Usefulness of skills in point of care ultrasound and simulation-based training as essential competencies in acute management of neonatal cardiac tamponade.

Peripherally inserted central catheter (PICC) insertion is a routine procedure in the neonatal intensive care unit required for prolonged intravenous fluid, nutrition and medication support. Neonatal cardiac tamponade is a serious and rare complication of PICC line insertion. Early detection by point of care ultrasound (POCUS) and management by pericardiocentesis improves the chances of survival. Regular simulation-based training sessions on a mannequin, along with knowledge of POCUS, can assist neonatologists and paediatricians for a quick and appropriate response in this emergency condition.

The physiology of cardiac tamponade and implications for patient management.

Exceeding the limit of pericardial stretch, intrapericardial collections exert compression on the right heart and decrease preload. Compensatory mechanisms ensue to maintain hemodynamics in the face of a depressed stroke volume but are outstripped as disease progresses. When constrained within a pressurized pericardial space, the right and left ventricles exhibit differential filling mediated by changes in intrathoracic pressure. Invasive hemodynamics and echocardiographic findings inform on the physiologic effects. In this review, we describe tamponade physiology and implications for supportive care and effusion drainage.

Pericardiocentesis for COVID-19 Associated Cardiac Tamponade Using a Central Venous Catheter in Rural Australia: A Case Report.

Pericardiocentesis is a high-acuity, low-occurrence procedure rarely performed by emergency and retrieval clinicians. We present a case of cardiac tamponade secondary to coronavirus disease 2019 managed with prehospital pericardiocentesis in remote Australia, 800 km from the nearest hospital. This was performed using a quadruple-lumen central venous catheter. The procedure significantly improved the patient's clinical state, enabling a safe transfer via fixed wing aircraft to a tertiary center. In this report, we highlight that the ability to diagnose cardiac tamponade in coronavirus disease 2019-positive patients and perform pericardiocentesis under point-of-care ultrasound guidance can be lifesaving.

[Exudative pericarditis with tamponade after COVID-19. Case report].

A description of a COVID-19 patient with the development of exudative pericarditis complicated by cardiac tamponade is provid. A peculiarity of this case is the presence of an underlying disease in the patient (chronic lymphocytic leukemia), which was in remission for 1.5 years after chemotherapy. Another feature of the patient was the relatively small area of lung damage and the hemorrhagic nature of the pericardial effusion, which persisted for a long time. The insignificant activity of inflammatory markers was noteworthy. Possible mechanisms of development and features of the course of exudative pericarditis in the described patient, issues of diagnosis and treatment of this category of patients are discusse.

Delayed coronary perforation four days after percutaneous coronary intervention with subsequent cardiac tamponade: A case report.

Coronary artery perforation (CAP) is a rare but lethal complication of percutaneous coronary interventions (PCIs), and its incidence has been increasing with advances in PCI techniques. Delayed CAP presents a highly challenging complication, as it occurs 30 min-9 days after intervention, making subsequent diagnosis and treatment difficult. We present the case of a 63-year-old male patient who underwent PCI for an obtuse marginalis II because of posterior wall myocardial infarction. Following 4 days of uneventful postoperative stay, the patient developed angina pectoris and hypotension 4 h after reinitiation of anticoagulant therapy with edoxaban. Angiography revealed distal vessel perforation from a side branch of the obtuse marginalis II. The vessel was occluded using autologous fat embolization via a microcatheter, resulting in complete sealing of the perforation. After discharge, 4 weeks after the infarction, the patient started rehabilitation therapy. Distal vessel perforations are typically caused by wire damage. In our case, we also suspected distal wire perforation, which was initially not recognized possibly due to distal occlusion through the thrombotic material. The temporal correlation between the re-initiation of anticoagulant therapy and the occurrence of cardiac tamponade suggests that the thrombotic material was resolved due to the former. The management of delayed CAP does not differ from that of CAP; thus, this rare complication should be considered even days after PCI as it could prove lethal if not recognized early.

Peripherally inserted central catheter related pericardial effusion/cardiac tamponade in neonates: Analysis of two cases and literature review.

