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Adrian RJ, Alerhand S, Liteplo A, Shokoohi H. Is pulmonary hypertension protective against cardiac tamponade? A systematic review. Intern Emerg Med 2024:10.1007/s11739-024-03566-y. [PMID: 38622465 DOI: 10.1007/s11739-024-03566-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 02/14/2024] [Indexed: 04/17/2024]
Abstract
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.
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Affiliation(s)
- Robert James Adrian
- Department of Emergency Medicine, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA.
- Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA.
| | - Stephen Alerhand
- Department of Emergency Medicine, Rutgers New Jersey Medical School, 185 S. Orange Ave, Newark, NJ, 07103, USA
| | - Andrew Liteplo
- Department of Emergency Medicine, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
| | - Hamid Shokoohi
- Department of Emergency Medicine, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
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Sobieski C, Herner M, Goyal N, Khor LL, Chang L, Bieging E, McGarry TJ. Pericardial Decompression Syndrome After Drainage of Chronic Pericardial Effusions. JACC Case Rep 2022; 4:1515-1521. [PMID: 36444176 PMCID: PMC9700074 DOI: 10.1016/j.jaccas.2022.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 07/20/2022] [Accepted: 08/10/2022] [Indexed: 06/16/2023]
Abstract
Pericardial decompression syndrome (PDS) is a potentially fatal disorder of left ventricular function that sometimes occurs after drainage of a pericardial effusion for cardiac tamponade. Patients at risk for PDS are difficult to identify. Here, we report 2 cases where PDS developed after drainage of effusions that had been present for years, suggesting that patients with chronic effusions are at higher risk for PDS. (Level of Difficulty: Advanced.).
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Affiliation(s)
- Catherine Sobieski
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Maranda Herner
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Noopur Goyal
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Lillian L. Khor
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Division of Cardiology, Department of Internal Medicine, George E. Wahlen VA Medical Center, Salt Lake City, Utah, USA
| | - Lowell Chang
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Division of Cardiology, Department of Internal Medicine, George E. Wahlen VA Medical Center, Salt Lake City, Utah, USA
| | - Erik Bieging
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Division of Cardiology, Department of Internal Medicine, George E. Wahlen VA Medical Center, Salt Lake City, Utah, USA
| | - Thomas J. McGarry
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Division of Cardiology, Department of Internal Medicine, George E. Wahlen VA Medical Center, Salt Lake City, Utah, USA
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Alnsasra H, Case BC, Yang M, Rogers T, Satler LF, Asch FM, Waksman R, Kumar P, Ben-Dor I, Medvedofsky D. Pericardiocentesis induced right ventricular changes in patients with and without pulmonary hypertension. Echocardiography 2021; 38:752-759. [PMID: 33835611 DOI: 10.1111/echo.15046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 03/09/2021] [Accepted: 03/29/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Pericardial effusion drainage in patients with significant pulmonary hypertension (PH) has been questioned because of hemodynamic collapse concern, mainly because of right ventricular (RV) function challenging assessment. We aimed to assess RV function changes related to pericardiocentesis in patients with and without PH. METHODS Consecutive patients with symptomatic moderate-to-large pericardial effusion who had either echocardiographic or clinical signs of cardiac tamponade and who underwent pericardiocentesis from 2013 to 2018 were included. RV speckle-tracking echocardiography analysis was performed before and after pericardiocentesis. Patients were stratified by significant PH (pulmonary artery systolic pressure [PASP] ≥50 mm Hg). RESULTS The study cohort consisted of 76 patients, 23 (30%) with PH. In patients with PH, both end-diastolic and end-systolic areas (EDA, ESA) increased significantly after pericardiocentesis (22.6 ± 8.0 cm2 -26.4 ± 8.4 cm2 , P = .01) and (15.9 ± 6.3 cm2 -18.7 ± 6.5 cm2 , P = .02), respectively. However, RV function indices including fractional area change (FAC: 30.6 ± 13.7%-29.1 ± 8.8%, P = .61) and free-wall longitudinal strain (FWLS: -16.7 ± 6.7 to -15.9 ± 5.0, P = .50) remained unchanged postpericardiocentesis. In contrast, in the non-PH group, after pericardiocentesis, EDA increased significantly (20.4 ± 6.2-22.4 ± 5.9 cm2 , P = .006) but ESA did not (14.9 ± 5.7 vs 15.0 ± 4.6 cm2 , P = .89), and RV function indices improved (FAC 27.9 ± 11.7%-33.1 ± 8.5%, P = .003; FWLS -13.6 ± 5.4 to -17.2 ± 3.9%, P < .001). CONCLUSION Quantification of RV size and function can improve understanding of echocardiographic and hemodynamic changes postpericardiocentesis, which has the potential to guide management of PH patients with large pericardial effusion.
