Resuscitative transesophageal echocardiography in emergency departments in the United States and Canada: A cross-sectional survey

INTRODUCTION

Over the past two decades, transesophageal echocardiography (TEE) has been used with increasing frequency to evaluate critically ill patients outside of traditional settings. The purpose of this study was to characterize the number of programs, users, practice characteristics, training and competency requirements and barriers for the current use of resuscitative transesophageal echocardiography (TEE) in Emergency Departments (EDs) in the United States and Canada.

METHODS

A closed internet-based, cross-sectional, point-prevalence survey was administered via email to 120 program directors of emergency ultrasound fellowships (EUSF) and 43 physicians from EDs without EUSF from the United States and Canada.

RESULTS

Ninety-eight percent of surveyed participants responded. Twenty percent of respondents reported having active resuscitative TEE programs. The majority of participating hospitals (70%) were academic centers with residency programs. A total of 33 programs reported using resuscitative TEE in their ED and of those, 82% were programs with EUSF. Most programs performing TEE (79%) had less than five attending physicians performing TEE. Evaluation of patients during resuscitation from cardiac arrest (100%) and post-arrest care (76%) are the two most frequent indications for TEE in the ED. The most common core elements of resuscitative TEE protocols used are: assessment of left ventricular (LV) systolic function (97%), assessment of right ventricular (RV) function (88%), evaluation of pericardial effusion / tamponade (52%). All programs reported using formal didactics in their training programs, 94% reported using high-fidelity simulation, and 79% live scanning of patients. Financial concerns were the most common barrier use of TEE in the ED (58%), followed by maintenance of equipment (30%), and credentialing/privileges (30%).

CONCLUSIONS

This study provides a snapshot of the practice of resuscitative TEE in EDs in the United States and Canada revealing the existence of 33 programs using this emerging modality in the care of critically ill patients.

A Propensity-Matched National Analysis of Transcatheter Aortic Valve Implantation Outcome in Patients With Gastrointestinal Bleeding

Gastrointestinal (GI) bleeding is often observed in severe aortic stenosis, which can be attributed to the presence of arteriovenous malformations and von Willebrand's factor deficiency. GI is one of the most common complications in patients who underwent transcatheter aortic valve implantation (TAVI). The outcome of the TAVI procedure with GI bleeding is unknown. We performed an International Classification of Diseases, Tenth Revision-based national cohort analysis using the national readmission database from 2016 to 2020. We compared cardiovascular outcomes, mortality, and readmission rates of patients with TAVI who developed GI bleeding compared with those who had no GI bleeding. A total of 320,353 hospitalizations with TAVI were identified from the year 2016 to 2020. Patients with TAVI with GI bleeding were 6,193.37 and without GI bleeding were 314,160. The median age of the patients with TAVI with GI or without GI bleeding was 80. GI bleed patients had statistically significantly higher readmission rates at 30, 90, and 180 days and they had higher odds of in-hospital mortality (adjusted odds ratio [aOR] = 6.35; 95% confidence interval [CI]: 5.37 to 7.52; p <0.0001), acute kidney injury (aOR = 5.22; 95% CI:4.75 to 5.74; p <0.0001), stroke (aOR = 2.83; 95% CI 2.05 to 3.91 p:0.0001, postprocedural bleeding (aOR: 1.76; 95% CI: 1.35 to 2.30; p:0.0001), cardiac tamponade (aOR = 2.54; 95% CI 1.86 to 3.49; p <0.0001), use of mechanical circulatory support (aOR: 5.33; 95% CI:4.13 to 6.86; p <0.0001), and heart failure (aOR:1.73; 95%CI: 1.54 to 1.94; p <0.0001). The total cost of hospitalization and length of stay was higher in the GI bleed group. Patients with TAVI with GI bleeding have worse clinical outcomes and higher in-hospital mortality and readmission rates compared with patients with no GI bleeding.

Pericardial effusion and systemic capillary leak syndrome late post-SARS-CoV-2 vaccination

We report an interesting case of pericardial effusion associated with idiopathic systemic capillary leak syndrome (ISCLS) following administration of SARS-CoV-2 vaccine. This patient initially presented with dyspnoea and chest pain, with non-pitting oedema and clear lung fields. The diagnosis of ISCLS was made based on the clinical syndrome and laboratory evidence of polycythaemia and hypoalbuminaemia. An enlarging pericardial effusion was diagnosed on transthoracic echocardiogram. Daily point-of-care ultrasound (POCUS)-guided volume management and serial transthoracic echocardiograms contributed to avoidance of refractory shock, cardiac tamponade and critical care admission.

