Pericardial and Pleural Effusions in Congestive Heart Failure—Anatomical, Pathophysiologic, and Clinical Considerations

Determinant factors of prolonged hospitalization in acute heart failure patients at Jimma Medical Center, Southwest Ethiopia

Millions of people worldwide suffer from heart failure, which is a serious public health concern that results in high medical costs from prolonged hospital stay. This study aimed to assess the determinant factors associated with prolonged hospitalization among admitted acute heart failure at Jimma Medical Center, south west Ethiopia. The study was conducted at Jimma Medical Center in Ethiopia from December 2023 to April 2024, employing a prospective observational design. Statistical analysis was performed using Epi-data V.4.6 and STATA V.17 and multiple linear regression was employed. T test and ANOVA were conducted and a p-value is deemed significant if it is less than 0.05, corresponding to a 95% confidence interval. A total of 294 individuals were enlisted, with a mean age of 56. Over half of the patients (53.4%) stayed eight days or more throughout their average 11.4-day hospital stay. The following were significant risk factors for extended hospital stays: living in a rural; being admitted to a cardiac unit having neck vein distension, having a third heart sound, having ankle edema; having hepatomegaly, and having pleural effusion were predictor's of length of hospital stay. Based on this finding, the length of hospital stay in heart failure patients is influenced by various factors. Addressing these factors can help reduce the duration of hospitalization. Implementing targeted interventions, such as improving physical activity, managing comorbidities, and enhancing discharge planning, may lead to better patient outcomes and decrease the prolongation of hospital stays for those with heart failure.

Nonhemorrhagic Pericardial Effusion With Tamponade and Cardiogenic Shock Due to Large Coronary Artery Fistula

BACKGROUND

Coronary artery fistulas (CAFs) are a rare congenital heart disease. Large fistulas can lead to coronary steal phenomena presenting with angina, heart failure, and in rare cases, cardiogenic shock.

CASE SUMMARY

A 55-year-old woman acutely presented at our heart center with nonhemorrhagic pericardial tamponade and cardiogenic shock. A large CAF of an aneurysmatic right coronary artery to the coronary sinus was diagnosed. Pericardiocentesis was used for initial hemodynamic stabilization. On cardiopulmonary bypass, perforations connecting right coronary artery and coronary sinus were closed via suture.

DISCUSSION

In cases of CAF, cardiogenic shock with pericardial tamponade is usually caused by rupture of an aneurysmatic vessel with successive hemopericardium. In this case, the pericardial tamponade was caused by acute right heart decompensation after long-term right ventricular overload.

TAKE-HOME MESSAGES

In adult right heart failure, early comprehensive cardiac imaging is essential for diagnosis of rare underlying congenital diseases. Surgical shunt closure can drastically improve symptoms.

Pleural Effusion: Shedding Light on Pleural Disease Beyond Infection and Malignancy

Background and Objectives: Non-malignant pleural effusions (NMPEs) are the most frequently encountered pleural disease. They arise from various non-malignant, non-infectious clinical conditions, including cardiac, renal, and hepatic organ dysfunction. Despite their wide prevalence, there is a lack of literature for NMPE. This publication aims to provide an updated overview of the causes, diagnostic strategies, and management options for NMPE. Materials and Methods: This review synthesizes findings from studies published on NMPE, focusing on the presentation, diagnosis (such as imaging and pleural fluid analysis), and management strategies. Studies were selected based on relevance and were analyzed to provide a comprehensive summary of current practices. Results: The review highlights different etiologies of NMPE, including organ-specific factors. Imaging, pleural fluid analysis, and clinical correlation remain crucial in diagnosing the etiology of NMPE. Treatment strategies are largely dependent on the underlying condition. Medical management remains the mainstay for many causes. In some cases, interventions, such as thoracentesis, tunneled indwelling pleural catheter, or pleurodesis, are necessary. Conclusions: NMPE is a heterogeneous condition with a wide prevalence and significant implications. They present a diagnostic and management challenge due to patient complexity and evolving therapeutic options.

Massive Exudative Pleural Effusion With Hypothyroidism: A Case Report

Here, we report the case of a 79-year-old woman with massive exudative pleural effusion and hypothyroidism. The patient underwent total thyroid and parathyroidectomy during pharyngoesophagectomy for hypopharyngeal cancer. She was administered a thyroid hormone preparation (87.5 μg of levothyroxine sodium), calcium supplementation (0.5 g of calcium lactate hydrate), and active vitamin D (2 g of alfacalcidol). Four months after missing her regular medical appointment and discontinuing her medications, she developed a severe exudative pleural effusion, circumferential pericardial effusion, and mild ascites secondary to hypothyroidism. The pleural effusion, which may have been exacerbated by prolonged hypothyroidism and associated heart failure, improved with drainage and did not recur after the initiation of thyroid hormone replacement therapy. The pericardial effusion and ascites improved with hormone replacement alone. Although fluid retention associated with hypothyroidism usually improves with thyroid hormone therapy, drainage may be required to treat severe exudative effusions in diverse body cavities when diuretic treatments are insufficient.

Incidence of secondary pericardial effusions associated with different etiologies: a comprehensive review of literature

Pericardial effusion is a relatively common complication associated with inflammatory and non-inflammatory diseases. The primary etiology of this condition could be considered when choosing therapeutic options and factors such as effusion size and its hemodynamic consequence. In most cases, small to moderate pericardial effusions can be managed with observation and anti-inflammatory medications unless the effusion develops rapidly. However, in a small proportion of patients, large effusions lead to impaired cardiac filling with hemodynamic compromise and cardiovascular collapse due to cardiac tamponade. The rate at which fluid accumulates is the primary determinant of hemodynamic impact and thus guides the choice of treatment, irrespective of the effusion's size. Severe cases are typically treated with pericardiocentesis with echocardiographic guidance. More aggressive treatments may be necessary for cases due to purulent or malignant etiologies. These cases may require a pericardial window to allow for long-term drainage of the pericardial fluid. This comprehensive review focuses on the epidemiology of pericardial effusion and discusses pathophysiology, diagnostic approaches, and therapeutic options for different causes of secondary pericardial effusions.

A machine learning-based lung ultrasound algorithm for the diagnosis of acute heart failure

Lung ultrasound (LUS) is an effective tool for diagnosing acute heart failure (AHF). However, several imaging protocols currently exist and how to best use LUS remains undefined. We aimed at developing a lung ultrasound-based model for AHF diagnosis using machine learning. Random forest and decision trees were generated using the LUS data (via an 8-zone scanning protocol) in patients with acute dyspnea admitted to the Emergency Department (PLUME study, N = 117) and subsequently validated in an external dataset (80 controls from the REMI study, 50 cases from the Nancy AHF cohort). Using the random forest model, total B-line sum (i.e., in both hemithoraces) was the most significant variable for identifying AHF, followed by the difference in B-line sum between the superior and inferior lung areas. The decision tree algorithm had a good diagnostic accuracy [area under the curve (AUC) = 0.865] and identified three risk groups (i.e., low 24%, high 70%, and very high-risk 96%) for AHF. The very high-risk group was defined by the presence of 14 or more B-lines in both hemithoraces while the high-risk group was described as having either B-lines mostly localized in superior points or in the right hemithorax. Accuracy in the validation cohort was excellent (AUC = 0.906). Importantly, adding the algorithm on top of a validated clinical score and classical definition of positive LUS scanning for AHF resulted in a significant improvement in diagnostic accuracy (continuous net reclassification improvement = 1.21, P < 0.001). Our simple lung ultrasound-based machine learning algorithm features an excellent performance and may constitute a validated strategy to diagnose AHF.