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Affiliation(s)
- Hilmi Alnsasra
- MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC, USA
| | - Brian C Case
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Michael Yang
- Department of Medicine, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Toby Rogers
- MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC, USA.,Cardiovascular Branch, Division of Intramural Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Lowell F Satler
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Federico M Asch
- MedStar Health Research Institute, MedStar Washington Hospital Center, Washington, DC, USA
| | - Ron Waksman
- MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC, USA
| | - Preetham Kumar
- MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC, USA
| | - Itsik Ben-Dor
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Diego Medvedofsky
- MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC, USA
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Amro A, Mansoor K, Amro M, Sobeih A, Suliman M, Okoro K, El-Hamdani R, Vilchez D, El-Hamdani M, Shweihat Y
R. A Comprehensive Systemic Literature Review of Pericardial Decompression Syndrome: Often Unrecognized and Potentially Fatal Syndrome. Curr Cardiol Rev 2021; 17:101-110. [PMID: 32515313 PMCID: PMC8142365 DOI: 10.2174/1573403x16666200607184501] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 04/28/2020] [Accepted: 05/05/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Pericardial Decompression Syndrome (PDS) is defined as paradoxical hemodynamic deterioration and/or pulmonary edema, commonly associated with ventricular dysfunction. This phenomenon was first described by Vandyke in 1983. PDS is a rare but formidable complication of pericardiocentesis, which, if not managed appropriately, is fatal. PDS, as an entity, has discrete literature; this review is to understand its epidemiology, presentation, and management. METHODOLOGY Medline, Science Direct and Google Scholar databases were utilized to do a systemic literature search. PRISMA protocol was employed. Abstracts, case reports, case series and clinical studies were identified from 1983 to 2019. A total of 6508 articles were reviewed, out of which, 210 were short-listed, and after removal of duplicates, 49 manuscripts were included in this review. For statistical analysis, patient data was tabulated in SPSS version 20. Cases were divided into two categories surgical and percutaneous groups. t-test was conducted for continuous variable and chi-square test was conducted for categorical data used for analysis. RESULTS A total of 42 full-length case reports, 2 poster abstracts, 3 case series of 2 patients, 1 case series of 4 patients and 1 case series of 5 patients were included in the study. A total of 59 cases were included in this manuscript. Our data had 45.8% (n=27) males and 54.2% (n=32) females. The mean age of patients was 48.04 ± 17 years. Pericardiocentesis was performed in 52.5% (n=31) cases, and pericardiostomy was performed in 45.8% (n=27). The most common identifiable cause of pericardial effusion was found to be malignancy in 35.6% (n=21). Twenty-three 23 cases reported pre-procedural ejection fraction, which ranged from 20%-75% with a mean of 55.8 ± 14.6%, while 26 cases reported post-procedural ejection fraction which ranged from 10%-65% with a mean of 30% ± 15.1%. Data was further divided into two categories, namely, pericardiocentesis and pericardiostomy. The outcome as death was significant in the pericardiostomy arm with a p-value of < 0.00. The use of inotropic agents for the treatment of PDS was more common in needle pericardiocentesis with a p-value of 0.04. Lastly, the computed recovery time did not yield any significance with a p-value of 0.275. CONCLUSION Pericardial decompression syndrome is a rare condition with high mortality. Operators performing pericardial drainage should be aware of this complication following drainage of cardiac tamponade, since early recognition and expeditious supportive care are the only therapeutic modalities available for adequate management of this complication.