Pericardial Windows: The Limited Diagnostic Value of Non-Targeted Pericardial Biopsy

BACKGROUND

Pericardial window, in addition to promoting pericardial drainage, can also provide samples of the pericardium for anatomopathological examination. However, such biopsies' contribution to clarifying the etiology of pericardial effusion has been debated.

OBJECTIVE

To analyze the diagnostic value of non-targeted pericardial biopsy obtained from pericardial window procedures.

METHODS

Data from 80 patients who had undergone parietal pericardial biopsies from 2011 to 2020 were retrospectively reviewed. Statistical significance was considered if p < 0.05.

RESULTS

Fifty patients were male (62.5%,) and 30 were female (37.5%). The median age was 52 years (interquartile range: 29 to 59) and 49 years (interquartile range: 38 to 65), respectively (p = 0.724). The suspected etiology of pericardial effusion was neoplastic in 31.3%, unclear in 25%, tuberculosis in 15%, autoimmune in 12.5%, edemagenic syndrome in 7.5%, and other miscellaneous conditions in 8.8%. The most frequent approach for pericardial drainage and biopsy was subxiphoid (74%), followed by video-assisted thoracoscopy (22%). Overall, in 78.8% of the biopsies, the histopathologic findings were compatible with nonspecific inflammation, and only 13.7% of all biopsies yielded a conclusive histopathological diagnostic. Those suffering from cancer and pericardial effusion had a higher proportion of conclusive histopathologic findings (32% had pericardial neoplastic infiltration). The hospital mortality rate was 27.5%, and 54.5% of the patients who died in the hospital had cancer. No deaths were attributed to cardiac tamponade or the drainage procedure.

CONCLUSION

Our results showed that pericardial window is a safe procedure, but it had little value to clarify the pericardial effusion etiology and no impact on the planned therapy for the primary diagnosis besides the cardiac decompression.

Successful palliative resection of giant epimyocardial lymphatic malformation with 14 years of follow-up: a case report

BACKGROUND

Primary tumors of the heart are a rare phenomenon. Lymphatic malformations are congenital anomalies of the lymphatic system that tend to grow progressively. Lymphatic malformations are typically found in the cervical and axillary regions and found on pediatric patients. We report a 40-year-old woman with giant epimyocardial lymphatic malformation.

CASE PRESENTATION

A 40-year-old woman was assessed due to suspected traumatic cardiac tamponade. Computed tomography of the heart and cardiac magnetic resonance imaging were compatible with either a large pericardial hemangioma or angiosarcoma. The tumor infiltrated deeply into the myocardium and could only be partially resected. Histopathological diagnosis was a cardiac lymphatic malformation with micro- and macrocystic components. The patient has remained asymptomatic for fourteen years after the surgery. In the latest follow-up, her left ventricular function had remained normal and the maximum thickness of the residual tumor had regressed.

CONCLUSIONS

Even when a complete removal of a cardiac lymphatic malformation is not possible, a debulking procedure can yield a good long-term result.

Evaluation of Time to Onset and Outcome of Cardiac Adverse Events Associated with Nilotinib using Post-Marketing Surveillance

INTRODUCTION

Cardiac adverse events (CAEs) have become a concern as serious adverse events (AEs) of nilotinib administration. No reports have described the incidence of CAEs associated with nilotinib in Japanese patients. Thus, we conducted this study to evaluate the risk of nilotinib-induced CAEs, time to onset, incidence rates, and post hoc outcomes using the Japanese Adverse Drug Event Report database.

METHODS

We analysed data for the period between April 2004 and March 2022. Data on CAEs were extracted, and relative risk of AEs was estimated using the reporting odds ratio.

RESULTS

We analysed 2,021,907 reports and identified 3,545 reports of AEs caused by nilotinib. Of these, 511 reports involved CAEs. Signals were detected for 19 CAEs. Of these, electrocardiogram QT prolonged was the most frequently reported (30.9%). Fatal outcomes were observed in eight AEs: cardiac failure, atrial fibrillation, acute myocardial infarction, pericardial effusion, myocardial infarction, cardiac arrest, pericarditis, and cardiac tamponade. Of these, acute myocardial infarction, myocardial infarction, pericarditis, and cardiac tamponade exhibited mortality rates >10%. A histogram of median times to onset showed nilotinib-associated AEs occurring 3-485 days after nilotinib administration.

CONCLUSION

We focused on CAEs caused by nilotinib as post-marketing AEs. Some cases resulted in serious outcomes. Patients should be monitored for signs of onset of these AEs not only at the start of administration but for a long period of time.

