Outcomes of clinically significant idiopathic pericardial effusion requiring intervention

Asymptomatic Chronic Large Pericardial Effusions: To Drain or to Observe?

Pericardial effusions, especially large ones, have traditionally been regarded with concern by clinicians due to the sometimes unpredictable development of life-threatening cardiac tamponade. In the European Society of Cardiology Guidelines on pericardial diseases, the simplified algorithm for pericardial effusion triage and management recommends pericardial drainage in cases of cardiac tamponade and/or suspicion of bacterial or neoplastic etiology. In the presence of acute pericarditis, empiric anti-inflammatory treatment should be given, while when a specific indication known to be associated with pericardial effusion is found, then treatment of the underlying cause is indicated. Notably, the most challenging subgroup of patients includes those with large, asymptomatic, C-reactive-protein-negative, idiopathic effusions. In the latter subjects, pericardial drainage is proposed in cases of chronic effusions (lasting more than three months). However, this recommendation is based on scant data stemming from small-sized non-randomized studies. Nevertheless, recent evidence in a larger cohort of patients pointed out that a watchful waiting strategy is a safe option in terms of complication-free survival. This review summarizes the contemporary evidence on this challenging topic and provides recommendations for tailoring individual patient treatments.

Prognostic Utility of Pericardial Effusion in the General Population: Findings From the STAAB Cohort Study

BACKGROUND

The incidental finding of a pericardial effusion (PE) poses a challenge in clinical care. PE is associated with malignant conditions or severe cardiac disease but may also be observed in healthy individuals. This study explored the prevalence, determinants, course, and prognostic relevance of PE in a population-based cohort.

METHODS AND RESULTS

The STAAB (Characteristics and Course of Heart Failure Stages A/B and Determinants of Progression) cohort study recruited a representative sample of the population of Würzburg, aged 30 to 79 years. Participants underwent quality-controlled transthoracic echocardiography including the dedicated evaluation of the pericardial space. Of 4965 individuals included at baseline (mean age, 55±12 years; 52% women), 134 (2.7%) exhibited an incidentally diagnosed PE (median diameter, 2.7 mm; quartiles, 2.0-4.1 mm). In multivariable logistic regression, lower body mass index and higher NT-proBNP (N-terminal pro-B-type natriuretic peptide) levels were associated with PE at baseline, whereas inflammation, malignancy, and rheumatoid disease were not. Among the 3901 participants attending the follow-up examination after a median time of 34 (30-41) months, PE was found in 60 individuals (1.5%; n=18 new PE, n=42 persistent PE). Within the follow-up period, 37 participants died and 93 participants reported a newly diagnosed malignancy. The presence of PE did not predict all-cause death or the development of new malignancy.

CONCLUSIONS

Incidental PE was detected in about 3% of individuals, with the vast majority measuring <10 mm and completely resolving. PE was not associated with inflammation markers, death, incident heart failure, or malignancy. Our findings corroborate the view of current guidelines that a small PE in asymptomatic individuals can be considered an innocent phenomenon and does not require extensive short-term monitoring.

Safety and feasibility of thoracoscopic pericardial window in recurrent pericardial effusion - A single-centre experience

BACKGROUND

This study aimed to report the surgical outcomes and also evaluating the safety and feasibility of thoracoscopic pericardial window (PW) for recurrent pericardial effusion.

MATERIALS AND METHODS

This was a retrospective analysis of eight cases of recurrent pericardial effusion, managed by thoracoscopic method in a tertiary-level thoracic surgery centre over 5 years. A detailed analysis of all perioperative variables, including complications, was carried out.

RESULTS

A total of eight patients underwent thoracoscopic PW during the study period. Males (87.5%) were predominant in the cohort. The median age was 54 years (range: 28-78 years). The median duration of symptoms was 2 months (range: 1-3 months). Tuberculosis (50%), malignancy (37.5%) and chronic kidney disease (12.5%) were the causes of recurrent effusion. All patients underwent thoracoscopic procedure with no conversions. The median operative time was 45 min (range: 40-70 min). The median effusion volume drained was 500 ± 100 ml. The median hospital stay was 3 days (range: 2-4 days) with no post-procedural complications. All the patients had complete resolution of symptoms. No recurrence was noted in the median follow-up period of 28 months (range: 6-60 months).

CONCLUSIONS

Thoracoscopic PW is a safe and feasible minimally invasive option in the management of recurrent pericardial effusion in selected patients. Surgical fitness, haemodynamic status and estimated survival (in malignant effusion) should be considered before the procedure.

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.

Chronic Pericardial Effusion: Causes and Management

Chronic pericardial effusion is a common pericardial syndrome whose approach has been well standardised in recent years. The main challenge associated with this condition is the progression (sometimes unheralded) to cardiac tamponade. Pericardial effusions may present either as an isolated finding or in the context of a specific etiology including autoimmune, neoplastic, or metabolic disease. Among investigations used during diagnostic work-up, echocardiography is of paramount importance for the diagnosis, sizing, and serial evaluation of the hemodynamic impact of effusions on heart diastolic function. In an individualised manner, advanced imaging including computed tomography and cardiac magnetic resonance imaging should be performed, especially if baseline tests are inconclusive. Triage of these patients according to the most recent 2015 European Society of Cardiology Guidelines for the diagnosis and management of pericardial diseases should take into account the presence of hemodynamic compromise as well as suspicion of malignant or purulent pericarditis as first step, C-reactive protein serum level measurement as second step, investigations for a specific condition known to be associated with pericardial effusion as third step, and finally the size and the duration of the effusion. Treatment depends on the evaluation of the above-mentioned parameters and should ideally be tailored to the individual patient. Prognosis of chronic pericardial effusions depends largely on the underlying etiology. According to novel data, the prognosis of individuals with idiopathic, chronic (> 3 months), large (> 2 cm), asymptomatic pericardial effusions is usually benign and a watchful waiting strategy seems more reasonable and cost-effective than routine drainage as previously recommended.