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Affiliation(s)
- Ahmed Amro
- Address correspondence to this author at the Internal Medicine Department, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV 25755, USA; Tel: 3046544199; E-mail:
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Amano M, Izumi C, Baba M, Abe R, Matsutani H, Nishimura S, Kuroda M, Harita T, Nishiuchi S, Sakamoto J, Tamaki Y, Enomoto S, Miyake M, Kondo H, Tamura T, Nakagawa Y. Occurrence of right ventricular dysfunction immediately after pericardiocentesis. Heart Vessels 2019; 35:69-77. [DOI: 10.1007/s00380-019-01456-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 06/14/2019] [Indexed: 12/27/2022]
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Kuroda M, Amano M, Enomoto S, Miyake M, Kondo H, Tamura T, Kaitani K, Izumi C, Nakagawa Y. Severe right ventricular and tricuspid valve dysfunction after pericardiocentesis. J Med Ultrason (2001) 2016; 43:533-6. [PMID: 27577563 DOI: 10.1007/s10396-016-0738-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 08/04/2016] [Indexed: 11/25/2022]
Abstract
Pericardiocentesis is performed to treat cardiac tamponade or diagnose the cause of pericardial effusion. Cardiogenic shock with right ventricular (RV) dysfunction is a rare complication after pericardiocentesis. We report a case of an 82-year-old man who suddenly suffered cardiopulmonary arrest 12 h after pericardiocentesis. A transthoracic echocardiogram showed remarkable RV dysfunction and tricuspid valve dysfunction. Tricuspid valve closure was severely impaired, and the tricuspid regurgitation signal showed laminar flow with an early peak. However, after treatment with high-dose inotropic drugs, hemodynamic parameters gradually recovered. A transthoracic echocardiogram performed 24 h later showed improved motion of the RV and the tricuspid valve, resulting in a reduction in tricuspid regurgitation. RV and tricuspid valve dysfunction after pericardiocentesis needs to be recognized as a critical complication. Physicians also need to pay attention to not only the amount of drainage but also underlying RV dysfunction.
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Affiliation(s)
- Maiko Kuroda
- Department of Cardiology, Tenri Hospital, 200 Mishima-cho, Tenri, Nara, 632-8552, Japan
| | - Masashi Amano
- Department of Cardiology, Tenri Hospital, 200 Mishima-cho, Tenri, Nara, 632-8552, Japan.
| | - Soichiro Enomoto
- Department of Cardiology, Tenri Hospital, 200 Mishima-cho, Tenri, Nara, 632-8552, Japan
| | - Makoto Miyake
- Department of Cardiology, Tenri Hospital, 200 Mishima-cho, Tenri, Nara, 632-8552, Japan
| | - Hirokazu Kondo
- Department of Cardiology, Tenri Hospital, 200 Mishima-cho, Tenri, Nara, 632-8552, Japan
| | - Toshihiro Tamura
- Department of Cardiology, Tenri Hospital, 200 Mishima-cho, Tenri, Nara, 632-8552, Japan
| | - Kazuaki Kaitani
- Department of Cardiology, Tenri Hospital, 200 Mishima-cho, Tenri, Nara, 632-8552, Japan
| | - Chisato Izumi
- Department of Cardiology, Tenri Hospital, 200 Mishima-cho, Tenri, Nara, 632-8552, Japan
| | - Yoshihisa Nakagawa
- Department of Cardiology, Tenri Hospital, 200 Mishima-cho, Tenri, Nara, 632-8552, Japan
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Concurrent pericardial and pleural effusions: a double jeopardy. J Clin Anesth 2016; 33:341-5. [PMID: 27555190 DOI: 10.1016/j.jclinane.2016.04.056] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 04/15/2016] [Accepted: 04/24/2016] [Indexed: 11/20/2022]
Abstract
A 19-year-old man with large malignant pleural and pericardial effusions with tamponade physiology and signs of congestive heart failure presented for emergent subxiphoid pericardial window. Surgical drainage of the pericardium was complicated by a paradoxical cardiovascular collapse that failed to respond to pressors and intravenous fluids. Suspecting a pericardial perforation, a median sternotomy was performed and revealed an intact heart. The arterial pressure was promptly restored after drainage of the pleural effusion. It is proposed that, in patients presenting with tamponading pericardial and pleural effusions, drainage of the pleural effusion be given priority. The pathophysiology of low cardiac output states resulting from pericardial and large pleural effusion is discussed and the literature reviewed.