Pericardial Diseases in Pregnancy

Pericardial effusion is the most common manifestation of pericardial diseases during pregnancy. This effusion is benign, mild, or moderate, well tolerated, with spontaneous resolution after delivery; no specific treatment is required. Acute pericarditis is the second most common condition, usually requiring medical therapy during pregnancy. Cardiac tamponade and constrictive pericarditis are rare in pregnancy. Pre-pregnancy counselling is essential in women of childbearing age with recurrent pericarditis to plan pregnancy in a phase of disease quiescence and to review therapy. High-dose aspirin or nonselective nonsteroidal anti-inflammatory drugs, such as ibuprofen and indomethacin, can be used up to the 20th week of gestation. Low-dose prednisone (2.5-10 mg/d) can be administered throughout pregnancy. All of these medications, apart from high-dose aspirin, may be used during lactation. Colchicine is compatible with pregnancy and breastfeeding, and it can be continued throughout pregnancy to prevent recurrences. Appropriate follow-up with a multidisciplinary team with experience in the field is recommended throughout pregnancy to ensure good maternal and fetal outcomes.

Cardiac Tamponade as a Recurrence of Angioimmunoblastic T-Cell Lymphoma with the Detection of a p.Gly17Val RHOA Mutation in the Pericardial Effusion

Angioimmunoblastic T-cell lymphoma (AITL) is an intractable type of T-cell lymphoma. We and others have identified that the p.Gly17Val RHOA mutation is specifically identified in AITL. We herein report a patient whose condition deteriorated, resulting from massive pericardial effusion one month after undergoing autologous transplantation for AITL. He was diagnosed with cardiac tamponade caused by AITL recurrence in the presence of the p.Gly17Val RHOA mutation as well as T-lineage cells with an aberrant immune-phenotype in the pericardial effusion. This case suggests that a precision medicine approach by detecting the presence of a p.Gly17Val RHOA mutation is useful for the management of AITL.

Using computed tomography to evaluate proper chest compression depth for cardiopulmonary resuscitation in Thai population: A retrospective cross-sectional study

INTRODUCTION

The effectiveness of cardiopulmonary resuscitation is determined by appropriate chest compression depth and rate. The American Heart Association recommended CC depth at 5-6 cm to indicate proper cardiac output during cardiac arrest. However, many studies showed the differences in the body builds between Caucasians and Asians. Therefore, this study aimed to determine heart compression fraction (HCF) in the Thai population by using contrast-enhanced computed tomography (CT) scan of the chest and a mathematical model.

MATERIALS AND METHODS

Consecutive contrast-enhanced CT scans of the chest performed at Ramathibodi Hospital were retrospectively reviewed from January to March 2018 by two independent radiologists. Patients' characteristics, including gender, age, weight, height, and pre-existing diseases, were recorded, and the chest parameters were measured from a CT scan. The heart compression fraction (HCF) was subsequently calculated.

RESULTS

Of 306 subjects, there were 139 (45.4%) males, 148 (47.4%) lung diseases and 10 (3.3%) heart diseases. Mean age and BMI were 60.4 years old and 23.8 kg/m2, respectively. Chest diameter, heart diameter, and non-cardiac soft tissue were significantly smaller in females compared to males. Mean (SD) HCF proportional with 50 mm and 60 mm depth were 38.3% (13.3%) and 50% (14.3%), respectively. There were significant differences of HCF proportional by 50 mm and 60 mm depth between men and women (33.2% vs 42.6% and 44% vs 54.9%, respectively (P<0.001)). In addition, a decrease in HCF was significantly observed among higher BMI groups.

CONCLUSION

The CT scan and mathematical model showed that 38% and 50% HCF proportions were generated by 50 mm and 60 mm CC depth. HCF proportions were significantly different between genders and among BMI groups. The recommended depth of 5-6 cm is likely to provide sufficient CC depth in the population of Thailand.

OUP accepted manuscript

Blunt chest trauma following a motor vehicle accident is the leading cause of non-penetrating cardiac injuries. Major structural heart injuries are fatal due to acute tamponade. We present the case of a 17-year-old male who was involved in a motor vehicle accident. He had an isolated coronary sinus rupture, which was successfully repaired. We propose a potential mechanism implicated in this rare injury, and we summarize a novel repair technique with adenosine-induced transient asystole.

Prevalence and prognosis of pericardial effusion in patients affected by pectus excavatum: A case-control study

BACKGROUND

The presence of pectus excavatum(PEX) has been occasionally associated with pericardial effusion. Aim of the present study was to compare incidence and prognosis of pericardial effusion in a group of unselected patients with PEX vs a control group.