An association between Dasatinib, elevated left atrial pressure and pleural effusion

BACKGROUND

Tyrosine kinase inhibitors (TKI), such as Dasatinib, are effective in the treatment of chronic myeloid leukemia (CML) but associated with development of pleural effusions (PE). The relationship between haemodynamic parameters identified on transthoracic echocardiogram (TTE) such as elevated estimated left atrial pressure (LAP), and PE development is unknown. This study aims to describe associations between Dasatinib, elevated LAP and PE.

METHODS

This was a retrospective study of 71 CML patients who underwent TTE during treatment with various TKIs. Descriptive analysis was performed to identify associations between TKI use, PE and elevated LAP on TTE. Multivariate logistic regression was performed to identify predictors of elevated LAP.

RESULTS

There were 36 patients treated with Dasatinib, 15 Nilotinib, and 20 Imatinib. Those treated with Dasatinib had higher rates of elevated LAP (44% vs 7% Nilotinib vs 10% Imatinib, p < 0.01) and PE (39% vs 7% vs 0%, p < 0.01). In the 15 patients who developed PE, 14 (93%) patients were treated with Dasatinib. Patients with PE had higher rates of elevated LAP (67% vs 16%, p < 0.01). Nineteen (26.8%) patients in the entire cohort had elevated LAP. After multivariate adjustment, Dasatinib (OR 33.50, 95% CI = 4.99-224.73, p < 0.01) and age (OR 1.12, 95% CI = 1.04-1.20, p < 0.01) were associated with elevated LAP.

CONCLUSIONS

Among patients with CML, there was an association between Dasatinib use, PE and elevated LAP on TTE. These findings are hypothesis generating and further studies are required to evaluate the utility of elevated LAP on TTE as a novel marker for prediction and surveillance of PE.

Pericardial Disease in Cardiac Amyloidosis: A Comprehensive Review

In patients with cardiac amyloidosis, pericardial involvement is common, with up to half of patients presenting with pericardial effusions. The pathophysiological mechanisms of pericardial pathology in cardiac amyloidosis include chronic elevations in right-sided filling pressures, myocardial and pericardial inflammation due to cytotoxic effects of amyloid deposits, and renal involvement with subsequent uremia and hypoalbuminemia. The pericardial effusions are typically small; however, several cases of life-threatening cardiac tamponade with hemorrhagic effusions have been described as a presenting clinical scenario. Constrictive pericarditis can also occur due to amyloidosis and its identification presents a clinical challenge in patients with cardiac amyloidosis who concurrently manifest signs of restrictive cardiomyopathy. Multimodality imaging, including echocardiography, cardiac computed tomography, and cardiac magnetic resonance imaging, is useful in the evaluation and management of this patient population. The recognition of pericardial effusion is important in the risk stratification of patients with cardiac amyloidosis as its presence confers a poor prognosis. However, specific treatment aimed at the effusions themselves is seldom indicated. Cardiac tamponade and constrictive pericarditis may necessitate pericardiocentesis and pericardiectomy, respectively.

Letter regarding the article: Trends, and Outcomes of Transcatheter Aortic Valve Implantation in Aortic Insufficiency; A Nationwide Readmission Database Analysis

With great interest, we have read the article "Trends, and Outcomes of Transcatheter Aortic Valve Implantation In Aortic Insufficiency; A Nationwide Readmission Database Analysis" by Ullah et al. For its clarity and conciseness, we applaud the author for his extensive research on this delicate topic. The authors have concisely written several scenarios including the current understanding of trends, and potential outcome of aortic insufficiency following transcatheter aortic valve implantation (TAVI). Nonetheless, we thought it would be helpful to add a few more things to the article's conclusion to strengthen it. The inclusion of the pathophysiology of coronary microcirculation disorder, and endothelial dysfunction in patients with aortic stenosis and then examine the impact of TAVI on these conditions can improve the results. Second, echocardiographic data regarding right and left ventricular dimensions and function or tricuspid regurgitation presence and its severity could lead to a better understanding of the mechanism.

The Impact of Comorbidities and Demographic Factors on Ejection Fraction

Heart failure (HF) presents an increasingly significant problem as the population ages. The cause of HF plays a significant role in determining treatment options and outcomes. It is worth noting that several studies have identified gender disparities in both morbidity and mortality, which may suggest differing causes of HF. The purpose of this research is to investigate the influence of various factors, including demographics and comorbidities, on ejection fraction (EF). The objectives of this study involve implementing preventive measures, ensuring timely diagnosis, and implementing interventions that target risk factors and specific comorbidities. These efforts aim to improve the prognosis for individuals affected by heart failure. The main method consists of linear regression. The demographic factors under scrutiny are gender and education, while the comorbidities of interest encompass valvulopathy, ischemia, smoking, obesity, high cholesterol, and diabetes. The main results consist of the fact that high education is associated with a 12.8% better EF on average, while among the factors with a negative role analyzed, ischemia is the most harmful, being 12.8% lower on average. Factors with a smaller impact are smoking, obesity, and high cholesterol. Diabetes does not seem to affect EF.

Congenital anomalous drainage of the inferior vena cava and hepatic veins into the left atrium associated with long QT syndrome: Multimodality imaging, pitfalls, and caveats

Isolated congenital anomalous drainage of the inferior vena cava (IVC) and partial hepatic veins (HV) into the left atrium (LA) via an interatrial communication (IAC), associated with the normal connection of the IVC to the right atrium is exceedingly rare. Therefore, there is a dearth of knowledge regarding the management of these cases. To date, there has been no report of abnormal IVC drainage caused by abnormal IVC-IAC alignment. Much more frequently, patients have an abnormal connection or abnormal drainage mediated by a persistent Eustachian valve that allows blood to pass from the inferior vena cava to the left atrium. Herein, we report an 8-year-old boy with anomalous IVC and hepatic vein drainage into the LA due to IVC-IAC malalignment. We describe the findings of multimodality imaging, including transthoracic, transesophageal, contrast, and speckle-tracking echocardiography, cardiac angiography, and cardiac magnetic resonance imaging. We go over the diagnostic and therapeutic pitfalls and caveats of this case that can apply to similar patients.