RATIONALE: Peripherally inserted central catheter (PICC)-related pericardial effusion/cardiac tamponade is a rare but fatal complication which cause a high mortality if not timely diagnosed and treated. However, the atypical manifestations and the rapid deterioration present challenges for neonatologists, and there has been limited investigation reported globally to date. Furthermore, a systematic review and comprehensive summary of clinical management are lacking. The significance of this article lies in emphasizing the importance of maintaining vigilance in high-risk neonates and implementing effective management strategies for PICC-related pericardial effusion/cardiac tamponade, thereby contributing to saving more lives. PATIENT CONCERNS: In the current report, we discuss 2 cases of neonatal pericardial effusion/cardiac tamponade following PICC catheterization. DIAGNOSIS: The first case was diagnosed based on forensic autopsy and the second case was diagnosed by bedside echocardiography. INTERVENTIONS AND OUTCOMES: The first case was treated conservatively and the second case underwent pericardiocentesis, unfortunately both were died. LESSONS: Once sudden hemodynamic or respiratory abnormalities are detected in neonates with PICC placement, particularly in the preterm infants, prompt diagnosis by cardiac ultrasound is required to verify pericardial effusion/cardiac tamponade and immediate pericardiocentesis or pericardiotomy is necessary to improve survival.

Cardiac tamponade due to eosinophilia treated with intravenous corticosteroid: A case report.

RATIONALE: Cardiac tamponade, a condition in which the heart is compressed by pericardial fluid retention, is easy to diagnose; however, identifying the cause may be challenging since it can be caused by a variety of conditions, including trauma and pericardial disease. PATIENT CONCERNS: A 22-year-old man was admitted to the intensive care unit with respiratory failure. He had previously received allogeneic hematopoietic stem cell transplantation for acute myeloid leukemia and developed chronic graft-versus-host disease (cGvHD) that was treated with a corticosteroid. At this time, he developed bilateral femur head necrosis and underwent surgery after discontinuation of the corticosteroid but developed respiratory failure postoperatively. The initial diagnosis was cardiac failure, which temporarily improved with treatment; however, eosinophilia and pericardial effusions became prominent. DIAGNOSES: Pericardial effusion gradually progressed, resulting in cardiac tamponade. INTERVENTIONS: Pericardiocentesis was performed. Eosinophilia could be the cause of cardiac tamponade; thus, corticosteroid was administered. OUTCOMES: Pericardial effusion improved remarkably after corticosteroid administration. The corticosteroid dose was gradually tapered, and the patient was discharged. LESSONS: This case presented with cardiac tamponade associated with eosinophilia, probably owing to graft-versus-host disease. This is an unusual condition associated with a history of hematologic neoplasms; although evaluation is challenging, appropriate assessment could help save the patient's life.

Peripheral VA-ECMO and pericardial drainage connected to the ECMO circuit for cardiac tamponade from blowout rupture: a case report.

BACKGROUND: Left ventricular free wall rupture, particularly the blowout type, is still one of the most lethal complications of myocardial infarction and can cause catastrophic cardiac tamponade. Extracorporeal membrane oxygenation (ECMO) is often used to treat haemodynamic instability due to cardiac tamponade. However, elevated pericardial pressure can cause collapse of the right atrium, resulting in inadequate ECMO inflow and preventing the stabilisation of the circulation. Further, it can interfere with the venous return from the superior vena cava (SVC), increasing the intracranial pressure and reducing cerebral perfusion levels. CASE PRESENTATION: A 65-year-old man was hospitalised for out-of-hospital cardiac arrest. We used ECMO for cardiopulmonary resuscitation. After the establishment of ECMO, transthoracic echocardiography and left ventriculography revealed massive pericardial effusion. The treatment was supplemented with pericardial drainage since ECMO flow was frequently hampered by suction events. However, the blowout rupture led to the requirement of constant drainage from the pericardial catheter. To tend to this leak, we connected the venous cannula of ECMO and the pericardial drainage catheter. The surgery was performed with stable circulation without suction failure of ECMO. During the course of the intensive care management, the neurological prognosis of the patient was revealed to be poor, and the patient was shifted to palliative care. Unfortunately, the patient died on day 10 of hospitalisation. CONCLUSION: We present a case wherein the combination of pericardial drainage and ECMO was used to maintain circulation in a patient with massive pericardial effusion due to cardiac rupture.

Pericardial Effusion and Cardiac Tamponade Pathophysiology and New Approaches to Treatment.

