Clinical outcome of patients with severe malignant pericardial effusion due to neoplastic disease undergoing percutaneous balloon pericardiotomy during COVID-19 pandemic

Background: Neoplastic pericardial effusion (NPE) is a serious complication that occurs in the setting of advanced oncological disease and is associated with a high recurrence rate. Currently, pericardiocentesis (PCT) remains the first therapeutic option and the use of percutaneous balloon pericardiotomy (PBP) is limited to the treatment of recurrences. However, it is not known whether some aspects of the procedure during PBP lead to different outcomes in terms of survival and recurrence, and no such patients have been included in studies during COVID-19 pandemic. Purpose(s): The aim is to analyses the success, complications and recurrence rate (defined as recurrence of NPE requiring PCT, PBP or surgical pericardial window (SPW) of both procedures (BP) in order to establish the optimal entry treatment for these patients. Method(s): This research analyzed the clinical characteristics and prognostic factors of patients with severe pericardial effusion of neoplastic etiology who underwent PBP during the COVID-19 pandemic. A prospective study was conducted involving 23 patients admitted between January 2020 and January 2022 for severe NPE who underwent PCT or PBP as initial treatment of NPE. Result(s): We included 23 patients, 62.9% were male with a mean age of 51.2+/-14.9 years NPE was the first manifestation of the oncological process in 12 patients (52.1%) with lung cancer being the most frequently associated primary cancer (58.7%) followed by breast cancer in 12.7% of cases. A total of 26 procedures were performed, 10 PCT, 15 PBP, 1 SPW, with tumors cells identified in the pericardial fluid in 13.0% of cases. PCT was used as an entry point in 10 patients (43.5%), 6 patients were COVID-19 positive and PCT was performed as the first treatment. While PBP was chosen as the first therapeutic option in 13 patients (56.5%) (2 Re-PBP). The initial efficacy of the procedure was 93.1% and 92.2% respectively (p=0.88), with 1 complication occurring in the PBP group but not requiring scheduled SPW. In the former group, the percentage of recurrences was higher (34.7%;8 recurrences in 10 patients) compared to patients treated with upfront PBP (8.6%;2 recurrences in 13 patients), p=0.09. In addition, only one patient had to resort to surgery. When analyses according to the BP. used, the recurrence rate was 4.0 times higher for PCT (34.7 vs. 8.6% recurrences), although without reaching statistical significance (p=0.16). Conclusion(s): The PBP is a simple, safe and effective technique for the treatment of NPE during the COVID-19 pandemic, in our series it was associated with a lower recurrence rate. Therefore, it could replace PCT in these patients during the COVID-19 pandemic as optimal first line treatment, providing better quality of life and reducing the need for re-interventions. (Figure Presented).

Pulmonary artery resection and reconstruction in locally advanced lung cancer with moderate hemoptysis

Lobectomy with pulmonary artery (PA) angioplasty in locally advanced lung cancer is an alternative to pneumonectomy. It is feasible, oncologically effective and the procedure of choice in patients with recurrent hemoptysis and limited pulmonary reserves. We present a case of a successful left upper lobectomy with PA resection and reconstruction by an autologous pericardial patch.Copyright © 2022 EDIZIONI MINERVA MEDICA.

A Unique Case of Pericardial Effusion and Tamponade

Background We present a unique case of a female who developed a large pericardial effusion (PEff) from a rare cause. Case A 36-year-old female with recent COVID-19 infection presented with acute dyspnea. She had undergone liposuction, rectus plication and breast augmentation two months ago. Heart rate was 90/min and blood pressure 86/57mmHg. CT angiogram of the chest revealed a massive PEff with tamponade. She had large right-sided pleural effusion also. She underwent ultrasound-guided pericardiocentesis with the removal of 950 milliliters of serosanguineous fluid. Follow-up echocardiogram showed re-accumulation of fluid. Due to the rapid onset of PEff, she underwent a pericardial window and bilateral chest tube placement. Decision-making Pleural and pericardial fluid analysis showed silicone-gel particles (Figure. 1). Pericardial biopsy showed nonspecific chronic inflammation. Autoimmune workup was unremarkable. Elevated ESR and CRP in the presence of embolized gel particles indicated foreign body reaction from silicone embolism. Plastic surgery advised implant removal. Silicone embolism is known to cause silicone thorax, pleural effusions, and anaplastic large cell lymphoma. To our knowledge, this is the first reported case of PEff due to silicone embolism from breast implants. Conclusion Cardiologists should be aware of this rare but serious complication. Silicone embolism should be considered in the differential of PEff in patients with breast implants. [Formula presented]Copyright © 2023 American College of Cardiology Foundation

