects as a sample size.

At the Heart of the Diagnosis: A Case of Systemic Lupus Erythematosus Presenting as Cardiac Tamponade

Systemic lupus erythematosus (SLE) is a heterogenous, systemic disease characterized by the production of pathogenic autoantibodies against nuclear antigens. Although the most common cardiac manifestation of SLE is pericardial effusions, their progression to cardiac tamponade is rare and has an incidence between 1-3%. We describe a case of a 42-year-old Hispanic woman who presented with severe shortness of breath, vague chest pain, and hemodynamic compromise secondary to cardiac tamponade. The patient's underlying etiology of cardiac tamponade was attributed to a new diagnosis of SLE based on the 2019 European Alliance of Associations for Rheumatology/American College of Rheumatology classification (EULAR/ACR) criteria for SLE. The patient's treatment consisted of a pericardial window and immunosuppressive therapy with corticosteroids, Mycophenolate, and hydroxychloroquine. This case aims to increase awareness of SLE as a possible differential diagnosis of cardiac tamponade in the appropriate clinical setting.

Myxedema Coma: A Rare Case of Shock Post-Pericardial Window Procedure

The clinical features of severe hypothyroidism vary in presentation, ranging from subclinical symptoms to multiorgan failure referred to as myxedema coma. The cornerstone treatments of myxedema coma include aggressive thyroid hormone replacement combined with excellent supportive care in the intensive care unit. We report a rare case of a 56-year-old female with history of hypothyroidism treated with levothyroxine, who developed myxedema coma post-pericardial window surgery for a large pericardial effusion. She was supported with substantial doses of vasopressors and inotropes for shock. In addition, she was initiated on lung-protection ventilation for acute respiratory distress syndrome. After the diagnosis of myxedema coma was made, she was started on intravenous levothyroxine and hydrocortisone with great sustained clinical response. This case illustrated myxedema coma as an unusual cause of shock in post-operative patients with past medical history of hypothyroidism.

Review of chylopericardium

Chylopericardium is a rare pathologic condition consisting of the accumulation of excess amounts of chylous fluid within the pericardial cavity. Most patients are asymptomatic at presentation; however, chest pressure, chest pain and lightheadedness have been reported, and the most common presenting symptom is shortness of breath. Patients are noted to have enlargement of the cardiac silhouette on routine chest radiograph, and evidence of a pericardial effusion on echocardiography. The diagnosis is only definitively confirmed with pericardiocentesis and fluid analysis. The fluid is typically turbid white or milky in appearance, with a triglyceride level in excess of 500 mg/dL. The mechanism by which chyle accumulates within the pericardium is believed to be secondary to abnormal or damaged lymphatics or due to elevated pressure within the thoracic duct that results in chyle reflux into the pericardium. Following drainage with a pericardiocentesis or pericardial drain, attempts at conservative therapy with nothing by mouth and parental nutrition can be made, but have a high rate of failure and subsequent reaccumulation of chyle. Surgical treatment provides the most definitive management and consists of ligation of the thoracic duct just above the level of the diaphragm and creation of a pericardial window. With this treatment, risk of recurrence is incredibly low (<5%).

COVID-19 Presenting as Recurrent Pericardial Effusion

Severe acute respiratory syndrome coronavirus (SARS-CoV-2) emerged from Wuhan, China, in 2019, causing coronavirus disease 19 (COVID-19) and creating a global pandemic affecting millions of people worldwide. Though COVID-19 primarily affects the pulmonary structures, deleterious effects can also occur in the cardiac system. We present a case of a patient with recurrent pericardial effusions secondary to COVID-19 infection, an unusual cardiovascular manifestation of this disease. A 47-year-old man presented with altered mental status and tested positive for COVID-19. He left against medical advice and later presented two weeks later with pleuritic chest pain associated with shortness of breath. His symptoms were attributed to a moderate- to large-sized pericardial effusion, without evidence of tamponade, as confirmed by echocardiography. The fluid was removed by pericardiocentesis; analysis was negative for malignant cells, inflammatory markers, or microbiologic studies. Reaccumulation of the fluid necessitated placement of a pericardial window, resulting in the resolution of his symptoms. There are limited case reports demonstrating the association of pericardial effusion with COVID-19 infection. The effusion is likely secondary to the inflammatory response leading to capillary leakage, resulting in pericardial fluid traversing the serous pericardium. In addition to other demonstrated cardiovascular effects, COVID-19 appears to be associated with recurrent pericardial effusion. Due to the rise in COVID-19 cases, it is essential to consider pericardial effusion as a rare but potential complication of this virus. The pericardial effusion can be the primary clinical manifestation, recurrent in nature, and potentially result in tamponade physiology.

