Pericardial-Peritoneal Window as an Alternative Treatment for Large and Recurrent Pericardial Effusion Post-Pericardiotomy

Abstract Introduction: The presence of mild to moderate pericardial effusion after cardiac surgery is common and oral medical therapy is usually able to treat it. Larger effusions are less frequent and surgical intervention is usually necessary. However, there are some rare cases of large effusions that are recurrent even after intervention and become challenging to treat. Methods: We describe the case of a patient submitted to coronary artery bypass grafting (CABG) without any intraoperative complications, who was regularly discharged from the hospital. She was referred to our emergency department twice after surgery with large pericardial effusion that was drained. Even after those two interventions and with adequate oral medication, the large effusion recurred. Results: During follow-up, the patient had her symptoms resolved, with no need for further hospital admission. Her echocardiograms after the last intervention showed no pericardial effusion. The present surgical technique demonstrated to be easy to perform, thus it should be considered as a treatment option for these rare cases of large and repetitive effusions, which do not respond to the traditional methods. Conclusions: In challenging cases of recurrent and large pericardial effusions, the pericardial-peritoneal window is an alternative surgical technique that brings clinical improvement and diminishes the risk of cardiac tamponade.

Late cardiac tamponade in a patient victim of penetrating trauma - case report

Abstract Case Presentation: A case of a 49-year-old patient, male, victim of stab wound, developing belatedly cardiac tamponade and hemodynamic stability was reported. The patient underwent a pericardial window with drainage of pericardial effusion of blackened aspect; however, without visualization of the cardiac lesion, enlargement of the incision by median sternotomy was opted for. A hematoma was spotted at the left ventricle with epicardial lesion and a patch of pericardium was made with 3-0 polypropylene. The patient developed acute pulmonary edema and atrial fibrillation, which improved after the intensive care unit clinical management, with hospital discharge in the 7th postoperative day.

Treatment of pericardial effusion through subxiphoid tube pericardiostomy and computerized tomography- or echocardiography - guided percutaneous catheter drainage methods

Abstract Objective: In this retrospective study, we aimed to observe the efficacy of pericardial effusion (PE) treatments by a survey conducted at the Department of Cardiovascular Surgery, Faculty of Medicine, Atatürk University. Methods: In order to get comparable results, the patients with PE were divided into three groups - group A, 480 patients who underwent subxiphoid pericardiostomy; group B, 28 patients who underwent computerized tomography (CT)-guided percutaneous catheter drainage; and group C, 45 patients who underwent echocardiography (ECHO)-guided percutaneous catheter drainage. Results: In the three groups of patients, the most important symptom and physical sign were dyspnea and tachycardia, respectively. The most common causes of PE were uremic pericarditis in patients who underwent tube pericardiostomy, postoperative PE in patients who underwent CT-guided percutaneous catheter drainage, and cancer-related PE in patients who underwent ECHO-guided percutaneous catheter drainage. In all the patients, relief of symptoms was achieved after surgical intervention. There was no treatment-related mortality in any group of patients. In patients with tuberculous pericarditis, the rates of recurrent PE and/or constrictive pericarditis progress were 2,9% and 2,2% after tube pericardiostomy and ECHO-guided percutaneous catheter drainage, respectively. Conclusion: Currently, there are many methods to treat PE. The correct treatment method for each patient should be selected according to a very careful analysis of the patient's clinical condition as well as the prospective benefit of surgical intervention.

Role of posterior pericardiotomy in prevention of Pericardial Effusion and Atrial Fibrillation after coronary artery bypass grafting surgery

The aim of this prospective study was to evaluate the efficacy of Posterior Pericardiotomy in decreasing the occurrence and development of Pericardial Effusion and related Atrial Fibrillation [AF] Randomized Control Trial [RCT]. Armed Forces Institute of Cardiology and National Institute of Heart Diseases Rawalpindi, from Jan 2009 to Feb 2010. This prospective randomised study was performed in the first 100 patients undergoing coronary artery bypass grafting surgery [CABG] between January 2009 and February 2010. Patients were randomized into two groups, Posterior Pericardiotomy was performed in 50 patients before releasing aortic cross clamp [Group I]; remaining other 50 patients served as the control Group [Group II]. Longitudinal incision was made parallel and posterior to the left phrenic nerve, extending from the left inferior pulmonary vein to the diaphragm in Group I. The difference between the two treatment groups, with regards to age, sex, number of bypass grafts, duration of cross clamp, total perfusion time and hospital stay time were not statistically significant. Atrial Fibrillation was noted in 02 [4%] patients in Group I and 12 [24%] patients in Group II [p 0.004]. Pericardial Effusion was present in 03 patients in Group I and 16 patients in Group II [p <0.001]. Atrial flutter and other supraventricular arrhythmias were not statistically significant. Posterior Pericardiotomy proved to be technically easy and efficient procedure in decreasing the occurrence and development of Pericardial Effusion and related Atrial Fibrillation [AF]

Mediastinal haemangioma with pericardial effusion: A rare entity.