Cardiac Angiosarcoma Presenting as Recurrent Pericardial Effusion and Constrictive Pericarditis

Background Malignancy accounts for 15-20% of moderate to large pericardial effusions. Among these, cardiac angiosarcomas are extremely rare. Case A 30-year-old male presented with dyspnea and fatigue, 9 months after COVID-19 infection. He had sinus tachycardia (117 beat/min). Chest X-ray showed cardiomegaly. Echocardiogram demonstrated a large circumferential pericardial effusion with right ventricular collapse. Decision-making Pericardiocentesis yielded 850 ml of bloody fluid, with symptomatic relief. He was discharged on colchicine and indomethacin with a presumptive diagnosis of post-viral pericarditis. A month later, he had recurrent symptoms and re-accumulation of large circumferential effusion. CT chest revealed multiple pulmonary nodules and bilateral pleural effusions. He underwent subxiphoid pericardial window and pleural biopsy. Fluid analysis and biopsy results were inconclusive. Over 3 weeks, he had worsening symptoms, despite a daily pericardial drain output of ~200 ml. Repeat echocardiogram showed loculation of the effusion with signs of constrictive pericarditis. He underwent pericardiectomy. Pathology revealed cardiac angiosarcoma. FDG PET scan showed thoracic metastasis. Anakinra was initiated. Conclusion Idiopathic and post-viral etiologies are the most common causes of pericardial effusion. Although rare, cardiac angiosarcoma should be on the differential diagnosis for recurrent pericardial effusion. [Formula presented]Copyright © 2023 American College of Cardiology Foundation

Pneumopericardium in COVID-19 Infection

Pneumopericardium is a rare medical condition that occurs following trauma, surgery, or other medical interventions. The presence of pneumopericardium after COVID-19 pneumonia has been reported in some cases, and it has been explained that most cases could be self-limited. Here, we describe a 51-year-old man afflicted by pneumopericardium with COVID-19 infection. The patient had pneumopericardium and massive pericardial effusions, necessitating surgical strategies such as pericardial windows. This case highlights the potential severity of COVID-19. We also suggest that cardiologists pay attention to the possibility of pneumopericardium in cases with COVID-19 infection. Copyright © 2023, Iranian Heart Association. All rights reserved.

