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European Heart Journal Nov 2015
2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC)Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS).
Topics: Acute Disease; Age Factors; Anti-Inflammatory Agents; Autoimmune Diseases; Bacterial Infections; Biomarkers; Biopsy; Cardiac Catheterization; Cardiac Tamponade; Chronic Disease; Drainage; Echocardiography; Endoscopy; Heart Injuries; Heart Neoplasms; Hospitalization; Humans; Kidney Failure, Chronic; Magnetic Resonance Angiography; Multimodal Imaging; Pericardial Effusion; Pericardiocentesis; Pericarditis; Physical Examination; Positron-Emission Tomography; Postoperative Complications; Radiation Injuries; Recurrence; Sex Factors; Syndrome; Tomography, X-Ray Computed; Treatment Outcome; Triage; Virus Diseases
PubMed: 26320112
DOI: 10.1093/eurheartj/ehv318 -
Current Cardiology Reports Jul 2021Pericardial effusion is a challenging pericardial syndrome and a cause of serious concern for physicians and patients due to its potential progression to... (Review)
Review
PURPOSE OF REVIEW
Pericardial effusion is a challenging pericardial syndrome and a cause of serious concern for physicians and patients due to its potential progression to life-threatening cardiac tamponade. In this review, we summarize the contemporary evidence of the etiology; diagnostic work-up, with particular emphasis on the contribution of multimodality imaging; therapeutic options; and short- and long-term outcomes of these patients.
RECENT FINDINGS
In recent years, an important piece of information has contributed to put together several missing parts of the puzzle of pericardial effusion. The most recent 2015 guidelines of the European Society of Cardiology for the diagnosis and management of pericardial diseases are a valuable aid for a tailored approach to this condition. Actually, current guidelines suggest a 4-step treatment algorithm depending on the presence or absence of hemodynamic impairment; the elevation of inflammatory markers; the presence of a known or first-diagnosed underlying condition, possibly related to pericardial effusion; and finally the duration and size of the effusion. In contrast to earlier perceptions, based on the most recent evidence, it seems that in the subgroup of asymptomatic patients with large (> 2-cm end-diastolic diameter), chronic (> 3 months) C-reactive protein negative, idiopathic (without an apparent cause) pericardial effusion, a conservative approach is the most reasonable option. At present there is an increasing interest in the pericardial syndromes in general and pericardial effusions in specific, which has consistently expanded our knowledge in this "hazy landscape." Apart from general recommendations applied to all cases, an individualized, etiologically driven treatment is of paramount importance.
Topics: Cardiac Tamponade; Cardiology; Hemodynamics; Humans; Pericardial Effusion; Pericardiocentesis
PubMed: 34196832
DOI: 10.1007/s11886-021-01539-7 -
Interactive Cardiovascular and Thoracic... Jun 2022Isolated Chylopericardium (without chylothorax) is a rare clinical disorder that may happen idiopathically or secondary to trauma, radiotherapy, lymphatic anomalies,...
Isolated Chylopericardium (without chylothorax) is a rare clinical disorder that may happen idiopathically or secondary to trauma, radiotherapy, lymphatic anomalies, infections or mediastinal neoplasm. We present a case of middle-aged male with no past medical history of note prior to developing heavy sweating, loss of weight and cough. A series of investigations were done including chest computed tomography which showed enlarged mediastinal lymph nodes leading to uncomplicated mediastinoscopy and lymph node biopsy. Six days after being discharged, he developed dyspnoea and chest pain. Echocardiography revealed massive pericardial effusion. Pericardiocentesis was done and surprisingly revealed milky white chylous fluid. The patient was then successfully managed without the need for further intervention.
Topics: Chylothorax; Humans; Lymph Nodes; Male; Mediastinum; Middle Aged; Pericardial Effusion; Pericardiocentesis
PubMed: 34964452
DOI: 10.1093/icvts/ivab365 -
Journal of Education & Teaching in... Oct 2020This simulation is designed to educate emergency medicine residents and medical students on the recognition and management of cardiac tamponade, as well as encourage...
AUDIENCE
This simulation is designed to educate emergency medicine residents and medical students on the recognition and management of cardiac tamponade, as well as encourage providers to become familiar with their states' disclosure laws for sentinel events.
INTRODUCTION
Cardiac tamponade is an emergent condition in which the accumulation of pericardial fluid and the consequent increase in hydrostatic pressure becomes severe enough to compromise the normal diastolic and systolic function of the heart, resulting in hemodynamic instability.1 The causes of cardiac tamponade are numerous because it is a potential complication of any of a number of pericardial disease processes, including infectious, inflammatory, traumatic, and malignant etiologies.1,2 Clinical presentations may vary and symptoms can be non-specific, which can lead to delayed or missed diagnoses and poor patient outcomes.3 In addition to this, the incidence of this condition is rising due to the increasing frequency of cardiac procedures performed (ie, pacemaker placement).4 Therefore, it is important for medical providers to have a high index of suspicion for the diagnosis based on patient presentation and to quickly provide necessary treatment to stabilize the patient.