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.

Demographic, clinical and etiological profile of pericardial effusion in India: A single centre experience

INTRODUCTION

Pericardial effusion (PE) is a life-threatening condition. However, there are very few Indian studies which determined etiological distribution. The current retrospective observational study was carried out to assess etiological factors responsible for PE in a tertiary care centre in India.

METHODS

The study enrolled consecutive 55 patients with the diagnosis of moderate to large PE as established by echocardiography between January 2018 and December 2018. The echocardiography guided percutaneous pericardiocentesis was performed by the standard procedure.

RESULTS

Amongst the enrolled PE patients in the study, 30 (54.55%) were males and 25 (45.45%) were females, with the average age of 43.00 ± 15.54 years. In clinical assessment, tamponade was found in 52 (94.54%) patients. Tuberculosis was the most common etiology for PE (n=35, 63.64%) followed by hypothyroidism (n = 6, 10.9%), and malignancies (n = 4, 7.27%). Among 12.72% patients, the PE was of recurrent type. Additionally, no death or any complication was encountered during pericardiocentesis.

CONCLUSION

Pericardial disease and effusion is a major cause of morbidity in India. Despite developments in the healthcare facilities, tuberculosis was the most common etiology for PE. Additionally, the raised number of hypothyroid and malignant PE cases demonstrates the changing etiological trends, similar to western countries.

Upper Back Pain: A Rare Clinical Presentation in Pericardial Effusion

Pericardial effusion is an important cardiac condition seen in clinical practice with several known underlying etiologies. We are aware of the challenge that exists in diagnosing the effusion. An interesting challenge that has caught our attention is the highest chance of missing the diagnosis if there is an atypical clinical presentation of the patient. In this case report, our objective is to discuss a case that enhances the importance of careful and meticulous investigation of a patient with an atypical clinical picture. This is a case report of a 92-year-old woman who presented to the emergency department with a chief complaint of upper back pain for a few days. She was found to have cardiomegaly on further imaging. An echocardiogram showed a moderate size pericardial effusion. Pericardiocentesis was done and a drain was left in place. Of note, the patient reported remarkable resolution of the back pain after the fluid was taken out. The serial echocardiogram post pericardiocentesis showed minimal drainage, hence the drain was taken out, and the patient was observed for clinical monitoring 24 hours post drain removal. A timely diagnosis and treatment saved our patient from the most dreadful life-threatening condition along with a secure discharge from the hospital.

Pathological Findings of Canine Idiopathic Pericarditis and Pericardial Mesotheliomas: Correlation with Clinical and Survival Data

Idiopathic pericarditis (IP) and pericardial mesothelioma (PM) are causes of pericardial effusion in dogs. Pericardiectomy can be a definitive treatment in the case of idiopathic pericardial effusion or a short-term intervention for mesothelioma. The aim of the present study was to investigate which histopathologic parameters are correlated with clinical outcomes in a cohort of dogs that underwent pericardiectomy. The histopathological findings of 22 IPs and 5 PMs were compared with clinical and survival data and the immunohistochemical characterization of immune cells (CD3, CD79α, Iba1). In IP, the mesothelium was lost in 20 cases, reactive in 9, atypical in 3, and mesothelial papillary hyperplasia (MPH) was observed in 4 cases. Numerous macrophages were found in both IPs and PMs especially at the superficial layer of the pericardium. T lymphocytes were observed in mild to moderate numbers and were more numerous than B lymphocytes in both IPs and PMs. MPH was correlated with the quantity of lymphoplasmacytic infiltrate in the superficial layer, inversely related to the thickness of the pericardium, and associated with a longer overall survival. Pericardial fibrosis was present in 19 out of 22 IPs and in all mesotheliomas and was correlated with increased time from initial presentation and pericardiectomy and lymphoplasmacytic infiltrate in the deep zone. Pericardial thickness was correlated with the amount of lymphoplasmacytic and macrophagic infiltrate in the deep zone. Mesothelioma was associated with an increased number of pericardiocentesis procedures before pericardiectomy and with the presence of macrophages in the superficial pericardial layer, edema, fibrin, and hemorrhage. Disease-free interval and overall survival were significantly shorter in patients with mesothelioma compared with IP.

Effusive-constrictive pericarditis in the spectrum of pericardial compressive syndromes

When pericardial fluid accumulates and exceed the reserve volume of the pericardium or when the pericardium becomes scarred and inelastic, one of three pericardial compressive syndromes may ensue, namely, cardiac tamponade (CT), characterised by the accumulation of pericardial fluid under pressure; constrictive pericarditis (CP), the result of scarring and loss of the normal elasticity of the pericardial sac; and effusive-constrictive pericarditis (ECP), characterised by the concurrence of a tense pericardial effusion and constriction of the heart by the visceral pericardium. Although relatively uncommon, prevalence estimates vary widely and depend on the nature of the cohorts studied, the methods used to diagnose ECP and the manner in which ECP is defined. Most cases of ECP are idiopathic, reflecting the frequency of idiopathic pericardial disease in general, and other causes include radiation, malignancy, chemotherapy, infection and postsurgical/iatrogenic pericardial disease. The diagnosis of ECP often becomes apparent when pericardiocentesis fails to decrease the right atrial pressure by 50% or to a level below 10 mm Hg. Important non-invasive diagnostic modalities include echocardiography, cardiac magnetic resonance and, to a lesser extent, cardiac CT. In cases with clear evidence of pericardial inflammation, a trial of an anti-inflammatory regimen is warranted. A complete pericardiectomy should be reserved for refractory symptoms or clinical evidence of chronic CP.

