Causes of moderate to large pericardial effusion requiring pericardiocentesis in 140 Han Chinese patients

Descriptions of Etiology, Clinical Course, and Prognosis of Patients Presenting with Pericardial Effusion

Pericardial effusion (PE) presentation varies from an incidental finding to a life-threatening situation; thus, its etiology and clinical course remain unknown. The aim of the present study was to retrospectively investigate these factors.We analyzed 171 patients (0.4%) who presented with PE among 34,873 patients who underwent echocardiography between 2011 and 2021 at our hospital. Clinical and prognostic information was retrieved from electronic medical records. The primary endpoints were all-cause death, hospitalization due to heart failure (HF), and other cardiovascular events such as cardiovascular death, acute coronary syndrome, elective percutaneous coronary intervention, and stroke.The etiologies of PE were as follows: idiopathic (32%), HF-related (18%), iatrogenic (11%), cardiac surgery-related (10%), radiation therapy-related (9%), malignancy (8%), pericarditis/myocarditis (8%), myocardial infarction-related (2%), and acute aortic dissection (2%). Patients with idiopathic/HF etiology were more likely to be older than the others.During a mean follow-up period of 2.5 years, all-cause death occurred in 21 patients (12.3%), cardiovascular events in 10 patients (5.8%), and hospitalization for HF in 24 patients (14.0%). All-cause death was frequently observed in patients with malignancy (44% per person-year). Cardiovascular events were mostly observed in patients with radiation therapy-related and malignancy (8.6% and 7.3% per person-year, respectively).The annual incidence of hospitalization for HF was the highest in patients with HF-related (25.1% per person-year), followed by radiation therapy-related (10.4% per person-year).This retrospective study is the first, to the best of our knowledge, to reveal the contemporary prevalence of PE, its cause, and outcome in patients who visited a cardiovascular hospital in an urban area of Japan.

Is pulmonary hypertension protective against cardiac tamponade? A systematic review

The presence of pulmonary hypertension (PH) may affect whether cardiac tamponade physiology develops from a pericardial effusion. Specifically, the increased intracardiac pressure and right ventricular hypertrophy associated with PH would seemingly increase the intrapericardial pressure threshold at which the right-sided chambers collapse. In this systematic review, we examined the impact of PH on the incidence, in-hospital and long-term mortality, and echocardiographic findings of patients with cardiac tamponade. Using the PRISMA guideline, a systematic search was conducted in PubMed, Academic Search Premier, Web of Science, Google Scholar, and the Cochrane Database for studies investigating PH and cardiac tamponade. The Newcastle-Ottawa Scale was used to analyze the quality of returned studies. Primary outcomes included the incidence of cardiac tamponade, as well as in-hospital and long-term mortality rates. Secondary outcomes were the presence or absence of echocardiographic findings of cardiac tamponade in patients with PH. Forty-three studies (9 cohort studies and 34 case reports) with 1054 patients were included. The incidence of cardiac tamponade was significantly higher in patients with PH compared to those without PH, 2.0% (95% CI 1.2-3.2%) vs. 0.05% (95% CI 0.05-0.05%), p < 0.0001, OR 40.76 (95% CI 24.8-66.9). The incidence of tamponade in patients with a known pericardial effusion was similar in those with and without PH, 20.3% (95% CI 12.0-32.3%) and 20.9% (95% CI 18.0-24.1%), p = 0.9267, OR 0.97 (95% CI 0.50-1.87). In patients with tamponade, those with PH demonstrated a significantly higher in-hospital mortality than those without PH, 38.8% (95% CI 26.4-52.8%) vs. 14.4% (95% CI 14.2-14.6%), p < 0.0001, OR 3.77 (95% CI 2.12-6.70). Long-term mortality in patients with tamponade was significantly lower in those with PH than in those without PH, 45.5% (95% CI 33.0-58.5%) vs. 59.1% (95% CI 54.7-63.4%), p = 0.0258, OR 0.576 (95% CI 0.33-1.01). However, after stratifying by non-malignant etiologies, the long-term mortality benefit for those with PH disappeared. In the studies that described specific echocardiographic findings of cardiac tamponade, only 10.5% of patients with PH and tamponade showed right atrial and right ventricular collapse. When evaluating patients with pericardial effusions, physicians must recognize the effects of underlying PH on the incidence, in-hospital and long-term mortality rates, and potentially atypical echocardiographic presentation of cardiac tamponade.

Epidemiological characteristics, etiological spectrum, and outcomes of adult patients with pericardial effusion at a Teaching Hospital in Somalia

Background

Pericardial effusion (PE) is an abnormal fluid volume in the pericardial space and is a common clinical entity. The incidence of PE is estimated diversely and depends on risk factors, etiologies, and geographic locations.

Objectives

This study aimed to assess the clinical characteristics, etiologic spectrum, echocardiographic features, and outcomes among patients with different types of PE.

Method

This retrospective observational study included 93 patients with confirmed PE. Their medical records were reviewed in the hospital information system of Mogadishu Somali Turkish Training and Research Hospital between April 2022 and September 2022. Patient demographics, clinical characteristics, chest X-rays, echocardiography, laboratory findings, management approaches, and outcome reports were reviewed and recorded.

Results

Out of the 3000 participants, 3.1% (n = 93/3000) met the definition of definitive PE. In this study, we included 51 females and 42 males. Among the patients, 86% (n = 80) had at least one comorbidity, with diabetes (38.7%) and hypertension (37.6%) being the most common. The most frequently reported clinical presentation findings were shortness of breath (67.7%), chest pain (49.4%), cough (47.3%), and palpitations (47.3%). Cardiac tamponade developed in 9.7% (n = 9) of the patients. Pericardial taps were performed in 64.5% of the cases. Our analysis showed that the most common cause of PE was cardiac disease (n = 33, 35.4%), followed by tuberculosis (TB) (n = 25, 26.8%), uremic pericarditis (n = 24, 25.8%), and hypothyroidism (n = 10, 10.7%). Regarding the severity of PE based on echocardiographic findings, nearly half of the patients (n = 46, 49.4%) had mild PE, whereas 26.8% (n = 25) had moderate PE, and 23.6% (n = 22) had severe PE. Two-thirds of the cases (66.6%) were managed with furosemide, 48 (51.6%) patients were treated with an anti-inflammatory, hemodialysis was performed in 24 (25.8%) patients and antituberculous medications were administered to 7 (7.5%) patients. Out of the 93 patients, 24 (25.8%) died during the hospital stay. It was determined that the mortality risk of patients with renal failure was 7.518 times higher than those without (p = 0.004), and the risk for those with TB was 5.554 times higher than those without (p = 0.011). Other variables were not influential on mortality (p > 0.050).

