Ružica Maksimović

Management strategies in pericardial emergencies

Background:The most frequent pericardial emergency is cardiac tamponade, but complications of an acute coronary syndrome and aortic dissection may also involve the pericardium. Acute pericarditis can also represent a medical emergency due to chest pain of upsetting intensity. Decompensations in chronic advanced constriction and in the clinical course of purulent pericarditis necessitate critical care as well.Diagnosis and Management:The diagnosis of cardiac tamponade is based on clinical presentation and physical findings, confirmed by echocardiography and cardiac catheterization. Tamponade is an absolute indication for urgent drainage, either by pericardiocentesis or surgical pericardiotomy. The approach for pericardiocentesis can be subxiphoid or intercostal using echocardiographic or fluoroscopic guidance. Urgent drainage, combined with intravenous antibiotics, is also mandatory in suspected purulent pericarditis. If confirmed, it should be combined with intrapericardial rinsing (best by a surgical drainage). Pericardiocentesis is contraindicated in cardiac tamponade complicating aortic dissection. This condition should immediately lead to cardiac surgery. Although pericardiectomy is the only treatment for permanent constriction, this procedure is contraindicated when extensive myocardial fibrosis and/or atrophy are demonstrated.Case Study:Iatrogenic tamponade may occur during percutaneous mitral valvuloplasty, implantation of pacemakers, electrophysiology and radiofrequency ablation procedures, right ventricular endomyocardial biopsy, percutaneous coronary interventions, and rarely during Swan-Ganz catheterization. The authors report on a 79-year-old who suffered coronary perforation and cardiac tamponade during elective stent implantation. Tamponade was successfully treated with pericardiocentesis and implantation of a membrane-covered graft stent. Subsequent recurrent pericarditis/postpericardial injury syndrome with moderate pericardial effusion was initially treated with aspirin and then with aspirin and colchicine. At 6 months, the patient is in stable remission even after withdrawal of colchicine.Conclusion:Natural history of pericardial diseases can be complicated with pericardial emergencies requiring prompt diagnosis, intensive care with hemodynamic monitoring, and early aggressive management. Medical supportive measures, drainage of pericardial effusion, surgical pericardiotomy, and pericardiectomy should be applied when needed with no delay. This procedural approach also applies to iatrogenic interventions leading to tamponade.ZusammenfassungHintergrund:Der häufigste Notfall bei Perikarderkrankungen ist die Herzbeuteltamponade. Komplikationen bei akutem Koronarsyndrom oder einer Aortendissektion können ebenfalls das Perikard betreffen. Dies gilt auch für die Exazerbation präkordialer Beschwerden einer akuten Perikarditis, die Dekompensation bei chronisch-konstriktiver Perikarditis oder bei einer purulenten Perikarditis.Diagnose und Management:Die Diagnose der Herzbeuteltamponade stützt sich auf Symptome, klinische Untersuchung, die Ergebnisse der Echokardiographie und ggf. einer Herzkatheteruntersuchung. Bei einer Tamponade ist die umgehende Entlastung eine lebensrettende Indikation zu Perikardpunktion oder chirurgischer Perikardiotomie. Die Perikardpunktion kann von subxiphoidal oder interkostal unter Röntgen- oder Echokardiographiekontrolle erfolgen. Bei V.a. purulenten Perikarderguss muss unter Antibiotikaschutz gleichfalls eine umgehende Drainage, am besten mit nachfolgender Spülung, erfolgen. Hingegen ist die Perikardpunktion bei Aortendissektion trotz Perikardtamponade kontraindiziert. Hier ist ein unmittelbares kardiochirurgisches Vorgehen erforderlich. Obgleich eine Perikardiektomie die einzige Behandlung für eine Pericarditis constrictiva darstellt, ist sie bei erheblicher Myokardfibrose und/oder Atrophie im Computer- oder Magnetresonanztomogramm kontraindiziert.Fallbericht:Eine iatrogene Tamponade kann gelegentlich bei perkutaner Mitralklappenvalvuloplastie, der Implantation von Herzschrittmachern, elektrophysiologischen Untersuchungen mit Ablationsbehandlung, rechtsventrikulärer Endomyokardbiopsie, orthoperkutaner transluminaler Koronarangioplastie und selten bei einer Rechtsherzkatheteruntersuchung mit einem Swan-Ganz-Katheter vorkommen. Als Fallbeispiel wird über eine Perikardtamponade bei einem 79-jährigen Patienten berichtet, die infolge einer Koronarperforation bei elektiver Stentimplantation auftrat. Die Tamponade konnte mit einer Perikardpunktion, die Leckagestelle durch die Implantation eines abdeckenden Stentgrafts erfolgreich behandelt werden. Das nachfolgende „postcardiac injury syndrome“ wurde initial mit Aspirin allein, später mit der Kombination von Aspirin und Colchicin erfolgreich behandelt. Colchicin konnte nach 6 Monaten abgesetzt werden.Schlussfolgerung:Der natürliche Verlauf von Perikarderkrankungen kann durch eine Exazerbation kompliziert werden, die ihn zum perikardialen Notfall macht. Dieser erfordert eine umgehende Diagnosestellung, hämodynamisches Monitoring auf der Intensivstation sowie umgehende und rechtzeitige Einleitung der Therapie, meist einschließlich einer Perikardpunktion oder einer chirurgischen Perikardiotomie. Gleiches gilt für kardiale prozedurale Notfälle.

