Case series of unusual cases of hypothyroidism-induced pericardial effusion.

Hypothyroidism is an endocrine disorder with a high worldwide prevalence and diverse clinical presentation and can affect multiple organ systems. It can be asymptomatic and subclinical or overtly symptomatic and can prove to be fatal if left untreated. It is an established cause of pericardial effusion, which can rarely lead to cardiac tamponade and severe haemodynamic instability. Herein, we present a few unusual case reports of patients presenting with hypothyroidism with varied causes who presented with tamponade.

Pericardiocentesis in Severe Pulmonary Arterial Hypertension Guided by a Pulmonary Artery Catheter.

Patients, often with underlying rheumatologic disease, may present with pericardial effusions in the setting of pulmonary hypertension (PHTN). Pericardial drainage in PHTN is associated with significant morbidity and mortality. We describe a patient with PHTN who developed cardiac tamponade that was managed safely and effectively with pulmonary artery catheter-guided pericardiocentesis.

Pericardial tamponade: a new perspective on echocardiographic features and application of a prediction score.

Few clinical decision rules have been used to guide clinical management and predict outcomes in patients with pericardial tamponade. The objectives of this study are to identify the echocardiographic features associated with adverse outcomes in patients with pericardial effusions requiring pericardiocentesis and to apply a previously described four-point clinical and echocardiographic score to predict clinical outcomes over 24-hr, 30-day, and 1-year intervals. We performed a retrospective cohort review of patients who had transthoracic echocardiogram (TTE) performed and underwent pericardiocentesis within 48 h of emergency department presentation at two large tertiary care institutions. We constructed different stepwise logistic regression models and examined the associations of TTE characteristics and clinical features with ICU admission, hospital length of stay (h-LOS), and survival. The data set was then employed against a previously proposed scoring system to predict factors associated with clinical outcomes over 24 hr, 30 days, and 1 year. Two hundred thirty-nine patients were included in the final analysis. Echocardiographic characteristics of patients with pericardial tamponade who underwent pericardiocentesis are as follows: 69.1% right ventricular (RV) diastolic collapse, 62.3% exaggerated mitral valve (MV) inflow velocities, 56.4% inferior vena cava (IVC) plethora, and 53.4% right atrial (RA) systolic collapse. Increase in systolic blood pressure and increased variation in MV inflow velocity were associated with reduced ICU admission [OR: 0.94 (CI 0.90, 0.99), 0.28 (CI 0.09, 0.89), respectively]. In addition, a history of malignancy increased the length of hospital stay by about 3.89 days (CI 1.43-6.35, p < 0.01) and prior pericardiocentesis history was associated with 4.82-day increase in hospital stay (CI 1.19-8.45, p = 0.01). In utilizing the previously published prediction score, we found no statistically significant correlation in predicting survival. RV diastolic collapse and exaggerated MV inflow velocity were the most common echocardiographic findings in patients requiring pericardiocentesis. Contrary to prior studies, exaggerated MV inflow velocity was associated with reduced ICU admission. In addition, a previously described prediction score did not correlate with decreased survival in this cohort.

Tuberculous Pericardial Effusion With Pleural Effusion in an Indian Female: A Rare Case.

Tuberculosis can present at various extrapulmonary sites. However, even in endemic countries, concomitant involvement of different sites in the same patient is rarely reported. Further, tuberculous pericarditis represents a fraction of all tuberculosis infections and is an uncommon form of extrapulmonary tuberculosis. In underdeveloped nations, it is the most frequent cause of massive pericardial effusion. Additionally, it is the most common cause of constrictive pericarditis in adults, which has a high death rate and a poor prognosis. Furthermore, concomitant pleural effusion due to Mycobacterium tuberculosis is infrequently reported. Herein, a case of concomitant pericardial and left-sided pleural effusion in an Indian female is reported. She came with complaints of breathlessness, chest pain, night sweats, and loss of appetite. A diagnostic pleural thoracentesis and pericardiocentesis helped establish the diagnosis, and she was commenced on antituberculous treatment for 168 days.

Off-plane technique ultrasound-guided pericardiocentesis via anterior approach: short communication.

The pericardiocentesis procedure is common, often performed via the subxiphoid approach, although other transthoracic approaches have been described. This short communication describes an off-plane technique ultrasound-guided pericardiocentesis using an anterior approach, performed using a linear transducer and guided in real-time by ultrasound, offering the advantage of continuous needle tracking to reduce complications associated with this approach such as pneumothorax, inadvertent cardiac puncture, and injury to the left internal mammary artery (LIMA).