Conclusion

Our study results demonstrate the epidemiological profile of PE in Somalia. The leading causes of PE were cardiac diseases, uremic pericarditis, TB, and hypothyroidism. PE is a significant cause of morbidity and mortality in Somalia, especially in individuals with renal failure and TB infection.

Pericardial Effusion and Cardiac Tamponade Pathophysiology and New Approaches to Treatment

PURPOSE OF REVIEW

The objective of this manuscript is to examine up-to-date approaches to the diagnosis and treatment of pericardial effusions and cardiac tamponade.

RECENT FINDINGS

Recent recommendations from the American Society of Echocardiography and the European Society of Cardiology have improved our management of the patient with pericardial effusion and cardiac tamponade, but significant knowledge gaps remain. Novel diagnostic and triage strategies have been suggested, and recent information have improved our facility to assess the presence and size of a pericardial effusion, assess its hemodynamic impact, and determine its cause. Despite these recent findings, there is a scarcity of evidence-based data to direct the management of pericardial effusion and cardiac tamponade. While the first-line function of echocardiography in managing these disorders is undisputed, there are increasingly niche functions for multimodality imaging.

The Evolving Etiologic and Epidemiologic Portrait of Pericardial Disease

Pericardial disease includes a variety of conditions, including inflammatory pericarditis, pericardial effusions, constrictive pericarditis, pericardial cysts, and primary and secondary pericardial neoplasms. The true incidence of this varied condition is not well established, and the causes vary greatly across the world. This review aims to describe the changing pattern of epidemiology of pericardial disease and to provide an overview of causative etiologies. Idiopathic pericarditis (assumed most often to be viral) remains the most common etiology for pericardial disease globally, with tuberculous pericarditis being most common in developing countries. Other important etiologies include fungal, autoimmune, autoinflammatory, neoplastic (both benign and malignant), immunotherapy-related, radiation therapy-induced, metabolic, postcardiac injury, postoperative, and postprocedural causes. Improved understanding of the immune pathophysiological pathways has led to identification and reclassification of some idiopathic pericarditis cases into autoinflammatory etiologies, including immunoglobulin G (IgG)4-related pericarditis, tumour necrosis factor receptor-associated periodic syndrome (TRAPS), and familial Mediterranean fever in the current era. Contemporary advances in percutaneous cardiac interventions and the recent COVID-19 pandemic have also resulted in changes in the epidemiology of pericardial diseases. Further research is needed to improve our understanding of the etiologies of pericarditis, using the assistance of contemporary advanced imaging techniques and laboratory testing. Careful consideration of the range of potential causes and local epidemiologic patterns of causality are important for the optimization of diagnostic and therapeutic approaches.

Evaluation of etiology of pericardial effusion in 81 patients who underwent pericardiostomy or pericardial window

<b>Introduction: </b>A wide variety of diseases lead to pericardial effusion including systemic inflammatory diseases, pericarditis, reduced pericardial fluid reabsorption due to increased systemic venous pressure, pneumonia, pulmonary embolism, endocrine diseases, post-cardiotomy syndrome, trauma, hypothyroidism, renal-hepatic failure, collagen-vascular diseases, infectious, and malignancy. In this study, we aimed to evaluate the underlying etiology of pericardial effusions in patients underwent surgical pericardial drainage or pericardial window and contemporary management.<br /> <b>Materials and methods: </b>Between January 2006 and January 2018, a total of 81 patients (49 males, 32 females; mean 52.9±10.6 years; range 5 to 84 years) who underwent subxiphoid pericardiostomy, pericardial window procedure with left anterior thoracotomy or subxiphoid approach, due to moderate or severe pericardial effusion and cardiac tamponade, were retrospectively analyzed.<br /> <b>Results: </b>Malignancy was diagnosed either with histopathological examination of the pericardial biopsy and/or fluid in 17 (80.9%) of 21 patients had a previous history of malignancy. Of the 21 patients diagnosed with malignancy, six patients (7.5%) had leukemia/lymphoma, and six patients (7.5%) had thyroid papillary cancer. Mycobacterium tuberculosis was identified in only one (1.2%) patient’s culture of the pericardial fluid. No etiology was found in the remaining 38 patients (46.9%); thus, they were considered as idiopathic pericarditis.<br /> <b>Conclusion: </b>Tuberculosis is no longer the leading cause of pericarditis. Idiopathic pericarditis is the leading cause of pericardial effusion and malignancy is the next most common cause of pericardial effusion in our region.

Pericardial Effusion: A Novel Presentation of Aplastic Anemia

Pericardial effusion is defined as the accumulation of fluid between the visceral and parietal pericardium. The underlying etiology varies as any pathology that causes pericarditis or involves the pericardium can cause effusion. In practice, the majority of pericarditis cases are idiopathic, although these are assumed to be secondary to occult viral infection or inflammatory phenomena. Malignancy, particularly the metastatic spread of noncardiac primary tumors, has been implicated as a differential in the diagnosis of pericardial effusion. Though commonly seen in solid malignancies, effusion has been reported in hematologic malignancies such as myelodysplastic syndrome (MDS), acute leukemia, and lymphoma. Nonetheless, pericardial effusions associated with hematologic conditions are extremely rare with only one case report published describing pericardial effusion secondary to immune thrombocytopenia (ITP). We herein report the first documented case, to our knowledge, of pericardial effusion as an initial clinical manifestation of aplastic anemia in a middle-aged male presenting with pancytopenia.