Outcomes of Valvular Endocarditis in Patients With and Without Pericardial Effusion: A National Inpatient Sample Study

Over the last decade, hospitalizations for infective endocarditis (IE) have been steadily increasing, leading to a significant healthcare burden. Pericardial effusion (PCE) has been identified as a serious complication of IE, yet no significant association with mortality has been established. Our study aims to further analyze and understand the significance of PCE in patients with IE. We performed a retrospective analysis using the national inpatient sample database to identify all the hospital admissions with IE using ICD 10 codes and stratified them into 2 groups based on the presence of PCE. The outcomes of interest were inhospital mortality, inhospital complications, need for cardiac surgery, and length of stay. From 2015 Q4-2019, a total of 76,260 hospitalizations were included (weighted: 381,300), of which 2.7% included a PCE diagnosis. Hospitalizations with a PCE diagnosis included patients that were younger (51 vs 61, P < 0.001), as well as slightly more males (58.0% vs 55.2%, P = 0.011), and black patients (16.9% vs 12.9%, P < 0.001). PCE was associated with higher in-hospital death (12.7% vs 9.0%, P < 0.001), longer lengths of stay (12 days vs 7 days, P < 0.001), higher rates of cardiac surgery (22.4% vs 7.3%, P < 0.001). The rates of heart failure, heart block, renal failure, cardiogenic shock, and embolic stroke were higher on PCE group. We found that presence of PCE is associated with higher inhospital mortality, longer length of stay, and greater utilization of cardiac surgery, as well as presence of heart failure, heart block, cardiogenic shock, and embolic stroke.

Assessment of E/A ratio helps emergency clinicians in the management of patients with acute dyspnea

Acute dyspnea (AD) is one of the main reasons for admission to the Emergency Department (ED). In the last years integrated ultrasound examination (IUE) of lung, heart and inferior vena cava (IVC) has become an extension of clinical examination for a fast differential diagnosis. The aim of present study is to assess the feasibility and diagnostic accuracy of E/A ratio for diagnosing acute heart failure (aHF) in patients with acute dyspnea. We included 92 patients presenting to the ED of CTO Hospital in Naples (Italy) for AD. All patients underwent IUE of lung-heart-IVC with a portable ultrasound device. Left ventricle diastolic function was assessed using pulse wave doppler at the tips of the mitral valve and E wave velocity and E/A ratio were recorded. The FINAL diagnosis was determined by two expert reviewers: acute HF or non-acute HF (non-aHF). We used 2 × 2 contingency tables to analyze sensitivity, specificity, positive predictive and negative predictive value of ultrasound parameters for the diagnosis of AD, comparing with the FINAL diagnosis. Lung ultrasound (LUS) showed high sensitivity, good specificity and accuracy in identification of patients with aHF. However, the highest accuracy was obtained by diastolic function parameters. The E/A ratio showed the highest diagnostic performance with an AUC for aHF of 0.93. In patients presenting with AD, E/A ratio is easy to obtain in a fast ultrasound protocol and showed an excellent accuracy for diagnosis of aHF.

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.

Complications of Endomyocardial fibrosis and their physiological compromise: A review

Endomyocardial fibrosis (EMF) is an endemic idiopathic cardiomyopathy denoted by restricted and fibrous myocardium and endocardium. Apical fibrosis may cause thickening of the myocardium and extend from the ventricular apices through to the valves, thereby, restricting inflow. EMF is a critical condition that is predominant in the young population. However, it may also be associated with older individuals. Identified areas recorded with cases include the under-developed populations i.e. the tropics of Africa- Uganda, Mozambique; South Asia, and South America. Unlike in the preceded years, further studies are currently on focus to completely evaluate this medical condition. Additionally, this review encompasses the complications that arise from EMF as studied and reported from case studies, clinical trials, experiments and research including heart failure, atrioventricular valves regurgitations, arrhythmias, serous cavities'effusions, circulatory shock, stroke, myocardial ischemic syndromes, hepatic and end-organ dysfunctions. Complications like heart failure may be very fatal to its victims. Moreover, left ventricular thrombosis may probably impose systemic or cerebral thromboembolism, which would risk the probability of a stroke. All in all, suggestions in the management strategies that have proved effective and advances in cardiac transplantation and of recently proposed therapeutic targets equally take part of this review and may form a foundation to diminishing the remaining inch of EMF and its outcomes.

Prognostic impact of small pericardial effusion in acute heart failure

BACKGROUND

The relationship between small pericardial effusion (SPE) and outcomes has not been well studied in patients with heart failure. Therefore, we aimed to investigate the prevalence and importance of SPE in acute heart failure (AHF).

METHODS

A total of 398 hospitalized patients with AHF were retrospectively reviewed. Patients' baseline demographic, clinical, echocardiographic, and laboratory characteristics were noted. SPE was defined as the presence of a pericardial effusion <10 mm. The primary outcome was one-year mortality.

RESULTS

SPE was noted in 54 (13.6%) of the patients. Mortality at one year was greater for patients with a small effusion compared with those without SPE (44.4 vs. 11.4%, respectively; p < 0.001), and the one-year mortality rate for the whole group was 15.8%. Age (HR = 1.12, 95% CI 1.054-1.854, p = 0.024), N-terminal pro-B-type natriuretic peptide >4800 pg/ml (HR = 1.628, 95% CI 01.102-4.805, p = 0.001), left ventricular ejection fraction <30% (HR = 1.878, 95% CI 1.154-4.524, p = 0.001), and presence of SPE (HR = 1.567, 95% CI 1.122-2.991, p = 0.005) were independent predictors of one-year mortality on multivariate analysis.

CONCLUSIONS

The presence of SPE on admission was an independent predictor of one-year mortality in AHF.

Acute Polyserositis with Cardiac Tamponade and Bilateral Refractory Pleural Effusion after ChAdOx1 nCoV-19 Vaccination

The association of SARS-CoV-2 messenger ribonucleic acid vaccines with pericarditis in young adults has been reported. However, data regarding other types of vaccines are extremely limited. We presented a 94-year-old man with rapidly progressive dyspnea and fatigue six days after his first ChAdOx1 nCoV-19 vaccination. Impending cardiac tamponade and bilateral pleural effusion were found. Hence, massive yellowish pericardial and pleural effusion were drained. However, the pleural effusion persisted and pigtail catheters were inserted bilaterally. After serial studies including surgical pleural biopsy, acute polyserositis (pericarditis and pleurisy) was diagnosed. Anti-inflammatory treatment with colchicine and prednisolone was administered. All effusions resolved accordingly. This rare case sheds light on the presentation of ChAdOx1 nCoV-19 vaccine-related acute polyserositis. In conclusion, awareness of this potential adverse event may facilitate the diagnosis for unexplained pericardial or pleural effusion after vaccination.

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.

Pericardial effusion among children: Retrospective analysis of the etiology and short-term outcome in a referral center in the south of Iran

Background and Aims

We reinvestigated the causes, symptoms, and management of childhood pericardial effusion (PE) and its gradual changes during recent years in a referral pediatric cardiology center in the south of Iran.

Methods

We retrospectively analyzed the profile of PE patients who were under 18 years old from 2015 to 2020. The patient's demographic, clinical, and paraclinical information was extracted and analyzed using SPSS software.