Prospective evaluation of pericardial catheter placement versus needle pericardiocentesis in the management of canine pericardial effusion

OBJECTIVE

To compare the safety and efficacy of pericardial catheter placement with needle pericardiocentesis in dogs with pericardial effusion (PE) DESIGN: Prospective, randomized clinical trial.

SETTING

University teaching hospital.

ANIMALS

Thirty client-owned dogs requiring pericardiocentesis between January 2017 and August 2019.

INTERVENTIONS

Dogs were randomized to undergo PE drainage via indwelling pericardial catheter placement (catheter group) followed by elective drainage every 4-6 hours or needle pericardiocentesis (needle group) repeated as necessary.

MEASUREMENTS AND MAIN RESULTS

Fifteen dogs were allocated to the catheter group and 15 to the needle group. Data collected included signalment, cause of effusion, occurrence of arrhythmias pre-, during, and post-pericardiocentesis, procedural length, and details of repeated drainages. There was no significant difference between mean procedural times for pericardial catheter placement (17.7 min [±11.8]) and needle pericardiocentesis (12.1 min [±8.6]) (P = 0.192) or the rate of new arrhythmias in the catheter (36%) and needle (64%) groups (P = 0.24). Pericardial catheters were kept in situ for a median of 21 hours (range, 14-85). Three of 15 (20%) dogs in the needle group required repeated pericardiocentesis within 24 hours of initial pericardiocentesis. Pericardial catheters enabled repeated large volume PE drainage in 4 cases (median, 10.6 mL/kg; range, 8-5-10.6).

CONCLUSIONS

Pericardial catheters appear to offer a safe alternative to needle pericardiocentesis. Minimal sedation is required for placement, and they can be placed quickly. Their indwelling nature and use was not associated with a higher rate of arrhythmia compared to that of needle pericardiocentesis alone, and may be beneficial in the event that clinically significant PE recurs.

Is malignancy associated with pericardial effusion fluid volume or fluid character?

INTRODUCTION

Pericardial effusion develops due to different etiologies. The main goals of our study are to understand the etiology and determine whether the amount of pericardial effusion is significant in terms of malignancy.

MATERIAL AND METHODS

142 patients with pericardial effusion, who met the criteria between 1 January 2014 and 1 January 2019, were retrospectively analyzed. All of these patients underwent operation with the subxiphoidal approach. The fluid samples were sent to the microbiology and pathology laboratories for evaluation. Patients underwent follow-up after 1 month.

RESULTS

Of the patients included in this study, 72 (61%) of 118 patients were operated on under general anesthesia with a laryngeal mask, and 46 (39%) underwent sedation and local anesthesia. The etiologies found in patients were as follows: effusions resulting from malignancy in 27 (22.9%), idiopathic in 24 (20.3%), cardiac causes (depending on the use of anticoagulants or postoperation) in 22 (18.6%), uremia in 20 (16.9%), infection in 18 (15.3%), and heart failure in 7 patients. The amount of fluid drained from the patients was 661.61 ± 458.34 mL. Out of 27 patients with malignancy, 21 (77.8%) had drainage over 500 mL of effusion fluid, and 6 (22.2%) had drainage under 500 mL. Patients who had positive results tended to have drainage over 500 mL compared with patients who had negative results in terms of malignancy (P = .033).

CONCLUSION

The subxiphoidal approach to pericardial effusion is an easily applicable operation, whether therapeutic or diagnostic. The advantages of the subxiphoidal approach include drainage of all of the fluid and ease of sampling the pericardial fluid. We believe that the amount of fluid drained can lead us to consider malignancy as an etiology.

Long-Term Outcome of Pericardial Drainage in Cases of Chronic, Large, Hemodynamically Insignificant, C-Reactive Protein Negative, Idiopathic Pericardial Effusions

Pericardial effusion (PE) prognosis depends on the underlying etiology. We sought to assess the outcome of patients with chronic (>3 months), large (diastolic echo-free space >2 cm), idiopathic (without apparent etiology), C-reactive protein (CRP) negative PE, a topic where data are lacking. A total of n = 74 patients were enrolled in this study. Patients were treated by pericardiocentesis (n = 39) or surgical pericardial "window" (PW) (n = 13) or conservatively (n = 22). The median follow-up was 24 months (interquartile range: 15 to 38). Among those patients who had PE drained (n = 52), PE re-accumulation occurred in 32 cases (61.5%) and the rate was significantly higher in the pericardiocentesis subgroup (76.9% for pericardiocentesis vs 15.4% for PW group, p <0.001). Patients with re-accumulation had longer disease duration (32.1 ± 25.7 months vs 19.5 ± 23.8 months, p = 0.01), higher maximum PE diameter (32.2 ± 9.4 mm vs 26.1 ± 4.9 mm, p = 0.003) and larger PE volume drained at baseline (1,912 ± 707 mL vs 1,508 ± 387 mL, p = 0.04). Large PE re-accumulation occurred in 41% of patients who underwent pericardiocentesis and in 7.7% of those who underwent PW. In Cox survival analysis the only independent predictor of fluid re-accumulation was the type of intervention, with PW being associated with significantly reduced risk (hazard ratio 0.115, 95% confidence interval 0.015 to 0.875, p = 0.037). Major complications needing treatment were recorded in 12.8% and 15.4% (p = 0.999) of patients who underwent pericardiocentesis and PW, respectively. Moreover, invasive procedures were not helpful in establishing new diagnoses and guide treatment. In conclusion, in asymptomatic patients with chronic, large, hemodynamically insignificant, CRP negative, idiopathic PE, conservative management seems a more reasonable approach in most cases.