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Han AJ, Slomka T, Mehrotra A, Murillo LC, Alsafwah SF, Khouzam RN. Paradoxical Hemodynamic Instability After Pericardial Window. Echocardiography 2016; 33:1251-2. [PMID: 27046800 DOI: 10.1111/echo.13229] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Paradoxical hemodynamic instability (PHI), also called postoperative low cardiac output syndrome (LCOS), is a rare but fatal complication after drainage of a pericardial effusion (PEf). This condition usually develops within hours postprocedure and appears unrelated to the method of drainage. The exact mechanism of this condition is not well understood. We present a case of an 84-year-old patient with no previous cardiac or cancer history who presented with acute shortness of breath (SOB). Computed tomography (CT) ruled out pulmonary embolism and echocardiography confirmed early tamponade. Following emergent subxiphoid pericardiectomy, the patient developed hemodynamic instability and shock and subsequent multiorgan failure. Repeat echocardiography revealed left ventricular (LV) hypercontractility and new right ventricular (RV) dilatation with akinesis. The patient's condition continued to deteriorate in spite of maximal doses of pressors. The patient died after the family's request to discontinue further extraordinary measures.
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Affiliation(s)
- Andrew J Han
- Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Teresa Slomka
- Division of Cardiovascular Diseases, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Anurag Mehrotra
- Division of Pulmonary Diseases, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Luis C Murillo
- Division of Pulmonary Diseases, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Shadwan F Alsafwah
- Division of Cardiovascular Diseases, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Rami N Khouzam
- Division of Cardiovascular Diseases, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
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Ayoub C, Chang M, Kritharides L. A case report of ventricular dysfunction post pericardiocentesis: stress cardiomyopathy or pericardial decompression syndrome? Cardiovasc Ultrasound 2015; 13:32. [PMID: 26179174 PMCID: PMC4502547 DOI: 10.1186/s12947-015-0026-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Accepted: 06/30/2015] [Indexed: 11/30/2022] Open
Abstract
We report a case of transient biventricular dysfunction post therapeutic pericardiocentesis, with classic features of stress cardiomyopathy (SCM). In our patient, the clinical and echocardiographic features were more in keeping with Takotsubo-type SCM than pericardial decompression syndrome (PDS). Our case is instructive in challenging our understanding of the aetiology of LV dysfunction complicating pericardiocentesis, and in highlighting the importance of careful clinical evaluation (altered heart rate and dyspnoea) in suspecting acute LV dysfunction after initial clinical improvement with pericardial aspiration.
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Affiliation(s)
- Chadi Ayoub
- Department of Cardiology, Concord Repatriation General Hospital, Concord, 2139, NSW, Australia. .,The University of Sydney, Sydney, NSW, Australia.
| | - Michael Chang
- Department of Cardiology, Concord Repatriation General Hospital, Concord, 2139, NSW, Australia. .,The University of Sydney, Sydney, NSW, Australia.
| | - Leonard Kritharides
- Department of Cardiology, Concord Repatriation General Hospital, Concord, 2139, NSW, Australia. .,The University of Sydney, Sydney, NSW, Australia.