Cardiac Tamponade: An Initial Manifestation of Diffuse Large B Cell Lymphoma.

Pericardial effusion, a clinical condition characterized by an abnormal accumulation of fluid in the pericardial cavity, has multiple etiological factors. One of the prominent causes is malignant effusion. The patient is a 69-year-old female with a past medical history of Crohn's disease, melanoma status post-resection, and osteoarthritis. She presented with complaints of abdominal discomfort, shortness of breath on exertion, and lower extremity swelling for the past 2-3 days. She was recently discharged four days before this visit after being treated for a viral infection. A physical examination was significant for tachycardia, muffled heart sounds, abdominal distention, and bilateral lower extremity swelling. Labs were in the normal range except for elevated liver enzymes and sodium of 130 mmol/L. A chest X-ray revealed a small bilateral effusion; a bedside echocardiogram showed an ejection fraction greater than 70% and a large pericardial effusion >2 cm, consistent with cardiac tamponade. Emergent pericardiocentesis was performed with the drainage of 250 milliliters of hemorrhagic fluid, which was sent for diagnostic studies. Post-procedure echo on the next day showed an EF of 35-40% and no recurrent pericardial effusion. The workup for connective tissue disease was negative except for elevated antinuclear antibodies (ANA). CT of the abdomen and pelvis revealed gastric wall thickening with no solid organ mass. Her pericardial fluid studies were consistent with exudative etiology and positive for atypical lymphoid cells, leading to the diagnosis of diffuse large B-cell lymphoma. Diffuse large B-cell lymphoma is the most common type of non-Hodgkin lymphoma. Malignant pericardial effusion is common due to solid organ malignancy; however, it is rare with diffuse large B cell lymphoma (DLBCL). We present an intriguing case where pericardial effusion was the precursor to the eventual diagnosis of DLBCL, highlighting the complexity and diverse manifestations of this lymphoma subtype.

Acute Large Pericardial Effusion With Haemodynamic Compromise Secondary to Undiagnosed Tuberculosis.

Tuberculous pericardial effusion is uncommon in the developed countries. However, it remains one of the main causes of presentation with a pericardial presentation with pericardial effusion in the developing world. We present the case of a 24-year-old male patient who presented with a weekly history of diarrhoea, vomiting, shortness of breath and feeling hot. Chest computed tomography revealed a large pericardial effusion with significant haemodynamic compromise. The patient underwent emergency pericardiocentesis, and the pericardial fluid interferon-gamma assay result was positive for tuberculosis. He was unable to tolerate endobronchial biopsy under ultrasound despite heavy sedation and was commenced on anti-tuberculous therapy following a discussion in a multidisciplinary team meeting. He was started on four standard anti-tuberculosis medications, including rifampicin, isoniazid, pyrazinamide, ethambutol and prednisolone. The patient had re-accumulation of pericardial fluid on repeat echocardiography in the first few weeks, which eventually resolved with anti-tuberculous therapy.

Secondary cardiac lymphoma presenting with cardiac tamponade and cardiac mass: a case report.

BACKGROUND: Cardiac tamponade as the presenting manifestation of systemic lymphoma is relatively uncommon. Pericardium is the commonest site of involvement in secondary malignancies with systemic lymphoma involving the heart in 20% of the cases. CASE PRESENTATION: We describe a case of a 78-year-old gentleman, who presented with symptoms of new onset cardiac failure, and hemodynamic compromise. An echocardiography revealed cardiac tamponade, necessitating an emergency pericardiocentesis. With the aid of multimodality imaging, he was found to have a right atrioventricular groove mass, widespread lymph node enlargement with bone and peritoneal involvement. Ultimately, a histopathological evaluation revealed a diagnosis of Diffuse Large B Cell Lymphoma (DLBCL). CONCLUSIONS: Our case illustrates that a patient with DLBCL may present with cardiac tamponade as a result of metastasis. This diagnosis, although rare, is likely to be missed, which can cause fatal complications, such as cardiac tamponade, fatal arrhythmias or sudden cardiac death.

Malignant Pericardial Effusion Presenting as a Sequela of Lung Adenocarcinoma.

Pericardial effusion is a collection of fluid in the pericardial sac that can result in symptoms such as shortness of breath, pleuritic chest pain, and/or hemodynamic instability. Malignant pleural effusions are seen in a few cancer patients and are associated with poor prognosis. Here, we present the case of a 65-year-old female with a large malignant pericardial effusion in the setting of advanced-stage lung adenocarcinoma.