Temporal trends, outcomes, and predictors of mortality after pericardiocentesis in the United States

BACKGROUND

Data regarding the temporal trends, outcomes, and predictors of in-hospital mortality after pericardiocentesis are limited.

METHODS

The National Inpatient Sample database was used to extract hospitalizations of patients who underwent pericardiocentesis from January 2007 to September 2015. We examined the rates of in-hospital mortality, its predictors, and the temporal trends of pericardiocentesis utilization in the United States during the study period. We also examined trends and outcomes of pericardiocentesis associated with different cardiovascular procedures.

RESULTS

A total of 96,377 hospitalizations with pericardiocentesis were examined. The number of pericardiocentesis procedures performed trended up significantly between 2007 and 2015 (p trend <.001), and this increase was observed predominantly in patients with unstable conditions. In-hospital mortality after pericardiocentesis decreased over time (14.6% in 2007 vs. 12.0% in 2015, p trend <.001), but remained higher than that after surgical pericardial intervention (13.1 vs. 8.9%, p value <.0001), predominantly attributable to a higher patient risk profile. Rates of in-hospital mortality were not statistically different between the procedural cohort and the nonprocedural cohort, 13.5 versus 13.0%, p value = .051. After multivariable adjustment, structural heart interventions (odds ratio [OR] 2.86; 95% confidence interval [CI] 2.35-3.49), bacterial and/or infective endocarditis (OR 2.09; 95% CI 1.72-2.54) and active neoplasms (OR 1.72; 95% CI 1.6-1.85) were independently associated with increased in-hospital mortality in pericardiocentesis patients.

CONCLUSION

In this nationwide analysis, the number of pericardiocentesis procedures increased significantly over time. Structural interventions, endocarditis, and active neoplasms were associated with increased in-hospital mortality after pericardiocentesis.

[Management of pericarditis and pericardial effusion, constrictive and effusive-constrictive pericarditis]

This CME review takes stock of the progress in the etiology, pathophysiology, diagnostics and treatment of pericarditis and pericardial effusion brought about by the publication of the 2nd European Society of Cardiology (ESC) guidelines on the management of pericardial diseases in 2015. It also emphasizes special forms, which have received less attention in the past, such as therapy-refractory (incessant), effusive-constrictive and constrictive pericarditis and the treatment of acute and recurrent pericarditis with colchicine. After the diagnosis of pericarditis with or without effusion has been made, the first step is to clarify its etiology, which affects the clinical symptoms, course, treatment and the prognosis. In this aspect the requirements of the guidelines and the reality of an etiological classification of pericardial diseases diverge in many cases. The diagnosis of "idiopathic" acute or recurrent pericarditis is still much too often the result of insufficient efforts to find the cause. Too often only malignant and bacterial forms are excluded. If the etiology is known local intrapericardial treatment with the already inserted pigtail catheter from the diagnostic pericardial puncture can be carried out with few systemic side effects. The 2015 ESC guidelines recommend colchicine as first line treatment in all forms of pericarditis except for neoplastic pericardial effusion. It accelerates healing and reduces the frequency of recurrence of pericarditis but cannot eliminate recurrence completely. The best treatment and prevention of recurrence is the eradication of the underlying etiological cause.

Retrospective evaluation of pericardial catheter placement in the management of pericardial effusion in dogs (2007-2015):18 cases

OBJECTIVE

To describe the use of pericardial catheters in dogs with pericardial effusion (PE), and detail any associated adverse events.

DESIGN

Retrospective study.

SETTING

University teaching hospital.

ANIMALS

Eighteen client-owned dogs that had pericardial catheters placed for pericardial fluid drainage between May 2007 and January 2015.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

All pericardial catheters were placed within 5 hours of presentation, usually within 1 hour (median 72.5 min, range 45-300 min). Ten of 18 cases were sedated with butorphanol, and 4 with additional midazolam. Four had pericardial catheters positioned for single drainage only and were immediately removed. The other 14 pericardial catheters remained in situ for a median of 18 hours (range 2-88 h). Ten of the remaining 14 cases were redrained after pericardial catheter placement. The main adverse events reported were new arrhythmias in 6/18 cases, with 4 of these 6 patients being administered anti-arrhythmic therapy. No infectious or functional complications were reported. Ten patients were discharged, 1 died and 7 were euthanized.

CONCLUSIONS

Thoracic drainage catheters inserted into the pericardial space via a modified-Seldinger technique can be positioned in dogs to aid management of PEs. The main associated adverse event is arrhythmia. Minimal sedation is required for placement, and dogs tend not to require postprocedural analgesia. Catheters can remain in situ for repeated drainage, potentially decreasing staffing time requirement and repeat sedation. Their use is associated with a rate of arrhythmia requiring treatment of 22%, compared to that of needle pericardiocentesis alone at 13%. They are easy to position using equipment available in many facilities.

