A rare complication of pericardiocentesis: Pneumopericardium.

Pneumopericardium is the presence of air in the pericardial sac. Pneumopericardium after pericardiocentesis has been rarely reported in the literature. In the present case, we report a patient who presented with tamponade physiology during COVID-19 and developed pneumopericardium after emergency pericardiocentesis. Immediate recognition and treatment are crucial and chest x-ray, thorax computerized tomography, and transthoracic echocardiography (TTE) are used for diagnosis.

Hemorrhagic Cardiac Tamponade-An Unusual Threat in the COVID-19 Recovery Phase.

Cardiac tamponade is a rare presentation in patients with COVID-19, which may be induced by the associated exacerbated inflammatory response. The onset of cardiac tamponade may be concomitant with the acute phase of the disease or may develop subsequently as a new health condition secondary to the disease. We report four cases of cardiac tamponade that occurred late after the acute phase of the disease. One of them may be considered a post-acute complication of the disease, and three of them may be classified as a new health condition induced by COVID-19. Only two cases had a history of severe respiratory distress due to COVID-19. In all four cases, pericardiocentesis was imposed, and surprisingly, in every case, hemorrhagic fluid was evacuated. In this case, series, immune-mediated etiology is supported by histopathological results, where the main identified feature was fibrous pericarditis with inflammatory infiltrate. Only one patient included in this report died, and three of them were discharged after anti-inflammatory treatment was initiated.

Life-Threatening Cardiac Tamponade Secondary to COVID-19 Treated with Uniportal Video-Assisted Thoracoscopic Surgery: A Case Report.

BACKGROUND The COVID-19 outbreak emerged in December 2019 in Wuhan, China. COVID-19 is caused by the SARS-CoV-2 coronavirus and mostly affects the respiratory system but can also affect other organs, including the cardiovascular system. Furthermore, the most common cardiac complications include severe left ventricular dysfunction, acute myocardial injury, and arrhythmias. Life-threatening cardiac tamponade and large pericardial effusion are exceedingly rare complications in patients recovered from COVID-19. Previously, this condition was treated with pericardiocentesis, colchicine, and corticosteroids. CASE REPORT We present the case of a 54-year-old man who recovered from a SARS-CoV-2 infection 7 days before presentation and describe a complicated pericardial effusion with life-threatening cardiac tamponade. To the best of our knowledge, this is the first case of pericardial effusion with cardiac tamponade that was successfully treated with single port or uniportal video-assisted thoracoscopic surgery with an excellent outcome. CONCLUSIONS Life-threatening cardiac tamponade with pericardial effusion is an exceedingly rare complication in patients recovered from COVID-19. Generally, patients diagnosed with pericardial effusion undergo a pericardiocentesis procedure. Although there are multiple treatment options for draining pericardial effusion, the recurrence rate with surgical pericardial window formation is the lowest. However, our patient underwent surgery using a uniportal video-assisted thoracoscopic surgery with an excellent outcome.

A Novel, Low-cost, Low-fidelity Pericardiocentesis Teaching Model.

INTRODUCTION: Pericardiocentesis is a high-risk/low-frequency procedure important to emergency medicine (EM). However, due to case rarity it is not often performed on a patient during residency training. Because the coronavirus disease 2019 pandemic limited cadaver-based practice, we developed a novel, low-cost, low-fidelity pericardiocentesis model using three dimensional-printing technology to provide advances on prior home-made models. METHODS: Residents watched a 20-minute video about performing a pericardiocentesis and practiced both a blind and ultrasound-guided technique. We assessed model fidelity, convenience, and perceived provider competence via post-workshop questionnaire. RESULTS: A total of 24/26 (93%) individuals practicing on the ultrasound-guided model and 22/24 (92%) on the blind approach model agreed or strongly agreed that the models reasonably mimicked a pericardial effusion. CONCLUSION: Our low-cost, low-fidelity model is durable, mimics the clinical case, and is easy to use. It also addresses known limitations from prior low-fidelity models.

Cardiac tamponade and massive pleural effusion in a young COVID-19-positive adult.

COVID-19 has a broad spectrum of cardiac manifestations, and cardiac tamponade leading to cardiogenic shock is a rare presentation. A 30-year-old man with a history of COVID-19-positive, reverse transcription polymerase chain reaction (RT-PCR) done 1 week ago and who was home-quarantined, came to the emergency department with palpitations, breathlessness and orthopnoea. His ECG showed sinus tachycardia with low-voltage complexes, chest X-ray showed cardiomegaly and left pleural effusion and two-dimensional echocardiography showed large pericardial effusion with features suggestive of cardiac tamponade. He was taken up for emergency pericardiocentesis which showed haemorrhagic pericardial fluid. Intercostal drainage insertion was done for left-sided large pleural effusion. After ruling out all the other causes for haemorrhagic pericardial effusion, the patient was started on colchicine, steroids, ibuprofen and antibiotics to which he responded. Both pericardial and pleural effusions resolved completely on follow-up.