Result

In general, 150 out of 63,736 admitted patients (0.23% of the total pediatric admissions) were diagnosed with PE (male/female 1:1.17). The median age was 3.25 years (range:\ 2 days to 18 years; interquartile range: 9.5), and 50% of them were under 3 years of age. 32.6% had moderate to severe PE. Most patients presented with acute symptoms (68%) and respiratory problems, as the most common symptoms (30.6%). Tamponade signs were presented in 2% (n = 3) of the patients, and 80.7% (n = 121) were in a stable hemodynamic condition. In total, renal failure (22%) and parapneumonic effusion were the leading etiologies. Viral (7%) and bacterial (5%) pericarditis were the seventh and eighth causes; however, in severe cases, renal failure (22%) and bacterial pericarditis (14%) were dominant. In total, 14.1% (n = 21) of the patients needed pericardiocentesis that increased to 78.3% (n = 18) in severe cases. Only 6% had persistent PE for more than 3 months.

Conclusion

Childhood PE is mostly a result of renal failure and noninfectious causes. True pericarditis cases are not common, except in severe cases. It is more common in less than 3-year-old patients, and chronicity is rare. Severe cases had a high chance of pericardiocentesis, but other cases were mainly managed by treatment of the underlying causes.

A case of an elderly female who developed subacute pleuropericarditis following BNT162b2 mRNA COVID-19 vaccination

Despite the established safety of BNT162b2 coronavirus disease 2019 (COVID-19) vaccine, some rare but serious complications have been previously reported. Here, we report a rare case of an elderly female who developed subacute pleuropericarditis after the vaccination. An 88-year-old female experienced weight gain and dyspnea three days after the second dose of BNT162b2 vaccination, and one month later, presented to our hospital due to the exacerbation of the symptoms. Computed tomography showed remarkable pericardial and bilateral pleural effusions, and transthoracic echocardiogram visualized collapse signs of right and left atrium which indicates pre-tamponade. Percutaneous drainages of pericardial and pleural effusions stabilized her vital condition and revealed that all of them were exudative, indicating the presence of pleuropericarditis. Finally, we diagnosed this case as COVID-19 vaccine-associated pleuropericarditis because there were no signs of bacterial/viral infection or any other relevant causes except for the vaccination. When the pericardial and pleural effusions are concurrently found after COVID-19 vaccination, vaccine-associated pleuropericarditis should be considered as a differential diagnosis. The aggressive drainage of pericardial and pleural effusions could be helpful not only for diagnosis but also for treatment in the clinical management of COVID-19 vaccine-associated pleuropericarditis.

Learning objective

Although the safety and efficacy of BNT162b2 have been widely accepted, it is clinically important to know the potential risk of side effects. When the pericardial and pleural effusions are concurrently found after the vaccination, coronavirus disease 2019 vaccine-associated pleuropericarditis should be considered as a differential diagnosis.

Right Heart Failure With Recurrent Pericardial Effusion Mimicking Effusive-Constrictive Pericarditis Several Years After Renal Transplantation

Pericardial disease is a rare complication after renal transplantation. We present a patient who developed high-output cardiac failure from a large arteriovenous (AV) fistula with recurrent pericardial effusion resulting in a constrictive hemodynamic pattern that was revealed during cardiac catheterization. Pericardiectomy was considered for recurrent effusive pericarditis, but per cardiac surgery recommendations, closure of the AV fistula dramatically cured the patient’s heart failure, and no recurrence of pericardial effusion was seen during follow-up almost a year later.

Reducing the Heart Failure Burden in Romania by Predicting Congestive Heart Failure Using Artificial Intelligence: Proof of Concept

Due to population aging, we are currently confronted with an increased number of chronic heart failure patients. The primary purpose of this study was to implement a noncontact system that can predict heart failure exacerbation through vocal analysis. We designed the system to evaluate the voice characteristics of every patient, and we used the identified variations as an input for a machine-learning-based approach. We collected data from a total of 16 patients, 9 men and 7 women, aged 65–91 years old, who agreed to take part in the study, with a detailed signed informed consent. We included hospitalized patients admitted with cardiogenic acute pulmonary edema in the study, regardless of the precipitation cause or other known cardiovascular comorbidities. There were no specific exclusion criteria, except age (which had to be over 18 years old) and patients with speech inabilities. We then recorded each patient’s voice twice a day, using the same smartphone, Lenovo P780, from day one of hospitalization—when their general status was critical—until the day of discharge, when they were clinically stable. We used the New York Heart Association Functional Classification (NYHA) classification system for heart failure to include the patients in stages based on their clinical evolution. Each voice recording has been accordingly equated and subsequently introduced into the machine-learning algorithm. We used multiple machine-learning techniques for classification in order to detect which one turns out to be more appropriate for the given dataset and the one that can be the starting point for future developments. We used algorithms such as Artificial Neural Networks (ANN), Support Vector Machine (SVM) and K-Nearest Neighbors (KNN). After integrating the information from 15 patients, the algorithm correctly classified the 16th patient into the third NYHA stage at hospitalization and second NYHA stage at discharge, based only on his voice recording. The KNN algorithm proved to have the best classification accuracy, with a value of 0.945. Voice is a cheap and easy way to monitor a patient’s health status. The algorithm we have used for analyzing the voice provides highly accurate preliminary results. We aim to obtain larger datasets and compute more complex voice analyzer algorithms to certify the outcomes presented.

Contemporary management of pericardial effusion

Pericardial effusion is a relatively common clinical condition with a variety of clinical manifestations ranging from incidentally discovered asymptomatic cases to life-threatening cardiac tamponade. The etiology encompasses idiopathic cases and forms secondary to different conditions, including autoimmune diseases, malignancies, metabolic disorders, etc. While medical therapy should be offered to patients with elevation of inflammatory markers, in specific forms treatment should be appropriate to the underlying disorder. In cases with hemodynamic compromise pericardial drainage either with pericardiocentesis or pericardial "window" is indicated for therapeutic and diagnostic purposes. In the remainder, factors like comorbidities, size and location of the pericardial effusion will influence the clinical decision making. In asymptomatic or minimally symptomatic chronic large idiopathic pericardial effusions, according to recent evidence, a conservative approach with watchful waiting seems the most reasonable option. The prognosis of pericardial effusions largely depends on the underlying etiologies. Metastatic spread to the pericardium has an ominous prognosis whereas large to moderate effusions have been often associated with known or newly discovered specific underlying causes. Chronic small idiopathic effusions have an excellent prognosis and do not require specific monitoring. Large chronic idiopathic effusions in clinically stable patients require a 3 to 6-month assessment ideally in a specialized unit.