EDUCATIONAL OBJECTIVES
By the end of this simulation session, the learner will be able to: (1) describe a diagnostic differential for dizziness (2) describe the pathophysiology of cardiac tamponade (3) describe the acute management of cardiac tamponade, including fluid bolus and pericardiocentesis (4) describe the electrocardiogram (ECG) findings of pericardial effusion (5) describe the ultrasound findings of cardiac tamponade (6) describe the indications for emergent bedside pericardiocentesis versus medical stabilization and delayed pericardiocentesis for cardiac tamponade (7) describe the procedural steps for pericardiocentesis, and (8) describe your state's laws regarding disclosure for sentinel events.
EDUCATIONAL METHODS
This session is conducted using high-fidelity simulation, followed by a debriefing session on evaluation and treatment of cardiac tamponade. However, it may also be run as an oral board case.
EDUCATIONAL METHODS
Our residents were provided an electronic survey at the completion of the debriefing session so they may rate different aspects of the simulation, as well as provide qualitative feedback on the scenario. This survey is specific to the local institution's simulation center.
RESULTS
Feedback was largely positive because many learners mentioned during debriefing that they are not comfortable with pericardiocentesis and have limited opportunities to practice the procedure. None of our residents were familiar with our state's or institution's disclosure laws for sentinel events.The local institution's simulation center feedback form is based on the Center of Medical Simulation's Debriefing Assessment for Simulation in Healthcare (DASH) Student Version Short Form with the inclusion of required qualitative feedback if an element was scored less than a 6 or 7.5 This session received a majority of 6 (consistently effective/very good) and 7 scores (extremely effective/outstanding).
DISCUSSION
This is a potential method for educating future medical providers on the diagnosis and management of cardiac tamponade in an emergency department setting. Learners initially had a wide range of differentials for the chief complaint of dizziness. We used an ECG with low voltage but without electrical alternans. When asked to provide an ECG interpretation, low voltage was intermittently explicitly interpreted by learners. We were concerned that if we showed an ECG with electrical alternans, learners may quickly arrive at the diagnosis without focusing on the subtleties of a physical exam, including looking for jugular venous distention (JVD) or pulsus paradoxus.We did not have the patient decompensate if their international normalized ratio (INR) was not immediately reversed, given likely delay for coagulation to occur in the face of life-threatening tamponade, but this provided a robust discussion during debriefing if reversal should be emergently initiated.Many residents voiced that they were uncomfortable performing a pericardiocentesis because they only had a few opportunities to do so on human cadavers, and they appreciated the opportunity to review this.Unexpectedly, when the patient asked the learners if he should sue the cardiologist, the majority of groups told the patient that the cardiologist was not liable because tamponade is a known complication of cardiac ablation and likely reviewed this while obtaining informed consent. None of the learners were familiar with Ohio's disclosure laws for sentinel events. This identified a gap in knowledge that may be addressed in future learning sessions.Our main take-away is to continue providing low-frequency, high-acuity cases that provide the opportunity to review infrequent pathologies and procedures, as well as including patient safety and administrative learning points.
TOPICS
Medical simulation, cardiac tamponade, pericardial effusion, cardiac emergencies, obstructive shock, sentinel events, iatrogenic injury, medical disclosure.
PubMed: 37465332
DOI: 10.21980/J81D1D -
The Journal of International Medical... Nov 2020Chronic massive pericardial effusion without cardiac tamponade is relatively rare. Nearly half of all patients with chronic large pericardial effusion are asymptomatic.... (Review)
Review
Chronic massive pericardial effusion without cardiac tamponade is relatively rare. Nearly half of all patients with chronic large pericardial effusion are asymptomatic. We report a case of a 77-year-old man who presented with an asymptomatic chronic massive pericardial effusion, with no evidence of cardiac tamponade or pericardial constriction during a 10-year follow-up. The patient had a complex history of lymph node tuberculosis, hypertension, hypothyroidism, and polycythemia vera, as well as high-dose P radiation exposure 45 years ago. There was no evidence of tuberculosis infection, hypothyroidism, malignant tumor, severe heart failure, uremia, trauma, severe bacterial or fungal infection, chronic myeloid leukemia, or bone marrow fibrosis after admission. The patient underwent pericardiocentesis twice. The pericardial effusion comprised exudate fluid with a high proportion of monocytes. The patient refused indwelling catheter drainage or pericardiectomy. The likely final diagnosis was recurrent chronic large idiopathic pericardial effusion.
Topics: Aged; Cardiac Tamponade; Humans; Male; Pericardial Effusion; Pericardiectomy; Pericardiocentesis; Pericarditis
PubMed: 33233991
DOI: 10.1177/0300060520973091 -
The New England Journal of Medicine Jan 2004Effusive-constrictive pericarditis is an uncommon pericardial syndrome characterized by concomitant tamponade, caused by tense pericardial effusion, and constriction,...
