[Echocardiography-guided pericardiocentesis with the apical approach]

OBJECTIVES

We aimed to evaluate our experience with echocardiography-guided pericardiocentesis with the apical approach for pericardial effusions.

STUDY DESIGN

We evaluated 32 pericardiocenteses performed under echocardiography guidance and with the apical approach in 29 patients (15 men, 14 women; mean age 49 years; range 18 to 72 years). Indications were diagnostic purpose, pericardial tamponade, or symptomatic pericardial effusion. Procedural success, the amount of drainage, and complications were assessed.

RESULTS

Common causes of pericardial effusion were malignancy (n=6), postpericardiotomy syndrome (n=5), idiopathic (n=5), chronic renal disease (n=4), and myocardial infarction (n=3). The amount of drainage was 120 ml to 2,200 ml and the duration of pericardial catheter placement in the pericardial space was 24 to 144 hours. Mortality did not occur. Echocardiographic control showed residual effusion in the lateral wall in one case, which required repositioning of the pericardial catheter for complete removal. The procedure failed in one patient due to insufficient drainage caused by multiple septations and fibrinous fluid in the pericardial space. The success rate of the procedures was 96.9%. Four cases developed hemopneumothorax requiring tube drainage, vasovagal reaction, nonsustained ventricular tachycardia, and frequent ventricular extrasystoles, respectively. Apical puncture was repeated in two cases due to erroneous left ventricular puncture and pleural catheter placement, respectively.

CONCLUSION

Echocardiography-guided pericardiocentesis with the apical approach is readily performed bedside without the need for catheterization laboratory, with a high success rate and low complication rate. It should be considered especially in cases in which anterior pericardial collection is more prominent where it will reduce unnecessary surgical interventions.

The postcardiac injury syndrome: case report and review of the literature

The postcardiac injury syndrome (PCIS) includes the postmyocardial infarction syndrome, the postcommissurotomy syndrome, and the postpericardiotomy syndrome. Dressler reported a series of patients who developed a pericarditis-like illness days to weeks after a myocardial infarction. Postcardiac injury syndrome also has been observed after cardiac surgery, percutaneous intervention, pacemaker implantation, and radiofrequency ablation. Postcardiac injury syndrome is characterized by pleuritic chest pain, low-grade fever, an abnormal chest x-ray, and the presence of exudative pericardial and/or pleural effusions. The pathophysiology of PCIS involves auto-antibodies that target antigens exposed after damage to cardiac tissue. The treatment of PCIS includes the use of nonsteroidal anti-inflammatory drugs and corticosteroids. Prophylactic use of corticosteroids before cardiac surgery has not been effective in preventing PCIS. The widespread use of reperfusion therapy and cardiac medications with anti-inflammatory properties may have reduced the incidence of PCIS. Although PCIS can follow a relapsing course, it does carry a favorable prognosis.

Intermediate follow-up of right ventricular outflow tract reconstruction with allograft conduits

BACKGROUND

Allograft conduits are among many varieties of material used for right ventricular outflow tract reconstruction. They invariably need to be replaced due to growth of the patient or conduit failure.

METHODS

From June 1984 to June 1996, a total of 76 patients underwent reconstruction of the right ventricular outflow tract with an allograft conduit: 51 aortic and 25 pulmonary. The median age, weight and conduit size at surgery were 37 months (range, 0.2 to 228 months), 12.4 kg (range, 2.9 to 61.4 kg), and 17 mm (range, 8 to 26 mm), respectively.

RESULTS

The hospital mortality was 5.3% (4 of 76 patients) and 2 patients died at 9 and 78 months follow-up. The median follow-up was 61 months (range, 2 to 132 months). Reoperation was necessary in 22 patients (28.9%) at a median interval of 50.5 months (range, 3 to 109 months) and the median conduit size was 21 mm (range, 12 to 23 months). There was no mortality. Freedom from reoperation at 64 months was 49.5% for conduits 15 mm and smaller, and 73.3% for conduits 16 mm and larger. Analysis by age shows freedom from reoperation at 64 months of 49.4% and 74.5% for patients younger than and older than 2 years, respectively. At 54 months there was no statistical difference in freedom from reoperation between pulmonary and aortic allografts.

CONCLUSION

Right ventricular outflow tract reconstruction with allograft conduits results in a high reoperation rate at 4 years but provides significantly longer freedom from reoperation with conduits larger than 15 mm or in patients over 24 months of age.