Is pericardial effusion a negative prognostic marker? Meta-analysis of outcomes of pericardial effusion

BACKGROUND

The prognostic relevance and the prevalence of pericardial effusion in several diseases are not well established. The aim of this meta-analysis is to summarize the available evidence related to pericardial effusion prevalence and outcomes according to the cause.

METHODS

Articles investigating the prognosis of pericardial effusion were identified by literature search. Twenty-three studies were finally included (17 022 patients). All-cause mortality was the primary end-point. Secondary end-point was the prevalence of pericardial effusion in most common diseases related to this clinical condition.

RESULTS

The pooled prevalence of pericardial effusion was 19.5% [95% confidence interval (CI): 14.3-26]. After a mean follow-up of 36 ± 23 months, the risk of death was higher in pericardial effusion patients [hazard ratio (HR) 1.59, 95% CI 1.37-1.85, P < 0.0001]. Stratifying for the main disease, pericardial effusion is associated with unfavourable outcome in all available subgroups: pulmonary arterial hypertension HR 1.53 (95% CI: 1.22-1.92; P < 0.0001), chronic heart failure (CHF) HR 1.53 (95% CI: 1.22-1.92; P < 0.0001), myocardial infarction HR 2.65 (95% CI: 1.4-4.99; P = 0.003) and malignancies HR 1.75 (95% CI: 1.09-2.81, P = 0.021). The lack of data concerning the idiopathic pericardial effusion does not permit a secure risk assessment but the average incidence of mortality is 14.5% (95% CI: 7.7-25.6).

CONCLUSION

Pericardial effusion should be considered a marker of the severity of the underlying disease, whereas for idiopathic pericardial effusion the correlation with poor prognosis is less clear.

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.

Diagnostic Utility of Cyfra 21-1 and Cea Assays in Pericardial Fluid for the Recognition of Neoplastic Pericarditis

A positive cytology result in pericardial fluid is the gold standard for recognition of malignant pericardial effusion. Unfortunately, in 30–50% of patients with malignant pericardial effusion cytological examination of the pericardial fluid is negative. Tumor marker assessment in pericardial fluid may help to recognize malignant pericardial effusion. The aim of our study was to estimate the value of CYFRA 21-1 and CEA measurement in pericardial fluid for the recognition of malignant pericardial effusion. To our knowledge this is the first study on CYFRA 21-1 assessment in pericardial effusion. The examined group consisted of 50 patients with malignant pericardial effusion and 34 patients with non-malignant pericardial effusion. Median CEA concentrations in malignant pericardial effusion and non-malignant pericardial effusion were 80 ng/mL (0–317) and 0.5 ng/mL (0–18.4), respectively (p<0.001). Median CYFRA 21-1 concentrations in malignant pericardial effusion and non-malignant pericardial effusion were 260 ng/mL (5.3–10080) and 22.4 ng/mL (1.87–317.6), respectively (p<0.001). The optimal cutoff value for CYFRA 21-1 in pericardial effusion was 100 ng/mL. CYFRA 21-1 >100 ng/mL or CEA >5 ng/mL were found in 14/15 patients with malignant pericardial effusion and negative pericardial fluid cytology. We therefore strongly recommend the use of CYFRA 21-1 and/or CEA in addition to pericardial fluid cytology for the recognition of malignant pericardial effusion.

Effusive-Constrictive Pericarditis After Pericardiocentesis: Incidence, Associated Findings, and Natural History

OBJECTIVES

This study sought to investigate the incidence, associated findings, and natural history of effusive-constrictive pericarditis (ECP) after pericardiocentesis.

BACKGROUND

ECP is characterized by the coexistence of tense pericardial effusion and constriction of the heart by the visceral pericardium. Echocardiography is currently the main diagnostic tool in the assessment of pericardial disease, but limited data have been published on the incidence and prognosis of ECP diagnosed by echo-Doppler.

METHODS

A total of 205 consecutive patients undergoing pericardiocentesis at Mayo Clinic, Rochester, Minnesota, were divided into 2 groups (ECP and non-ECP) based on the presence or absence of post-centesis echocardiographic findings of constrictive pericarditis. Clinical, laboratory, and imaging characteristics were compared.

RESULTS

ECP was subsequently diagnosed in 33 patients (16%) after pericardiocentesis. Overt clinical cardiac tamponade was present in 52% of ECP patients and 36% of non-ECP patients (p = 0.08). Post-procedure hemopericardium was more frequent in the ECP group (33% vs. 13%; p = 0.003), and a higher percentage of neutrophils and lower percentage of monocytes were noted on pericardial fluid analysis in those patients. Clinical and laboratory findings were otherwise similar. Baseline early diastolic mitral septal annular velocity was significantly higher in the ECP group. Before pericardiocentesis, respiratory variation of mitral inflow velocity, expiratory diastolic flow reversal of hepatic vein, and respirophasic septal shift were significantly more frequent in the ECP group. Fibrinous or loculated effusions were also more frequently observed in the ECP group. Four deaths occurred in the ECP group; all 4 patients had known malignancies. During median follow-up of 3.8 years (interquartile range: 0.5 to 8.3 years), only 2 patients required pericardiectomy for persistent constrictive features and symptoms.

CONCLUSIONS

In a large cohort of unselected patients undergoing pericardiocentesis, 16% were found to have ECP. Pre-centesis echocardiographic findings might identify such patients. Long-term prognosis in those patients remains good, and pericardiectomy was rarely required.

