Risk factors associated with clinically relevant pericardial effusion after primary cardiac implantable electronic device implantation.

INTRODUCTION: Pericardial effusion, a known complication to implantation of cardiac implantable electronic devices (CIED), may cause life-threatening cardiac tamponade. Limited knowledge is available about risk factors for clinically relevant procedural pericardial effusion. The aim is to identify the patient- and procedure-related risk factors associated with clinically relevant procedural pericardial effusion. METHOD: A nationwide observational cohort study based on data on 55 121 patients from the Danish Pacemaker Register between 2000 and 2018. We defined a clinically relevant procedural pericardial effusion related to the implantation if it occurred within 90 days after the primary CIED-procedure. Prespecified risk factors were analysed by multivariable logistic regression models to estimate the association with pericardial effusion. RESULTS: There were 115 (0.21%) patients diagnosed with clinically relevant procedural pericardial effusion, with a median age of 75 years and 38.3% were females. Of these, 80.9% lead to a subsequent pericardiocentesis procedure. In adjusted logistic regression analysis, an increased risk of clinically relevant pericardial effusion was associated with female sex (OR:1.49 [95%CI: 1.03-2.16]), heart failure (OR:1.54 [95%CI: 1.06-2.23]), previous cardiac surgery (OR:1.63 [95%CI: 1.05-2.55]), CRT-device (OR:2.05 [95%CI: 1.23-3.41]), tertiary-centres (OR:1.8 [95%CI: 1.18-2.73]), increased procedural volume per year (>1000) (OR:1.85 [95%CI: 1.03-3.30]), indication of device-implantation (atrioventricular block) (OR:2.37 [95CI: 1.45-3.87]), and increasing number of leads implanted (two leads (OR:2.39 [95%CI: 1.43-4.00]), three leads (OR:4.77 [95%CI: 2.50-9.10])). CONCLUSION: Clinically relevant procedural pericardial effusion is a rare complication after CIED-implantation in Denmark. This study reveals important patient- and procedure-related risk factors associated with clinically relevant procedural pericardial effusion.

A Vascular Plug for Persistent Shock Following Transcatheter Mitral Valve Replacement.

A 78-year-old woman with severe bioprosthetic mitral valve degeneration underwent successful transcatheter mitral valve replacement with a valve-in-valve procedure. This case postprocedure was complicated by cardiogenic shock from left ventricular perforation and underscores the importance of the accurate assessment and treatment of patients following transcatheter valvular procedures.

Purulent pericarditis and cardiac tamponade in HIV: a case report on a dreaded complication of Streptococcus pneumoniae.

Introduction and importance: Purulent pericarditis is an uncommon complication of Streptococcus pneumoniae, which commonly occurs in an immunocompromised state such as HIV and can lead to life-threatening complications such as cardiac tamponade and potentially death if untreated. Early identification, pericardiocentesis, and general measures such as antibiotics and anti-inflammatory medications can be life-saving. Case presentation: The authors present a case of a 64-year-old male with HIV who presented with clinical symptoms suggestive of pericarditis. Chest imaging revealed multifocal airspace diseases and moderate pericardial effusion. He had worsening lactic acidosis, and bedside point-of-care ultrasound showed pericardial effusion with features suggestive of cardiac tamponade. His lactic acidosis improved with emergency pericardiocentesis. Blood and pericardial fluid cultures revealed Streptococcus pneumoniae. He was further treated with intravenous antibiotics, colchicine, and ibuprofen. Clinical discussion: Although Streptococcus pneumoniae is a common etiology of community-acquired pneumonia (CAP), it has not been cited as the leading cause of pericarditis or pericardial effusion. In immunocompromised patients, it is necessary to consider a broad differential diagnosis as an etiology of acute chest pain, as it may be challenging to differentiate pleuritic and pericarditic chest pain from clinical presentation only. Moreover, infectious etiology of acute pericarditis and pericardial effusion should be considered in this patient population, especially those with HIV. At the same time, it is crucial to promptly identify and treat cardiac tamponade to prevent further deterioration. Conclusion: This case provides insight into the diagnosis and management of CAP and its potential complication of purulent pericarditis and cardiac tamponade in immunocompromised patients.