Endoscopic Ultrasound-Guided Transesophageal Pericardiocentesis in the Treatment of Localized Cardiac Tamponade Following Coronary Perforation.

We present a case of an 81-year-old male patient who developed a posteriorly localized pericardial effusion and tamponade of the left atrium after percutaneous intervention of the right coronary artery. Endoscopic ultrasound-guided transesophageal pericardiocentesis was performed when conventional transthoracic and surgical access options were associated with unacceptable risk.

Case Report: Traumatic cardiac arrest due to pericardial tamponade: successful pericardiocentesis with a Shaldon catheter.

In this report, we describe the successful resuscitation of a 4-year-old child who suffered a traumatic cardiac arrest during a routine procedure in the operating room. The diagnosis of a sanguineous pericardial tamponade was made by emergency ultrasonography. Consecutive subxiphoid pericardiocentesis with an adult Shaldon catheter led to return of spontaneous circulation. Subsequent thoracotomy and surgical suturing definitively stopped the bleeding from the right ventricle. The combined expertise of all perioperative disciplines was decisive for the patient's survival.

A Case of Tubercular Pericardial Tamponade With Anti-tuberculosis Treatment-Induced Hepatitis.

Pericarditis can be a common complication of tuberculosis (TB) in developing countries like India. It is associated with fever, fatigue, and weight loss and can often be accompanied by shortness of breath and chest pain. Other common causes of pericardial effusion include malignancy, renal failure, autoimmune disease, and viral and bacterial infections. When the pericardial fluid is bloody, TB is likely to be present in developing countries. It can often get complicated with cardiac tamponade, which has a high mortality rate. We present a case of a 55-year-old female with no co-morbidities who presented with shortness of breath, fatigue for two weeks, and chest pain for one week. She had no history of fever, chills, or rigour, and no history of TB contact. Clinical examination revealed low blood pressure with raised jugular venous pressure (JVP). Her electrocardiography (ECG) showed sinus tachycardia with a low-voltage complex. Echocardiography (ECHO) showed a large pericardial effusion, compromising ventricular function. We performed pericardiocentesis, drained 1.4 L of bloody fluid, and sent the pericardial fluid for analysis. Pericardial fluid adenosine deaminase (ADA) and cartridge-based nucleic acid amplification testing (CBNAAT) came positive for Mycobacterium TB. The patient was started on anti-tubercular treatment (ATT) and broad-spectrum antibiotics with drainage. Other routine investigations and autoimmune immune workups were normal. The patient also developed ATT-induced hepatitis, for which modified ATT was initiated. The patient improved clinically and symptomatically, was discharged, and was advised to follow up in the outpatient department (OPD).

Use of three-dimensional electroanatomic mapping for epicardial access: needle tracking, electrographic characteristics, and clinical application.

AIMS: Pericardiocentesis is usually completed under fluoroscopy. The electroanatomic mapping (EAM) system allows visualizing puncture needle tip (NT) while displaying the electrogram recorded from NT, making it possible to obtain epicardial access (EA) independent of fluoroscopy. This study was designed to establish and validate a technique by which EA is obtained under guidance of three-dimensional (3D) EAM combined with NT electrogram. METHODS AND RESULTS: 3D shell of the heart was generated, and the NT was made trackable in the EAM system. Unipolar NT electrogram was continuously monitored. Penetration into pericardial sac was determined by an increase in NT potential amplitude and an injury current. A long guidewire of which the tip was also visible in the EAM system was advanced to confirm EA. Epicardial access was successfully obtained without complication in 13 pigs and 22 patients. In the animals, NT potential amplitude was 3.2 ± 1.0 mV when it was located in mediastinum, 5.2 ± 1.6 mV when in contact with fibrous pericardium, and 9.8 ± 2.8 mV after penetrating into pericardial sac (all P ≤ 0.001). In human subjects, it measured 1.54 ± 0.40 mV, 3.61 ± 1.08 mV, and 7.15 ± 2.88 mV, respectively (all P < 0.001). Fluoroscopy time decreased in every 4-5 cases (64 ± 15, 23 ± 17, and 0 s for animals 1-4, 5-8, 9-13, respectively, P = 0.01; 44 ± 23, 31 ± 18, 4±7 s for patients 1-7, 8-14, 15-22, respectively, P < 0.001). In five pigs and seven patients, EA was obtained without X-ray exposure. CONCLUSION: By tracking NT in the 3D EAM system and continuously monitoring the NT electrogram, it is feasible and safe to obtain EA with minimum or no fluoroscopic guidance.