The value of magnetic resonance imaging for the diagnosis of arrhythmogenic right ventricular cardiomyopathy.

This study evaluated the diagnostic significance of a magnetic resonance imaging (MRI) based scoring model for identification of arrhythmogenic right ventricular cardiomyopathy (ARVC) in patients with MRI evidence of RV abnormalities. Fifty-three patients with RV myocardial abnormalities on MRI were divided into a group with ARVC 1 (n=17) and a group with other RV arrhythmias (n=37). Decision tree learning (DTL) and linear classification (based on a modified ARVC scoring model of major and minor criteria) were used to identify and assess MRI criterion information value, and to induce ARVC diagnostic rules. All major ARVC criteria were more frequent in the ARVC group. Among minor criteria regional RV hypokinesia, mild segmental RV dilatation, and prominent trabeculae were more frequent in the ARVC group while mild global RV dilatation was more frequent in the non-ARVC group. RV aneurysm achieved highest importance in ARVC diagnosis (predictive accuracy 76.8%). Better diagnostic accuracy (sensitivity 93.3%, specificity 89.5%) was achieved when the MRI score for the major and minor criteria reached threshold value of four: two major criteria, or one major and two minor, or four minor criteria. Combinations between major and minor criteria contributed to a statistically valid model for ARVC diagnosis.

Magnetic resonance imaging in pericardial diseases : Indications and diagnostic value

Introduction Echocardiography is the standard for the assessment of patients with pericardial diseases. It provides valuable morphological and functional information. However, it is sometimes limited by acoustic window, low signal-to-noise ratio, and can be difficult in obese patients or in those with obstructive lung diseases [1]. Additionally, it is often of limited value in patients with loculated/localized effusions, and with the exception of transesophageal echocardiography, it is generally unreliable for the assessment of pericardial thickening [2]. Cardiac magnetic resonance imaging (MRI) is a reliable method for the assessment of the pericardium, because it offers good temporal and spatial resolution, functional and three-dimensional imaging with highly reproducible measurements without exposing patients to radiation [3].

Progression of Myocarditis to Dilated Cardiomyopathy: Role of the Adrenergic System and Myocardial Catecholamines

A progression from viral myocarditis to dilated cardiomyopathy has long been hypothesized and clinically accepted, but the exact pathogenetic mechanisms remained uncertain. With developments in the molecular analyses of tissue specimens, new techniques of viral gene amplification, and biochemical analyses, this causal link became even more apparent.1–3 Perhaps the major breakthrough in understanding this burdensome clinical issue was the demonstration of viral RNA/DNA persistence in the myocardium beyond 90 days after inoculation, confirmed by the polymerase chain reaction. Although acute viral myocarditis has various clinical presentations, only the severe cases can lead to substantial cardiac damage and development of dilated cardiomyopathy. In addition to the direct injury of the myocytes, other mechanisms are likely to be involved.4 Several studies have revealed T cell immune-mediated and viral-induced cardiac damage as the major pathophysiologic mechanisms.4,5 Apoptotic cell death may provide another concept to explain the harmful clinical course of acute myocarditis.6