Mediastinal haemangioma is a rare benign vascular tumour. A young male presented with complaints of cough and dyspnoea. Serial chest radiographs were suggestive of progressive mediastinal widening and cardiomegaly. Pericardiocentesis revealed haemorrhagic fluid which was negative for microbiology and malignant cells. Patient was unresponsive to antituberculosis treatment and steroids. Computed tomography (CT) of thorax revealed an anterior mediastinal mass lesion with pericardial effusion which on biopsy was found to be a mediastinal haemangioma.

First percutaneous balloon pericardiotomy [PBP] or pericardioplasty in Jordan: a case report and review of literature

Patients with large pericardial effusions regardless of their etiology frequently undergo surgical pericardial window to avoid recurrence that occurs in more than 50% if pericardiocentesis alone was done through the percutaneous approach. Some patients are very sick to undergo surgery options. A newly developed old procedure, Percutaneous Balloon Pericardiotomy [PBP], was introduced in 1991 and has been proven to be safe and efficient, with very low rate of recurrence, and little chance of complications. Herein, we describe this procedure done for the first time in Jordan

Derrame pericárdico, enfrentamiento clínico / Clinical approach to pericardial effusion

Pericardial effusion is the main complication of pericarditis, and can create serious consequences depending on the speed of development and etiology. The most common causes are neoplasms and idiopathic, even though viral etiology is a frequently underestimated cause because of the difficulty in its confirmation. In cases of significant pericardial effusion, pericardiocenthesis has demonstrated to be an effective and safe procedure. We present a clinical case of a 14 year old adolescent who complained of persistent abdominal pain, and whose study showed significant pericardial effusion. Pericardiocenthesis was performed, along with installation of a pigtail catheter which drained 500 ml of serohematic pericardial effusion. The etiologic study included an PCR (polymerase chain reaction) positive for Enterovirus. The patient recovered favorably and was dismissed from the hospital in good condition. The objective of this report is to expose a current revision of the clinical management of pericardial effusion and the technical skills of pericardiocenthesis. Knowledge of the technique is fundamental in the treatment of pericardial effusion, especially in situations associated with hemodynamic compromise.

El derrame pericárdico es la principal complicación de la pericarditis, la cual puede generar graves consecuencias dependiendo de la velocidad de instauración como de su etiología. Las principales causas reportadas son las neoplásicas y las idiopáticas, sin embargo, la etiología viral es subestimada debido a la dificultad de confirmar el diagnóstico. En casos de derrame pericárdico significativo la pericardiocentesis ha mostrado ser un procedimiento eficaz y seguro. Presentamos caso clínico de un adolescente de 14 a±os quién consulta por dolor abdominal persistente, cuyo estudio demuestra un derrame pericárdico. Se realizó pericardiocentesis e instalación de catéter pigtail dando salida a 500 mL de líquido pericárdico serohemático. Dentro del estudio etiológico presenta PCR (Reacción de Polimerasa en cadena) positivo para enterovirus. Paciente evoluciona favorablemente y es dado de alta en buenas condiciones. El objetivo del presente reporte es exponer la revisión actualizada del enfrentamiento clínico del derrame pericárdico y la técnica de pericardiocentesis. El conocimiento de la técnica de pericardiocentesis en fundamental en el tratamiento del derrame pericárdico, en especial en situaciones con compromiso hemodinámico.

Quilopericárdio idiopático primário: relato de caso / Quilopericardio idiopático primario: informe de caso clínico / Primary idiopathic chylopericardium: case report

O acúmulo de quilo no espaço pericárdico ou quilopericárdio é uma condição que, com maior frequência, ocorre após trauma, cirurgia cardíaca e torácica ou associado a tumores, tuberculose ou linfoangiomatose. Quando não é possível a identificação precisa da etiologia, o quilopericárdio é denominado primário ou idiopático. Essa é uma situação clínica rara. Descrevemos um caso em paciente do sexo feminino, com 20 anos de idade, tratada cirurgicamente. A propósito do caso, apresentamos breve revisão da literatura e comentários sobre quadro clínico, etiopatogenia, exames diagnósticos complementares e opções de tratamento.

