Gaietà Permanyer-Miralda

Purulent pericarditis : review of a 20-year experience in a general hospital

OBJECTIVES The purpose of this study was to review the features of purulent pericarditis in patients from a general hospital during a recent 20-year period. BACKGROUND Although studies published from 1974 to 1977 suggested a changing spectrum for purulent pericarditis, this view has not been proved. METHODS We retrospectively evaluated the records of 33 patients from one general hospital who had a diagnosis of purulent pericarditis during the period 1972 to 1991. All autopsy protocols from the same period were also reviewed. In 19 patients (group I), the condition was diagnosed during life; in 14 (group II), it was identified at autopsy. RESULTS In group I, the possible sources of pericardial infection were identified in 17 patients; pneumonia (6 patients) was the most common source. Empyema was present in 10 patients; 15 had cardiac tamponade. The most common microorganisms were streptococci, pneumococci and staphylococci. Six patients developed constrictive pericarditis and required pericardiectomy. Three patients died, 1 patient was lost to follow up and 15 patients had a favorable outcome at a mean follow-up interval of 35 months. In group II, the clinical diagnoses included pneumonia (five patients) among other infections, with empyema in six patients. Purulent pericarditis was probably the direct cause of death in two patients. CONCLUSIONS In our experience, the spectrum of purulent pericarditis has not changed in recent years. Many patients do not have the classical findings of pericarditis, and diagnosis is made only at autopsy or after tamponade has developed. Empyema remains a common predisposing condition. Purulent pericarditis is still a severe disease, but its prognosis is excellent in patients who can be discharged from the hospital.

Long-Term Follow-up of Idiopathic Chronic Pericardial Effusion

BACKGROUND A large idiopathic chronic pericardial effusion can be defined as a collection of pericardial fluid that persists for more than three months and has no apparent cause. We conducted a prospective study of the natural history and treatment of this disorder. METHODS Between 1977 and 1992, we prospectively evaluated and enrolled patients with large idiopathic chronic pericardial effusion. We performed pericardiocentesis in most of the patients. We performed pericardiectomy when large pericardial effusion reappeared after pericardiocentesis. Follow-up ranged from 18 months to 20 years (median, 7 years). RESULTS During the study period, we evaluated a total of 1108 patients with pericarditis, 461 of whom had large pericardial effusion. Twenty-eight of these patients (age range, 7 to 85 years; median, 61) had large idiopathic chronic effusion and were included in the study. The duration of effusion ranged from 6 months to 15 years (median, 3 years). At the initial evaluation, 13 patients were asymptomatic. Overt tamponade was found in eight patients (29 percent). Therapeutic pericardiocentesis, performed in 24 patients, was followed by the disappearance of or marked reduction in the effusion in 8. Five of the 24 patients underwent early pericardiectomy, and in 11 large pericardial effusion reappeared. Cardiac catheterization, performed in 16 patients, showed elevated intrapericardial pressure (4.75+/-3.79 mm Hg) and reduced transmural pressure (1.0+/-2.50 mm Hg) before pericardiocentesis. Both of these abnormalities in pressure improved significantly after pericardiocentesis. Pericardiectomy, performed in 20 patients, yielded excellent long-term results. At the end of the follow-up period, 10 patients had died, but none had died from pericardial disease. CONCLUSIONS Large idiopathic chronic pericardial effusion is well tolerated for long periods in most patients, but severe tamponade can develop unexpectedly at any time. Pericardiocentesis alone frequently results in the resolution of large effusions, but recurrence is common and pericardiectomy should be considered whenever a large effusion recurs after pericardiocentesis.