PURPOSE OF REVIEW: The objective of this manuscript is to examine up-to-date approaches to the diagnosis and treatment of pericardial effusions and cardiac tamponade. RECENT FINDINGS: Recent recommendations from the American Society of Echocardiography and the European Society of Cardiology have improved our management of the patient with pericardial effusion and cardiac tamponade, but significant knowledge gaps remain. Novel diagnostic and triage strategies have been suggested, and recent information have improved our facility to assess the presence and size of a pericardial effusion, assess its hemodynamic impact, and determine its cause. Despite these recent findings, there is a scarcity of evidence-based data to direct the management of pericardial effusion and cardiac tamponade. While the first-line function of echocardiography in managing these disorders is undisputed, there are increasingly niche functions for multimodality imaging.

Cardiac Tamponade in Patients Treated with Direct Oral Anticoagulants.

BACKGROUND: Direct oral anticoagulants (DOACs) are the treatment of choice for patients with non-valvular atrial fibrillation; however, bleeding risk remains significant. We reported a single-center experience with 11 patients who presented with hemorrhagic cardiac tamponade while treated with DOACs. OBJECTIVES: To evaluate the characteristics and clinical outcomes of patients under DOACs with cardiac tamponade. METHODS: We retrospectively identified 11 patients treated with DOACs admitted with pericardial tamponade in our cardiology unit during 2018-2021. RESULTS: The mean age was 84 ± 4 years; 7 males. Atrial fibrillation was the indication for anticoagulation in all cases. DOACs included apixaban (8 patients), dabigatran (2 patients), and rivaroxaban (1 patient). Urgent pericardiocentesis via a subxiphoid approach under echocardiography guidance was successfully performed in 10 patients. One patient was treated with urgent surgical drainage with a pericardial window. Reversal of anticoagulation using prothrombin complex concentrate and idarucizumab was given before the procedure to 6 patients treated with apixaban and one patient treated with dabigatran. One patient, initially treated with urgent pericardiocentesis, underwent pericardial window surgery due to re-accumulation of blood in the pericardium. The pericardial fluid analysis demonstrated hemopericardium. Cytology tests were negative for malignant cells in all cases. Discharge diagnoses regarding the cause of hemopericardium included pericarditis (3 patients) and idiopathic (8 patients). Medical therapy included non-steroidal anti-inflammatory drugs (1 patient), colchicine (3 patients), and steroids (3 patients). No patient died during hospitalization. CONCLUSIONS: Hemorrhagic cardiac tamponade is a rare complication of DOACs. We found good short-term prognosis following pericardiocentesis.

Post-cardiac injury syndrome occurred two months after permanent dual-chamber pacemaker implantation.

BACKGROUND: Post cardiac injury syndrome (PCIS) is characterized by the development of pericarditis with or without pericardial effusion due to a recent cardiac injury. The relatively low incidence makes diagnosis of PCIS after implantation of a pacemaker easily be overlooked or underestimated. This report describes one typical case of PCIS. CASE PRESENTATION: We present a case report of a 94-year-old male with a history of sick sinus syndrome managed with a dual-chamber pacemaker who presented with PCIS after two months of pacemaker implantation. He gradually developed chest discomfort, weakness, tachycardia and paroxysmal nocturnal dyspnea and cardiac tamponade after two months of pacemaker. Post-cardiac injury syndrome related to dual-chamber pacemaker implantation was considered based on exclusion of other possible causes of pericarditis. His therapy was drainage of pericardial fluid and managed with a combination of colchicine and support therapy. He was placed on long-term colchicine therapy to prevent any recurrences. CONCLUSION: This case illustrated that PCIS can occur after minor myocardial injury, and that the possibility of PCIS should be considered if there is a history of possible cardiac insult.

Pericardial effusions: perspective of the acute cardiac care physician.

Pericardial effusions can result in acute haemodynamic compromise and require rapid intervention. Understanding pericardial restraint is essential to determine the approach to newly identified pericardial effusions in the intensive care unit. As pericardial effusions stretch the pericardium, the pericardial compliance reserve is eventually exhausted, with an exponential rise in compressive pericardial pressure. The severity of pericardial pressure increase depends on both the rapidity and volume of pericardial fluid accumulation. This increase in pericardial pressure is reflected in an increase in measured left- and right-sided 'filling' pressures, but paradoxically left ventricular end-diastolic volume (the true left ventricular preload) is decreased. This uncoupling of filling pressures and preload is the hallmark of pericardial restraint. When this occurs acutely from a pericardial effusion, rapid recognition and pericardiocentesis can be lifesaving. In this review, we will discuss the haemodynamics and pathophysiology of acute pericardial effusions, provide a physiological guide to determine the need for pericardiocentesis in acute care, and discuss important caveats to management.