METHODS

From a prospective registry of consecutive patients who underwent chest CT for cardiovascular disease, subjects with a radiological diagnosis of PEX were retrospectively identified (cases); from the same registry patients (controls) without rib cage abnormalities were randomly selected, until a 1:2 ratio was reached. The presence of pericardial effusion at CT was quantified. Follow-up was obtained for a composite end-point: cardiac tamponade, need for pericardiocentesis, need for cardiac surgery for relapsing pericardial effusion.

RESULTS

A total of 43 patients with PEX (20 females) and a control group of 86 cases (31 females) without rib cage abnormalities were identified. Pericardial effusion evaluated at CT was significatively more prevalent in patients with PEX vs control group, 37.2% vs 13.9% (p < 0.001), respectively; four patients with PEX (9.3%) had at least moderate pericardial effusion vs no subjects among the controls (p = 0.004). PEX diagnosis was significantly associated to pericardial effusion at multi-variate analysis (OR95%CI 10.91[3.47-34.29], p < 0.001). At a mean follow-up of 6.5 ± 3.4 years no pericardial events were recorded.

CONCLUSION

Our findings support the higher prevalence of pericardial effusion in patients with PEX when compared to a control group. The absence of adverse pericardial events at follow-up suggest the good prognosis of these effusions, that in the appropriate clinical setting might not be considered "idiopathic".

Percutaneous pericardiocentesis for pericardial effusion: predictors of mortality and outcomes

Pericardial effusion can dangerously precipitate patient's hemodynamic stability and requires prompt intervention in case of tamponade. We investigated potential predictors of in-hospital mortality, a composite outcome of in-hospital mortality, pericardiocentesis-related complications, and the need for emergency cardiac surgery and all-cause mortality in patients undergoing percutaneous pericardiocentesis. This is an observational, retrospective, single-center study on patients undergoing percutaneous pericardiocentesis (2010-2019). We enrolled 81 consecutive patients. Median age was 71.4 years (interquartile range [IQR] 58.1-78.1 years) and 51 (63%) were male. Most of the pericardiocentesis were performed in an urgency setting (76.5%) for cardiac tamponade (77.8%). The most common etiology was idiopathic (33.3%) followed by neoplastic (22.2%). In-hospital mortality was 14.8% while mortality during follow-up (mean 17.1 months) was 44.4%. Only hemodynamic instability (i.e., cardiogenic shock, hypotension refractory to fluid challenge therapy and inotropes) was associated with in-hospital mortality at the univariate analysis (odds ratio [OR] 7.2; 95% confidence interval [CI] 1.76-29.4). Non-neoplastic/non-idiopathic etiology and hemodynamic instability were associated with the composite outcome of in-hospital mortality, need for emergency cardiac surgery, or pericardiocentesis-related complications (OR 5.75, 95% CI 1.65-20.01, and OR 5.81, 95% CI 2.11-15.97, respectively). Multivariate Cox regression analysis adjusted for possible confounding variables (age, coronary artery disease, and hemodynamic instability) showed that neoplastic etiology was independently associated with medium-term mortality (hazard ratio [HR] 4.05, 95% CI 1.45-11.36). In a real-world population treated with pericardiocentesis for pericardial effusion, in-hospital adverse outcomes and medium-term mortality are consistent, in particular for patients presenting with hemodynamic instability or neoplastic pericardial effusion.

Difficulty Diagnosing Retrograde Type A Aortic Dissection with Intramural Hematoma and Risk of Re-dissection and Rupture: A Report of Two Cases

Acute type A aortic dissection is a potentially fatal disease, and emergency surgery should be considered when it is diagnosed. We herein report two cases of retrograde type A aortic dissection with intramural hematoma, followed by re-dissection, rupture, and cardiac tamponade. The diagnoses in these cases had to be made carefully, as the false lumen of the ascending aorta was sometimes unclear on contrast-enhanced computed tomography.

Fulminant methicillin-sensitive Staphylococcus aureus infection: from pinprick to multiorgan failure

A woman in her 60s with diabetes presented to our institution with altered mental status. Preceding symptoms included headaches, nausea and vomiting. One month prior to presentation, she cut her left thumb and developed a pustule, which she occasionally manipulated with a non-sterile needle. On arrival, the patient was in shock, with a Glasgow Coma Scale of 3, requiring emergent intubation and intensive care unit admission. Her initial imaging studies revealed a large pericardial effusion and cerebral subcortical hypodensities. She suffered from a cardiopulmonary arrest with return of spontaneous circulation, with bedside echocardiogram revealing cardiac tamponade. She underwent emergent pericardiocentesis which revealed purulent drainage. Blood, pericardial fluid, cerebrospinal fluid, sputum and urine cultures returned positive for methicillin-sensitive Staphylococcus aureus The hospital course was further complicated by refractory septic shock and fulminant multiorgan failure, ultimately leading to her demise.