Tension pneumomediastinum and diffuse subcutaneous emphysema with severe acute respiratory syndrome coronavirus 2 infection requiring operative management for impending airway collapse: A case report

Tension pneumomediastinum is a rare complication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection that has increased in incidence with the novel coronavirus disease 2019 pandemic. Although traditionally managed with conservative measures, we present the indications and methods for the first operative management of tension pneumomediastinum with concomitant SARS-CoV-2 infection.

Supravalvular pulmonary stenosis 9 years after surgically created pleuro-pericardial window

Supravalvular pulmonary stenosis acquired as a postoperative cardiac procedure complication is relatively common. However, that occurring after a surgically created pleuro-pericardial window has not been described until now, to the best of our knowledge. We present a case of acquired supravalvular pulmonary stenosis that developed 9 years after the pleuro-pericardial window creation for pyopericardium due to a constricting pericardial band. The child underwent successful surgical relief of the stenosis along with repair of the atrial and ventricular septal defects.

Selective use of pericardial window and drainage as sole treatment for hemopericardium from penetrating chest trauma

Background

Penetrating cardiac injuries (PCIs) are highly lethal, and a sternotomy is considered mandatory for suspected PCI. Recent literature suggests pericardial window (PCW) may be sufficient for superficial cardiac injuries to drain hemopericardium and assess for continued bleeding and instability. This study objective is to review patients with PCI managed with sternotomy and PCW and compare outcomes.

Methods

All patients with penetrating chest trauma from 2000 to 2016 requiring PCW or sternotomy were reviewed. Data were collected for patients who had PCW for hemopericardium managed with only pericardial drain, or underwent sternotomy for cardiac injuries grade 1-3 according to the American Association for the Surgery of Trauma (AAST) Cardiac Organ Injury Scale (OIS). The PCW+drain group was compared with the Sternotomy group using Fisher's exact and Wilcoxon rank-sum test with P<0.05 considered statistically significant.

Results

Sternotomy was performed in 57 patients for suspected PCI, including 7 with AAST OIS grade 1-3 injuries (Sternotomy group). Four patients had pericardial injuries, three had partial thickness cardiac injuries, two of which were suture-repaired. Average blood drained was 285 mL (100-500 mL). PCW was performed in 37 patients, and 21 had hemopericardium; 16 patients proceeded to sternotomy and 5 were treated with pericardial drainage (PCW+drain group). All PCW+drain patients had suction evacuation of hemopericardium, pericardial lavage, and verified bleeding cessation, followed by pericardial drain placement and admission to intensive care unit (ICU). Average blood drained was 240 mL (40-600 mL), and pericardial drains were removed on postoperative day 3.6 (2-5). There was no significant difference in demographics, injury mechanism, Revised Trauma Score exploratory laparotomies, hospital or ICU length of stay, or ventilator days. No in-hospital mortality occurred in either group.

Conclusions

Hemodynamically stable patients with penetrating chest trauma and hemopericardium may be safely managed with PCW, lavage and drainage with documented cessation of bleeding, and postoperative ICU monitoring.

Level of evidence

Therapeutic study, level IV.

Pneumopericardium Leading to Cardiac Tamponade in a Patient with Lung Cancer

Pneumopericardium resulting in cardiac tamponade in patients with lung cancer is not documented. We report a case of squamous cell carcinoma of the lung complicated by pneumopericardium and subsequent cardiac tamponade. The patient underwent an urgent pericardial window with rapid improvement in symptoms. We discuss the possible pathogenesis and treatment options for this rare condition.

Paradoxical Hemodynamic Instability After Pericardial Window

Paradoxical hemodynamic instability (PHI), also called postoperative low cardiac output syndrome (LCOS), is a rare but fatal complication after drainage of a pericardial effusion (PEf). This condition usually develops within hours postprocedure and appears unrelated to the method of drainage. The exact mechanism of this condition is not well understood. We present a case of an 84-year-old patient with no previous cardiac or cancer history who presented with acute shortness of breath (SOB). Computed tomography (CT) ruled out pulmonary embolism and echocardiography confirmed early tamponade. Following emergent subxiphoid pericardiectomy, the patient developed hemodynamic instability and shock and subsequent multiorgan failure. Repeat echocardiography revealed left ventricular (LV) hypercontractility and new right ventricular (RV) dilatation with akinesis. The patient's condition continued to deteriorate in spite of maximal doses of pressors. The patient died after the family's request to discontinue further extraordinary measures.