[Contribution of planar scintigraphy and SPECT with Ga-67 in the diagnosis of infectious complications after median sternotomy]

The prognosis of infections complications after median sternotomy depends of precocious diagnoses and depth extension of infection. We wanted to analyze the use of 67Ga scintigraphy in this pathology, comparing planar studies an SPECT. We studied 22 patients with suspect of infection complication after median sternotomy, the final diagnoses were 5 mediastinitis, 10 osteomyelitis and 7 patients with other pathology. 67Ga scintigraphy diagnosed correctly the 5 mediastinitis, 9 of 10 osteomyelitis and descarted both pathology in the other 7 patients. Planar studies only were able to diagnose correctly 3 of 5 mediastinitis and the another 2 were correctly diagnosed by SPECT. 67Ga scintigraphy is useful in the diagnosis of infection complication after median sternotomy and SPECT is better than planar studies in the diagnosis of mediastinitis.

Pericardial color Doppler flow in postpericardiotomy effusive constrictive pericarditis

A laminar color Doppler flow was discovered in the pericardial space in a 35-year-old man with postpericardiotomy effusive constrictive pericarditis. The flow was detected by transesophageal color Doppler echocardiography. A further pulsed Doppler study revealed a to-and-fro flow, which was synchronized with the cardiac rhythm. We hypothesized that this flow was generated by the rhythmic cardiac contraction. It was then augmented by hard fibrous pericardium and became detectable by color Doppler echocardiography. Pericardial effusion is a frequent echocardiographic finding but little attention has been paid to the flow in it. The laminar flow in the pericardial space in our patient is related to his hard pericardium and can aid in making the diagnosis of effusive constrictive pericarditis. We suggest that flow in the pericardial space deserves more attention and may provide valuable diagnostic aid.

Postpericardiotomy and postmyocardial infarction syndrome presenting as noncardiac pulmonary edema

Three cases are reported that describe acute pulmonary edema as an early manifestation of a postpericardiotomy or postmyocardial infarction syndrome. Each of these cases occurred in the presence of good left ventricular function. The cases suggest this syndrome occurs in immunologically primed patients who have had prior cardiac injury resulting in readily available heart antibody. The first report followed an acute myocardial infarction that required a temporary pacemaker, and the two other cases occurred following coronary artery bypass surgery. Two of the patients had a history of distant myocardial or pericardial injury, and the third patient had an acute anteroseptal myocardial infarction two to three weeks before cardiac surgery. All three patients with pulmonary edema responded dramatically to corticosteroids, having been resistant to diuretic and pre-load and afterload reduction therapy, suggesting an autoimmune capillary injury process. Early recognition of such a syndrome is important since all three patients were successfully treated, and might otherwise have been confused with other causes of pulmonary edema.

Prevalence and significance of gallium-67 uptake in the heart after open-heart surgery

Radioactive gallium-67 (Ga-67) has been shown to accumulate within areas of pericardial inflammation. The present study estimated prospectively the prevalence and clinical significance of Ga-67 uptake in the heart in 62 patients 10 to 16 days after open-heart surgery. Of 62 patients studied, markedly diffuse Ga-67 uptake was detected in 21 (34%) and focal or mild diffuse uptake in 23 (37%). Results were negative in 18 (29%). Nine patients with a negative scan result (50%) had received corticosteroid therapy before imaging, whereas only 2 patients with a positive scan result (5%) were receiving steroids. The erythrocyte sedimentation rate and C-reactive protein level were both higher in patients with Ga-67 uptake compared with those with a negative scan result (p less than 0.01 in both). No other clinical, echocardiographic or electrocardiographic indicators of postpericardiotomy syndrome were related to Ga-67 uptake. No patient developed cardiac tamponade or constrictive pericarditis during the 12-week follow-up and the Ga-67 scan results did not predict the occlusion of coronary artery bypass grafts. Thus, pericardial inflammation manifested as Ga-67 uptake is a common finding after open-heart surgery and appears to be a benign condition.

Postpericardiotomy syndrome

Postpericardiotomy syndrome is an immune phenomenon that occurs from several days to months after surgical incision of the pericardium. Prominent clinical features include fever, pericarditis, and pleuritis. Of 161 patients with Wolff-Parkinson-White syndrome who underwent surgical treatment, 50 (31%) developed postpericardiotomy syndrome 4-12 days later. Of these 50 patients, 38 had sufficiently complete records for analysis. Significant radiographic abnormalities were present in 30 (79%) of these 38 patients, pericardial effusions in 19 (50%), pleural effusions in 26 (68%), and pulmonary infiltrates in four (10%). These radiographic signs almost always developed within 2 days of the onset of symptoms, either before or after, and were essentially absent in the 76 patients who did not clinically develop the syndrome. Postoperative radiographs can be extremely valuable in first suggesting or confirming the suspicion of postpericardiotomy syndrome.