Impact of proton pump inhibitors on mortality and severe esophageal injury after catheter ablation for atrial fibrillation: a nationwide retrospective study using propensity score matching

Studies on the protective effects of proton pump inhibitors (PPIs) on mortality and severe esophageal injury after catheter ablation for atrial fibrillation are lacking. However, some reports have recommended use of PPIs for prophylaxis against esophageal injury. We investigated the effects of PPIs on mortality and severe esophageal injury after ablation. We retrospectively extracted data for adult in-patients who received catheter ablation with a diagnosis of atrial fibrillation from July 2010 to March 2018. The patients were divided into two groups: with PPI (PPI group) and without PPI (non-PPI group) administration before or on the day of ablation. The primary composite outcome was all-cause 30-day mortality and incidence of severe esophageal injury with complication (cardiac tamponade, ischemic stroke, or sepsis) within 30 days of ablation. Secondary outcomes included incidence of cardiac tamponade, ischemic stroke, and sepsis within 30 days of ablation. Propensity score matching was performed to compare the primary and secondary outcomes between the two groups. We identified 141,649 eligible patients, comprising 62,558 in the PPI group and 79,091 in the non-PPI group. Propensity score-matching analysis showed that PPI use was not associated with reduced proportion of the primary outcome (adjusted odds ratio 1.02; 95% confidence interval 0.71-1.47). PPI use may not be beneficial for reducing mortality or severe complications.

Immediate Postoperative Results in the Surgical Treatment of Neoplastic Pericarditis - 76 Consecutive Cases

Introduction: Pericardial effusion, accumulation of fluid in the pericardial sac, may develop in any type of cancer. It was revealed in up to 20% of oncological patients. Method: We made a retrospective study of patients with pericardial efusion presented in our clinic between 2010 and 2015. We included 76 consecutive patients with indication for peri cardial drainage - we performed on them 80 surgical procedures: pericardocentesis, subxiphoid pericardial window, left paraxifoidian pericardial window, intercostal video-assisted thoracic surgery (VATS) pericardial fenestration, and classical thoracic surgery (fenestration or partial pericardiectomy). We had patients with ages between 28 and 83 years. 23 patients were admitted with cardiac tamponade. The immediate postoperatory survival is 97.3 % and the 30-days-postoperatory survival is 81.5 %. Results: The immediate postoperatory mortality is 2.7% and the 30-days-postoperatory mortality is 8.5%. Conclusions: The immediate prognosis of the patient with malignant pericardial effusion is influenced by the risk of postoperative Low-Cardiac-Output-Syndrome (LCOS), or pericardial decompression syndrome (PDS), which remains the main cause of mortality. The long-term prognosis is related to the type of malignant tumor. The most effective tehnique with the lowest rate of recurrence is pericardo-pleural window done thoracoscopically/ by VATS; pericardocentesis has the highest rate of recurrence - 90% and is associated with high rates of cardiac complications and mortality.

[Cardiac Tamponade by Chest Compression at Cardiopulmonary Resuscitation;Report of a Case]

We report a case of right ventricular rupture caused by sternal bone fracture following chest compression at cardiopulmonary resuscitation (CPR). A 68-year-old man presented with syncope and was referred to our hospital in an ambulance. Ventricular fibrillation was confirmed by electrocardiography(ECG), and CPR was performed with chest compression. He was resuscitated and his ECG showed ST elevation. He immediately underwent percutaneous coronary intervention to the right coronary #1 which was subtotally occluded. Thereafter, massive cardiac tamponade was noted by echocardiography, and coronary injury or left ventricle( LV) rupture was suspected. Emergency exploratory surgery was performed through median sternotomy. Laceration of the right ventricle corresponding to the sternal bone fracture was found intraoperatively. We repaired the injury and he was discharged without complication. The possibility of iatrogenic cardiac tamponade should be considered when a resuscitated patient by chest compression develops hypotension.