TENSION PNEUMOMEDIASTINUM RESULTING IN OBSTRUCTIVE SHOCK IN COVID-19

SESSION TITLE: Bad bugs and Mediastinal Madness SESSION TYPE: Case Reports PRESENTED ON: 10/19/2022 09:15 am - 10:15 am INTRODUCTION: Pneumomediastinum is often witnessed in intensive care units secondary to mechanical ventilation, or blunt and penetrating trauma. However, it is rare for patients to develop tension pneumomediastinum. Tension pneumomediastinum within the context of Covid-19 pneumonia is even more rarely discussed. Here we discuss a patient with Covid-19 pneumonia who developed rapidly progressive tension pneumomediastinum. CASE PRESENTATION: 72-year-old male was admitted to the ICU for Covid-19 infection causing hypoxemic respiratory failure requiring mechanical ventilation. On ICU day 2 the patient developed sudden worsening of shock requiring multiple pressors. Clinical exam revealed extensive subcutaneous crepitus in the supraclavicular region extending to the neck. Chest XR showed extensive pneumomediastinum and pneumopericardium and no pneumothorax. There was concern for ongoing obstructive shock due to cardiac tamponade, cardiology was called to bedside to perform POC ultrasound. The heart could not be visualized due to subcutaneous air. CT scan showed extensive mediastinal air and subcutaneous emphysema. The significantly increasing air in the retrocardiac space and concavity of the atria were concerning for worsening tension physiology. Cardiothoracic surgery decided to place a mediastinal drain and create a pericardial window. In the hours that followed, the patient's hemodynamics improved, and his pressor requirement decreased to only low dose norepinephrine. On ICU day 3 he developed worsening severe mixed acidosis. On day 4, the patient was requiring over 100mcg per hour of norepinephrine and labs showed worsening renal and liver failure. In the afternoon of day 4, the patient experienced a cardiac arrest and expired. DISCUSSION: Most reported cases of pneumomediastinum with associated pneumopericardium are self-limited, however 38% of cases progress to create tension pneumomediastinum and life-threatening cardiac tamponade.1 There are few reports of tension pneumomediastinum complicated by pneumopericardium in patients with Covid-19,2 but there is concern that this condition occurs more frequently in critically ill patients with Covid-19.3 The management of cardiac tamponade as a result of tension pneumopericardium may include pericardiocentesis,2 placement of a pericardial window, or insertion of a mediastinal drain.3 While several reported patients who underwent these procedures survived to discharge successfully,1,3 there are also reports that suggest that the development of subcutaneous emphysema and pneumomediastinum may be indicative of worsening prognosis.3 CONCLUSIONS: The ideal management of tension pneumomediastinum in Covid-19 is not clear and prognosis of patients who develop tension pneumomediastinum is highly varied. Further study is needed to develop tools to identify pneumomediastinum with the potential to develop tension physiology and progress to obstructive shock. Reference #1: Hazariwala, V., Hadid, H., Kirsch, D. et al. Spontaneous pneumomediastinum, pneumopericardium, pneumothorax and subcutaneous emphysema in patients with COVID-19 pneumonia, a case report. J Cardiothorac Surg 15, 301 (2020). https://doi.org/10.1186/s13019-020-01308-7 Reference #2: Cummings RG, Wesly RL, Adams DH, Lowe JE. Pneumopericardium resulting in cardiac tamponade. Ann Thorac Surg. 1984;37(6):511-518. doi:10.1016/s0003-4975(10)61146-0 Reference #3: Al-Azzawi M, Douedi S, Alshami A, Al-Saoudi G, Mikhail J. Spontaneous Subcutaneous Emphysema and Pneumomediastinum in COVID-19 Patients: An Indicator of Poor Prognosis? Am J Case Rep. 2020;21:e925557-1-e925557-6. doi:10.12659/AJCR.925557 DISCLOSURES: No relevant relationships by Roger Alvarez, value=Travel Removed 03/30/2022 by Roger Alvarez No relevant relationships by Roger Alvarez, value=Consulting fee Removed 03/30/2022 by Roger Alvarez no disclosure on file for Michelle Hernandez;No relevant relationships by Rose Puthumana

ACUTE MYOPERICARDITIS COMPLICATED WITH CARDIAC TAMPONADE IN COVID-19

CASE: 68yo Caucasian female with no significant cardiac history presented with worsening dyspnea and fatigue started around 7 days ago. She denied having any travel or known history of tuberculosis or any other autoimmune conditions. COVID RT-PCR test was positive on the day soon after admission. Initial vitals include SpO2 of 96% on 2L, BP 118/72 mmHg and HR in 110s/min Sinus. EKG revealed sinus tachycardia with non-specific ST-T changes. Labs showed c-reactive protein 2.0 mg/dl, ferritin 1061 ng/ml, LDH 300 EnzU/L;cardiac markers-troponin 212-261 ng/L and proBNP of 11,497 pg/mL. ECHO showed EF of 30-45% with global hypokinesis, and circumferential pericardial effusion with fibrinous strands. Within 48 hours, the patient sustained cardiac arrest with recurrent hemodynamically unstable tachyarrhythmia requiring multiple cardioversions. Repeat Bedside ECHO revealed larger effusion compared to prior, worrisome for cardiac tamponade. Emergent pericardiocentesis yielded 200ml of serous fluid improving the hemodynamics in form of improved SBP to 140mmHg from 70mmHg. Although this improvement appeared promising, it was only transient with rapid decline. Her ferritin levels went up 10-fold correlating with the worsening status. Her pressor requirement gradually worsened to the point of requiring IMPELLA, intercepting the initiation of RRT for acute renal failure. Unfortunately, with higher risk of poor outcome, the family opted to respect the patient's wishes and further care was withdrawn. IMPACT/DISCUSSION: As of January 2022, there have been close to 300 million confirmed COVID-19 cases all over the world. This ongoing pandemic disease, although primarily occur as respiratory illness, the florid symptoms with increasing mortality are due to its systemic inflammatory response causing multiorgan failure. Hence the symptoms can be anywhere from mild febrile illness to sudden death. As such, Cardiac involvement in form of Myo-pericarditis is less recognized in such scenario and often underestimated. The onset can vary as the primary presenting symptom to late presentation following respiratory course. While the association of pericarditis with COVID has been documented, the global presentation as Myo-pericarditis is still less known. Our case depicts one such occurrence where cardiac presentation is the key finding having led to poor prognosis more than the lung damage. The management is still the same using NSAIDs / Colchicine like any other type of pericarditis. If there were signs of cardiac tamponade, pericardiocentesis is warranted. In some cases, especially in the setting of recurrent effusions, pericardial window will be useful. CONCLUSION: Myo-pericarditis in COVID-19 can predispose to life threatening arrhythmias which would increase mortality. With the cytokine storm and inflammatory response associated with COVID being the primary offender, it can be challenging to treat them as any other type as the treatment should also focus on removal of inciting factors simultaneously.