Unveiling the causes of pericardial effusion in a contemporary case series of pericardiocentesis in Latin America

Pericardial effusions requiring pericardiocentesis have multiple causes that vary among geographical regions and health contexts. This procedure can be performed for diagnostic or therapeutic indications. The purpose of this study was to identify the principal causes of pericardial effusions and indications for pericardiocentesis, exploring differences among groups. This was a retrospective case series of patients who underwent pericardiocentesis for pericardial effusion in a single center in Latin America. Demographic, clinical, echocardiographic, and procedural variables were recorded and analyzed. The primary outcome was to determine the causes of pericardial effusions in these patients and the indication (diagnostic, therapeutic, or both). The results are presented in two groups (inflammatory and noninflammatory) according to the cause of the pericardial effusion. One hundred sixteen patients with pericardial effusion underwent pericardiocentesis. The median age was 58 years (IQR 46.2–70.7), and 50% were male. In the noninflammatory pericardial effusion group, there were 61 cases (53%), among which neoplastic pericardial effusion was the most frequent cause (n = 25, 40.9%). In the inflammatory group, there were 55 cases (47%), and the main cause was postpericardiectomy syndrome after cardiac surgery (n = 31, 56.4%). The principal indication for pericardiocentesis was therapeutic (n = 66, 56.8%). Large pericardial effusion without hemodynamic effect of cardiac tamponade was significantly more frequent in the inflammatory group (p = 0.03). In conclusion, the principal cause of pericardial effusion in patients who underwent pericardiocentesis was postpericardiectomy syndrome after cardiac surgery, followed by neoplastic pericardial effusion. Pericardiocentesis is mainly a therapeutic procedure.

The safety of pericardiocentesis in patients under antithrombotic therapy: A single-center experience

Objective

This study aimed to analyze the characteristics of patients with pericardial effusion requiring pericardiocentesis and to evaluate the safety of pericardiocentesis without discontinuation of anticoagulant or antiplatelet drugs.

Methods

We performed a retrospective study of patients undergoing pericardiocentesis in our hospital between 2012 and 2022. Patients were categorized into the Antithrombotic Group if they had used any antiplatelet or anticoagulant drugs on the day of pericardiocentesis; otherwise they were categorized into the Non-antithrombotic Group. All procedures were performed by experienced cardiologists with echocardiographic guidance. Bleeding events were defined using the National Institutes of Health scale of adverse events.

Results

A total of 501 consecutive patients were identified and 70 cases were under antithrombotic drugs (Antithrombotic Group). Patients in Antithrombotic Group were older, had more comorbidities, presented with lower platelet counts and prolonged activated partial thromboplastin time (all p < 0.05). Malignancy was the most common etiology for pericardial effusion in both groups (28.6% in Antithrombotic Group and 54.7% in Non-antithrombotic Group) and tuberculosis was the second etiology in the Non-antithrombotic Group (21.9%), while procedure-related effusion (17.1%) accounted for the second cause in the Antithrombotic Group. Two patients in the Antithrombotic Group had mild oozing at the puncture site that resolved without interventions (2.9 vs. 0%, p = 0.019), and no bleeding events higher than Grade 1 occurred in either group.

Conclusion

Although antiplatelet or anticoagulant drugs may put patients undergoing pericardiocentesis at theoretically higher risk of bleeding, our study demonstrated that they are not associated with increased major bleeding complications.

Precautions When Performing Pericardiocentesis in Patients with Cardiac Tamponade-complicated Malignancy: A Case Report and Review of the Literature

A 51-year-old woman who had previously undergone left mastectomy for left breast cancer accompanied by multiple metastasis experienced worsening dyspnea. Physical and imaging assessments of the hemodynamics suggested cardiac tamponade, and emergency pericardiocentesis was successfully performed. However, immediately after the procedure, the patient's condition deteriorated rapidly and showed pulseless electrical activity. Contrast-enhanced computed tomography with continuous mechanical support demonstrated massive thrombi in both pulmonary arteries. An abrupt decrease in the central venous pressure and an increase in the venous return following pericardiocentesis might result in the migration of a deep venous thrombus and fatal acute pulmonary thromboembolism.

Chronic pericardial effusion: current concepts and emerging trends

INTRODUCTION

Pericardial effusion (PEF) is a common and challenging pericardial syndrome with a variety of clinical manifestations ranging from asymptomatic, incidentally uncovered small PEFs, to life-threatening cardiac tamponade.

AREAS COVERED

: This review focuses on the pathophysiology, epidemiology, etiology, classification, clinical findings, diagnostic work-up, management and outcome of PEFs. Particular emphasis has been given on the most recent evidence concerning the contribution of imaging for the detection, differential diagnosis and evaluation of the hemodynamic impact of PEFs on the diastolic filling of the heart. Moreover, simplified algorithms for PEF triage and management have been included.

EXPERT OPINION

The management of patients with PEFs is mainly based on four parameters namely hemodynamic impact on diastolic function, elevation of inflammatory markers, presence of a specific underlying condition known to be associated with PEF and finally size and duration of the effusion. Novel data have contributed to change our view towards large, asymptomatic, "idiopathic" PEFs and dictated a rather conservative approach in most cases. It is also stressed that there is a compelling need for additional research, which is essential for tailored treatments aiming at the improvement of quality of life and containment of health care costs.

Automated Detection, Segmentation, and Classification of Pericardial Effusions on Chest CT Using a Deep Convolutional Neural Network

Pericardial effusions (PEFs) are often missed on Computed Tomography (CT), which particularly affects the outcome of patients presenting with hemodynamic compromise. An automatic PEF detection, segmentation, and classification tool would expedite and improve CT based PEF diagnosis; 258 CTs with (206 with simple PEF, 52 with hemopericardium) and without PEF (each 134 with contrast, 124 non-enhanced) were identified using the radiology report (01/2016−01/2021). PEF were manually 3D-segmented. A deep convolutional neural network (nnU-Net) was trained on 316 cases and separately tested on the remaining 200 and 22 external post-mortem CTs. Inter-reader variability was tested on 40 CTs. PEF classification utilized the median Hounsfield unit from each prediction. The sensitivity and specificity for PEF detection was 97% (95% CI 91.48−99.38%) and 100.00% (95% CI 96.38−100.00%) and 89.74% and 83.61% for diagnosing hemopericardium (AUC 0.944, 95% CI 0.904−0.984). Model performance (Dice coefficient: 0.75 ± 0.01) was non-inferior to inter-reader (0.69 ± 0.02) and was unaffected by contrast administration nor alternative chest pathology (p > 0.05). External dataset testing yielded similar results. Our model reliably detects, segments, and classifies PEF on CT in a complex dataset, potentially serving as an alert tool whilst enhancing report quality. The model and corresponding datasets are publicly available.