Acute primary purulent pericarditis in an adult patient with unknown X-linked agammaglobulinemia

X-linked agammaglobulinemia (XLA) is a rare form of inherited immunodeficiency due to an impairment in B-lymphocyte differentiation and maturation. In the majority of cases XLA is diagnosed in childhood, particularly among males affected by recurrent infections and with a family history of immunodeficiency. Infections of respiratory tract, gastrointestinal apparatus, eyes, nose and ears are frequent in XLA patients; on the contrary, infections of myocardium, cardiac valves and pericardium are rarely described in XLA. A 34-year-old man with unknown XLA was hospitalized because of syncope, due to pericardial tamponade, caused by acute primary purulent pericarditis. Immediate pericardiocentesis was effective in improving hemodynamics, and empiric antibiotic therapy was successful in controlling the infection. Purulent pericarditis is a rare disease with high mortality rate: it is usually caused by hematogenous bacterial propagation, direct infection of pericardial space by chest wounds or thoracic surgery, or extension of infection from adjacent tissues. However, this patient had no recent local or systemic infections. Because of unusual clinical picture during hospitalization he underwent further clinical and laboratory evaluations, that showed low immunoglobulin levels. After exclusion of acquired immunodeficiency, genetic tests were performed: they detected deletion of exons 8-9-10 of Bruton Tyrosine Kinase gene on X chromosome, leading to the diagnosis of XLA. Acute purulent primary pericarditis may also occur in adult XLA patients as first clinical manifestation. According to this case report, a primary immunodeficiency syndrome should be considered in patients with atypical cardiac infections and no predisposing conditions, regardless of age.

[Pericardiocentesis and Pericardial Drainage]

Peicardiocentesis and surgical pericardial drainage are essential treatment and diagnostic modality for pericardial effusion. Though it theoretically is a simple therapeutic method, accurate diagnosis, correct decision, and safe procedure are not always easy. Thoracic and cardiovascular surgeons are required to have high level of expertise in pericardial drainage as surgeons who specialize this anatomical part of the body. The presence of pericardial effusion does not always require drainage. Accurate diagnosis is essential to determine correct indication. Echocardiography and computed tomography are useful tools for accurate diagnosis. The percutaneous drainage has become much safer in these 2 decades with the aid of imaging technology, especially echocardiography and fluoroscopy. Surgical pericardial window still has its role and is considered one of the standard treatment methods with minimal chance to require repeat procedure compared to percutaneous drainage.

[Iatrogenic clinically cardiac arrest after administration of nitroglycerin]

This case report highlights the importance of preload in cardiac tamponade, as cardiac arrest with pulseless electrical activity was unintentionally induced after sublingual administration of nitroglycerin in an 83-year-old woman with unrecognised haemopericardium. Cardiac tamponade is a life-threatening condition, as accumulation of fluids in the pericardial sac diminishes preload which can ultimately lead to cardiac arrest. Primary elements in the development of critical haemodynamic tamponade are rate of fluid-accumulation and compensatory mechanisms, mainly tachycardia and vasoconstriction.

Acute and recurrent pericarditis

Pericardial diseases have been until recently relatively neglected entity; however, there has been a markedly increased interest in these disorders in the last decade due to new diagnostic as well as therapeutic options. Various clinical manifestations of pericardial diseases may be generally grouped into pericardial syndromes including pericarditis, pericardial effusion, cardiac tamponade and constrictive pericarditis. In this review, the comprehensive analysis of acute and recurrent pericarditis is presented. Acute and recurrent pericarditis represent the most common pericardial disorders in clinical practice, in which major changes in therapeutic procedures occurred based on recently published trials, particularly the introduction of colchicine therapy.

Cardiac and Vascular Injuries Sustained During Transvenous Lead Extraction

The rise in indications for cardiac implantable electronic devices has necessitated the development of tools for removal of the electrodes that connect the heart to these externally located pacemakers and defibrillators. After implant of a cardiac electrode, variable but progressive fibrous adhesion occurs. Removal of these adhesions can cause devastating complications with high risk of mortality if not treated surgically in a highly expeditious and appropriate manner. This article describes the incidence, risk factors, and diagnosis of these injuries followed by discussion of recent evidence for use of superior vena cava balloon occlusion, and conventional surgical repair of these injuries.

Getting to the heart of hypopituitarism

A 53-year-old woman was diagnosed with hypopituitarism following an acute presentation with cardiac tamponade and hyponatraemia, having recently been investigated for a pericardial effusion. Secondary hypothyroidism is a rare cause of pericardial effusion and tamponade, but an important differential to consider. Management requires appropriate hormone replacement and, critically, a low threshold for commencing stress dose steroids. Clinical signs classically associated with cardiac tamponade are frequently absent in cases of tamponade due to primary and secondary hypothyroidism, and the relatively volume deplete state of secondary hypoadrenalism in hypopituitarism may further mask an evolving tamponade, as the rise in right atrial pressure is less marked even in the presence of large effusion. Our case demonstrates the importance of a high index of suspicion for cardiac tamponade in this patient cohort, even in the absence of clinical signs, and for measuring both thyroid-stimulating hormone and thyroxine levels when evaluating a pericardial effusion.