Accidental cannulation of amoebic liver abscess during pericardiocentesis: a case report.

Background: Amoebiasis is a prevalent infection in the tropics and can sometimes present as liver abscess. Cardiac tamponade is an uncommon complication of ruptured amoebic liver abscess requiring urgent pericardiocentesis, which has a high success rate, but procedural complications can include injury to cardiac chambers, abdominal viscera, and even death. This case underscores the approach to diagnose and manage an unintended visceral puncture during pericardiocentesis, which is a rare but life-threatening complication. Case summary: A 41-year-old male presented with intermittent fever over 2 months and chest pain for 15 days. Echocardiography revealed a significant pericardial effusion causing cardiac tamponade. In an emergency setting, percutaneous pericardiocentesis was attempted to drain the effusion. However, the pigtail inadvertently punctured a sizable liver abscess. Consequently, another pigtail was inserted into the pericardial cavity to successfully drain the effusion. Patient was discharged on Day 12 and is doing well at 6 months follow-up. Discussion: A previously undiagnosed case of a ruptured amoebic liver abscess presented with the uncommon complication of cardiac tamponade, necessitating emergency pericardiocentesis, which inadvertently led to the cannulation of the liver abscess. This case underscores the significance of image-guided pericardiocentesis in minimizing procedural complications. This case also highlights the intricacies of addressing accidental visceral puncture during pericardiocentesis, specially involving the liver. It also underscores the need to consider the possibility of a ruptured amoebic liver abscess when anchovy sauce-like pus is drained from pericardial cavity, especially in high epidemiologically prevalent country like India.

Cardiac Point-Of-Care Ultrasound: An Emergency Medicine Review.

Cardiac point-of-care ultrasound (POCUS) can make critical diagnoses and monitor the response to interventions. In contrast with consultative echocardiography, cardiac POCUS serves to answer a specific clinical question. This imaging modality can be used to evaluate for left ventricular systolic and diastolic dysfunction, pericardial effusion and tamponade, acute and chronic right ventricular dysfunction, valvular dysfunction, and cardiac activity in cardiac arrest.

Direct reinfusion of pericardial blood complications: A case of acute respiratory distress syndrome and disseminated intravascular coagulation.

Background: Direct reinfusion of pericardial blood during cardiac surgery triggers a systemic inflammatory response. Although various inflammatory mediators have been identified as triggers, the role of damage-associated molecular patterns (DAMPs) remains poorly understood. Despite guidelines recommending against this practice owing to its harmful effects, it is sometimes used in emergencies. Case Presentation: A 72-year-old man with atrial fibrillation and cerebral infarction developed cardiac tamponade during catheter ablation. He underwent pericardial drainage and direct blood reinfusion. He was transferred to our ICU, where he developed acute respiratory distress syndrome (ARDS) and disseminated intravascular coagulation (DIC). Despite aggressive management, the patient died 41 days after admission. Conclusion: This case highlights severe adverse events following direct reinfusion of pericardial blood. These findings suggest a significant role for DAMPs in mediating these inflammatory responses. Direct reinfusion of pericardial drainage blood should be avoided during emergencies to prevent life-threatening complications.

Contemporary management of traumatic cardiac arrest and peri-arrest states: a narrative review.