Limitations of head-up tilt test for evaluating the efficacy of therapeutic interventions in patients with vasovagal syncope: Results of a controlled study of etilefrine versus placebo

OBJECTIVES This study assessed the efficacy of oral etilefrine (10 mg three times a day) in preventing a positive response to head-up tilt testing. BACKGROUND Previous reports have suggested that oral etilefrine can be effective either in preventing a positive response to head-up tilt testing or in reducing syncopal recurrences in patients with vasovagal syncope. Up to now most studies assessing drug therapy in these patients have been uncontrolled. METHODS This was a randomized double-blind crossover study of etilefrine versus placebo in 30 consecutive patients with syncope and a baseline positive head-up tilt test. After the first test, patients had no treatment for 3 days and were randomized to receive etilefrine or placebo for 4 additional days. They underwent tilt testing under treatment and again after 3 days of washout; they then received the alternative treatment for 4 days, and a third test was performed. RESULTS Head-up tilt test results were negative in 13 (43%) patients with etilefrine and 15 (50%) with placebo (p = NS). Therefore, the statistical power of the study was only 10%. The rate of positive responses decreased with repeated testing irrespective of the assigned treatment: A positive response was obtained during the second head-up tilt test in 20 patients (10 with placebo, 10 with etilefrine) but in only 12 during the third (7 with etilefrine, 5 with placebo) (p < 0.05). CONCLUSIONS Oral etilefrine (10 mg three times a day) was not superior to placebo in preventing a positive response to head-up tilt testing. Despite a low statistical power, the high rate of negative response with placebo (50%) suggests that controlled trials are needed to assess the real efficacy of any treatment in patients with vasovagal syncope.

Long-Term Complications of Native Valve Infective Endocarditis in Non-Addicts: A 15-Year Follow-up Study

OBJECTIVE To describe the incidence and clinical manifestations of long-term cardiac complications of endocarditis. DESIGN Cohort study. SETTING University-affiliated tertiary medical center. PATIENTS One hundred twelve consecutive patients, survivors from a series of 140 non-addicted patients with a first episode of infective endocarditis on native valves hospitalized from 1975 to 1990. Thirty-two patients had had valve replacement during the active phase of the infection, and the remaining 80 patients received medical treatment alone. MEASUREMENTS Relapse, recurrence, need for late cardiac surgery, and cardiac mortality. RESULTS Relapses occurred in three patients (2.7%) and recurrences in five patients (4.5%, incidence density at 15 years, 0.0030 per patient-year). Late cardiac surgery was needed by 47% of the patients treated medically during the active phase, and most had surgery in the first 2 years of follow-up (incidence density, 0.25 per patient-year at 2 years). Aortic valve involvement (relative risk, 2.66; 95% CI, 1.15 to 6.17) and end-diastolic diameter greater than 60 mm (relative risk, 1.04; 95% CI, 1.03 to 2.43) were associated with the need for late surgery in univariate analysis. Multiple logistic regression analysis showed aortic valve involvement to be an independent predictor of the need for late surgery (relative risk, 3.04; CI, 1.23 to 7.54). Only 2 of the 32 patients who had surgery during the active infection needed a second operation during follow-up. At the end of follow-up, the number of patients who had surgery after the onset of the infection was 86 (60% of the whole series). Cardiac death occurred in 16 patients; most deaths were sudden or postoperative and occurred in the first 2 years of follow-up (incidence density, 0.047 per patient-year at 2 years). Independent predictors of death were not found. Survival was 90% at 2 years, 88% at 5 years, 81% at 10 years, and 61% at 15 years. CONCLUSIONS Survival after infective endocarditis is fair (81% probability of survival at 10 years), and the most common types of cardiac death are sudden and postoperative. Aortic valve involvement is an independent predictor of the need for late cardiac surgery. The rate of recurrences is not negligible (incidence density at 15 years, 0.0030 per patient-year).

Clinical outcome of severe asymptomatic chronic aortic regurgitation: a long-term prospective follow-up study.