Performance, pain, and quality of life on use of central venous catheter for management of pericardial effusions in patients undergoing coronary artery bypass graft surgery

Different pericardial catheters have been suggested as an effective alternative method for drainage of pericardial effusion. The aim of this study was to determine the performance, pain, and quality of life on use of central venous catheter (CVC) for drainage of pericardial effusion in patients undergoing open heart surgery. Fifty-five patients who had developed pericardial effusion after an open heart surgery (2012-2015) were prospectively assessed. Triple-lumen central catheters were inserted under echocardiographic guidance. Clinical, procedural, complication, and outcome details were analyzed. Intensity of pain and quality of life of patients were assessed using the numerical rating scale and Short-Form Health Survey. CVC was inserted for 36 males and 19 females, all of whom had a mean age of 58.5±15 years, and the mean duration of the open heart surgery was 8±3.5 hours. The mean central venous pressure catheter life span was 14.6 days. No cases of recurrent effusion and complication were reported. The technical success rate of procedure was 100%. Intensity of pain and quality of life of patients had improved during follow-up. CVC insertion is a safe and effective technique for the management of pericardial effusion in patients after open heart surgery.

Predictors of tamponade and constriction in patients with pericardial disease undergoing interventional and surgical treatment

OBJECTIVE

The aim of our study was to define predictors of cardiac compression development including clinical, electrocardiographic, echocardiographic, chest-X-ray and perioperative parameters and their diagnostic value.

METHODS

Overall 243 patients with pericardial disease, among them 123 with compression (tamponade, constriction) and 120 without signs of compression were included in the study. Clinical, laboratory, electrocardiographic, chest-X-Ray, echocardiographic and perioperative data were included in the logistic regression analysis to define predictors of tamponade/constriction development.

RESULTS

Logistic regression analysis demonstrated large effusion (> 20 mm) (OR 5.393, 95%CI 1.202-24.199, p = 0.028), cardiac chamber collapse (OR 31.426, 95%CI 1.609-613-914, p = 0.023) and NYHA class > 3 (OR 8.671, 95%CI 1.730-43.451, p = 0.009) were multivariable predictors of compression development. The model including these three variables allowed predicting compression in 91.7% of cases. ROC analyses demonstrated that all three variables had significant diagnostic value with sensitivity of 75.6% and specificity of 74.2% for large effusion, low sensitivity and high specificity for cardiac chamber collapse (35% and 92%) and NYHA class (32.5% and 94.2%).

CONCLUSION

The independent predictors of compression development are presence of large effusion > 20 mm, cardiac chamber collapse and high NYHA class. The model including all three parameters allows correctly predicting compression in 91.4% of cases. The diagnostic accuracy of each parameter is characterized by high sensitivity and specificity of large effusion, high specificity of cardiac chamber collapse and NYHA class.

Efficacy and safety of thoracoscopic pericardial window in patients with pericardial effusions: a single-center case series

Background

Pericardial effusion (PE) is a common finding in patients who had chronic cardiac failure, who had undergone cardiac surgery, or who had certain other benign and malignant diseases. PE ranges in severity from mild, asymptomatic effusions to cardiac tamponade. Although a thoracoscopic pericardial window (TPW) is a minimally invasive surgical option for patients with PE, there are few published data regarding the outcomes of TPW for PE. We investigated the contribution of the TPW to the treatment of PEs that are recurrent or difficult to drain percutaneously.

Methods

We conducted a retrospective chart review of the indications for TPW that included data on preoperative, intraoperative, and postoperative variables; morbidity; recurrence; and survival. Fourteen consecutive patients with PE that was recurrent or difficult to drain percutaneously and who underwent treatment with a TPW were enrolled in this study. Trocars for passage of the thoracoscope and surgical instruments were introduced through two or three incisions. Mini-thoracotomy was also performed in patients with hemopericardium and loculated fibrinous effusions. All patients were evaluated by face-to-face interviews, transthoracic echocardiography (TTE), and chest radiography 3–6 months after the TPW was obtained.

Results

The mean age of the patients was 70 years (range 28–83 years). The operative time was 72.1 ± 29.5 min. Six patients had undergone open heart surgery during the month prior to their presentation with PE. No intraoperative or postoperative complications occurred, although PE had recurred in one patient. Two patients died of malignant disease several months after the TPW. The cardiothoracic ratio (determined on chest radiographs) and the ejection fraction ratio (determined using TTE) had improved at the 3- and 6-month follow-up evaluations (p < 0.0001 and p = 0.012, respectively). Some patients could discontinue diuretics after the procedure, as assessed by the cardiologist based on symptom alleviation, chest radiography, and TTE findings.

Conclusions

For patients with PEs that are recurrent or difficult to drain percutaneously, TPW is an effective, safe surgical approach in terms of cardiac function and radiological findings.

Complications of pericardiocentesis: A clinical synopsis

Pericardiocentesis (PC) is both a diagnostic and a potentially life-saving therapeutic procedure. Currently echocardiography-guided pericardiocentesis is considered the standard clinical practice in the treatment of large pericardial effusions and cardiac tamponade. Although considered relatively safe, this invasive procedure may be associated with certain risks and potentially serious complications. This review provides a summary of pericardiocentesis and a focused overview of the potential complications of this procedure.

Acute cardiac tamponade: an unusual cause of acute renal failure in a renal transplant recipient

We report a case of slow graft function in a renal transplant recipient caused by uremic acute pericardial effusion with tamponade. Urgent pericardiocentesis was done with an improvement in blood pressure, immediate diuresis, and quick recovery of renal function back to baseline. Pericardial tamponade should be included in consideration of causes of type 1 cardiorenal syndrome in renal transplant recipients.