Case Report: A Young Man With Giant Pericardial Synovial Sarcoma

Pericardial synovial sarcomas are sporadic tumors. Herein, we report a case of primary pericardial synovial sarcoma originating from the right pericardium. Missed diagnosis delayed surgical treatment. Eventually, the tumor occupied the almost entire pericardial cavity. The pericardial tumor was surgically removed as soon as possible after admission. In this paper, we aim to provide details that can help further understand the differing symptoms and presentations of pericardial synovial sarcoma and highlight the importance of consideration of this disease in similar cases where the etiology of pericardial effusion is unknown.

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".

Characteristics and Clinical Outcomes of Cancer Patients Who Developed Constrictive Physiology after Pericardiocentesis

BACKGROUND AND OBJECTIVES

This study aimed to identify the characteristics and clinical outcomes of cancer patients who developed constrictive physiology (CP) after percutaneous pericardiocentesis.

METHODS

One-hundred thirty-three cancer patients who underwent pericardiocentesis were divided into 2 groups according to follow-up echocardiography (CP vs. non-CP). The clinical history, imaging findings, and laboratory results, and overall survival were compared.

RESULTS

CP developed in 49 (36.8%) patients after pericardiocentesis. The CP group had a more frequent history of radiation therapy. Pericardial enhancement and malignant masses abutting the pericardium were more frequently observed in the CP group. Fever and ST segment elevation were more frequent in the CP group, with higher C-reactive protein levels (6.6±4.3mg/dL vs. 3.3±2.5mg/dL, p<0.001). Pericardial fluid leukocytes counts were significantly higher, and positive cytology was more frequent in the CP group. In baseline echocardiography before pericardiocentesis, medial e' velocity was significantly higher in the CP group (8.6±2.1cm/s vs. 6.5±2.3cm/s, p<0.001), and respirophasic ventricular septal shift, prominent expiratory hepatic venous flow reversal, pericardial adhesion, and loculated pericardial fluid were also more frequent. The risk of all-cause death was significantly high in the CP group (hazard ratio, 1.53; 95% confidence interval,1.10-2.13; p=0.005).

CONCLUSIONS

CP frequently develops after pericardiocentesis, and it is associated with poor survival in cancer patients. Several clinical signs, imaging, and laboratory findings suggestive of pericardial inflammation and/or direct malignant pericardial invasion are frequently observed and could be used as predictors of CP development.

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.

An Unusual Case of Hashimoto's Thyroiditis Presenting as Impending Cardiac Tamponade in a Patient with Acquired Immune Deficiency Syndrome (AIDS)

Patient: Male, 52-year-old

Final Diagnosis: Hashimoto’s thyroiditis

Symptoms: Acute epigastric pain • confusion • diarrhea • episodic gastrointestinal discomfort • fatigue • nausea • vomiting

Medication: —

Clinical Procedure: Radiographic-assisted pericardiocentesis

Specialty: Hematology

Diagnostic approach to a cardiac mass: a case report of misdiagnosed cardiac synovial sarcoma

Background

Cardiac synovial sarcoma (CSS) is an extremely rare malignant tumour with a poor prognosis. We report the case of a 31-year-old woman who presented with a CSS in the right atrium and was initially misdiagnosed with a tuberculoma. The aim of this article is to focus on the importance of having broad differential diagnoses including rare entities.

Case summary

A 31-year-old White woman, with a close contact with a relative having pulmonary tuberculosis, presented to the emergency unit with severe dyspnoea. Chest radiography and echocardiography showed a large pericardial effusion with a mass in the right atrium. Pericardiocentesis removed bloody exudative fluid with adenosine desaminase at 17 UI/L and no malignant cells in the cytological study. Cardiac magnetic resonance revealed a tuberculoma of the right atrium. Intraoperatively, the mass was only biopsied because of the local invasion. Histological study concluded to a CSS. The patient died 3 days later.

Discussion

This case highlights the importance of having broad differential diagnoses including rare entities. Histology was the key investigation for the diagnosis of CSS which has no clinical nor laboratory or imaging pathognomonic signs.

Myxedema Heart and Pseudotamponade

Context

Thyroid hormone plays a critical role in cardiovascular function. Severe hypothyroidism can be associated with “myxedema heart” characterized by relative bradycardia and pericardial effusion. Effusions associated with severe hypothyroidism can be large. Despite the large volume of effusions, tamponade is not a common consequence. However, with the incorporation of echocardiography into routine practice for evaluation of effusion, echocardiographic findings suggestive of clinical tamponade occur frequently.

Case Description

We report a series of 3 patients with large pericardial effusions secondary to severe hypothyroidism. These cases serve to demonstrate the discordance between echocardiographic signs consistent with tamponade with a patient’s stable clinical hemodynamics. We also report the development of bronchial obstruction, a rare complication of a large effusion due to severe hypothyroidism.

Conclusions

While pericardial effusion associated with severe hypothyroidism has been described for decades, the echocardiographic findings may be less well known and may lead to unnecessary downstream testing or invasive management. We use our case series to facilitate a summary of what is known about the epidemiology, mechanism and physiology, and expected outcomes of myxedema associated pericardial effusion. Finally, in the setting of current paucity of clinical guidelines, we aim to familiarize clinicians with the phenomenon of pseudotamponade and suggest management strategies for myxedema associated pericardial effusion to guide clinicians to use conservative medical management in majority of cases.