An unfortunate case of acute aortic regurgitation: Isolated aortic valve prolapse following a motor vehicle accident

We present an unfortunate case of severe acute aortic regurgitation (AR) following a motor vehicle accident (MVA) linked to isolated aortic valve prolapse, with no evidence of aortic root disruption or other valvular pathology missed on initial presentation. A 55-year-old gentleman, with known hypertension, was brought into the emergency department following a MVA, where he sustained severe intra-thoracic injuries. A bedside transthoracic echocardiogram (TTE) revealed a trileaflet aortic valve with evidence of mal-coaptation and severe AR. A computed tomography angiography of the thorax, however, failed to demonstrate evidence of dissection along the aortic root or ascending aorta. Following successful weaning off ventilatory support, the patient was discharged, but he presented back within a week with worsening dyspnoea and palpitations. Examination and investigation supported a diagnosis of acute heart failure with evident severe AR on repeat TTE. Transoesophageal echocardiography was performed, revealing prolapsed right and non-coronary cusps which were not seen in previous studies but absent evidence of the aortic root, ascending and descending aorta dilatation or dissection. Valvular complications rarely occur following blunt chest wall trauma, often involving right-sided valves due to their proximity to the sternum. Although aortic valve disruption can occur following MVAs, it is often associated with trauma to the aorta. Based on our literature search, there have been only a handful of reported cases of severe acute AR due to isolated prolapse or ruptured aortic valves in the absence of aortic valve perforation, aortic root disruption or dissection and other valvular abnormalities following trauma.

Incidence and prognostic significance of pleural effusions in pulmonary arterial hypertension

It has been suggested pleural effusions may develop in right heart failure in the absence of left heart disease. The incidence and prognostic significance of pleural effusions in pulmonary arterial hypertension is uncertain. Patients with pulmonary arterial hypertension followed at our tertiary care center were reviewed. Survival was examined based on the subsequent development of a pleural effusion. A total of 191 patients with pulmonary arterial hypertension met the inclusion criteria. The prevalence of pleural effusions on initial assessment was 7.3%. Among patients without a pleural effusion on initial imaging and at least one follow-up computerized tomography (N = 142), pleural effusion developed in 27.5% (N = 39) of patients. No alternative etiology of the effusion was identified in 19 (48.7%) cases and effusions deemed related to pulmonary arterial hypertension occurred at an incident rate of 38.6 cases per 1000 person-years. Of these, 14 (73.7%) were bilateral, 3 (15.8%) were right-sided, and 2 (10.5%) were left-sided. Effusion size was trace or small in 18 patients (94.7%). Development of a new pleural effusion was associated with attenuated survival in unadjusted survival analysis (HR: 3.80; 95% CI: 1.55–9.31), multivariate analysis (HR: 5.13; 95% CI: 1.86–14.16), and after the multivariate model was adjusted for concomitant pericardial effusion (HR: 4.86; 95% CI: 1.51–15.71). Negative impact on survival remained unchanged when effusions more likely related to an alternative cause were removed from analysis. In conclusion, pleural effusions can complicate pulmonary arterial hypertension in the absence of left heart disease. These effusions are frequently small in size, bilateral in location, and their presence is associated with decreased survival. Attenuated survival appears independent of the risk associated with a new pericardial effusion.

Associated Pleural and Pericardial Effusions: An Extensive Differential Explored

Concurrent pleural and pericardial effusions are not an unusual finding, but their differential diagnosis remains uncertain. Medline-based review identified an extensive list of infectious, inflammatory, neoplastic, iatrogenic, and myriad other etiologies. A single retrospective study had addressed this presentation. Several principles of a diagnostic workup are suggested, acknowledging that a significant minority of patients may not require a comprehensive workup and remain 'idiopathic'.

Prognostic implications of pericardial and pleural effusion in patients with cardiac amyloidosis

BACKGROUND

Pericardial and pleural effusion are common findings in patients with cardiac amyloidosis (CA). It is not known, whether effusions correlate with right ventricular (RV) function in these patients. Furthermore, data on the prognostic significance of pleural and pericardial effusion in CA is scarce.

METHODS

Patients with transthyretin (ATTR) and light chain (AL) CA were included in a clinical registry. All patients underwent transthoracic echocardiography at baseline. The presence of pericardial and pleural effusion was determined in every patient. The clinical endpoint was defined as cardiac death or heart failure hospitalization.

RESULTS

In total, 143 patients were analysed. Of these, 85 patients were diagnosed with ATTR and 58 patients with AL. Twenty-four patients presented with isolated pericardial effusion and 35 with isolated pleural effusion. In 19 patients, both pericardial and pleural effusion were found and in 65 patients no effusion was present at baseline. The presence of pleural effusion correlated well with poor RV function, measured by global RV free-wall strain (p = 0.007) in patients with AL, but not in ATTR. No such correlation could be found for pericardial effusion in either amyloidosis subtype. Patients with AL presenting with pleural effusion had worse outcomes compared to patients with pericardial effusion alone or no effusion at baseline. In the ATTR group, there was no difference in outcomes according to presence and type of effusion.

CONCLUSION

More than 50% of patients with CA presented with pleural and/or pericardial effusions. While pleural effusion was clearly associated with poor RV function in AL, we were not able to detect this association with pericardial effusion.

Lung ultrasound-guided therapeutic thoracentesis in refractory congestive heart failure

Background: Pleural effusion refractory to diuretic treatment is frequent in advanced heart failure. Therapeutic thoracentesis is a time-honored practice, recently made simpler and safer by guidance with lung ultrasound. To assess the feasibility and clinical impact of lung ultrasound-driven therapeutic thoracentesis in refractory heart failure.Methods and results: In a single-centre retrospective analysis we recruited 373 patients with heart failure with reduced ejection fraction (26 ± 12%), New York Heart Association class ≥3, and pleural effusion ≥ moderate at lung ultrasound. All patients underwent lung ultrasound-guided therapeutic thoracentesis. Total of 462 lung ultrasound-guided therapeutic thoracentesis procedures were successfully performed without complications. Evacuated pleural fluid by passive drainage was 1030 ± 534 mL. The maximal interpleural space was 73.6 ± 15.6 mm before, and 12.4 ± 3.1 mm after therapeutic thoracentesis (p < .001). Therapeutic thoracentesis induced an immediate symptomatic improvement in all patients, with New York Heart Association class decrease from 3.84 ± 0.37 pre- to 2.7 ± 0.55 post-therapeutic thoracentesis (p <.001). The improvement was long-lasting (for weeks/months) in 89% of patients. The 6-min walking test was 52 ± 29 m before, and 287 ± 56 m one month after therapeutic thoracentesis (p < .05).Conclusion: Lung ultrasound-driven therapeutic thoracentesis of pleural effusion in decompensated heart failure patients is feasible, safe, and efficient. Therapeutic thoracentesis induces immediate and substantial symptomatic relief followed by long-lasting improvement.

Effusion-Serum Chloride Gradient in Heart Failure-Associated Pleural Effusion - Pathophysiologic Implications

Background: There is scant clinical data of electrolyte analyses in the pleural fluid under heart failure (HF) pathophysiology.

Methods and Results: This study retrospectively analyzed data from 17 consecutive patients who presented with pleural effusion and underwent thoracentesis. A diagnosis of worsening HF was established by clinical criteria (presentation, echocardiography, serum B-type natriuretic peptide, and response to therapy). Samples of non-heparinized pleural fluid and peripheral venous blood, obtained within 2 h of each other, were subjected to biochemical analysis. The source of pleural effusion was determined as transudate or exudate according to Light’s criteria. Fifteen patients (53% men; mean [±SD] age 85±11 years) had HF-associated pleural effusion, 10 of whom had transudative effusion and 5 who had exudative effusion (fulfilling only 1 [n=4] or both [n=1] lactate dehydrogenase criteria). The effusion-serum gradient (calculated by subtracting the serum electrolyte concentration from the effusion electrolyte concentration) was significantly higher for chloride (mean [±SD] 7.4±2.6 mEq/L; range 4–14 mEq/L) than sodium (0.9±1.4 mEq/L; ranging from −1 to 4 mEq/L) and potassium (−0.1±0.3 mEq/L; ranging from −0.8 to 0.2 mEq/L; P<0.001 for each).