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Sabzi F, Faraji R. Predictors of post pericardiotomy low cardiac output syndrome in patients with pericardial effusion. J Cardiovasc Thorac Res 2015; 7:18-23. [PMID: 25859311 PMCID: PMC4378670 DOI: 10.15171/jcvtr.2015.04] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Accepted: 01/21/2015] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Pathological involvement of pericardium by any disease that resulting in effusion may require decompression and pericardiectomy. The current article describes rare patients with effusion who after pericadiectomy and transient hemodynamic improvement rapidly developed progressive heart failure and subsequent multi organ failure. METHODS During periods of five years, 423 patients in our hospital underwent pericardiotomy for decompression of effusion. The clinical characteristics of those patient with postoperative low cardiac output (B group) (14 cases) recorded and compared with other patients without this postoperative complication (A group) by test and X2. Significant variables in invariables (P≤0.1) entered in logistic regression analysis and odd ratio of these significant variables obtained. RESULTS Idiopathic pericardial effusion, malignancy, renal failure, connective tissue disease, viral pericarditis was found in 125 patients (27%), 105 patients (25.4%), 65 patients (15.6%), 50 (17.1%) and 10 (2.4%) of patients subsequently. The factors that predict post-operative death in logistic regression analysis were malignancy, radiotherapy, constrictive pericarditis inotropic drug using IABP using, pre-operative EF and pericardial calcification. CONCLUSION Certain preoperative variables such as malignancy, radiotherapy, low EF, calcified pericardium and connective tissue disease are associated with POLCOS and post-operative risk of death. This paradoxical response to pericardial decompression may be more frequent than currently appreciated. Its cause may relate to the sudden removal of the chronic external ventricular support from the effusion or thicken pericardium resulting in ventricular dilatation and failure or intra operative myocardial injury due to pericardiectomy of calcified pericardium, radiation and cardiomyopathy.
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Affiliation(s)
- Feridoun Sabzi
- Department of Cardiovascular Surgery, Imam Ali Heart Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Reza Faraji
- Yazd Cardiovascular Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
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Mahapatra RP, Kumar RV, Tella RD, Barik R, Krishna L, Malempati AR. Pericardiectomy for chronic constrictive pericarditis: risks factors and predictors of survival. Indian J Thorac Cardiovasc Surg 2014. [DOI: 10.1007/s12055-014-0308-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Pradhan R, Okabe T, Yoshida K, Angouras DC, DeCaro MV, Marhefka GD. Patient characteristics and predictors of mortality associated with pericardial decompression syndrome: a comprehensive analysis of published cases. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2014; 4:113-20. [PMID: 25178691 DOI: 10.1177/2048872614547975] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Pericardial decompression syndrome (PDS) is a rare and potentially fatal complication of pericardial drainage, either by needle pericardiocentesis or surgical pericardiostomy. It manifests with paradoxical hemodynamic deterioration and/or pulmonary edema, commonly associated with ventricular dysfunction. We sought to elucidate factors associated with mortality in PDS. METHODS MEDLINE was systematically searched for PDS case reports and case series published between 1983 and 2013. For this analysis, clinical variables, echocardiographic and hemodynamic variables, details of drainage procedure and clinical outcomes were collected for each case. RESULTS A total of 35 cases (12 male, 23 female) were identified. PDS developed after pericardiocentesis, pericardiostomy, or both, in 18, 16, and one patients, respectively. Cardiac tamponade was the indication in 33 cases (94%). The mean age was 47 ± 17 years. The mean amount of effusion drained was 888 mL. The minimum amount of effusion drained was 450 mL. The onset of PDS after the procedure varied widely, ranging from 'immediate' to 48 hours. Presentations included 10 (29%) with cardiogenic pulmonary edema without shock, 14 (40%) with left ventricular failure, three (9%) with right ventricular failure, seven (20%) with biventricular failure, and one (3%) with non-cardiogenic pulmonary edema. Ten patients (29%) died of PDS. Mortality was associated only with surgical drainage (p<0.001). Severe LV dysfunction normalized in PDS survivors. CONCLUSIONS PDS is a rare complication of pericardial drainage with a high mortality rate. Surgical pericardiostomy was associated with mortality in PDS.