Chronic massive pericardial effusion: a case report and literature review

Chronic massive pericardial effusion without cardiac tamponade is relatively rare. Nearly half of all patients with chronic large pericardial effusion are asymptomatic. We report a case of a 77-year-old man who presented with an asymptomatic chronic massive pericardial effusion, with no evidence of cardiac tamponade or pericardial constriction during a 10-year follow-up. The patient had a complex history of lymph node tuberculosis, hypertension, hypothyroidism, and polycythemia vera, as well as high-dose ³¹P radiation exposure 45 years ago. There was no evidence of tuberculosis infection, hypothyroidism, malignant tumor, severe heart failure, uremia, trauma, severe bacterial or fungal infection, chronic myeloid leukemia, or bone marrow fibrosis after admission. The patient underwent pericardiocentesis twice. The pericardial effusion comprised exudate fluid with a high proportion of monocytes. The patient refused indwelling catheter drainage or pericardiectomy. The likely final diagnosis was recurrent chronic large idiopathic pericardial effusion.

What is the normal composition of pericardial fluid?

Objective

Biochemical and cytological pericardial fluid (PF) analysis is essentially based on the knowledge of pleural fluid composition. The aim of the present study is to identify reference intervals (RIs) for PF according to state-of-art methodological standards.

Methods

We prospectively collected and analysed the PF and venous blood of consecutive subjects undergoing elective open-heart surgery from July 2017 to October 2018. Exclusion criteria for study enrolment were evidence of pericardial diseases at preoperatory workup or at intraoperatory assessment, or any other condition that could affect PF analysis.

Results

The final study sample included 120 patients (median age 69 years, 83 men, 69.1%). The main findings were (1) High levels of proteins, albumin and lactate dehydrogenase (LDH), but not of glucose and cholesterol (2) High cellularity, mainly represented by mesothelial cells. RIs for pericardial biochemistry were: protein content 1.7–4.6 g/dL PF/serum protein ratio 0.29–0.83, albumin 1.19–3.06 g/dL, pericardium-to-serum albumin gradient 0.18–2.37 g/dL, LDH 141–2613 U/L, PF/serum LDH ratio 0.40–2.99, glucose 80–134 mg/dL, total cholesterol 12–69 mg/dL, PF/serum cholesterol ratio 0.07–0.51. RIs for pericardial cells by optic microscopy were: 278–5608 × 106 nucleated cells/L, 40–3790 × 106 mesothelial cells/L, 35–2210 × 106 leucocytes/L, 19–1634 × 106 lymphocytes/L.

Conclusions

PF is rich in nucleated cells, protein, albumin, LDH, at levels consistent with inflammatory exudates in other biological fluids. Physicians should stop to interpret PF as exudate or transudate according to tools not validated for this setting.

Diagnostic values of Xpert MTB/RIF, T-SPOT.TB and adenosine deaminase for HIV-negative tuberculous pericarditis in a high burden setting: a prospective observational study

The diagnosis of tuberculous pericarditis (TBP) remains challenging. This prospective study evaluated the diagnostic value of Xpert MTB/RIF (Xpert) and T-SPOT.TB and adenosine deaminase (ADA) for TBP in a high burden setting. A total of 123 HIV-negative patients with suspected TBP were enrolled at a tertiary referral hospital in China. Pericardial fluids were collected and subjected to the three rapid tests, and the results were compared with the final confirmed diagnosis. Of 105 patients in the final analysis, 39 (37.1%) were microbiologically, histopathologically or clinically diagnosed with TBP. The sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, negative likelihood ratio and diagnostic odds ratio (DOR) for Xpert were 66.7%, 98.5%, 96.3%, 83.3%, 44.0, 0.338, and 130.0, respectively, compared to 92.3%, 87.9%, 81.8%, 95.1%, 7.6, 0.088, and 87.0, respectively, for T-SPOT.TB, and 82.1%, 92.4%, 86.5%, 89.7%, 10.8, 0.194, and 55.8, respectively, for ADA (≥ 40 U/L). ROC curve analysis revealed a cut-off point of 48.5 spot-forming cells per million pericardial effusion mononuclear cells for T-SPOT.TB, which had a DOR value of 183.8, while a cut-off point of 41.5 U/L for ADA had a DOR value of 70.9. Xpert (Step 1: rule-in) followed by T-SPOT.TB [cut-off point] (Step 2: rule-out) showed the highest DOR value of 252.0, with only 5.7% (6/105) of patients misdiagnosed. The two-step algorithm consisting of Xpert and T-SPOT.TB could offer rapid and accurate diagnosis of TBP.

Ultrasonographic assessment of right heart intracardiac mass in patients with hepatitis B virus infection

OBJECTIVE

The characteristics of right heart intracardiac mass in hepatitis B virus infection patients are not well known. Our aim is to describe their ultrasonographic features and nature of such masses.

METHODS

We retrospectively reviewed imaging reports of hepatitis B virus infection patients from January 2014 to December 2018. Patients with a confirmed finding of right heart intracardiac mass were included, whose pathology reports and contrast-enhanced images were analyzed. Various masses were compared to a general control group from a published study.

RESULTS

Thirty-eight cases were finally included. Different types of masses presented with a variety of echocardiographic manifestations. Thirty-six cases had masses located in the right atrium, including five thrombus and 31 metastatic carcinoma. The later included one metastatic non-Hodgkin lymphoma and 30 metastatic hepatic carcinoma cases (27 of which had inferior vena cava tumor thrombus). Two cases presented with masses in the right ventricle that included one multiple myxoma and one tricuspid valve leaflet vegetation. Compared with the general population, no primary malignant tumor was found in our study (65% vs. 100%, P = 0.001), and hepatic metastasis was the most common type of malignant tumors (P < 0.001).

CONCLUSION

The nature and ultrasonographic features of right heart intracardiac masses in hepatitis B virus infection patients are diverse, and the incidence of malignant tumors was similar to that seen in the general population. Hepatic metastasis, possibly extending via the inferior vena cava into the right atrium, was the most common type. Our study may improve understanding of the right heart intracardiac mass in hepatitis B virus infection patients.

Causes and prognosis of symptomatic pericardial effusions treated by pericardiocentesis in an Asian academic medical centre

INTRODUCTION

This study aimed to investigate the causes, clinical management and outcomes of clinically significant pericardial effusions, and evaluate the practice of pericardiocentesis within an academic medical centre in Singapore, a multiethnic country in Southeast Asia.