Conclusions: In HF-associated pleural effusion, the chloride concentration is higher in the pleural effusion than the serum, indicating that chloride may have an important role in the formation and retention of body fluid in the pleural space.

Quantification of pleural effusions on thoracic ultrasound in acute heart failure

BACKGROUND

Although pleural effusions are common among patients with acute heart failure, the relevance of pleural effusion size assessed on thoracic ultrasound has not been investigated systematically.

METHODS

In this prospective observational study, we included patients hospitalised for acute heart failure and performed a thoracic ultrasound early after admission (thoracic ultrasound 1) and at discharge (thoracic ultrasound 2) independently of routine clinical management. A semiquantitative score was applied offline blinded to clinical findings to categorise and monitor pleural effusion size.

RESULTS

Among 188 patients (median age 72 years, 62% men, 78% white, median left ventricular ejection fraction 38%), pleural effusions on thoracic ultrasound 1 were present in 66% of patients and decreased in size during the hospitalisation in 75% based on the pleural effusion score (P<0.0001). Higher values of the pleural effusion score were associated with higher pleural effusion volumes on computed tomography (P<0.001), higher NT-pro brain natriuretic peptide values (P=0.001) and a greater number of B-lines on lung ultrasound (P=0.004). Nevertheless, 47% of patients were discharged with persistent pleural effusions, 19% with large effusions. However, higher values of the pleural effusion score on thoracic ultrasound 2 did not identify patients at increased risk of 90-day heart failure rehospitalisations or death (adjusted hazard ratio (HR) 1.05, 95% confidence interval (CI) 0.92-1.19; P=0.46) whereas seven or more B-lines on lung ultrasound at discharge were independently associated with adverse events (adjusted HR 2.43, 95% CI 1.11-5.37; P=0.027).

CONCLUSION

Among patients with acute heart failure, pleural effusions are associated with other clinical, imaging and laboratory markers of congestion and improve with heart failure therapy. The prognostic relevance of persistent pleural effusions at discharge should be investigated in larger studies.

Imaging of Pericardial Disease

Although the pericardium is simply a 2-layered membrane enveloping the heart and great vessels, there are numerous anatomic variations, congenital anomalies, and pathologic conditions that can occur. Although echocardiography is most often the first imaging modality used to assess the pericardium, computed tomography and MR imaging are frequently being used to aid in diagnosis and assess response to therapy. Therefore, detailed knowledge of the pericardium in both its normal and diseased states is important to best direct patient care and potentially improve patient outcomes.

Cancer antigen-125 and outcomes in acute heart failure: a systematic review and meta-analysis

BACKGROUND

Carbohydrate antigen-125 (CA125) is an ovarian cancer marker, but recent work has examined its role in risk stratification in heart failure. A recent meta-analysis examined its prognostic value in heart failure generally. However, there has been no systematic evaluation of its role specifically in acute heart failure (AHF).

METHODS

PubMed and EMBASE databases were searched until 11 May 2018 for studies that evaluated the prognostic value of CA125 in AHF.

RESULTS

A total of 129 and 179 entries were retrieved from PubMed and EMBASE. Sixteen studies (15 cohort studies, 1 randomised trial) including 8401 subjects with AHF (mean age 71 years old, 52% male, mean follow-up 13 months, range of patients 525.1±598.2) were included. High CA125 levels were associated with a 68% increase in all-cause mortality (8 studies, HRs: 1.68, 95% CI 1.36 to 2.07; p<0.0001; I2: 74%) and 77% increase in heart failure-related readmissions (5 studies, HRs: 1.77, 95% CI 1.22 to 2.59; p<0.01; I2: 73%). CA125 levels were higher in patients with fluid overload symptoms and signs compared with those without them, with a mean difference of 54.8 U/mL (5 studies, SE: 13.2 U/mL; p<0.0001; I2: 78%).

CONCLUSION

Our meta-analysis found that high CA125 levels are associated with AHF symptoms, heart failure-related hospital readmissions and all-cause mortality. Therefore, CA125 emerges as a useful risk stratification tool for identifying high-risk patients with more severe fluid overload, as well as for monitoring following an AHF episode.

Risk factors of pericardial effusion in native valve infective endocarditis and its influence on outcome: A multicenter prospective cohort study

BACKGROUND

Pericardial effusion is a frequent finding in the setting of infective endocarditis. Limited data exists on clinical characteristics and outcomes in this group of patients. We aimed to determine the associated factors, clinical characteristics, and outcomes of patients who had pericardial effusion and native valve infective endocarditis.

METHODS AND RESULTS

A total of 1205 episodes of infective endocarditis from 25 Spanish centers between June 2007 and March 2013 within the Spanish Collaboration on Endocarditis (GAMES) registry were included. Echocardiogram at admission, clinical and microbiological variables, and one-year follow-up were analyzed. Pericardial effusion was observed in 7.8% (94/1205 episodes) of episodes of infective endocarditis, most of them being mild or moderate (93.6%). The presence of pericardial effusion was associated with a higher risk of heart failure during admission (OR 1.9; CI 95% 1.2-3.0). Patients with pericardial effusion had a higher rate of surgery (53.2% vs. 41.1%; p = 0.02); however, this association was no longer significant after adjusting for possible confounders (OR 1.4; CI 95% 0.9-2.2; p = 0.10). The presence of pericardial effusion was not associated with a higher in-hospital or one-year mortality (33.0% vs. 25.2%; p = 0.10 and 40.2% vs. 37.3%; p = 0.60 respectively).

CONCLUSIONS

The prevalence of pericardial effusion in patients with infective endocarditis was lower than previously reported. The presence of pericardial effusion is associated with the development of heart failure during hospitalization making it a warning sign, possibly reflecting indirectly a mechanical complication, which, however, if treated surgically in a timely manner does not change the final outcome of patients.

Pericardial Effusion in Obstructive Sleep Apnea without Pulmonary Arterial Hypertension and Daily Hypoxemia - is it Unusual?

Background:

Pericardial effusion in chronic hypoxemic lung diseases, such as Obstructive Sleep Apnea syndrome, usually occurs after the development of severe pulmonary arterial hypertension. However, data about the frequency of pericardial effusions in Obstructive Sleep Apnea syndrome without pulmonary arterial hypertension and/or daytime hypoxemia are still scarce, and their pathogenesis is unclear.

Aims:

To assess the prevalence of pericardial effusions and their volume and location in patients with obesity and Obstructive Sleep Apnea syndrome without pulmonary arterial hypertension and/or hypoxemia.

Study Design:

Cross-sectional study.