BACKGROUND
Effusive-constrictive pericarditis is an uncommon pericardial syndrome characterized by concomitant tamponade, caused by tense pericardial effusion, and constriction, caused by the visceral pericardium. We conducted a prospective study of its clinical evolution and management.
METHODS
From 1986 through 2001, all patients with effusive-constrictive pericarditis were prospectively evaluated. Combined pericardiocentesis and cardiac catheterization were performed in all patients, and pericardiectomy was performed in those with persistent constriction. Follow-up ranged from 1 month to 15 years (median, 7 years).
RESULTS
A total of 1184 patients with pericarditis were evaluated, 218 of whom had tamponade. Of these 218, 190 underwent combined pericardiocentesis and catheterization. Fifteen of these patients had effusive-constrictive pericarditis and were included in the study. All patients presented with clinical tamponade; however, concomitant constriction was recognized in only seven patients. At catheterization, all patients had elevated intrapericardial pressure (median, 12 mm Hg; interquartile range, 7 to 18) and elevated right atrial and end-diastolic right and left ventricular pressures. After pericardiocentesis, the intrapericardial pressure decreased (median value, -5 mm Hg; interquartile range, -5 to 0), whereas right atrial and end-diastolic right and left ventricular pressures, although slightly reduced, remained elevated, with a dip-plateau morphology. The causes were diverse, and death was mainly related to the underlying disease. Pericardiectomy was required in seven patients, all of whom had involvement of the visceral pericardium. Three patients had spontaneous resolution.
CONCLUSIONS
Effusive-constrictive pericarditis is an uncommon pericardial syndrome that may be missed in some patients who present with tamponade. Although evolution to persistent constriction is frequent, idiopathic cases may resolve spontaneously. In our opinion, extensive epicardiectomy is the procedure of choice in patients requiring surgery.
Topics: Adolescent; Adult; Aged; Anti-Inflammatory Agents, Non-Steroidal; Cardiac Tamponade; Female; Follow-Up Studies; Humans; Male; Middle Aged; Pericardial Effusion; Pericardiectomy; Pericardiocentesis; Pericarditis, Constrictive; Prospective Studies; Treatment Outcome
PubMed: 14749455
DOI: 10.1056/NEJMoa035630 -
Annals of Medicine and Surgery (2012) Aug 2022The hemodynamic stability of the heart and pericardium are maintained by the pericardial fluid of volume ∼10-50 ml. Pericardial effusion is associated with the... (Review)
Review
The hemodynamic stability of the heart and pericardium are maintained by the pericardial fluid of volume ∼10-50 ml. Pericardial effusion is associated with the abnormal accumulation of pericardial fluid in the pericardial cavity. Numerous imaging techniques are utilized to evaluate pericardial effusion including chest X-ray, electrocardiogram, transthoracic echocardiography, computed tomography scan, cardiac magnetic resonance imaging, and pericardiocentesis. Once diagnosed, there are numerous treatment options available for the management of patients with pericardial effusion. These include various invasive and non-invasive strategies such as pericardiocentesis, pericardial window, and sclerosing therapies. In recent times, few studies have been conducted to evaluate the safety and efficacy of each approach in routine clinical practice. In this review, we review the role of different modalities in the diagnosis of pericardial effusion while highlighting existing therapies aimed at the management and treatment of pericardial effusion.
PubMed: 35846853
DOI: 10.1016/j.amsu.2022.104142 -
World Journal of Cardiology Dec 2019Pericardial decompression syndrome (PDS) is an infrequent, life-threatening complication following pericardial drainage for cardiac tamponade physiology. PDS usually... (Review)
Review
Pericardial decompression syndrome (PDS) is an infrequent, life-threatening complication following pericardial drainage for cardiac tamponade physiology. PDS usually develops after initial clinical improvement following pericardiocentesis and is significantly underreported and may be overlooked in the clinical practice. Although the precise mechanisms resulting in PDS are not well understood, this seems to be highly associated with patients who have some underlying ventricular dysfunction. Physicians performing pericardial drainage should be mindful of the risk factors associated with the procedure including the rare potential for the development of PDS.
PubMed: 31908728
DOI: 10.4330/wjc.v11.i12.282 -
Biomedica : Revista Del Instituto... May 2020
Topics: Antitubercular Agents; Biopsy; Disease Progression; Drug Therapy, Combination; Humans; Lymph Nodes; Male; Middle Aged; Mycobacterium tuberculosis; Pericardiocentesis; Pericarditis, Tuberculous; Pericardium; Prednisone; Symptom Assessment; Tomography, X-Ray Computed; Tuberculoma
PubMed: 32463604
DOI: 10.7705/biomedica.4911