METHODS

Consecutive patients undergoing pericardiocentesis at a single Asian academic medical centre were identified. Patient demographics, echocardiographic findings, investigations, pericardiocentesis procedural details and clinical progress were tracked using a comprehensive electronic medical records system.

RESULTS

Of 149 patients who underwent pericardiocentesis, malignancy (46.3%) was the most common cause of pericardial effusions, followed by iatrogenic postsurgical complications (17.4%). 77.3% of effusions were large and 69.8% demonstrated tamponade physiology. Pericardiocentesis guided by echocardiography and fluoroscopy was successful in 99.3% of patients and had a complication rate of 2.0%. Likelihood of effusion recurrence and survival to discharge was determined by the aetiology of the pericardial effusion. 24.6% of malignant effusions recurred, and the survival rate 12 months after drainage of a malignant pericardial effusion was 45.0%. Short-term mortality was highest among patients presenting with tamponade due to acute aortic syndromes and those with myocardial rupture due to ischaemic heart disease.

CONCLUSION

Cancer and iatrogenic complications were the most common causes of pericardial effusion in this large cohort of Singapore patients. Pericardiocentesis has a high success rate and relatively low complication rate. Prognosis and clinical course after pericardiocentesis are determined by the underlying cause of the pericardial effusion.

Pericardial diseases in patients with hypothyroidism

Hypothyroidism is a well-known cause of pericardial effusion (with an incidence of 3%-37%) and can cause cardiac tamponade in severe cases. In this review, we present the current knowledge on the epidemiology of hypothyroid-induced pericardial diseases, the mechanism through which low thyroid hormone levels affect the pericardium, the associated clinical manifestations, diagnostic tests and management options. Hypothyroidism causes pericardial effusion through increased permeability of the epicardial vessels and decreased lymphatic drainage of albumin, resulting in accumulation of fluid in the pericardial space. Interestingly, autoimmunity does not seem to play a major role in the pathophysiology, and a majority of effusions are asymptomatic due to slow fluid accumulation. The diagnosis is generally made when the pericardial disease is associated with an elevated thyroid-stimulating hormone level, and other secondary causes are excluded. Management consists of thyroid replacement therapy, along with pericardial drainage in case of tamponade.In conclusion, hypothyroidism-induced pericardial diseases are underdiagnosed. Initiating treatment early in the disease process and preventing complications relies on early diagnosis through systematic screening per guidelines.

A contemporary look at pericardiocentesis

Percutaneous drainage is the default strategy for evacuating a pericardial effusion. A pericardiocentesis can be necessary or required in a wide variety of clinical settings ranging from urgent tamponade to relieve in iatrogenic hemorrhagic effusions in the electrophysiology or catheterization room, to planned diagnostic procedures in patients with suspected or known malignancy or infections. With the help of several procedural improvements over the past decades, echocardiography and fluoroscopy-guided percutaneous pericardiocentesis has become the standard intervention for evacuating pericardial effusions, as well as an essential tool in the diagnostic work-up of an unexplained pericardial effusion. When performed by skilled physicians assisted by appropriate imaging it is a very safe procedure, and provided that an indwelling catheter is placed, it is also very effective with an acceptably low risk of recurrences. In this review, the indications and standard techniques for pericardiocentesis are discussed, as well as their consequences for patients with iatrogenic and malignant effusions.

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.

Primary Pericardial Angiosarcoma Shown on FDG PET/CT

A 63-year-old woman had persistent bloody pericardial effusion. Tuberculous pericarditis was initially suspected, but empirical antituberculosis therapy was futile. FDG PET/CT study revealed abnormal FDG activity in multiple parts of the pericardium, especially along with aorta and main pulmonary artery, and in the left atrium. However, there was no abnormal activity in other parts of the body. Histopathologic examination revealed primary pericardial angiosarcoma.

Etiology and Long-Term Outcome of Patients Undergoing Pericardiocentesis

Background

Pericardial effusions can be caused by a variety of disorders. The frequency of the underlying diseases varies with patient population; therefore, previously reported series are not necessarily representative of other populations. Our purpose was to examine the etiology of pericardial effusions and the survival of patients requiring pericardiocentesis at a tertiary center.

Methods and Results

We performed a retrospective observational study of 269 consecutive patients who underwent percutaneous pericardiocentesis at our university hospital between 2006 and 2016 and had prospective follow‐up for up to 10 years. The most frequent etiologies were idiopathic (26%), malignancy (25%), and iatrogenicity (20%), whereas bacterial causes were very rare. The most frequent malignancies originated from the lung (53%) or breast (18%). A new cancer was diagnosed with malignant pericardial effusion as the presenting complaint for 9% of patients, whereas the pericardium was the first metastatic site of a known malignancy in 4% of patients. Survival was significantly poorer in malignancy‐related versus non–malignancy‐related effusions (P<0.001) and in cytology‐positive versus cytology‐negative effusions in the overall cohort (P<0.001). Among cancer‐only patients, however, there was no significant difference in long‐term survival between cytology‐positive and ‐negative effusions.

Conclusions

In this contemporary tertiary‐center cohort, pericardial effusions often represent the primary instance of a new malignancy, underscoring the importance of cytological analyses of noniatrogenic effusions in patients without known cancer, as survival is significantly worse. In cancer patients, however, the presence of pericardial malignant cytology does not appear to affect outcome significantly.

Comparison between the diagnostic validities of Xpert MTB/RIF and interferon-γ release assays for tuberculous pericarditis using pericardial tissue

BACKGROUND

This study aimed to assess the diagnostic performance of Xpert MTB/RIF for tuberculous pericarditis (TBP) using pericardial tissues.

METHODS

The study involved 30 patients admitted with suspected TBP from January-December 2016; three patients were later excluded. The interferon-γ release assay (T-SPOT.TB) and the Xpert MTB/RIF test were performed using peripheral blood and pericardial tissues, respectively. TBP was confirmed using pericardial histopathology and a composite reference standard (CRS). We analyzed the sensitivity, specificity, predictive value (PV), likelihood ratio (LR), and area under curve (AUC) of both assays.