Trauma is a leading cause of death and disability worldwide across all age groups, with traumatic cardiac arrest (TCA) presenting a significant economic and societal burden due to the loss of productive life years. Despite TCA's high mortality rate, recent evidence indicates that survival with good and moderate neurological recovery is possible. Successful resuscitation in TCA depends on the immediate and simultaneous treatment of reversible causes according to pre-established algorithms. The HOTT protocol, addressing hypovolaemia, oxygenation (hypoxia), tension pneumothorax, and cardiac tamponade, forms the foundation of TCA management. Advanced interventions, such as resuscitative thoracotomy and resuscitative endovascular balloon occlusion of the aorta (REBOA), further enhance treatment. Contemporary approaches also consider metabolic factors (e.g. hyperkalaemia, calcium imbalances) and hemostatic resuscitation. This narrative review explores the advanced management of TCA and peri-arrest states, discussing the epidemiology and pathophysiology of peri-arrest and TCA. It integrates classic TCA management strategies with the latest evidence and practical applications.

Cardiac and mediastinum involvement in Burkholderia thailandensis infection: A case report and literature review.

Melioidosis, an infectious disease caused by Burkholderia pseudomallei, is prevalent in Southeast Asia and Northern Australia, presenting various clinical manifestations from asymptomatic to life-threatening infections. Although primarily affecting the lungs, intra-abdominal viscera, and musculoskeletal system, melioidosis can rarely involve the heart and mediastinum, which pose significant diagnostic and therapeutic challenges. Herein, we present the case of a 53-year-old male farmer who presented with persistent fever and chest pain, progressing to pericarditis and cardiac tamponade. Imaging revealed necrotic mediastinal lymphadenopathy and an enhancing pericardium with pericardial effusion. The patient underwent emergency surgical drainage and was treated with intravenous followed by oral antibiotics. Culture confirmed Burkholderia thailandensis, a closely related but less commonly reported species. This report highlights the complexities of diagnosing and managing B. thailandensis, which can mimic aortic disease, tuberculosis, malignancies, and other inflammatory conditions, especially in endemic areas, emphasizing the need for prompt medical and surgical treatment to improve patient outcomes.

Penetrating cardiac injury after percutaneous breast core-needle biopsy, unusual life-threatening complication: a case report.

BACKGROUND: Complications after percutaneous breast biopsy are infrequent but may include hematoma, pseudoaneurysm formation, persistent pain, infection, delayed wound healing, vasovagal reaction, hemothorax, pneumothorax, and neoplastic seeding. The risk factors include tumor factors (size, location, vascularity), procedure-related factors (needle diameter, number of biopsies), and interventionist experience. There has been no previous report of a fatal complication resulting from percutaneous breast biopsy. CASE PRESENTATION: We report a 54-year-old Asian woman with a 3 cm BI-RADS® 4B left breast mass in the lower-inner quadrant who was biopsied by a 16 G needle under ultrasound guidance at a province hospital. She experienced dizziness and near-syncope afterward. The initial evaluation showed evidence of cardiac tamponade with hemodynamic instability. She underwent urgent subxiphoid pericardial window and was transferred to our facility. We brought her directly to the operating room to perform an explorative median sternotomy and found a 0.2 cm hole in the right ventricle. The injured site was successfully repaired without cardiopulmonary bypass. Postoperative echocardiography demonstrated mild right ventricular dysfunction without evidence of septal or valvular injury. She survived with no significant complications. DISCUSSION: This case might be the first report of a life-threatening complication related to percutaneous breast core-needle biopsy. The rapid pericardial release is key to the survival of cardiac tamponade. The patient subsequently required cardiac repair and monitoring to avoid long-term complications. In this report, we suggested a safe biopsy method, complications recognition, and appropriate management of penetrating cardiac injury. CONCLUSION: Penetrating cardiac injury resulting from percutaneous breast biopsy is extremely rare but can occur. A biopsy must be done cautiously, and worst-case management should promptly be considered.

The Role of POCUS and Monitoring Systems during Emergency Pericardial Effusion in the NICU.