In-hospital adverse events and recurrence in hospitalized patients with acute pericarditis.

BACKGROUND: Acute pericarditis occasionally requires invasive treatment, and may recur after discharge. However, there are no studies on acute pericarditis in Japan, and its clinical characteristics and prognosis are unknown. METHODS: This was a single-center, retrospective cohort study of clinical characteristics, invasive procedures, mortality, and recurrence in patients with acute pericarditis hospitalized from 2010 to 2022. The primary in-hospital outcome was adverse events (AEs), a composite of all-cause mortality and cardiac tamponade. The primary outcome in the long-term analysis was hospitalization for recurrent pericarditis. RESULTS: The median age of all 65 patients was 65.0 years [interquartile range (IQR), 48.0-76.0 years], and 49 (75.3 %) were male. The etiology of acute pericarditis was idiopathic in 55 patients (84.6 %), collagenous in 5 (7.6 %), bacterial in 1 (1.5 %), malignant in 3 (4.6 %), and related to previous open-heart surgery in 1 (1.5 %). Of the 8 patients (12.3 %) with in-hospital AE, 1 (1.5 %) died during hospitalization and 7 (10.8 %) developed cardiac tamponade. Patients with AE were less likely to have chest pain (p = 0.011) but were more likely to have symptoms lasting 72 h after treatment (p = 0.006), heart failure (p < 0.001), and higher levels of C-reactive protein (p = 0.040) and B-type natriuretic peptide (p = 0.032). All patients complicated with cardiac tamponade were treated with pericardial drainage or pericardiotomy. We analyzed 57 patients for recurrent pericarditis after excluding 8 patients: 1 with in-hospital death, 3 with malignant pericarditis, 1 with bacterial pericarditis, and 3 lost to follow-up. During a median follow-up of 2.5 years (IQR 1.3-3.0 years), 6 patients (10.5 %) had recurrences requiring hospitalization. The recurrence rate of pericarditis was not associated with colchicine treatment or aspirin dose or titration. CONCLUSIONS: In acute pericarditis requiring hospitalization, in-hospital AE and recurrence were each observed in >10 % of patients. Further large studies on treatment are warranted.

Chronic Pericardial Effusion: Causes and Management.

Chronic pericardial effusion is a common pericardial syndrome whose approach has been well standardised in recent years. The main challenge associated with this condition is the progression (sometimes unheralded) to cardiac tamponade. Pericardial effusions may present either as an isolated finding or in the context of a specific etiology including autoimmune, neoplastic, or metabolic disease. Among investigations used during diagnostic work-up, echocardiography is of paramount importance for the diagnosis, sizing, and serial evaluation of the hemodynamic impact of effusions on heart diastolic function. In an individualised manner, advanced imaging including computed tomography and cardiac magnetic resonance imaging should be performed, especially if baseline tests are inconclusive. Triage of these patients according to the most recent 2015 European Society of Cardiology Guidelines for the diagnosis and management of pericardial diseases should take into account the presence of hemodynamic compromise as well as suspicion of malignant or purulent pericarditis as first step, C-reactive protein serum level measurement as second step, investigations for a specific condition known to be associated with pericardial effusion as third step, and finally the size and the duration of the effusion. Treatment depends on the evaluation of the above-mentioned parameters and should ideally be tailored to the individual patient. Prognosis of chronic pericardial effusions depends largely on the underlying etiology. According to novel data, the prognosis of individuals with idiopathic, chronic (> 3 months), large (> 2 cm), asymptomatic pericardial effusions is usually benign and a watchful waiting strategy seems more reasonable and cost-effective than routine drainage as previously recommended.

Cardiac tamponade during venoarterial extracorporeal membrane oxygenation: a case report.

BACKGROUND: Cardiac tamponade may present with very different signs and clinical consequences in patients who are supported with venoarterial extracorporeal membrane oxygenation. Failure to recognize cardiac tamponade in this setting can cause failure to wean from venoarterial extracorporeal membrane oxygenation, and even lead to death. CASE PRESENTATION: We present a 44-year-old Caucasian female in whom cardiac tamponade manifested as venoarterial extracorporeal membrane oxygenation weaning failure. After discovering the contribution of cardiac tamponade, it was possible to wean the patient from venoarterial extracorporeal membrane oxygenation support. No clear signs of cardiac tamponade had existed beforehand. CONCLUSIONS: The diagnosis of cardiac tamponade can be very challenging in venoarterial extracorporeal membrane oxygenation supported patients due to (patho)physiological particularities related to the parallel blood flow.