RESULTS

Fourteen patients were confirmed as TBP, 10 as non-TBP, and 3 as probable TBP. The sensitivity, specificity, positive PV (PPV), negative PV (NPV), PLR, NLR, and AUC (95% confidence interval [CI]) of the Xpert MTB/RIF assay were 78.6% (49.2-95.3%) and 70.6% (44.0-89.7%); 92.3% (64.0-99.8%) and 100% (69.2-100%); 91.7% (61.5-99.8%) and 100% (73.5-100%); 80.0% (51.9-95.7%) and 66.7% (38.4-88.2%); 10.21 (1.52-68.49) and the PLR value was undefined with CRS as the reference; 0.23 (0.08-0.64) and 0.29(0.14-0.61); and 0.854 (0.666-0.959) and 0.853 (0.664-0.959), against histopathology and CRS, respectively. The sensitivity, specificity, PPV, NPV, PLR, NLR, and AUC values (95% CI) of T-SPOT.TB were 92.9% (66.1-99.8%) and 94.1% (71.3-99.9%); 15.4% (1.9-45.5%) and 20.0% (2.5-55.6%); 54.2% (32.8-74.5%) and 66.7% (44.7-84.4%); 66.7% (9.4-99.2%) and 66.7% (9.4-99.2%); 1.10 (0.83-1.44) and 1.18 (0.84-1.6); 0.46 (0.05-4.53) and 0.29 (0.03-2.85); and 0.541(0.340-0.733) and 0.571(0.367-0.758), against histopathology and CRS, respectively. The differences in sensitivity, PPV, and AUC of Xpert MTB/RIF and T-SPOT.TB were not statistically significant (P > 0.05), compared to those of histopathology and CRS. However, the differences in specificity and NPV of the two assays were significant (P < 0.05), compared to those of histopathology and CRS.

CONCLUSIONS

Xpert MTB/RIF test is a valid diagnostic technique for TBP with higher sensitivity and specificity than T-SPOT.TB.

Transitory effusive-constrictive pericarditis

Pericardial effusion of various sizes is a quite common clinical finding, while its progression to effusive-constrictive pericarditis occurs in about 1.4-14% of cases. Although available evidence on prevalence and prognosis of this rare pericardial syndrome is poor, apparently a considerable proportion of patients conservatively managed has a spontaneous resolution after several weeks. A 61-year-old female presented to our emergency department reporting fatigue, effort dyspnea and abdominal swelling. The echocardiography showed large pericardial effusion with initial hemodynamic impact, so she underwent a pericardiocentesis with drainage of 800-850cm³ of exudative fluid, on which diagnostic investigations were undertaken: possible viral and bacterial infections, medical conditions, iatrogenic causes, neoplastic and connective tissue diseases were all excluded. Despite empirical therapy with NSAIDs and colchicine, after about one week she had a recurrence of pericardial effusion and progressive development of constriction. Echocardiography performed after a few weeks of anti-inflammatory therapy showed resolution of constriction and PE, with clinical improvement. If progression of pericardial syndromes to a constrictive form is rarely described in literature, cases of transitory effusive-constrictive phase are even more uncommon, mainly reported during the evolution of pericardial effusion. According to the available data, risk of progression to a constrictive form is very low in case of idiopathic pericardial effusion. We report a case of large idiopathic subacute pericardial effusion, treated with pericardiocentesis and then evolved into an effusive-constrictive pericarditis. A prolonged anti-inflammatory treatment leads to complete resolution of pericardial syndrome without necessity of pericardiectomy.

Contemporary management of pericardial effusion: practical aspects for clinical practice

A pericardial effusion (PE) is a relatively common finding in clinical practice. It may be either isolated or associated with pericarditis with or without an underlying disease. The aetiology is varied and may be either infectious (especially tuberculosis as the most common cause in developing countries) or non-infectious (cancer, systemic inflammatory diseases). The management is essentially guided by the hemodynamic effect (presence or absence of cardiac tamponade), the presence of concomitant pericarditis or underlying disease, and its size and duration. The present paper reviews the current knowledge on the aetiology, classification, diagnosis, management, therapy, and prognosis of PE in clinical practice.

Diagnostic Value of Interferon-γ Release Assays on Pericardial Effusion for Diagnosis of Tuberculous Pericarditis

Diagnosis of tuberculous pericarditis remains a challenge. We aimed in this study to evaluate the diagnostic value of T-SPOT.TB on pericardial effusion for diagnosis of tuberculous pericarditis. Patients with suspected tuberculous pericarditis were enrolled consecutively between August 2011 and December 2015. T-SPOT.TB was performed on both pericardial effusion mononuclear cells (PEMCs)and peripheral blood mononuclear cells (PBMCs). Sensitivity, specificity, predictive value (PV), and likelihood ratio (LR) of T-SPOT.TB on PEMCs and PBMCs were analyzed. Among the 75 patients enrolled, 24 patients (32%) were diagnosed with tuberculous pericarditis, 38 patients (51%) with nontuberculous pericarditis, and 13 patients (17%) were clinically indeterminate and were excluded from the final analysis. The sensitivity, specificity, positive PV (PPV), negative PV (NPV), positive LR (LR+), and negative LR (LR-) of T-SPOT.TB on PEMCs was 92%,92%,88%,95%,11.61, and 0.09, respectively, compared to 83%, 95%, 91%, 90%,15.83, and 0.18, respectively of T-SPOT.TB on PBMCs. In patients with tuberculous pericarditis, the median frequencies of spot-forming cells (SFCs) of T-SPOT.TB on PEMCs and PBMCs was 172SFCs/106MCs (IQR 39~486), and 66 SFCs/106MCs (IQR 24~526), respectively, but the difference was not statistically significant (P = 0.183). T-SPOT.TB on PEMCs appeared to be a valuable and rapid diagnostic method for diagnosis of tuberculous pericarditis with high sensitivity and specificity.