Central venous catheterization is, now, one of the most routinely used procedures in the NICUs, helping during the care of very sick infants. Pericardial effusion is a very rare but severe complication, with a high mortality. The cases described are part of an ongoing retrospective study where the use of central catheters inserted in our surgical NICU, and its complications is being analyzed. 16 cases over 13 years are presented in this article, varying in severity from mild, self-resolving cases that were discovered during routine cardiac POCUS to cases with important hemodynamic impact associated with cardiac tamponade and cardiac arrest. Due to immediate intervention, only one of the cases led to catheter-related mortality and that was under particular conditions. Our aim is to highlight the severity of this complication, the importance of early intervention, and the impact of a highly technologized unit and widely available cardiac POCUS.

Trends and outcomes of inpatient cardiac implantable electronic device transvenous lead extractions: a nationwide analysis.

BACKGROUND: Higher rates of CIED implantations have been associated with an increased rate of lead failures and complications resulting in higher rates of transvenous lead extractions (TLE). OBJECTIVE: To assess the trends TLE admissions and evaluate the patient related predictors of safety outcomes. METHODS: National Readmission Database was queried to identify patients who underwent TLE from January 2016 to December 2019. We conducted a multivariate regression analysis to identify variables associated with in-hospital mortality in patients undergoing TLE. Additionally, we compared trends and outcomes of TLE among patients with prior sternotomy versus those without prior sternotomy and analyzed sex-based differences among patients undergoing TLE. RESULTS: We identified 30,128 hospitalizations for TLE. The index admission in-hospital mortality rate was 3.21% with cardiac tamponade happening in 1.46% of the admissions. Age, infective endocarditis, CKD, congestive heart failure and anemia were associated with higher in-hospital mortality rates. There was a lower rate of in-hospital mortality in patients with history of prior sternotomy versus patients without (OR 0.72, CI: 0.59-0.87, p-value < 0.001). There was no difference in in-hospital mortality rate between males and females. Females had a shorter length and a higher cost of stay when compared to male gender. CONCLUSION: TLE admissions continue to increase. Overall rates of mortality and complications are relatively low. Patients with prior sternotomy had better outcomes and less complications when compared to those without prior sternotomy. Female gender is associated with higher rates of cardiac tamponade, yet shorter length of stay with lower cost.

Cardiac tamponade in people living with HIV: a systematic review of case reports and case series.

BACKGROUND: Cardiac tamponade is a life-threatening condition requiring prompt diagnosis and therapeutic intervention. Diagnosis and management of cardiac tamponade in patients with human immunodeficiency virus (HIV) infection pose a major challenge for clinicians. This study aimed to investigate clinical characteristics, paraclinical findings, therapeutic options, patient outcomes, and etiologies of cardiac tamponade in people living with HIV. METHODS: Pubmed, Embase, Scopus, and Web of Science databases were systematically searched for case reports or case series reporting HIV-infected patients with cardiac tamponade up to February 29, 2024. Baseline characteristics, clinical manifestations, paraclinical findings, therapeutic options, patient outcomes, and etiologies of cardiac tamponade were independently extracted by two reviewers. RESULTS: A total of 37 articles reporting 40 HIV-positive patients with cardiac tamponade were included. These patients mainly experienced dyspnea, fever, chest pain, and cough. They were mostly presented with abnormal vital signs, such as tachypnea, tachycardia, fever, and hypotension. Physical examination predominantly revealed elevated Jugular venous pressure (JVP), muffled heart sounds, and palsus paradoxus. Echocardiography mostly indicated pericardial effusion, right ventricular collapse, and right atrial collapse. Most patients underwent pericardiocentesis, while others underwent thoracotomy, pericardiotomy, and pericardiostomy. Furthermore, infections and malignancies were the most common etiologies of cardiac tamponade in HIV-positive patients, respectively. Eventually, 80.55% of the patients survived, while the rest expired. CONCLUSION: Infections and malignancies are the most common causes of cardiac tamponade in HIV-positive patients. If these patients demonstrate clinical manifestations of cardiac tamponade, clinicians should conduct echocardiography to diagnose it promptly. They should also undergo pericardial fluid drainage and receive additional therapy, depending on the etiology, to reduce the mortality rate.