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Affiliation(s)
- Rajesh Pradhan
- Department of Medicine, Division of Cardiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Toshimasa Okabe
- Department of Medicine, Division of Cardiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | | | - Dimitrios C Angouras
- Department of Cardiac Surgery, University of Athens, Faculty of Medicine, Attikon University Hospital, Athens, Greece
| | - Matthew V DeCaro
- Department of Medicine, Division of Cardiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Gregary D Marhefka
- Department of Medicine, Division of Cardiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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Wagner PL, McAleer E, Stillwell E, Bott M, Rusch VW, Schaffer W, Huang J. Pericardial effusions in the cancer population: prognostic factors after pericardial window and the impact of paradoxical hemodynamic instability. J Thorac Cardiovasc Surg 2010; 141:34-8. [PMID: 21092993 DOI: 10.1016/j.jtcvs.2010.09.015] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2010] [Revised: 09/20/2010] [Accepted: 09/22/2010] [Indexed: 12/17/2022]
Abstract
OBJECTIVE In the cancer population, pericardial effusions are a common and potentially life-threatening occurrence. Although decompression benefits most patients, paradoxical hemodynamic instability (PHI) develops in some, with hypotension and shock in the immediate postoperative period. This study examines paradoxical hemodynamic instability after pericardial window and identifies prognostic factors in patients with cancer who are treated for pericardial effusion. METHODS Retrospective review of 179 consecutive pericardial windows performed for pericardial effusion in a tertiary cancer center over a 5-year period (January 2004 through March 2009). Demographic, surgical, pathologic, and echocardiographic data were analyzed for the end points of paradoxical hemodynamic instability (pressor-dependent hypotension requiring intensive care unit admission) and overall survival. RESULTS The most common malignancies were lung (44%), breast (20%), hematologic (10%), and gastrointestinal (7%). Overall survival for the group was poor (median, 5 months); patients with hematologic malignant disease fared significantly better than the others (median survival 36 months; P = .008). Paradoxical hemodynamic instability occurred in 19 (11%) patients. These patients were more likely to have evidence of tamponade on echocardiogram (89% vs 56%; P = .005), positive cytology/pathology (68% vs 41%; P = .03), and higher volume drained (674 mL vs 495 mL; P = .003). Overall survival was significantly shorter in those in whom paradoxical hemodynamic instability developed (median survival 35 vs 189 days; hazard ratio = 3; P < .001), and the majority of them (11/19, 58%) did not survive their hospitalization. CONCLUSIONS Postoperative hemodynamic instability after pericardial window portends a grave prognosis. Evidence of tamponade, larger effusion volumes, and positive cytologic findings may predict a higher risk of paradoxical hemodynamic instability and anticipate a need for invasive monitoring and intensive care postoperatively.
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Affiliation(s)
- Patrick L Wagner
- Thoracic Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA
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Ischaki E, Vasileiadis I, Koroneos A, Kolias S, Floros I, Roussos C, Vassilakopoulos T. Acute heart failure following decompression of tuberculosis induced pericardial tamponade. ACTA ACUST UNITED AC 2008. [DOI: 10.1016/j.rmedc.2007.10.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Dosios T, Stefanidis A, Chatziantoniou C, Sgouropoulou S. Thorough clinical investigation of low cardiac output syndrome after subxiphoid pericardiostomy. Angiology 2007; 58:483-6. [PMID: 17875962 DOI: 10.1177/0003319706291147] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The paradoxical hemodynamic response after surgical or catheter pericardial drainage for cardiac tamponade is an infrequent complication. This case report describes this occasional ominous consequence of surgical pericardial decompression and suggests possible physiological explanations of rapidly progressive heart failure and death.