Community Acquired Methicillin-Resistant Staphylococcus Aureus Pneumonia in a Previously Healthy 12-Year-Old Male

Introduction: Methicillin-resistant Staphylococcus aureus (MRSA) was better recognized to be a nosocomial pathogen found mainly in intensive care units and occurring especially in elderly persons. However, rare but potentially fatal cases of community-acquired MRSA infection have emerged. Risk factors such as infection of the skin or soft tissues, influenza virus infection, history of recent hospital admissions, or immunocompromised status were identified. The prevalence of MRSA in children especially those without risk factors is extremely low. Case: This is a case of a previously healthy 12-year-old male who presented with acute onset of high-grade fever and exertional dyspnea. Upon admission, the patient was in respiratory distress and hypotensive. The patient was managed as a case of severe sepsis with the following considerations: COVID-19 infection, severe pneumonia, tuberculosis, and malignancy. Although the clinical presentation and imaging findings were suggestive of pulmonary tuberculosis infection, sputum and blood culture were positive for MRSA. The patient required admission to the intensive care unit and underwent close tube thoracotomy insertion and tube pericardiostomy due to the rapid spread of infection. The patient was also treated for pulmonary tuberculosis. Thus, anti-tuberculosis medications were added to Vancomycin, with noted improvement thereafter. Discussion: This case highlights the importance of prompt and accurate diagnosis of MRSA pneumonia leading to optimal patient outcome. With this, the rapid institution of appropriate antibiotics is crucial. However, clinical diagnosis is frequently difficult resulting in to delay of diagnosis.

A COMPLICATED CASE OF INCIDENTAL PERICARDIAL EFFUSION IN RECENT SARS-COVID-19 INFECTION

Background: SARS-COV2 enters the host cells via angiotensin-converting enzyme 2 receptor, which is heavily expressed by the lungs and heart. Few cases of pericarditis in COVID-19 infection were reported. Case: A 55-year-old Hispanic male with recent flu-like symptoms presented with abdominal pain. CT abdomen showed large pericardial effusion with 4cm thickness. An inferior echo showed effusion without signs of tamponade. He was discharged with NSAID and diuretics. Eleven days later, he returned with worsening dyspnea due to bilateral pulmonary emboli. Repeat echo significant for right atrial and ventricular collapse. Emergent pericardial window was performed with 1.2L dark bloody pericardial fluid was drained. Fluid cytology and cultures were negative. Cell analysis suggested transudative effusion. SARS-COVID-19 IgG antibody was positive. The etiology of the effusions is likely to be viral pleuropericarditis from recent COVID-19 infection. Decision-making: Multiple case reports had been published showing a high risk for pericardial effusion to convert into tamponade requiring emergent intervention. There has also been a higher risk for biventricular failure on COVID-19 patients. Knowing this risk, the patient presented should have had an intervention earlier during the first visit or closer monitoring. Conclusion: It is important to know the complications of COVID-19 infection including pericarditis and high risk for progression into tamponade, requiring prompt intervention. [Formula presented]