Methods:

We included 279 consecutive patients (162 males) with newly diagnosed Obstructive Sleep Apnea syndrome having a mean age of 42.8±12.4 years and a mean body mass index of 37.3±7.8 kg/m². Obstructive Sleep Apnea syndrome was confirmed by polysomnography. Main exclusion criteria were concomitant inflammatory diseases, thyroid dysfunction, daytime hypoxemia, nephrotic syndrome, left ventricular systolic dysfunction and pulmonary arterial hypertension.

Results:

Pericardial effusion was found in 102 (36.56%) -all of them with moderate to severe obstructive Sleep Apnea syndrome. The mean effusion volume was mild to moderate (up to 250 mL). In 36 patients (35.3%) the pericardial effusion was diffuse, in 42 (41.2%), the pericardial effusion was located in front of the right atrium and the right ventricle, and in 24 (23.5%) the pericardial effusion was situated in front of the right cardiac cavities and the left atrium. We found a significant positive correlation between the presence of pericardial effusion and apnea-hypopnea index (r=0.374, p<0.001), body mass index (r=0.473, p<0.001), and desaturation time during sleep (r=0.289, p<0.001).

Conclusion:

Pericardial effusion in patients with obesity and moderate to severe Obstructive Sleep Apnea syndrome without daily hypoxemia and/or pulmonary hypertension is a relatively common finding. The occurrence of pericardial effusions is dependent mostly on the grade of Obstructive Sleep Apnea syndrome, degree of obesity, and duration of sleep desaturation.

Diagnostic performance of multi-organ ultrasound with pocket-sized device in the management of acute dyspnea

BACKGROUND

The availability of ultra-miniaturized pocket ultrasound devices (PUD) adds diagnostic power to the clinical examination. Information on accuracy of ultrasound with handheld units in immediate differential diagnosis in emergency department (ED) is poor. The aim of this study is to test the usefulness and accuracy of lung ultrasound (LUS) alone or combined with ultrasound of the heart and inferior vena cava (IVC) using a PUD for the differential diagnosis of acute dyspnea (AD).

METHODS

We included 68 patients presenting to the ED of "Maurizio Bufalini" Hospital in Cesena (Italy) for AD. All patients underwent integrated ultrasound examination (IUE) of lung-heart-IVC, using PUD. The series was divided into patients with dyspnea of cardiac or non-cardiac origin. We used 2 × 2 contingency tables to analyze sensitivity, specificity, positive predictive value and negative predictive value of the three ultrasonic methods and their various combinations for the diagnosis of cardiogenic dyspnea (CD), comparing with the final diagnosis made by an independent emergency physician.

RESULTS

LUS alone exhibited a good sensitivity (92.6%) and specificity (80.5%). The highest accuracy (90%) for the diagnosis of CD was obtained with the combination of LUS and one of the other two methods (heart or IVC).

CONCLUSIONS

The IUE with PUD is a useful extension of the clinical examination, can be readily available at the bedside or in ambulance, requires few minutes and has a reliable diagnostic discriminant ability in the setting of AD.

Transthoracic echocardiography in the evaluation of pediatric pulmonary hypertension and ventricular dysfunction

Transthoracic echocardiography (TTE) is the most accessible noninvasive diagnostic procedure for the initial assessment of pediatric pulmonary hypertension (PH). This review focuses on principles and use of TTE to determine morphologic and functional parameters that are also useful for follow-up investigations in pediatric PH patients. A basic echocardiographic study of a patient with PH commonly includes the hemodynamic calculation of the systolic pulmonary artery pressure (PAP), the mean and diastolic PAP, the pulmonary artery acceleration time, and the presence of a pericardial effusion. A more detailed TTE investigation of the right ventricle (RV) includes assessment of its size and function. RV function can be evaluated by RV longitudinal systolic performance (e.g., tricuspid annular plane systolic excursion), the tricuspid regurgitation velocity/right ventricular outflow tract velocity time integral ratio, the fractional area change, tissue Doppler imaging-derived parameters, strain measurements, the systolic-to-diastolic duration ratio, the myocardial performance (Tei) index, the RV/left ventricle (LV) diameter ratio, the LV eccentricity index, determination of an enlarged right atrium and RV size, and RV volume determination by 3-dimensional echocardiography. Here, we discuss the potential use and limitations of TTE techniques in children with PH and/or ventricular dysfunction. We suggest a protocol for TTE assessment of PH and myocardial function that helps to identify PH patients and their response to pharmacotherapy. The outlined protocol focuses on the detailed assessment of the hypertensive RV; RV-LV crosstalk must be analyzed separately in the evaluation of different pathologies that account for pediatric PH.

Imaging Congestion With a Pocket Ultrasound Device: Prognostic Implications in Patients With Chronic Heart Failure

BACKGROUND

Venous congestion is common in patients with chronic heart failure (HF). We used a pocket-sized ultrasound imaging device (PID) to assess the patients' congestive status and related our findings to prognosis.

METHODS AND RESULTS

One hundred four consecutive outpatients from an HF outpatient clinic were studied. Interstitial lung water (ILW), pleural effusion (PE), and the diameter of the inferior vena cava (VCI) were assessed with the use of a PID. ILW was assessed by demonstration of B-lines (comet tail artifact (CTA). Out of the 104 patients, 28 had CTA and 8 had PE. Median VCI diameter was 18 mm (interquartile range 14-22 mm). Each of these parameters correlated weakly (r = 0.26-0.37; P < .05) with the HF biomarker N-terminal pro-B-type natriuretic peptide (NT-proBNP). During the median follow-up time of 530 days, 18 hospitalizations and 14 deaths were registered. Findings of CTA, PE, or both increased the risk of death or hospitalization (hazard ratio 3-4; P < .05). After adjustment for age, cardiac systolic function, and NT-proBNP, this difference remained significant for CTA alone and CTA + PE combined, but not for PE alone.

CONCLUSIONS

With the use of a handheld ultrasound device, signs of pulmonary congestion could be demonstrated. When found, these had a significant prognostic impact in clinically stable HF.

Pocket-sized ultrasound examination of fluid imbalance in patients with heart failure: a pilot and feasibility study of heart failure nurses without prior experience of ultrasonography

BACKGROUND

Detecting fluid imbalance in patients with chronic heart failure can be challenging. Use of a pocket-sized ultrasound device (PSUD) in addition to physical examination can be helpful to assess this important information.

AIM

To evaluate the feasibility for nurses without prior experience of ultrasonography to examine fluid imbalance by the use of a PSUD on heart failure patients.

METHOD

Four heart failure nurses and an expert cardiologist participated. The nurses underwent a four-hour PSUD training programme. One hundred and four heart failure outpatients were included. The examinations obtained information of pulmonary congestion, pleural effusion and the diameter of the vena cava inferior.

RESULTS

Examinations took nine minutes on average. In 28% and 14% of the patients, pulmonary congestion and pleural effusion respectively were found by the nurses. The sensitivities and specificities for nurses' findings were 79% and 91%, and, 88% and 93% respectively. The inter-operator agreement between the nurses and the cardiologist reached a substantial level (kappa values: 0.71 and 0.66). The inter-operator agreement for vena cava inferior reached a fair level (kappa value=0.39). Bland-Altman plots of the level of agreement revealed a mean difference of vena cava inferior diameter of 0.11 cm, while the 95% lower and upper limits ranged from -0.78 cm to 1.00 cm.