Acute fatal pericardial effusion induced by accidental ingestion of cigarette butts in a dog

A dog was referred for collapse and tachypnea after ingesting cigarette butts. Thoracic radiography and echocardiography indicated pericardial effusion, and an electrocardiogram showed tachycardia, variable QRS complexes, and ventricular premature complexes. This is the first description of fatal pericardial effusion associated with cigarette butt ingestion in a veterinary patient.

Interplay of co-inherited diseases can turn benign syndromes in a deadly combination: haemoglobinopathy and bilirubin transport disorder

We present a case about a 25-year-old male patient suffering from a rare genetic disorder called Mizuho haemoglobin. He was admitted to the Intensive Care Unit with acute liver and renal failure. During admission he also developed a cardiac tamponade twice. Finally he received a liver transplantation. Hereafter the patient stabilised and his liver and renal functions improved. His symptoms could not be explained solely by his known disease. After searching the literature, similarities between his symptoms and a rare complication of sickle cell disease were found. Molecular diagnostics showed that the patient also suffered from Gilbert's syndrome. Due to his chronic haemolysis, symptoms of this other disease were masked. This stresses the importance of always looking for other causes if symptoms or changes cannot be explained by a known rare disorder.

Lesson of the month 1: Pericardial mass and cardiac tamponade associated with Mycoplasma pneumoniae

Mycoplasma pneumoniae primarily causes respiratory tract infections. Extrapulmonary manifestations are seen in 20-25% of cases. Cardiac involvement is rarely reported. We present a unique case of a pericardial mass and cardiac tamponade associated with a Mycoplasma pneumoniae pneumonia. This required emergency pericardial fenestration. The patient improved dramatically postoperatively on antibiotics and there was no recurrence of the pericardial effusion on follow up. This case highlights the often forgotten invasive properties of a common respiratory tract pathogen and emphasises the need to consider this easily treatable entity in the differential diagnosis of idiopathic pericardial effusions.

Percutaneous balloon pericardiotomy in a patient with end stage renal disease with recurrent pericardial effusion & pericardial tamponade

A case report of 37-year-old female with end stage renal disease presented with recurrent pericardial effusion and cardiac tamponade, who underwent percutaneous balloon pericardiotomy using an Inoue balloon dilating catheter, to create a non-surgical pericardial window. The procedure of non-surgical pericardial window is safe and effective alternative to conventional more invasive surgical pericardial window. It is concluded that percutaneous balloon pericardiotomy is helpful in the management of massive pericardial effusions particularly in patients with chronic renal failure and poor clinical condition.

Pericarditis as a presenting sign of infective endocarditis: two case reports and review of the literature

Pericarditis as a presenting sign of infective endocarditis is rare. Here we describe 2 cases and an additional 19 cases of pericarditis as a presenting sign of infective endocarditis reported during the last 40 y. 71% of patients were young males (mean age 43.2 y). The most commonly reported underlying conditions were diabetes mellitus type 2 (5 patients, 24%), and substance or alcohol abuse (4 patients, 19%). The native aortic valve was the most frequently involved valve. The most common symptoms were fever, cough or dyspnoea, and chest pain. Overt tamponade was diagnosed in 47% of the patients. However, pulsus paradoxus and pericardial friction rub were rare. A heart murmur was heard in 12 patients (57%). Staphylococcus aureus was the most commonly isolated pathogen concomitantly from blood and pericardial fluid. 16 patients (76%) were operated. Six underwent a pericardial procedure, 5 underwent valve replacement, 4 both, and 1 patient was operated for pseudoaneurysm. Mortality rates were 60% and 31% of patients treated with antibiotics alone versus antibiotics and surgical intervention, respectively. In patients presenting with pericarditis with or without cardiac tamponade, the possibility of infective endocarditis should be considered. Optimal therapy should consist of antibiotics and surgical intervention.

Indicators of Poor Prognosis of Acute Pericarditis

Background— The clinical search for indicators of poor prognosis of acute pericarditis may be useful for clinical triage of patients at high risk of specific causal conditions or complications. The aim of the present article is to assess the relationship between clinical features at presentation and specific causes or complications.