Coronavirus Disease 2019 (COVID-19) and Severe Pericardial Effusion: From Pathogenesis to Management: A Case Report Based Systematic Review.

The Severe acute respiratory syndrome coronavirus-2 (SARS-COV-2) created a global pandemic that continues to this day. In addition to pulmonary symptoms, the virus can have destructive effects on other organs, especially the heart. For example, large pericardial effusion has been observed as a critical and life-threatening finding in Coronavirus disease of 2019 (COVID-19) patients. In this case report based systematic review, we review the reports of moderate to severe pericardial effusion associated with tamponade physiology. Direct cardiomyocyte and pericardium invasion, inflammation and cytokine storms and oxidative stress due to acute respiratory distress syndrome, are the pathogenesis of this phenomenon. The results showed that the manifestations of this finding are variable. Pericardial effusion can be seen as a delayed complication, accompanied by myocarditis or pericarditis, isolated, or with acute respiratory distress syndrome. In most patients, emergency percutaneous pericardiocentesis was performed, and fluid analysis was often exudative in 3 pattern of hemorrhagic, serous, and serosanguinous. Medical treatment and follow-up are recommended, especially in cases of pericarditis.

Coronavirus disease 2019 (COVID-19)-associated constrictive pericarditis.

This report documents a rare case of COVID-19-associated constrictive pericarditis (CP) in the setting of a recent COVID-19 infection. A 55-year-old man with a history of hypertension and gout presented with acute hypoxic respiratory failure and was diagnosed with COVID-19 pneumonia with progression to acute respiratory distress syndrome. His hospital course was complicated by a large pericardial effusion; an emergent bedside transthoracic echocardiography was concerning for cardiac tamponade, so pericardiocentesis was performed. A workup with cardiac magnetic resonance imaging showed changes consistent with a diagnosis of CP. Viral and idiopathic aetiologies are the most common cause of CP in the developed world, with COVID-19 now a proposed predisposing viral illness. The virus induces systemic inflammation and pericardial changes that can lead to CP physiology. Imaging modalities including echocardiogram and cardiac magnetic resonance play an integral role in confirming the diagnosis.

A case of a very large haemorrhagic pericardial effusion in an adolescent patient with COVID-19 infection.

An otherwise healthy 17-year-old adolescent boy presented with upper respiratory tract symptoms and was diagnosed with coronavirus disease 2019 infection. A haemorrhagic pericardial effusion was found in the transthoracic echocardiography. He was treated with pericardiocentesis, ibuprofen, and hydroxychloroquine. A large pericardial effusion may complicate COVID-19 in children and should be considered in acute decompensation.

Pediatric COVID-19 and Pericarditis Presenting With Acute Pericardial Tamponade.

We describe a seven-year-old female with acute pericarditis presenting with pericardial tamponade, who screened positive for coronavirus disease 2019 (COVID-19 [SARS-CoV-2]) in the setting of cough, chest pain, and orthopnea. She required emergent pericardiocentesis. Due to continued chest pain and orthopnea, rising inflammatory markers, and worsening pericardial inflammation, she underwent surgical pericardial decortication and pericardiectomy. Her symptoms and pericardial effusion resolved, and she was discharged to home 3 days later on ibuprofen and colchicine with instruction to quarantine at home for 14 days from the date of her positive testing for COVID-19.

Symptomatic pericardial effusion in the setting of asymptomatic COVID-19 infection: A case report.

RATIONALE: Infection with the severe acute respiratory coronavirus disease 2019 (COVID-19) has been shown to cause multi-organ involvement including cardiopulmonary serosal layers infection and inflammation. As a result, pericarditis and pericardial effusion may occur with or without COVID-19 related respiratory signs. Due to limitations in sensitivity and specificity of current COVID-19 diagnostic studies, cases that trigger high clinical intuition, even with negative serologic and polymerase chain reaction testing results, may necessitate further diagnostic workup to discover the underlying etiology. PATIENT CONCERNS: Here we present a rare case of pericardial effusion in the setting of asymptomatic COVID-19 infection manifesting with the chief complaint of chest pain. DIAGNOSIS: While undergoing diagnostic workup, the patients first 2 sets of COVID 19 reverse transcription-polymerase chain reaction (RT-PCR) were negative while a latter RT-PCR test, as well as serology, were positive, leading to the diagnosis of COVID-19 reinfection or subacute presentation of viral infection with pericardial effusion. Echocardiogram depicted large circumferential pericardial effusion with mildly thickened pericardium. INTERVENTIONS: The patient underwent pericardial window placement followed by ibuprofen administration and discharged from the hospital. OUTCOMES: During the follow-up visit patient had no symptoms and echocardiogram demonstrated complete resolution of the effusion. LESSONS: Due to the possible establishment of pericardial effusions and consecutively tamponade even without any COVID-19 related clinical presentation, it is crucial for clinicians to trust their intuition, conduct the appropriate diagnostic tests, find the underlying diagnosis and prevent the devastating consequences.

Cardiac tamponade in COVID-19 patients: Management and outcomes.