Sanguineous Pericardial Effusion and Cardiac Tamponade in the Setting of Graves' Disease: Report of a Case and Review of Previously Reported Cases

Introduction. Pericardial effusion in the setting of hyperthyroidism is rare. We present a patient with Graves' disease who developed a sanguineous pericardial effusion and cardiac tamponade. Case Description. A 76-year-old man presenting with fatigue was diagnosed with Graves' disease and treated with methimazole. Two months later, he was hospitalized for uncontrolled atrial fibrillation. Electrocardiography showed diffuse low voltage and atrial fibrillation with rapid ventricular rate. Chest radiograph revealed an enlarged cardiac silhouette and left-sided pleural effusion. Thyroid stimulating hormone was undetectable, and free thyroxine was elevated. Diltiazem and heparin were started, and methimazole was increased. Transthoracic echocardiography revealed a large pericardial effusion with cardiac tamponade physiology. Pericardiocentesis obtained 1,050 mL of sanguineous fluid. The patient progressed to thyroid storm, treated with propylthiouracil, potassium iodine, hydrocortisone, and cholestyramine. Cultures and cytology of the pericardial fluid were negative. Thyroid hormone markers progressively normalized, and he improved clinically and was discharged. Discussion. We found 10 previously reported cases of pericardial effusions in the setting of hyperthyroidism. Heparin use may have contributed to the sanguineous nature of our patient's pericardial effusion, but other reported cases occurred without anticoagulation. Sanguineous and nonsanguineous pericardial effusions and cardiac tamponade may be due to hyperthyroidism.

The role of early contrast-enhanced chest computed tomography in the aetiological diagnosis of patients presenting with cardiac tamponade or large pericardial effusion

AIMS

The role of chest computed tomography (CT) is not well defined for either diagnosis or management of pericardial disease. The aim of this study was to evaluate the added value of early chest CT in the diagnostic workup for patients presenting with cardiac tamponade or large pericardial effusion of unknown aetiology as the first manifestation of disease.

METHODS AND RESULTS

We performed CT scan on 55 patients with pericardial effusion as defined above, undergoing echo-guided pericardiocentesis. We compared the success rate in making diagnosis and/or staging the underlying disorder of three sequential workups, including, respectively, (i) clinical presentation, inflammatory markers, chest X-ray imaging, (ii) all of the above and pericardial fluid analysis, and (iii) all of the above and chest CT. We were able to make diagnosis in 53 patients (96%): the major cause of effusion was malignancy (38%). Clinical and biochemical data were not able to differentiate non-tumour from tumour patients. CT revealed pathological findings in all patients with malignancy: tumour mass in 15/21 (71%) and pathological lymphadenopathy in the remaining 6 cases. The workup including CT provided a significantly higher diagnostic yield than the other two workups (P < 0.0001), both in the overall population and in the two subgroups of neoplastic (Npl) and non-Npl patients.

CONCLUSION

In all patients with cardiac tamponade or large pericardial effusion, CT was useful either in identifying the underlying disease or in excluding other potential causes of pericardial effusion. We conclude that chest CT is a very useful non-invasive diagnostic tool to identify and stage pericardial diseases.

Echo-guided pericardiocentesis in patients with clinically significant pericardial effusion. Outcomes over a 10-year period

BACKGROUND

The purpose of the present study is to evaluate current echocardiographically (echo)-guided pericardiocentesis practice with regard to procedural success, complication rate, etiological causes, and outcomes of patients with clinically significant pericardial effusion.

PATIENTS AND METHODS

Patients who underwent echo-guided pericardiocentesis between January 2004 and February 2014 were identified using an institutional code for the procedure. Other complementary data were obtained by interviewing patients or their relatives (directly or by telephone) and by searching the social security death index.

RESULTS

A total of 301 patients were identified. The pericardium was approached via the subcostal (85 %) or apical (15 %) route under echo guidance in all procedures. The success rate was 97 %, with an intervention-requiring complication rate of 1.3 %. No patient died from complications. The most common etiology was malignancy (n = 84, 28 %). Patients were followed-up for a median of 35 months. Median survival for patients with malignant effusion was 5.9 months compared with 54 months for those with nonmalignant effusion.

CONCLUSIONS

Echo-guided pericardiocentesis has a high success and low complication rate in current practice. Among etiologies, malignancy remains the most common cause of clinically significant pericardial effusion and is associated with a poor prognosis.

A patient with primary pericardial synovial sarcoma who presented with cardiac tamponade: a case report and review of the literature

A 36-year-old man presented with near-syncope. He was found to have massive pericardial effusion with a giant pericardial tumorous lesion. The pericardial effusion exhibited a bloody nature; however, neither malignant cells nor infectious organisms were detected. (18)F-fluorodeoxyglucose-positron emission tomography (FDG-PET) showed an increased uptake of FDG in the pericardial tumor only. Although the tumor was not resectable, thoracotomy and tissue sampling were performed. A histological analysis showed CD99 positivity and SYT gene rearrangement, leading to a diagnosis of synovial sarcoma arising from the left lateral pericardial surface. The patient is now receiving chemotherapy.

Management of pericardial effusion

Pericardial effusion is a common finding in clinical practice either as incidental finding or manifestation of a systemic or cardiac disease. The spectrum of pericardial effusions ranges from mild asymptomatic effusions to cardiac tamponade. The aetiology is varied (infectious, neoplastic, autoimmune, metabolic, and drug-related), being tuberculosis the leading cause of pericardial effusions in developing countries and all over the world, while concurrent HIV infection may have an important promoting role in this setting. Management is guided by the haemodynamic impact, size, presence of inflammation (i.e. pericarditis), associated medical conditions, and the aetiology whenever possible. Pericardiocentesis is mandatory for cardiac tamponade and when a bacterial or neoplastic aetiology is suspected. Pericardial biopsy is generally reserved for cases with recurrent cardiac tamponade or persistence without a defined aetiology, especially when a bacterial or neoplastic aetiology is suspected and cannot be assessed by other conventional and less invasive means. A true isolated effusion may not require a specific treatment if the patient is asymptomatic, but large ones are at risk of progression to cardiac tamponade (up to one third). Pericardiocentesis alone may be curative for large effusions, but recurrences are also common and pericardiectomy or less invasive options (i.e. pericardial window) should be considered with recurrent cardiac tamponade or symptomatic pericardial effusion (either circumferential or loculated). The aim of this paper was to summarize and critically evaluate current knowledge on the management of pericardial effusion.