Rare cardiac metastasis of lung cancer mimicking aneurysm and tamponade.

Metastasis of non-small cell lung carcinoma (NSCLC) is a rare cause of cardiac metastatic tumors (CMT). We present a case of NSCLC infiltrating the apical left ventricle mimicking cardiac aneurysm and tamponade. The patient, who had a history of NSCLC, presented with acute shortness of breath and an echocardiogram concerning for ruptured left ventricular aneurysm. A neoplastic mass found at the cardiac apex suggested CMT leading to ventricular wall rupture and cardiac tamponade. Transthoracic echocardiography is the most ubiquitous imaging modality for CMT diagnosis, with cardiac magnetic resonance imaging offering a more detailed assessment. CMT from NSCLC can cause dangerous cardiac tamponade, warranting consideration in patients with suspected metastases.

Metastasis of non­small cell lung carcinoma (NSCLC) to the heart is uncommon but can lead to serious complications including life-threatening cardiac tamponade.Diagnosis of cardiac metastatic tumors from NSCLC often involves echocardiography, but cardiac magnetic resonance imaging provides additional insights in cases where echocardiography results are inconclusive.

Acute procedural safety of the latest radiofrequency ablation catheters in atrial fibrillation ablation: Data from a large prospective ablation registry.

BACKGROUND: Safety data of the latest radiofrequency (RF) technologies during atrial fibrillation (AF) ablation in real-world clinical practice are limited. OBJECTIVES: We sought to evaluate the acute procedural safety of the four latest ablation catheters commonly used for AF ablation. METHODS: A total of 3957 AF ablation procedures performed between January 2022 and December 2023 at 20 centers with either the THERMOCOOL SMARTTOUCH SF (STSF), TactiCath (TC), QDOT Micro (QDM), or TactiFlex (TF) were retrospectively analyzed. RESULTS: In total, QDM, STSF, TF, and TC were used in 343 (8.7%), 1793 (45.3%), 1121 (28.4%), and 700(17.7%) procedures. Among 2406 index procedures, electrical pulmonary vein isolations were successfully achieved in 99.5%. Despite similar total procedure times in the four groups, the total fluoroscopic time was significantly shorter for QDM/STSF with CARTO than TF/TC with EnSite (18.7 ± 14 vs. 27.6 ± 20.6 min, p < .001) and longest in the TF group. The incidence of cardiac tamponade was 0.7% (0.5% and 0.9% during index and redo procedures, 0.8% and 0.3% for paroxysmal and non-paroxysmal AF) and was significantly lower for QDM/STSF than TF/TC (0.2% vs. 1.1%, p = .008) and highest in the TF group. The incidence of cardiac tamponade was higher for TF than TC and STSF than QDM. In the multivariate analysis, TF/TC with EnSite was a significant independent predictor of cardiac tamponade during both the index (odds ratio [OR] = 4.8, 95% confidence interval [CI] = 1.3-17.5, p = .02) and all procedures (OR = 3.0, 95% CI = 1.3-7.2, p = .01). CONCLUSIONS: The incidence of cardiac tamponade and the fluoroscopic time during AF ablation significantly differed among the latest RF catheters and mapping systems in real-world clinical practice.

Percutaneous pericardiocentesis using the apical approach: case series and review of the literature.