Methods and Results— A total of 453 patients aged 17 to 90 years (mean age 52±18 years, 245 men) with acute pericarditis (post–myocardial infarction pericarditis was excluded) were prospectively evaluated from January 1996 to August 2004. A specific cause was found in 76 of 453 patients (16.8%): autoimmune in 33 patients (7.3%), neoplastic in 23 patients (5.1%), tuberculous in 17 patients (3.8%), and purulent in 3 patients (0.7%). In multivariable analysis, women (hazard ratio [HR] 1.67, 95% confidence interval [CI] 1.03 to 2.70; P =0.036) and patients with fever >38°C (HR 3.56, 95% CI 1.82 to 6.95; P <0.001), subacute course (HR 3.97, 95% CI 1.66 to 9.50; P =0.002), large effusion or tamponade (HR 2.15, 95% CI 1.09 to 4.23; P =0.026), and failure of aspirin or of nonsteroidal anti-inflammatory drugs (HR 2.50, 95% CI 1.28 to 4.91; P =0.008) were at increased risk of specific causal conditions. After a mean follow-up of 31 months, complications were detected in 95 patients (21.0%): recurrences in 83 patients (18.3%), tamponade in 14 patients (3.1%), and constriction in 7 patients (1.5%). In multivariable analysis, women (HR 1.65, 95% CI 1.08 to 2.52; P =0.020) and patients with large effusion or tamponade (HR 2.51, 95% CI 1.37 to 4.61; P =0.003) and failure of aspirin or of nonsteroidal anti-inflammatory drugs (HR 5.50, 95% CI 3.56 to 8.51; P <0.001) were at increased risk of complications.

Conclusions— Specific clinical features (fever >38°C, subacute course, large effusion or tamponade, and aspirin or NSAID failure) may be useful to identify higher risk of specific causal conditions and complications.

Incidence and significance of upper body cyanosis in nontraumatic cardiac arrest

OBJECTIVE

Upper body cyanosis is a physical finding sometimes noted at the time of cardiac resuscitation. We attempted to determine the incidence and significance of upper body cyanosis in cases of nontraumatic cardiac arrest.

METHODS

This was a retrospective case-control study. We reviewed all nontraumatic cardiac arrests evaluated by King County, Washington emergency medical system (EMS) personnel during 2000-2004 and identified patients with upper body or nipple-line cyanosis. Those patients who were autopsied comprised the cases for our study. Cases were age and sex matched with controls who also had cardiac arrest with an autopsy but no mention of cyanosis.

RESULTS

EMS personnel treated 3,526 patients, age 18 and older, for nontraumatic out-of-hospital cardiac arrest. One hundred eight (3.1%) had specific mention of upper chest or nipple-line cyanosis, of whom 38 had autopsy. Among the 38 autopsy cases, 6 were died of hemopericardium compared to none in age-and sex-matched controls.

CONCLUSION

Cardiac arrest with upper chest or nipple-line cyanosis had a higher incidence of hemopericardium or dissecting thoracic aortic aneurysm than patients without mention of cyanosis.

Heart embolization with the Kirschner wire without cardiac tamponade

The case of the heart embolization with the Kirschner wire that was used for shoulder trauma fixation, 2 years previously in a 67-year-old female, is reported. This case is unique; although embolization of foreign bodies to the heart is not a novel occurrence, heart embolization with non-broken Kirschner wire with a total length of 13.5 cm without cardiac tamponade was not described in medical literature so far.

[Diagnosis and management of acute pericardial syndromes]

Essentially, acute pericardial syndromes include acute pericarditis and cardiac tamponade. This article focuses on the diagnosis and management of acute pericarditis. In Spain, most cases of acute pericarditis whose etiology is not apparent at initial clinical presentation are either idiopathic or viral pericarditis, which follow a benign or self-limiting clinical course (although tamponade may develop in some patients). Knowledge of this basic epidemiologic fact is essential for the development of a rational management protocol that, on the one hand, avoids the unnecessary use of invasive pericardial diagnostic procedures in patients with idiopathic pericarditis and that, on the other hand, correctly identifies most cases of specific pericarditis, which mainly comprise purulent, tuberculous or neoplastic pericarditis. In accordance with this rationale and on the basis of our own experience, we have proposed a protocol for the management of acute pericardial disease that differs markedly from the "Guidelines on the Diagnosis and Management of Pericardial Disease" recently produced by the European Society of Cardiology. In addition, we have made some comments on the cardiac tamponade and the acute and subacute constrictive pericarditis that can occur during the resolution of acute pericarditis.