One hundred one patients with asymptomatic chronic severe aortic regurgitation and normal ejection fraction were monitored for up to 10 years (mean 55.4 +/- 33.5 months). Predefined surgical indications were the development of cardiac symptoms or the documentation of impaired basal left ventricular function. During the follow-up period there were no cardiac deaths; 14 patients needed surgery, 8 because of development of symptoms and 6 because of left ventricular impairment. The risk of surgery was 12% at 5 years and 24% at 10 years. Baseline end-systolic diameter > 50 mm and radionuclide ejection fraction < 60% were independent predictors or either cardiac symptoms or left ventricular dysfunction. In patients needing surgery, a pattern of progressive left ventricular dilatation was demonstrated. There were no deaths during surgery, and echocardiographic and radionuclide parameters normalized in the first year of follow-up. Our data confirm that the prognosis of severe aortic regurgitation in patients with no symptoms is good and that the occurrence of asymptomatic left ventricular dysfunction is an uncommon event. Surgery can be safely postponed until the appearance of cardiac symptoms or the documentation of left ventricular dysfunction at rest.

Transient cardiac constriction: an unrecognized pattern of evolution in effusive acute idiopathic pericarditis

In 16 of 177 patients with effusive acute idiopathic pericarditis (10 men, 6 women, mean age 38 years), features of cardiac constriction were detected (by physical examination in 6 patients and by noninvasive recordings in all) between 5 and 30 days after an echocardiogram had shown pericardial effusion, at a time when signs of activity had abated and effusion was already minimal or had altogether disappeared. Cardiac catheterization was performed in 5 patients, showing either overt (3 patients) or occult (2 patients) cardiac constriction. Two patients had clinical signs of cardiac failure. After a mean of 2.7 months, the features of constriction had spontaneously disappeared in all patients in the clinical examination and noninvasive recordings, and remained so in subsequent control studies (mean follow-up 31 months). Repeat cardiac catheterization in the 5 patients in whom it had been previously performed showed normal features both in the basal state and after fluid overload. The results of the present study show that some patients may go through a transient phase of cardiac constriction at the end of the effusive period of acute idiopathic pericarditis. Features of constriction are, in most cases, subtle and can go unrecognized if not specifically sought. However, they may have clinical relevance in some patients. These findings provide insight into the resolution phase of effusive acute idiopathic pericarditis, and an unnecessary pericardiectomy may be avoided.

Should pericardial drainage be performed routinely in patients who have a large pericardial effusion without tamponade

PURPOSE To assess whether drainage of pericardial effusion by pericardiocentesis or surgery is justified as a routine measure in the initial management of patients with large pericardial effusion without tamponade or suspected purulent pericarditis. SUBJECTS AND METHODS All patients with large pericardial effusion without tamponade or suspected purulent pericarditis who were seen at our institution during a span of 6 years (1990 to 1995) were retrospectively (46) or prospectively (25) reviewed. Large pericardial effusion was defined as a sum of echo-free pericardial spaces in diastole exceeding 20 mm. RESULTS Large pericardial effusion was diagnosed in 162 patients, 71 of whom fulfilled criteria for inclusion. Of these, 26 underwent a pericardial drainage procedure. Diagnostic yield was 7%, as only 2 specific diagnoses were made using these procedures. During follow-up (95% of patients, median 10 months), no patient developed cardiac tamponade or died as a result of pericardial disease, nor did any new diagnoses become manifest in the 45 patients who did not have pericardial drainage initially. Moderate or large effusions persisted in only 2 of 45 patients managed conservatively. CONCLUSIONS Routine pericardial drainage procedures have a very low diagnostic yield in patients with large pericardial effusion without tamponade or suspected purulent pericarditis, and no clear therapeutic benefit is obtained with this approach. Clinical outcomes depend on underlying diseases, and do not appear to be influenced by drainage of pericardial fluid.