Cardiac Tamponade and Pericardiocentesis: Recognition, Standard Techniques, and Modern Advancements.

Pericardiocentesis is an important diagnostic and therapeutic procedure. In the setting of cardiac tamponade, pericardiocentesis can rapidly improve hemodynamics, and in cases of diagnostic uncertainty, pericardiocentesis allows for fluid analysis to aid in diagnosis. In contemporary practice, the widespread availability of ultrasonography has made echocardiographic guidance the standard of care. Additional tools such as micropuncture technique, live ultrasonographic guidance, and adjunctive tools including fluoroscopy continue to advance and enhance procedural efficiency and safety. When performed by experienced operators, pericardiocentesis is a safe, effective, and potentially life-saving procedure.

Spontaneous Hemorrhagic Pericardial Effusion as a Consequence of Apixaban Utilization for New-Onset Atrial Fibrillation.

Although anticoagulation stands as a standardized therapeutic approach for mitigating thrombotic risks in atrial fibrillation, the potential for bleeding associated with direct oral anticoagulants (DOACs) is consistently weighed in the risk/benefit analysis prior to initiating therapy for non-valvular atrial fibrillation. While the typical bleeding risks from DOACs predominantly affect the gastrointestinal system, occurrences of spontaneous hemorrhagic pericardial effusions are rare. This case presentation illustrates a patient developing spontaneous hemorrhagic pericardial effusion four days after commencing apixaban therapy and subsequent management.

Comparison of PLANE Technique versus Standard Echocardiography Guidance for Pediatric Pericardiocentesis.

Percutaneous pericardiocentesis remains a challenging and potentially dangerous procedure, particularly in small, critically ill patients. We present outcomes of the PLANE (pericardiocentesis using long-axis in-plane real-time echocardiography) technique for pediatric pericardiocentesis compared with a standard echocardiography (ECHO) guidance cohort. This was a retrospective chart review of all children undergoing percutaneous pericardiocentesis from March 2013 to February 2021 at a single center. A total of 78 procedures were performed, 52 utilizing PLANE technique and 26 utilizing standard ECHO-guidance technique. There was 100% technical success rate with only one minor complication for the entire cohort. Procedures were evenly split between the bedside intensive care unit and cardiac catheterization laboratory. PLANE technique was utilized in significantly younger (1.4 vs. 8.4 years, p = 0.008) and smaller (11.1 vs. 31.8 kg, p = 0.007) patients, as well as in most patients deemed high risk (postoperative < 7 days, extracorporeal membrane oxygenation (ECMO) support, and/or weight less than 5 kg; 19/22, p = 0.021). Other patient characteristics were similar between the two groups. There was a trend toward PLANE technique utilization by noncardiology trained operators. The PLANE technique for pediatric pericardiocentesis is safe and effective and can be effectively utilized in small and high-risk patient populations. The technical similarity to other long-axis ultrasound-guided procedures may facilitate adoption and mastery by critical care trained operators.

ECG Changes Post-pericardiocentesis for Cardiac Tamponade Secondary to Non-small Cell Carcinoma of the Lung.

Electrical alternans on electrocardiograph (ECG) is an uncommon but nearly pathognomonic sign of cardiac tamponade. Here, we present a male quadragenarian who came to the emergency department complaining of low back and right upper abdominal pain. Work-up revealed a large pericardial effusion associated with electrical alternans on ECG and clinical findings of cardiac tamponade. Pericardiocentesis drained approximately 1 liter of hemorrhagic fluid with resolution of cardiac tamponade and normalization of the ECG. Further evaluation with right hilar lymph node biopsy confirmed a diagnosis of poorly differentiated non-small cell adenocarcinoma of the lung.

Intraoperative Acute Cardiac Tamponade as a Result of Intracardiac Perforation Requiring Emergency Continuous Pericardiocentesis and Open Sternotomy: A Case Report and Literature Review of a Rare but Fatal Complication.