Pericardial Effusion with Tamponade in Untreated Hypothyroidism.

BACKGROUND Small pericardial effusions are common with chronic hypothyroidism, but large pericardial effusion with tamponade or pre-tamponade physiology is a rare complication of severe uncontrolled hypothyroidism. Presentation of pericardial effusion of any etiology can range from being asymptomatic to hemodynamic instability with cardiac tamponade, depending on the amount and speed of accumulation of pericardial fluid, but pericardial effusion associated with hypothyroidism are usually small. Protracted medication non-adherence was a key factor in our patient's presentation. CASE REPORT We present a case of a woman in her 40s with a known history of autoimmune hypothyroidism with medication non-adherence for longer than 9 months who presented with fatigue, weight gain, limited physical activity, and exertional dyspnea with bilateral swelling of the upper and lower extremities. Examination revealed muffled heart sounds, positive JVD, and positive pulsus paradoxus. She had an elevated TSH, low free T4, and a high anti-thyroid peroxidase antibody level. Echocardiography revealed a large pericardial effusion with impending tamponade. Pericardiocentesis with pericardial drain was done and the patient's symptoms resolved quickly. The patient was restarted on a prior dose of levothyroxine 175 mcg. She had improved by the 3rd day of hospitalization; the pericardial drain was removed, and she was discharged with access to medication. Follow-up revealed complete resolution of her symptoms. CONCLUSIONS This case emphasizes the importance of recognition of hypothyroidism as the etiology of life-threatening large pericardial effusions, as it is treatable and recurrences are preventable. To prevent recurrence, it is important to achieve euthyroidism after treating an episode of pericardial effusion.

[The timing of pericardial drainage catheter removal and restart of the anticoagulation in patients suffered from perioperative pericardial tamponade during atrial fibrillation catheter ablation and uninterrupted dabigatran: Experiences from 20 cases].

Objective: To investigate the timing of pericardial drainage catheter removal and restart of the anticoagulation in patients with atrial fibrillation (AF) suffered from perioperative pericardial tamponade during atrial fibrillation catheter ablation and uninterrupted dabigatran. Methods: A total of 20 patients with pericardial tamponade, who underwent AF catheter ablation with uninterrupted dabigatran in Beijing Anzhen Hospital from January 2019 to August 2021, were included in this retrospective analysis. The clinical characteristics of enrolled patients, information of catheter ablation procedures, pericardial tamponade management, perioperative complications, the timing of pericardial drainage catheter removal and restart of anticoagulation were analyzed. Results: All patients underwent pericardiocentesis and pericardial effusion drainage was successful in all patients. The average drainage volume was (427.8±527.4) ml. Seven cases were treated with idarucizumab, of which 1 patient received surgical repair. The average timing of pericardial drainage catheter removal and restart of anticoagulation in 19 patients without surgical repair was (1.4±0.7) and (0.8±0.4) days, respectively. No new bleeding, embolism and death were reported during hospitalization and within 30 days following hospital discharge. Time of removal of pericardial drainage catheter, restart of anticoagulation and hospital stay were similar between patients treated with idarucizumab or not. Conclusion: It is safe and reasonable to remove pericardial drainage catheter and restart anticoagulation as soon as possible during catheter ablation of atrial fibrillation with uninterrupted dabigatran independent of the idarucizumab use or not in case of confirmed hemostasis.

A Rare Case of Primary Purulent Pericarditis Caused by Streptococcus constellatus.

Background: Bacteria-caused acute pericarditis is a very rare entity. It is usually associated with an underlying infection or compromised immune system. Primary purulent pericarditis in a previously healthy individual is highly unexpected; therefore, it is likely to have a delayed diagnosis and poor outcomes. Case: We report a case of an adult immunocompetent patient with primary bacterial pericarditis caused by a member of the commensal oral flora Streptococcus constellatus. The patient presented with septic shock and cardiac tamponade, and was further complicated with constrictive pericarditis, which was successfully treated with pericardiectomy. Conclusions: Bacterial pericarditis is a fulminant disease with a high mortality and complication rate. Fast recognition and prompt therapy are required to achieve a full recovery.