Pericardiocentesis adverse event risk factors: a nationwide population-based cohort study

OBJECTIVES

Echocardiography-guided pericardiocentesis has been the leading procedure for diagnosis and therapy of pericardial effusion. We aimed to identify risk factors for recurrence, complications, and mortality in pericardial effusion patients treated with pericardiocentesis.

METHODS

We identified and collected data from 8,101 patients receiving pericardiocentesis between 1997 and 2010 from the Taiwan National Health Insurance Research Database. A multivariate regression model was used to investigate risk factors for recurrence, complications, and death.

RESULTS

There were 8,565 admissions among 8,101 patients. The most common underlying condition was malignancy (41%), especially lung cancer (23%), tuberculosis (9.0%), and acute pericarditis (8.2%). Surgical drainage was required in 12.7% of cases. Recurrence was more likely in patients with malignancy (HR 2.20, p < 0.001), but complications were less likely (OR 0.52, p = 0.003). In-hospital death numbers and complication risks (OR 2.38, p < 0.001; OR 1.27, p = 0.01) were greater in the catheter-related cardiac procedure group than in the other groups.

CONCLUSIONS

Malignant neoplasms and catheter-based cardiac procedures have become major risk factors for adverse events in patients receiving pericardiocentesis in Taiwan. Malignancy leads to an increase in recurrence and in-hospital mortality but is associated with a lower rate of acute complications. Cardiac catheterization procedures and surgery increase both complications and in-hospital mortality.

Aspiration in injections: should we continue or abandon the practice?

Aspiration during any kind of injection is meant to ensure that the needle tip is at the desired location during this blind procedure. While aspiration appears to be a simple procedure, it has generated a lot of controversy concerning the perceived benefits and indications. Advocates and opponents of aspiration both make logically sound claims. However, due to scarcity of available data, there is no evidence that this procedure is truly beneficial or unwarranted. Keeping in view the huge number of injections given worldwide, it is important that we draw attention to key questions regarding aspiration that, up till now, remain unanswered. In this review, we have attempted to gather and present literature on aspiration both from published and non-published sources in order to provide not only an exhaustive review of the subject, but also a starting point for further studies on more specific areas requiring clarification. A literature review was conducted using the US National Institute of Health’s PubMed service (including Medline), Google Scholar and Scopus. Guidelines provided by the World Health Organization, Safe Injection Global Network, International Council of Nursing, Center for Disease Control, US Federal Drug Agency, UK National Health Services, British Medical Association, Europe Nursing and Midwifery Council, Public Health Agency Canada, Pakistan Medical Association and International Organization of Standardization recommendations 7886 parts 1-4 for sterile hypodermics were reviewed for relevant information. In addition, curricula of several medical/nursing schools from India, Nigeria and Pakistan, the US pharmacopeia Data from the WHO Program for International Drug Monitoring network in regard to adverse events as a result of not aspirating prior to injection delivery were reviewed. Curricula of selected major medical/nursing schools in India, Nigeria and Pakistan, national therapeutic formularies, product inserts of most commonly used drugs and other possible sources of information regarding aspiration and injections were consulted as well.

Effusive-constrictive pericarditis

Effusive-constrictive pericarditis (ECP) is an increasingly recognized clinical syndrome. It has been best characterized in patients with tamponade who continue to have elevated intracardiac pressure after the removal of pericardial fluid. The disorder is due to pericardial inflammation causing constriction in conjunction with the presence of pericardial fluid under pressure. The etiology is diverse with similar causes to constrictive pericarditis and the condition is more prevalent with certain etiologies such as tuberculous pericarditis. The diagnosis is most accurately made using simultaneous intrapericardial and right atrial pressure measurements with pericardiocentesis, although non-invasive Doppler hemodynamic assessment can assess residual hemodynamic findings of constriction following pericardiocentesis. The clinical presentation has considerable overlap with other pericardial syndromes and as yet there are no biomarkers or non-invasive findings that can accurately predict the condition. Identifying patients with ECP therefore requires a certain index of clinical suspicion at the outset, and in practice, a proportion of patients may be identified once there is objective evidence for persistent atrial pressure elevation after pericardiocentesis. Although a significant number of patients will require pericardiectomy, a proportion of patients have a predominantly inflammatory and reversible pericardial reaction and may improve with the treatment of the underlying cause and the use of anti-inflammatory medications. Patients should therefore be observed for the improvement on these treatments for a period, whenever possible, before advocating pericardiectomy. Imaging modalities identifying ongoing pericardial inflammation such as contrast-enhanced magnetic resonance imaging or nuclear imaging may identify those subsets more likely to respond to medical therapies. Pericardiectomy, if necessary, requires removal of the visceral pericardium.

The prevalence and outcome of effusive constrictive pericarditis: a systematic review of the literature

There is sparse information on the epidemiology of effusive constrictive pericarditis (ECP). The objective of this article was to review and summarise the literature on the prevalence and outcome of ECP, and identify gaps for further research. The prevalence of ECP ranged from 2.4 to 14.8%, with a weighted average of 4.5% [95% confidence interval (CI) 2.2-7.5%]. Sixty-five per cent (95% CI: 43-82%) of patients required pericardiectomy regardless of the aetiology. The combined death rate across the studies was 22% (95(CI: 4-50%). The prevalence of ECP is low in non-tuberculous pericarditis, while pericardiectomy rates are high and mortality is variable. In this review, of 10 patients identified with tuberculous ECP, only one presumed case had a definite diagnosis of ECP. Appropriate studies are needed to determine the epidemiology of ECP in tuberculous pericarditis, which is one of the leading causes of pericardial disease in the world.