BACKGROUND: Pericardiocentesis offers a definitive diagnostic and a life-saving therapeutic modality through removal of pericardial fluid and relief of high intrapericardial pressure. Percutaneous pericardiocentesis has been performed via different approaches depending on different institutional experiences. In this paper, we present our institutional experience and review the current literature of the different approaches for performing percutaneous pericardiocentesis. MATERIALS AND METHODS: We evaluated consecutive patients who underwent echocardiographic-guided pericardiocentesis via the apical approach for pericardial effusion between the period of April 1st, 2022, and April 1st, 2023, at University of Arkansas for Medical Sciences (UAMS). Health records were reviewed for clinical presentations, available imaging findings, procedural outcomes, and short-term follow up. RESULTS: A total of eight consecutive cases of pericardiocentesis via the apical approach were found. Seven were successful. No complications were reported. Six patients had evidence of tamponade physiology on echocardiogram. CONCLUSION: Historically, pericardiocentesis has been most performed via the subxiphoid approach. However, an ultrasound-guided apical approach offers a safe and effective alternative and may be preferable in patients with challenging anatomies.

Pericardial Decompression Syndrome: A Comprehensive Review of a Controversial Entity.

Pericardial decompression syndrome is an ambiguous clinical entity which has generated controversy regarding its existence. Following pericardial decompression, patients experienced clinical deterioration ranging in complications from pulmonary edema to death that could not be attributed to any other distinct clinical pathology. Multiple theories have suggested the pathophysiology behind pericardial decompression syndrome is related to preload-afterload mismatch following pericardial decompression, coronary microvascular ischemia, and stress from high adrenergic state. Our review aims to describe this syndrome by analyzing demographics, etiology of pericardial effusion, method of drainage, volume of pericardial fluid removed, time to decompensation, and clinical outcomes. A systematic review of MEDLINE/PubMed and Google Scholar literature databases were queried for case reports, case series, review articles, and abstracts published in English journals between 1983 and December 2022. Each author's interpretation of echocardiographic and/or pulmonary arterial catheterization data provided in the case reports was used to characterize ventricular dysfunction. Based on our inclusion criteria, 72 cases of pericardial decompression syndrome were included in our review. Our results showed that phenotypic heterogeneity was present based on echocardiographic findings of right/left or biventricular failure with similar proportions in each type of ventricular dysfunction. Time to decompensation was similar between immediate, subacute, and acute cases with presentation varying between hypoxic respiratory failure and shock. This review article highlights theories behind the pathophysiology, clinical outcomes, and therapeutic options in this high mortality condition.

Survival predictor in emergency resuscitative thoracotomy for blunt trauma patients: Insights from a Chinese trauma center.

PURPOSE: Emergency resuscitative thoracotomy (ERT) is a final salvage procedure for critically injured trauma patients. Given its low success rate and ambiguous indications, its use in blunt trauma scenarios remains highly debated. Consequently, our study seeks to ascertain the overall survival rate of ERT in blunt trauma patients and determine which patients would benefit most from this procedure. METHODS: A retrospective case-control study was conducted for this research. Blunt trauma patients who underwent ERT between January 2020 and December 2023 in our trauma center were selected for analysis, with the endpoint outcome being in-hospital survival, divided into survival and non-survival groups. Inter-group comparisons were conducted using Chi-square and Fisher's exact tests, the Kruskal-Wallis test, Student's t-test, or the Mann-Whitney U test. Univariate and multivariate logistic regression analyses were conducted to assess potential predictors of survival. Then, the efficacy of the predictors was assessed through sensitivity and specificity analysis. RESULTS: A total of 33 patients were included in the study, with 4 survivors (12.12%). Multivariate logistic regression analysis indicated a significant association between cardiac tamponade and survival, with an adjusted odds ratio of 33.4 (95% CI: 1.31 - 850, p = 0.034). Additionally, an analysis of sensitivity and specificity, targeting cardiac tamponade as an indicator for survivor identification, showed a sensitivity rate of 75.0% and a specificity rate of 96.6%. CONCLUSION: The survival rate among blunt trauma patients undergoing ERT exceeds traditional expectations, suggesting that select individuals with blunt trauma can significantly benefit from the procedure. Notably, those presenting with cardiac tamponade are identified as the subgroup most likely to derive substantial benefits from ERT.