Purulent pericarditis can be near fatal

A previously healthy 27 years-old male presented with 2 weeks of substernal chest pain, progressive dyspnea, palpitations, dizziness, and(&) fever. On exam, he had tachypnea & tachycardia, was hypotensive with an elevated JVP & muffled heart sounds. Labs showed elevated WBC, CRP, lactate & high sensitive troponin. Negative for COVID-19, flu. EKG showed sinus tachycardia. CT showed large pericardial effusion with gas in the pericardial space. Echo (Figure 1) revealed large pericardial effusion with tamponade. Emergent pericardiocentesis was performed draining a liter of straw-colored thick fluid (fluid: serum LDH >3) (Figure 2). Cultures grew Strep. Anginosus & Propionibacterium acnes. Extensive infectious & immunological workup returned negative. He had initially improved on broad-spectrum antibiotics however declined clinically on day 5. Repeat CT (Figures 3 & 4) showed recurrent pericardial effusion & mediastinal abscess with trace extravasation of contrast from the esophagus to posterior mediastinum. We present a case of esophageal perforation leading to Pyopneumopericardium. Stephenson et al. reported a case series of 13 patients with esophagopericardial fistulas & pyopneumopericardium with a 100% mortality rate. Another case series showed survival rates of only 17% in 60 patients with pyopneumopericardium secondary to esophageal perforation. Erosion of esophageal ulcers, ingestion of foreign body, iatrogenic, trauma, malignancy, localized inflammation can lead to esophageal perforation. Streptococcus pneumoniae & Staphylococcus aureus are common pathogens involved. Constrictive pericarditis is a possible complication in up to 20 to 30%. Our patient underwent pericardial window & surgical debridement followed by EGD-guided gastro-jejunal tube placement. He did well after 4 weeks of IV antibiotics. Our case demonstrates that early recognition & intervention can favorably alter the course of this potentially fatal cardiac condition.

DISSEMINATED MRSA INFECTION WITH PURULENT PERICARDITIS: AN EXTREMELY RARE CASE, LIKELY MORE COMMON THAN REPORTED

TYPE: Late Breaking Case Report TOPIC: Critical Care INTRODUCTION: Methicillin-resistant staphylococcus aureus (MRSA) purulent pericarditis is a life-threatening infection, characterized by frank pus collection in the pericardium1-4. While incidents of MRSA infection continue to increase, MRSA pericarditis remains extremely rare in the absence of prior surgical intervention1,4. We present a rare case of disseminated MRSA infection with purulent pericarditis. CASE PRESENTATION: This is a 71-year-old male who presented with a 12 days history of cough and shortness of breath. Vital signs were 153/81mmHg, 98.5oF, 76bpm, 18bpm, 85%. He was diagnosed with novel coronavirus-19 (COVID-19), started on remdesivir, corticosteroids, and vitamins. Blood and urine cultures resulted negative. He continued to improve. Three weeks into the hospitalization, he reported chest pain and clinically decompensated with refractory hypotension, tachycardia, and hypoxia, requiring increased supplemental oxygen and vasopressor support. Echocardiogram revealed pericardial effusion with early tamponade physiology. Patient underwent pericardial window with drainage of 600 mL of purulent fluid. Repeat labs revealed white blood cell count of 25.3K/uL, platelets of 69 K/uL, lactic acid of 5.0 mmol/L. MRSA grew from blood, urine, respiratory and pericardial fluid cultures. Patient was started on intravenous vancomycin. DISCUSSION: Purulent pericarditis due to MRSA is typically seen in immunocompromised state or with prior surgical intervention. While the source of pericarditis in our patients remains unclear, we suspect intrathoracic or hematogenous spread, compounded with an immunosuppressive state, attributed to COVID therapy with corticosteroids. CONCLUSIONS: This case not only illustrates a rare case of disseminated MRSA purulent pericarditis, but it also depicts the importance of heightened suspicion, prompt diagnosis, and early initiation of treatment. DISCLOSURE: Nothing to declare. KEYWORD: Disseminated MRSA Infection