The accumulation of chyle in the pericardial space, or chylopericardium, is a condition occurring most frequently after trauma, cardiac and thoracic surgery, or in association with tumors, tuberculosis or lymphangiomatosis. When its precise cause cannot be identified, it is called primary or idiopathic chylopericardium. This is a rare clinical entity. We report the case of a surgically treated 20-year-old female patient. A brief review of the literature and comments on the clinical presentation, etiopathogenesis, ancillary diagnostic tests and treatment options are also presented.

La acumulación de quilo en el espacio pericárdico o quilopericardio es una condición que con mayor frecuencia ocurre después de trauma, cirugía cardíaca y torácica o asociado a tumores, tuberculosis o linfoangiomatosis. Cuando no es posible la identificación precisa de la etiología, el quilopericardio se denomina primario o idiopático. Esta es una situación clínica rara. Describimos un caso en paciente del sexo femenino, con 20 años de edad, tratada quirúrgicamente. A propósito del caso, presentamos una breve revisión bibliográfica y comentarios sobre el cuadro clínico, la etiopatogenia, exámenes diagnósticos complementarios y opciones de tratamiento.

Derrame pericárdico masivo como manifestación de hipotiroidismo / Massive pericardial effusion as manifestation of hypothyroidism

Pericardial effusion is a common finding in patients with decompensate hypothyroidism or without treatment, but this finding generally is of small quantity and slow filling. The following case shows a 64 year old male patient with no previous history of hypothyroidism that made debuted with a massive pericardial effusion; was treated with pericardiocentesis and levotyroxine after diagnosis was made. The patient evolved favourably with progressive disappearing of pericardial effusion.

El derrame pericárdico es un hallazgo común entre pacientes con hipotiroidismo sin tratamiento o descompensados, siendo por lo general de escasa cuantía y de lenta acumulación. Este caso clínico muestra un paciente varón de 64 años sin antecedentes de hipo tiroidismo que debutó con derrame pericárdico masivo, tratado con pericardiocentesis y terapia de reemplazo hormonal tiroídea posterior al diagnóstico realizado durante su hospitalización. El paciente evolucionó favorablemente con una disminución progresiva del derrame hasta su desaparición.

Quilopericardio / Chylopericardium

El quilopericardio es una entidad relativamente rara, inclusive para quienes nos dedicamos a tratar enfermos con patología del tórax. Generalmene existe una anomalía del conducto linfático o de sus tributarios, ya sea por neoplasias, o por lesiones. Estas últimas pueden ser civiles o iatrogénicas. En algunos pocos enfermos no se encuentra una causa clara y se les clasifica como de origen idiopático. El manejo inicial es mediante el drenaje y administración de dietas especiales, sin embargo un grupo de enfermos requiere cirugía que generalmente consiste enligadura del conducto torácico. Presentamos 2 casos de pacientes con quilotórax, uno por linfagiomas y otro idiopático, ambos fueron finalmente intervenidos, evolucionando satisfactoriamente.

Diagnosis and management of pericardial effusions

Pericardial effusions are a relatively common phenomenon, largely in part due to its many possible etiologies. Although a considerable amount of cases are idiopathic, careful history and physical examination will reveal the etiology in a vast majority of patients. The most effective tools, echocardiography and right heart catheterization, should be aimed not only at the diagnosis of the pericardial effusion, but also to the assessment of the severity of the pericardial effusion, since this will determine that individual patient's management. A small, asymptomatic pleural effusion of known etiology can be treated conservatively, mostly by treating the underlying cause and with careful observation for signs or symptoms of deterioration. Large effusions can be treated with closed pericardiocentesis after routine evaluation for possible etiologies. For patients presenting actual or impending tamponade, the definitive treatment is either closed or open pericardiocentesis, depending on fluid accumulation characteristics, and it should not be delayed for the administration of medical treatment (inotropes, intravenous fluids). Routine evaluation of pericardial fluid is warranted in those cases in which a clear etiology was not established prior to pericardiocentesis.

Diagnosis and management of neoplastic pericardial effusion with cardiac tamponade; review of two case studies at the San Juan Veteran Administration Medical Center

Two case reports of patients with known non-small cell lung cancer that developed cardiac tamponade related to metastatic pericardial disease are described. Both of these patients underwent urgent subxiphoid echocardiographic guided pericardiocentesis. They both were treated with sclerotherapy using intrapericardial bleomycin. There were no complications from these procedures and no recurrence of cardiac tamponade. They both lived more than 6 months after this intervention. This article reviews the pathogenesis, clinical presentation, diagnosis, and current therapeutic interventions of patients with neoplastic pericardial effusion and cardiac tamponade

Heridas cardíacas: utilidad de la ecografía en su diagnóstico / Cardiac wounds: surgeon-performed ultrasound for diagnostic procedure