CONCLUSION

After brief training, heart failure nurses can reliably identify pulmonary congestion and pleural effusion with a PSUD. Assessment of vena cava inferior was less valid. PSUD readings, when added to the history and a physical examination, can improve nurse assessment of fluid status in patients with heart failure.

Right ventricular function quantification in Takotsubo cardiomyopathy using two-dimensional strain echocardiography

Aims

This study sought to characterize global and regional right ventricular (RV) myocardial function in patients with Takotsubo cardiomyopathy (TC) using 2D strain imaging.

Methods

We compared various parameters of RV and left ventricular (LV) systolic function between 2 groups of consecutive patients with TC at initial presentation and upon follow-up. Group 1 had RV involvement and group 2 did not have RV involvement.

Results

At initial presentation, RV peak systolic longitudinal strain (RVPSS) and RV fractional area change (RVFAC) were significantly lower in group 1 (−13.2±8.6% vs. −21.8±5.4%, p = 0.001; 30.7±9.3% vs. 43.5±6.3%, p = 0.001) and improved significantly upon follow-up. Tricuspid annular plane systolic excursion (TAPSE) did not differ significantly at initial presentation between both groups (14.8±4.1 mm vs. 17.9±3.5 mm, p = 0.050). Differences in regional systolic RV strain were only observed in the mid and apical segments. LV ejection fraction (LVEF) and LV global strain were significantly lower in group 1 (36±8% vs. 46±10%, p = 0.006 and −5.5±4.8% vs. −10.2±6.2%, p = 0.040) at initial presentation. None of the parameters were significantly different between the 2 groups upon follow-up. A RVPSS cut-off value of >−19.1% had a sensitivity of 85% and a specificity of 71% to discriminate between the 2 groups.

Conclusion

In TC, RVFAC, RVPSS, LVEF and LV global strain differed significantly between patients with and without RV dysfunction, whereas TAPSE did not. 2 D strain imaging was feasible for the assessment of RV dysfunction in TC and could discriminate between patients with and without RV involvement in a clinically meaningful way.

A structured, parsimonious approach to establish the cause of moderate-to-large pericardial effusion

The workup of moderate-to-large pericardial effusion should focus on its hemodynamic impact and potential cause. A structured approach to diagnostic evaluation of pericardial effusion is needed. We retrospectively studied a contemporary cohort of 103 patients with moderate-to-large pericardial effusion hospitalized at St. Luke's Roosevelt Hospital Center from July 2009 till August 2013. Diagnosis of pericardial effusion was independently ascertained by chart review. We applied a stepwise parsimonious approach to establish the cause of pericardial effusion. In the studied cohort, the mean age was 61 years, 50% were men, and 65 patients (63%) underwent pericardial effusion drainage. Using the structured approach, the cause of the effusion was ascertained in 70 patients (68%) by noninvasive targeted testing. Malignant effusion was confirmed in 19 patients (19%). All patients with malignant effusion had either history of malignancy or suggestive noninvasive findings. In conclusion, a structured approach can help to ascertain the diagnosis in patients with moderate-to-large pericardial effusion and guide the need for pericardial drainage or sampling.

Prognostic factors in pulmonary arterial hypertension with Dana Point group 1

AIMS

To clarify the prognosis and prognostic factors in pulmonary arterial hypertension (PAH) patients in real-world medical practice in the Tokai area in Japan.

MAIN METHODS

We conducted a retrospective, multicenter observational study. The data of 81 patients diagnosed with Dana Point group 1 or 1' PAH was collected from January 2005 to January 2013. The primary outcome was all-cause death.

KEY FINDINGS

The patients consisted of 34 cases of idiopathic PAH (IPAH), 28 of connective tissue-associated PAH (CTD-PAH), 16 of congenital heart disease-associated PAH (CHD-PAH) and others. Mean age was 51 years and mean observation period was 46 months. The systolic blood pressure (BPs) was 117±23 mm Hg. Pericardial effusion was observed in 27.0% of patients. The mean right atrial pressure (mRAP) was 10.2±7.3 mm Hg. In the univariate Cox regression analysis, WHO-FCS III & IV, a cardiac index (CI)<2.5 L/min/m(2), and the presence of pericardial effusion at baseline were significantly associated with all-cause death. In the multivariate analysis, the pericardial effusion (HR 3.3, 95% CI 1.03-10.63, p=0.04) and mRAP (HR 3.2, 95% CI 1.03-9.83, p=0.04) or CI<2.5 L/min/m(2) (HR 3.89, 95% CI 1.05-14.45, p=0.04) were the independent predictors of mortality.

SIGNIFICANCE

The presence of pericardial effusion and mRAP or CI<2.5 L/min/m(2) at diagnosis indicated high mortality.

Pericardial effusions in pulmonary arterial hypertension: characteristics, prognosis, and role of drainage

BACKGROUND

The presence and size of a pericardial effusion in pulmonary arterial hypertension (PAH) and its association with outcome is unclear.

METHODS

In this single-center cohort study of 577 patients with group 1 PAH seen between January 1, 1995, and December 31, 2005, all patients underwent transthoracic echocardiography and were followed for ≥ 5 years. Echocardiography-guided pericardiocentesis was performed as needed.

RESULTS

Pericardial effusions on index echocardiography occurred in 150 patients (26%); 128 patients had small and 22 had moderate-sized or larger effusions. Most of the moderate or greater effusions occurred in patients who had connective tissue disease (82%). Mean right atrial pressure was 13.4 ± 4.4 mm Hg (no effusion), 15.1 ± 4.4 mm Hg (small effusion), and 17.0 ± 4.0 mm Hg (moderate or greater effusion) (P &lt; .0001). Median survival for patients with moderate or greater effusion, mild effusion, or no effusion was 11.3 months, 42.3 months, and 76.5 months, respectively. Four of the 22 patients with moderate or greater pericardial effusions eventually required echocardiography-guided pericardiocentesis because of clinical and echocardiographic evidence of hemodynamic impact. When drained, the effusions were large (858 ± 469 mL) and generally serous. All pericardiocenteses were performed cautiously under echocardiographic guidance by a highly experienced echocardiologist, with low immediate morbidity and mortality.

CONCLUSIONS

Pericardial effusions are relatively common but rarely of hemodynamic significance in patients with PAH. However, even modest degrees of pericardial fluid are associated with a significant increase in mortality and appear to reflect the presence of associated collagen vascular disease and high right atrial pressure.

Misconceptions and facts about pericardial effusion and tamponade

Several common misconceptions can make the clinical diagnosis of subacute pericardial tamponade challenging. Widely known physical findings of pericardial tamponade lack sensitivity and specificity. Interpretation of echocardiographic signs requires good understanding of pathophysiology. Over-reliance on echocardiography may result in over-utilization of pericardial drainage procedures. Awareness of these misconceptions with an integrative approach to both clinical and imaging data will help clinicians to assess the hemodynamic impact of pericardial effusion and the need for drainage.