Frequency of recurrence of pericardial tamponade in patients with extended versus nonextended pericardial catheter drainage

Recurrence of pericardial tamponade is relatively common after pericardiocentesis. We evaluated the clinical and procedural predictors of recurrent pericardial tamponade after pericardiocentesis. We included 157 consecutive patients with pericardial tamponade (age 62 ± 18 years, 54% men) who had undergone pericardiocentesis from 2000 to 2007. An intrapericardial catheter was used for prolonged drainage of the pericardial effusion (78% of cases) at the discretion of the operator. The overall recurrence rate 11.8 ± 0.6 months after pericardiocentesis was 20% and the mean interval to recurrence was 1.2 ± 2.1 months. However, patients with extended catheter drainage had a reduced recurrence rate of 12% compared to 52% in patients without extended drainage (p <0.001). In the Cox regression modeling, absence of extended drainage (hazard ratio [HR] 4.1, 95% confidence interval [CI] 1.7 to 10, p = 0.002), incomplete drainage of pericardial effusion (HR 9.7, 95% CI 3.6 to 22.7, p <0.001), loculated effusion (HR 11.1, 95% CI 2.9 to 43, p = 0.001), and malignancy (HR 3.3, 95% CI 1.8 to 10.3, p = 0.037) independently correlated with recurrence at 1 year. In conclusion, extended pericardial drainage after catheter placement is associated with a reduced recurrence of pericardial tamponade after pericardiocentesis.

A small pericardial effusion is a marker of increased mortality

OBJECTIVE

the study aimed to evaluate the prognostic importance of an incidental small pericardial effusion found on echocardiography.

METHODS

we identified 10,067 consecutive patients undergoing echocardiography at 1 of 3 laboratories. Patients were excluded if they were referred for evaluation of the pericardium (n = 133), had cardiac surgery within the previous 60 days (n = 393), had a moderate or greater pericardial effusion (>1 cm if circumferential, n = 29), had no follow-up (n = 153), or had inadequate visualization of the pericardial space (n = 9). The Social Security Death Index was used to determine survival.

RESULTS

a small pericardial effusion was noted in 534 (5.7%) of 9,350 patients. Compared to patients without a small effusion, those with an effusion were slightly older (68 ± 13 vs 67 ± 12 years, P = .02) and had a lower ejection fraction (52% vs 55%, P < .0001). Mortality at 1 year was greater for patients with a small effusion (26%) compared to those without an effusion (11%, P < .0001). After adjustment for demographics, medical history, patient location, and other echocardiographic findings, small pericardial effusion remained associated with higher mortality (hazard ratio 1.17, 95% CI 1.09-1.28, P = .0002). Of 211 with an effusion and follow-up echocardiography (mean 547 days), 136 (60%) had resolution, 63 (28%) showed no change, and 12 (5%) had an increase in size, although no patient developed a large effusion or cardiac tamponade.

CONCLUSION

the presence of a small asymptomatic pericardial effusion is associated with increased mortality.

Severe heart failure due to subacute effusive-constrictive pericarditis in a child

We report a 9-year-old boy with progressive heart failure due to effusive-constrictive pericarditis. The patient was successfully rescued by extensive surgical removal of the thickened pericardium. The histopathological examination revealed degenerative changes of myocardium without significant inflammation, indicating that surgical pericardiectomy should be performed for subacute effusive-constrictive pericarditis before progression to definite constrictive pericarditis.

Effusive-constrictive pericarditis

BACKGROUND

Effusive-constrictive pericarditis is an uncommon pericardial syndrome characterized by concomitant tamponade, caused by tense pericardial effusion, and constriction, caused by the visceral pericardium. We conducted a prospective study of its clinical evolution and management.

METHODS

From 1986 through 2001, all patients with effusive-constrictive pericarditis were prospectively evaluated. Combined pericardiocentesis and cardiac catheterization were performed in all patients, and pericardiectomy was performed in those with persistent constriction. Follow-up ranged from 1 month to 15 years (median, 7 years).

RESULTS

A total of 1184 patients with pericarditis were evaluated, 218 of whom had tamponade. Of these 218, 190 underwent combined pericardiocentesis and catheterization. Fifteen of these patients had effusive-constrictive pericarditis and were included in the study. All patients presented with clinical tamponade; however, concomitant constriction was recognized in only seven patients. At catheterization, all patients had elevated intrapericardial pressure (median, 12 mm Hg; interquartile range, 7 to 18) and elevated right atrial and end-diastolic right and left ventricular pressures. After pericardiocentesis, the intrapericardial pressure decreased (median value, -5 mm Hg; interquartile range, -5 to 0), whereas right atrial and end-diastolic right and left ventricular pressures, although slightly reduced, remained elevated, with a dip-plateau morphology. The causes were diverse, and death was mainly related to the underlying disease. Pericardiectomy was required in seven patients, all of whom had involvement of the visceral pericardium. Three patients had spontaneous resolution.

CONCLUSIONS

Effusive-constrictive pericarditis is an uncommon pericardial syndrome that may be missed in some patients who present with tamponade. Although evolution to persistent constriction is frequent, idiopathic cases may resolve spontaneously. In our opinion, extensive epicardiectomy is the procedure of choice in patients requiring surgery.