Introducción: En muchos centros dedicados a la atención del trauma la ecografía ha pasado a formar parte, en forma sistemática, de la evaluación inicial de los pacientes con traumatismos toracoabdominales. Objetivos: Evaluar la utilidad de la ecografía realizada por el cirujano para certificar o descartar la presencia de un hemopericardio en las heridas torácicas. Lugar de aplicación: Hospital Donación Francisco Santojanni y Hospital José Equiza (González Catán). Diseño: Estudio observacional prospectivo. Población: Se estudiaron ecográficamente 29 pacientes con heridas en el área cardíaca o con heridas de proyectil que interesaban ambos hemitórax. Se incluyó una paciente con un hemipericardio a consecuencia de un cateterismo cardíaco. Resultados: No falleció ningún paciente. Presentaban hemopericardio traumático 3 (10,3 por ciento) de los 29 pacientes estudiados: verdaderos positivos 3; verdaderos negativos 26; falsos positivos 0; falsos negativos 0; sensibilidad 100 por ciento; especificidad 100 por ciento. Conclusiones: Basados en una revisión de la bibliografía sobre el tema y en nuestra experiencia consideramos que la ecografía, en pacientes con posibles heridas cardíacas, es un procedimiento de diagnóstico no invasivo, altamente sensible y específico, económico, rápido, repetible y que puede ser realizado e interpretado por un cirujano convenientemente entrenado

Resolución de la pericarditis tuberculosa en pacientes HIV / Solution in pericardial tuberculous effusions in HIV patients

Antecedentes: Entre las manifestaciones cardíacas de los pacientes con SIDA, el derrame pericárdico constituye una de las entidades que pone en peligro la vida. El reconocimiento temprano del mismo, como de su etiología y su pronta evacuación aseguran un pronóstico favorable. Objetivo: Demostrar que la cirugía torácica videoasistida (VATS) es ideal para el diagnóstico y tratamiento de los derrames pericárdicos tuberculosos en pacientes con SIDA. Lugar de aplicación: Hospital público. Diseño: Estudio retrospectivo. Población: Se operaron 4 pacientes con SIDA y pericarditis tuberculosa concomitante. Método: Los pacientes con derrames pericárdico, por clínica y ecografía, y SIDA asociado fueron tratados quirúrgicamente, mediante VATS. El líquido obtenido así como el pericardio resecado fueron procesados en el laboratorio. Resultados: 4 pacientes presentaron pericarditis tuberculosa, 2 demostrados con biopsia y 2 con PCR. La cirugía de inicio en todos fue la VATS. La morbilidad fue nula y sólo hubo un caso de mortalidad, no relacionado con el procedimiento quirúrgico. El promedio de internación fue de 9 días. Ninguno presentó recidiva del derrame. Conclusiones: La VATS es el procedimiento de elección ante la presencia de ésta patología, ya que con buenos resultados asegura el diagnóstico etiológico, y al mismo tiempo brinda el tratamiento que menos recidiva ocasiona

Massive primary chylopericardium in an infant.

We report a case of massive spontaneous primary chylopericardium in a 2-month-old infant who was successfully treated with thoracic duct ligation and creation of a posterior pericardial window.

Manejo de los traumatismos penetrantes de tórax / Thorax penetrating trauma management

Antecedentes: Los traumatismos penetrantes de tórax (TPT) constituyen una patología de creciente frecuencia, pudiendo asociarse a lesiones de estructuras vitales. Objetivo: Analizar los procedimientos diagnósticos y terapéuticos empleados en su manejo. Diseño: Estudio retrospectivo. Población: 142 pacientes con TPT desde junio de 1997 a marzo de 1999. Métodos: Evaluación y manejo inicial según normas ATLS. Resultados: El avenamiento pleural fue el primer gesto terapéutico, siendo suficiente en la mayoría de los casos. A 14 pacientes se les efectuó toracotomía amplia como tratamiento inicial o complementario, mientras 4 pacientes fueron sometidos a videotoracoscopía (VTC) como tratamiento secundario antes de las 72 horas. En 8 pacientes adoptamos una conducta selectiva no operatoria, a través de controles clínicos y radiológicos. La estadía hospitalaria promedio fue de 6 días. La complicación más frecuente fue el hemotórax residual mínimo. Conclusiones: El diagnóstico y tratamiento de los TPT debe ser precoz, siendo el avenamiento pleural el primer gesto terapéutico. Las conductas no invasivas son adecuadas para injurias mínimas, bajo estricto control clínico y radiológico. Se recomienda el uso del ultrasonido y la TAC para valorar complicaciones y lesiones asociadas. Para resolver colecciones residuales proponemos la videotoracoscopía (VTC) y la toracotomía posterior respetando el Serrato mayor