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.

Atrial receptors and renal function

The hypothesis that receptors in the heart or pulmonary vasculature initiate a reflex that influences urine flow was derived from experiments designed to evaluate the effect of mechanical ventilation on renal function. These experiments indicated that urine flow usually decreases during positive-pressure breathing and usually increases during negative-pressure breathing. It was surmised that impulses from certain cardiopulmonary receptors affect the secretion of ADH, which in turn influences urine flow. A subsequent investigation appeared to localize the pertinent receptors to the left atrium, but the results of this particular investigation were influenced by several complication factors that have not been widely appreciated. The apparent localization of volume-regulating recpetors to the left atrium and the accumulating evidence that atrial receptors do respond to changes in atrial pressure or atrial volume triggered a myriad of further studies on the function of left receptors. Nearly all these studies employed indirect techniques that produced changes in systemic and pulmonary hemodynamics in addition to changes in left atrial pressure. Nevertheless, it often was assumed that if changes in left pressure were produced, any concomitant changes in circulating ADH or in urine flow were attributable to a reflex elicited from atrial receptors. Mush of the data obtained were interpreted as being compatible with the elft atrial volume-receptor hypothesis, but very liggle of the data pertained to left atrial receptors specifically.

RUPTURE OF THE CORONARY SINUS WITH HEMOPERICARDIUM. A RARE COMPLICATION OF CORONARY ARTERIOVENOUS FISTULA

Sudden death is reported in a previously healthy 52-year-old man resulting from a rare complication of a coronary arteriovenous fistula. It is believed that the primary defect was congenital and that the sequence of events was dilatation and thrombosis of the coronary sinus, necrosis of the sinus wall, perforation, and fatal tamponade.

Penetrating cardiac injuries

Penetrating cardiac injuries pose a tremendous challenge to any trauma surgeon. Time, sound judgment, aggressive intervention, and surgical technique are the most important factors contributing to positive outcomes. This article extensively reviews the history, surgical management, and techniques needed to deal with these critical injuries. This year commemorates the one hundredth anniversary of the first successful repair of a cardiac injury.

Effect of respiration on venous return and stroke volume in cardiac tamponade. Mechanism of pulsus parodoxus

In 40 lightly anesthetized dogs, 5 to 30 days after surgical preparation, flow was measured simultaneously in the venae cavae, pulmonary artery, pulmonary vein, and aorta with ultrasonic flowmeters. Intrapleural and pericardial pressures were measured via silastic cannulas. Pulmonary vein diameter was monitored by miniature mutual inductance coils. In the resting animal with sinus arrhythmia, inspiration increased heart rate and flow in the vena cava, and to a lesser extent, in the pulmonary vein. Left ventricular stroke volume (LVSV) varied directly with the right ventricular stroke volume (RVSV) in dogs with slow heart rates. Cardiac tamponade invariably caused tachycardia and a marked decrease in cardiac output, arterial pressure, pulse pressure, and stroke volume; venous pressure and diameter increased. Pericardial pressure, although markedly elevated, fell with inspiration paralleling the fall in intrapleural pressure. Flow in the pulmonary vein rose or remained constant with inspiration. Pulmonary vein diameter frequently increased with inspiration during tamponade, but only after the pulmonary artery diameter increased with the inspiratory surge. LVSV did not decline sharply with inspiration, and actually increased within 2 beats of the increase in RVSV. The sum of LVSV plus RVSV increased markedly with inspiration, contradicting the concept of fixed intrapericardial volume. Almost all of the changes of pulsus paradoxus reflect the normal respiratory effects on the RVSV, delayed by transit through the pulmonary bed and exaggerated by the small LVSV in a vasoconstricted state.

Transmural Ventricular Pressures in Experimental Cardiac Tamponade

Experimental cardiac tamponade was produced in open-chest dogs. Left and right ventricular systolic pressures fell when intrapericardial pressure was increased only a few millimeters of mercury. Negative diastolic transmural pressures of 1 to 6 mm. Hg developed in the left ventricle and negative diastolic transmural pressures of 2 to 8.5 mm. Hg developed in the right ventricle. In some instances the period of right ventricular systolic ejection was greatly abbreviated at higher levels of intrapericardial pressure.

Cardiac angiosarcoma responding to multidisciplinary treatment

Early detection of cardiac angiosarcoma is usually difficult and the prognosis is very poor. We experienced a 32-year-old man with cardiac angiosarcoma who responded to multidisciplinary treatment with recombinant interleukin-2, postoperative chemotherapy (cyclophosphamide, vincristine, doxorubicin, Dacarbazine) and radiation. At 30 months after surgery, there was no evidence of recurrence or metastasis in spite of incomplete resection.