Intraoperative acute cardiac tamponade associated with iatrogenic intracardiac perforation from percutaneous interventional cardiac procedures is a rare but potentially catastrophic complication. We report a case of intraoperative acute hemopericardium caused by a left atrial (LA) perforation resulting in cardiac tamponade in a patient undergoing a baffling procedure for the correction of two anomalous pulmonary veins draining into her superior vena cava (SVC) that required continuous pericardiocentesis with autologous blood transfusion via the femoral vein and an emergency intraoperative transfer from the interventional cardiology cath lab to the cardiac operating room for an open sternotomy and primary repair. An 86-year-old female with known right-ventricular (RV) failure with preserved ejection fraction (left ventricular ejection fraction (LVEF): 50-55% on transesophageal echocardiography (TEE) one week prior) and atrial fibrillation was admitted for her third heat failure exacerbation in two months despite being adherent to her aggressive diuresis medication regimen. Upon her readmission and due to her symptomatic and seemingly refractory heart failure, the patient underwent a cardiac computer tomography (CT) with 3D reconstruction that showed previously undiagnosed partial anomalous pulmonary venous return (PAPVR) of two of her four pulmonary veins aberrantly draining into the SVC. This anatomic pathology was deemed to be the likely etiology of her repeated episodes of recurring heart failure exacerbations, shortness of breath, peripheral edema, and fatigue. The patient was counseled and consented to a percutaneous baffle of the two anomalous veins to redirect more of the returning pulmonary venous blood away from the SVC and to the LA. While under general endotracheal anesthesia (GETA) with a TEE in place during the procedure, the patient suddenly developed acute hypotension, tachycardia, and a reduction in expired carbon dioxide (EtCO2) was noted quickly followed by evidence of a rapidly accumulating hemopericardium on TEE. Cardiothoracic surgery was urgently consulted to the interventional cardiology cath lab while the patient underwent an emergency pericardiocentesis that momentarily alleviated her hemodynamic instability, cardiac tamponade physiology, and deteriorating overall clinical picture. While performing continuous pericardiocentesis with autologous return of the aspirated blood via femoral venous access the patient was urgently transported to the cardiac operating room and prepped for emergency sternotomy for primary repair of the LA. Following primary repair via sternotomy, multiple drains were placed and the thoracic cavity was closed with wires. The patient was immediately transported to the surgical intensive care unit (SICU) intubated, mechanically ventilated, and sedated. During this time, the patient progressively required additional vasoactive and inotropic agents to support her mean arterial pressure (MAP), and following a multidisciplinary discussion with the patient's family regarding her goals of care, the decision was made to withdraw further resuscitation efforts and the patient expired four hours later.

Large pericardial effusion in a woman in the second trimester of pregnancy: a case report.

Background: Pericardial effusion is common in pregnancy, with causes similar to the general population. Usually, it is found in the third trimester and disappears spontaneously after labour; however, there is a risk of progression to tamponade. Management is based on expert opinion, since few studies have been published. Case summary: A woman with enlargement of a known, chronic, presumably idiopathic pericardial effusion, in the 17th gestation week, presented with mild dyspnoea, without specific echocardiographic signs of cardiac tamponade. She received double antithrombotic treatment with aspirin 100 mg, started before conception, and a prophylactic dose of tinzaparin 4500 IU, started at the beginning of the pregnancy due to obstetrical antiphospholipid syndrome. A multidisciplinary team consisting of the treating obstetrician-gynaecologist, haematologist, cardiothoracic surgeon, and cardiologist discussed the management, taking into account the large size of the effusion and the significant increase during pregnancy, the possibility of further increase during the third trimester, the antiplatelet and antithrombotic treatment, which increased the haemorrhagic risk, and the difficulty and risk to intervene later in pregnancy. A surgical pericardial window was proposed to the patient and family and was performed uneventfully. Discussion: This case demonstrates the importance of a multidisciplinary team approach and shared decision-making in the management of these complex cardio-obstetric patients in order to achieve optimal therapeutic results.

Non-tamponade Indications for Pericardial Drainage: A Case Report of Acute Streptococcus pneumoniae Purulent Pericarditis.

Pericardial drainage is a procedure completed to evacuate fluid from the pericardial space. This can be completed by pericardiocentesis or pericardial window. These procedures are most often done in the setting of cardiac tamponade, typically to correct low blood pressure due to low stroke volume from extrinsic compression of the heart chambers by the pericardial fluid. Elective pericardiocentesis can be done in cases where fluid accumulation is secondary to pathological processes, including hemopericardium secondary to complications of trauma to the chest, toxins, myocardial infarction, cardiac surgery, serosanguinous pericardial effusion due to malignancy, right heart failure, acute pericarditis, chemotherapeutic agents, metabolic derangements like uremia, and autoimmune disorders. Here, we report a case of a 66-year-old immunocompetent male with acute bacterial pericarditis resulting in fibrinous pericardial effusion without echocardiographic cardiac tamponade physiology in whom pericardial drainage proved beneficial.