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Affiliation(s)
- Theodosios Dosios
- Division of Thoracic Surgery, Department of Surgery, Henry Dunant Hospital, Athens, Greece.
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Suita C, Shiraishi I, Tanaka T, Shuntoh K, Yamagishi M, Hamaoka K. Severe heart failure due to subacute effusive-constrictive pericarditis in a child. Pediatr Cardiol 2005; 26:101-3. [PMID: 15054551 DOI: 10.1007/s00246-003-0697-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- C Suita
- Department of Pediatric Cardiology and Nephrology, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kawaramachi-Hirokoji, Kamigyo, Kyoto, 602-8566, Japan
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Rychik J, Tian Z, Cohen MS, Ewing SG, Cohen D, Howell LJ, Wilson RD, Johnson MP, Hedrick HL, Flake AW, Crombleholme TM, Adzick NS. Acute Cardiovascular Effects of Fetal Surgery in the Human. Circulation 2004; 110:1549-56. [PMID: 15353490 DOI: 10.1161/01.cir.0000142294.95388.c4] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Prenatal surgery for congenital anomalies can prevent fetal demise or alter the course of organ development, resulting in a more favorable condition at birth. The indications for fetal surgery continue to expand, yet little is known about the acute sequelae of fetal surgery on the human cardiovascular system.
Methods and Results—
Echocardiography was used to evaluate the heart before, during, and early after fetal surgery for congenital anomalies, including repair of myelomeningocele (MMC, n=51), resection of intrathoracic masses (ITM, n=15), tracheal occlusion for congenital diaphragmatic hernia (CDH, n=13), and resection of sacrococcygeal teratoma (SCT, n=4). Fetuses with MMC all had normal cardiovascular systems entering into fetal surgery, whereas those with ITM, CDH, and SCT all exhibited secondary cardiovascular sequelae of the anomaly present. At fetal surgery, heart rate increased acutely, and combined cardiac output diminished at the time of fetal incision for all groups including those with MMC, which suggests diminished stroke volume. Ventricular dysfunction and valvular dysfunction were identified in all groups, as was acute constriction of the ductus arteriosus. Fetuses with ITM and SCT had the most significant changes at surgery.
Conclusions—
Acute cardiovascular changes take place during fetal surgery that are likely a consequence of the physiology of the anomaly and the general effects of surgical stress, tocolytic agents, and anesthesia. Echocardiographic monitoring during fetal surgery is an important adjunct in the management of these patients.
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Affiliation(s)
- Jack Rychik
- Center for Fetal Diagnosis and Treatment and the Fetal Heart Program, The Children's Hospital of Philadelphia, 34th St and Civic Center Blvd, Philadelphia, PA 19104, USA.