IMPORTANCE: Cardiac tamponade requiring emergent intervention is a possible complication of coronavirus disease 2019 (COVID-19) infection. Favorable clinical outcomes are possible if timely management and drainage are performed unless ventricular failure develops. OBSERVATION: Cardiac tamponade in COVID-19, based on the limited reported cases, seems to be more common among middle-aged men with observed complications in black and ethnic minorities. Prognosis is worse amongst patients with concomitant ventricular failure. DESIGN AND METHODS: This is a case series of three COVID-19 patients complicated by cardiac tamponade, requiring surgical intervention at a single institution in New York. INTERVENTION: Pericardial window, Pericardiocentesis. OUTCOME: One patient had recurrence of cardiac tamponade with hemorrhagic component but fully recovered and was discharged home. Two patients developed cardiac tamponade with concomitant biventricular failure, resulting in death. CONCLUSION AND RELEVANCE: Cardiac tamponade with possible concomitant biventricular failure can develop in COVID-19 patients; incidence seems to be highest at the point of marked inflammatory response. Concomitant ventricular failure seems to be a predictor of poor prognosis.

Concomitant new diagnosis of systemic lupus erythematosus and COVID-19 with possible antiphospholipid syndrome. Just a coincidence? A case report and review of intertwining pathophysiology.

In the midst of the COVID-19 pandemic, further understanding of its complications points towards dysregulated immune response as a major component. Systemic lupus erythematosus (SLE) is also a disease of immune dysregulation leading to multisystem compromise. We present a case of new-onset SLE concomitantly with COVID-19 and development of antiphospholipid antibodies. An 18-year-old female that presented with hemodynamic collapse and respiratory failure, progressed to cardiac arrest, and had a pericardial tamponade drained. She then progressed to severe acute respiratory distress syndrome, severe ventricular dysfunction, and worsening renal function with proteinuria and hematuria. Further studies showed bilateral pleural effusions, positive antinuclear and antidouble-stranded DNA antibodies, lupus anticoagulant, and anticardiolipin B. C3 and C4 levels were low. SARS-Cov-2 PCR was positive after 2 negative tests. She also developed multiple deep venous thrombosis, in the setting of positive antiphospholipid antibodies and lupus anticoagulant. In terms of pathophysiology, COVID-19 is believed to cause a dysregulated cytokine response which could potentially be exacerbated by the shift in Th1 to Th2 response seen in SLE. Also, it is well documented that viral infections are an environmental factor that contributes to the development of autoimmunity; however, COVID-19 is a new entity, and it is not known if it could trigger autoimmune conditions. Additionally, it is possible that SARS-CoV-2, as it happens with other viruses, might lead to the formation of antiphospholipid antibodies, potentially contributing to the increased rates of thrombosis seen in COVID-19.

Acute Myopericarditis with Pericardial Effusion and Cardiac Tamponade in a Patient with COVID-19.

BACKGROUND Coronavirus disease 2019 (COVID-19) is primarily a respiratory illness. However, with rising numbers of cases, multiple reports of cardiovascular manifestations have emerged. We present a case of COVID-19 infection complicated by myopericarditis and tamponade requiring drainage. CASE REPORT An 82-year-old woman with multiple comorbidities presented with five days of productive cough, fever with chills, and intermittent diarrhea. She tested positive for COVID-19. Index EKG revealed new diffuse T-wave inversions and a prolonged QT interval (>500 ms). Troponin was mildly elevated without any anginal symptoms. Hydroxychloroquine and azithromycin were not initiated due to concerns about QT prolongation. The echocardiogram revealed preserved left ventricular (LV) function, a small global pericardial effusion, and apical hypokinesis. Serial echocardiograms revealed an enlarging circumferential pericardial effusion with pacemaker wire reported as 'piercing' the right ventricular (RV) apex alongside early diastolic collapse of the right ventricle, suggesting echocardiographic tamponade. Chest CT revealed extension of the RV pacemaker lead into the pericardial fat. Interestingly, on comparison with a previous chest CT from 2019, similar lead positions were confirmed. Pericardiocentesis was performed with removal of 400 cc exudate. CONCLUSIONS Acute myopericarditis and pericardial effusion can occur in COVID-19 infection, even in the absence of severe pulmonary disease. This case highlights the importance of awareness of rare cardiac manifestations of COVID-19 in the form of acute myopericarditis and cardiac tamponade and their early diagnosis and management.

Coronavirus disease 2019 (Covid-19) presenting as purulent fulminant myopericarditis and cardiac tamponade: A case report and literature review.

The vast majority of patients in the ongoing coronavirus Disease 2019 (Covid-19) pandemic primarily present with severe respiratory illness. We report a Covid-19 patient who presented with findings of acute coronary syndrome and was found to have purulent fulminant myopericarditis and cardiac tamponade. We compare our case to the previously reported instances of Covid-19-associated myocarditis. Through review of the available literature, we also highlight the potential mechanisms of cardiac injury in Covid-19. We hope to increase awareness amongst clinicians about this unusual presentation of Covid-19.