Diagnosis of ascending aortic dissection by transesophageal echocardiography: Utility of M-mode in recognizing artifacts

OBJECTIVES This study sought to assess the reliability of biplanar transesophageal echocardiography in the diagnosis of ascending aortic dissection and to test the utility of M-mode information in the differential diagnosis of ascending aortic ultrasound artifacts and intimal flap images. BACKGROUND Transesophageal echocardiography is a useful technique in the diagnosis of aortic dissection. However, ultrasound artifacts in the ascending aorta are an important limitation. METHODS Transesophageal echocardiography was performed in 132 consecutive patients with clinically suspected aortic dissection. Two-dimensional and M-mode echocardiography and color Doppler were used to diagnose intimal flap and artifact images. Diagnoses were validated either anatomically or with reference techniques. RESULTS The sensitivity and specificity of transesophageal echocardiography in the diagnosis of ascending aortic dissection were 96.8% and 100%, respectively. Ninety-three artifacts were observed in 56 (55%) of 101 patients without ascending aortic dissection. Two-dimensional echocardiography easily identified 74 artifacts (80%). Color Doppler showed no ascending flow abnormalities in 71% of artifact images. M-mode echocardiography showed three location and mobility artifact patterns related to the posterior wall of the aorta or the right pulmonary artery. In contrast, intimal flap movement showed no relation to the aortic wall movement in 25 cases (83%). Blind analysis of transesophageal echocardiographic study tapes underlined the utility of M-mode in the differential diagnosis. Ranges of sensitivity, specificity and positive predictive value (established by including doubtful results as either positive or negative) improved from 87.1-93.5% to 93.5-96.8%, from 85.1-94.1% to 99-100% and from 65.9-81.8% to 96.8-100%, respectively, with the inclusion of M-mode data. CONCLUSIONS Biplanar transesophageal echocardiography permits reliable diagnosis of ascending aortic dissection. Ultrasound artifacts are common, but assessment of the location and mobility of intraluminal images by M-mode echocardiography definitely improves diagnostic accuracy.

Pericardial effusion in the course of myocardial infarction: incidence, natural history, and clinical relevance.

Incidence and significance of pericardial effusion in patients with acute myocardial infarction (AMI) have not been established. To evaluate these issues, we studied prospectively 138 consecutive patients with AMI. An echocardiogram was obtained in each 1, 3, and 10 days and 3 and 6 months after admission. Fifty four patients with unstable angina and 57 without heart disease were studied as controls. Echocardiographic diagnostic criteria of pericardial effusion were established from 33 additional patients undergoing surgery. Pericardial effusion was found in 28% of patients with AMI. Twenty-five percent of patients with AMI had pericardial effusion on the third day, vs 8% of patients with unstable angina (p less than .02) and 5% of patients without heart disease (p less than .01). At 1, 3, and 10 days and 3 and 6 months prevalence of pericardial effusion was 17%, 25%, 21%, 11%, and 8%, respectively. There was no case of tamponade. Pericardial effusion was more common in anterior AMI (p less than .02) and in patients with heart failure (p less than .05) but it was not significantly associated with early pericarditis, peak creatine kinase-MB, the level of anticoagulation, or mortality. Thus, pericardial effusion is a common event in patients with AMI (incidence of 28%), but does not result in specific complications. The reabsorption rate of pericardial effusion is slow and, in our experience, mild or moderate pericardial effusion does not preclude heparin therapy.

Comparison of perceived health status and conventional functional evaluation in stable patients with coronary artery disease

A cross-sectional study of stable coronary hospital patients was carried out to compare perceived health assessment with conventional clinical measures; 93 consecutive patients were studied, 45 of whom had undergone bypass surgery. Exercise tests and clinical functional classification were obtained together with blind concurrent self-responses to the Nottingham Health Profile (NHP), a measure of distress. Coronary arteriography was available for all patients. Patients with negative exercise tests had lower NHP scores (lower levels of distress) than those with positive or inconclusive tests, especially in the energy, pain and physical mobility NHP dimensions (p less than 0.01). High Spearman correlation coefficients were found between exercise performance and energy (rs = -0.51) and pain (rs = -0.36) scores. This correlation was closer than that found with clinical functional class. In these patients, exercise performance closely correlated with perceived distress. Self-perceived health status measures may improve the evaluation of coronary patients based on clinical assessment alone.