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Geffroy A, Beloeil H, Bouvier E, Chaumeil A, Albaladejo P, Marty J. Prolonged right ventricular failure after relief of cardiac tamponade. Can J Anaesth 2004; 51:482-5. [PMID: 15128635 DOI: 10.1007/bf03018312] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
PURPOSE To report a case of severe and fatal cardiac complication following pericardiotomy to relieve a malignant tamponade. Right ventricular (RV) failure was responsible for major hypoxemia and for a persistent shunt through a patent foramen ovale. In the absence of pulmonary embolism and coronary occlusion, possible pathophysiologic mechanisms are discussed. CLINICAL FEATURES This 53-yr-old patient presented with oropharyngeal carcinoma previously treated by chemotherapy. One month later, he showed clinical and echocardiographic signs of cardiac tamponade. He had a circumferential pericardial effusion with complete end-diastolic collapse of the right cavities. After an emergent pericardiotomy, he rapidly presented severe hypoxemia. Transesophageal echocardiography showed an akinetic and dilated right ventricle, paradoxical septal wall motion and a normal left ventricular function. A contrast study revealed a right-to-left shunt. No residual pericardial effusion was detectable. Pulmonary angiography excluded a pulmonary embolism and the coronary angiogram was normal. Troponin Ic was elevated postoperatively and peaked on day two (3.78 micro g x L(-1)). The patient died of refractory shock with persistent intracardiac shunt and RV akinesia on day nine. CONCLUSION Although pulmonary embolism or thrombus of a coronary vessel are the most common causes of prolonged RV failure after pericardiotomy, other mechanisms may be invoked. The possibility is raised that a rapid increase in RV tension may induce the development of muscular injury and impair coronary blood flow, despite a normal coronary angiogram. These could result in a stunned myocardium and opening of a patent foramen ovale. We hypothesize that gradual decompression of a chronic pericardial effusion might be beneficial in patients at risk.
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Affiliation(s)
- Arnaud Geffroy
- Department of Anesthesiology and Critical Care, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Université Xavier Bichat Paris 7, Clichy Cedex, France.
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Maisch B, Seferović PM, Ristić AD, Erbel R, Rienmüller R, Adler Y, Tomkowski WZ, Thiene G, Yacoub MH. Guía de Práctica Clínica para el diagnóstico y tratamiento de las enfermedades del pericardio. Versión resumida. Rev Esp Cardiol 2004; 57:1090-114. [PMID: 15544758 DOI: 10.1016/s0300-8932(04)77245-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Dosios T, Theakos N, Angouras D, Asimacopoulos P. Risk factors affecting the survival of patients with pericardial effusion submitted to subxiphoid pericardiostomy. Chest 2003; 124:242-6. [PMID: 12853529 DOI: 10.1378/chest.124.1.242] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
STUDY OBJECTIVES Surgical subxiphoid drainage of the pericardial cavity has been established as a safe and effective method of treatment of pericardial effusion; however, the risk factors affecting survival of these patients have not been clarified. The aim of this study was to investigate the risk factors affecting the short-term and long-term survival of patients with pericardial effusion submitted to subxiphoid pericardiostomy. DESIGN Retrospective study. PATIENTS The records of all patients who underwent subxiphoid pericardiostomy for treatment of pericardial effusion from January 1991 to December 2001 were reviewed. According to underlying pathology the patients were classified into four groups: (1) hematologic malignancies (n = 17); (2) other malignant diseases (n = 29); (3) AIDS (n = 5); and (4) other benign diseases (n = 53). Multivariate Cox regression analysis was used to test the relationship of short-term and long-term survival to age, sex, cardiac tamponade, pericardial malignant invasion, postoperative low cardiac output syndrome (PLCOS), and underlying pathology. RESULTS There were 104 patients (59 men) with a mean age of 53.6 years (range, 13 to 85 years). Follow-up was complete in 99 patients (95.2%) for a mean of 23.9 months (range, 0 to 92 months). Overall 30-day mortality was 16.3%, while operation-related mortality was 4.8%. The underlying disease was the main risk factor for short-term and long-term survival (p < 0.00001), while PLCOS was a major predictor of early mortality (p = 0.029). Patients with AIDS showed the worst prognosis. On the contrary, patients with hematologic malignancies presented significantly longer survival compared to all other patients with malignant diseases (p < 0.05). CONCLUSIONS The underlying disease was the main risk factor for short-term and long-term survival, while PLCOS was a major predictor of early mortality. The prognosis of AIDS patients with pericardial effusion was grave; therefore, surgical intervention in such patients should be reevaluated. Patients with hematologic malignancies had significantly longer survival compared to all other patients with malignant diseases.
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Affiliation(s)
- Theodosios Dosios
- Division of Thoracic Surgery, Athens University Medical School, Athens, Greece.
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