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Archive for the ‘Pericardium’ Category

Pericardial effusion associated with Infective Endocarditis : Incidence , mechansim and clinical Implication.

Posted in cardiology -Therapeutics, Cardiology -unresolved questions, Infrequently asked questions in cardiology (iFAQs), pericardial disease, pericardial effusion, Pericardium, tagged , , on January 28, 2020|

Pericardial effusion is often detected in patients with Infective endocarditis. Incidence can be as high as 25% . Most often it is mild, can be moderate in few.

Mechanism

  1. Sympathetic effusion in response to endocardial infection. It’s never more than minimal. (Evidence ? it’s only an assumption)
  2. IE related cardiac failure (Raised systemic venous pressure to which pericardial veins drain)
  3. Local sepsis, Abcess formation tracks to pericardial space through transmural lymphatics
  4. Fungal , granulomatous , Tuberculous IE (Rare) Here IE and PE  share the same pathology
  5. Part of systemic sepsis activated Immune mechanism (Polyseroists)
  6. Renal Involvement of IE-Renal failure
  7. Postoperative pericardial effusion in Prosthetic valve IE (Common, often loculated)

Clinical Implication

  • If the pericardial effusion is more than mild, it often denotes worse outcome. This implies more extensive infection or a marker of extracardiac causes of effusion like renal dysfunction.
  • Effusion may predispose to local dissemination of infection and ends up as peri-annular abscess is whether it is a cause or effect of effusion remains to be understood.It is often exudate as one would expect, but transudative  effusions also occur and would indicate more benign course.
  • The sterility of pericardial fluid has not been proven. Culture studies are rarely done from effusions associated with IE.
  • Pericardial effusions appear more often seen in IE of right heart valves. They turn out to be  IV drug abusers.
  • Contained rupture of an abscess needs to be differentiated from effusion

Can we give steroids for PE associated with IE?

Steroids can rapidly plug the inflammatory pores in the from the pericardial surface.It may also prevent future constriction. Currently, routine steroid therapy is not advised in infective pathology . If the infection is confirmed and is being taken care of by antimicrobial therapy there could be a role for steroids with user discretion.

Final message

During the echocardiographic evaluation of IE, the presence of pericardial effusion should be specifically looked for. These patients should be flagged and will require monitoring as the prognosis of PE complicating IE is a concern unless proved benign.

Reference

Two studies one from Spain and other from Egypt looked into this issue specifically.

1.Regueiro A, Falces C, Cervera C Risk factors for pericardial effusion in native valve infective endocarditis and its influence on outcome. R Am J Cardiol. 2013 Nov 15;112(10):1646-51. 

 

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Percutaneous balloon pericardiotomy :What is the anatomical track ? Where does the fluid drain ?

Posted in cardiac tamponade, Cardiology -Therapeutic dilemma, Pericardium, tagged , on February 24, 2016|

Answer  : I guess all mechanisms  contribute.Though E appears unlikely,  its backed by evidence (Ref 5)

Balloon pericardiotomy is done as a drainage procedure in recurrent pericardial effusion. It is actually a replication of surgical pericardial window by Interventional cardiologist.The window not only drains the effusion , it also act as a continuous drain. Though the  benefits are real (Pericardial fluid is shunted away from the pericardial space)  the exact mechanism of its benefit is not clear .

By concept , the catheter and  balloon should not cross the pleural space , (As pneumothorax may ensue) but still pleural effusion is a common consequence of this procedure .How is this possible ? One probable explanation is, the pleural space has some hidden communication with pericardial space .The other possibility is that, balloon creates virtual tissue channels  in the para-cardiac spaces of mediastinum .The extra-cardiac lymphatics does the drainage job without true shunting  pericardial space into the pleural space..

There is an article  from Annals of thoracic surgery which specifically   looked  into the  mechanism of benefit of  surgical pericardial window and came to a surprise conclusion, ie, it is not the continuous  drainage that keeps the space dry , rather it is likely the window  somehow obliterates the pericardial space permanently.(Sugimoto 1990,Annals of thoracic surgery )

Future  Innovation  : A technical add-on to  balloon pericarditomy  could be , delivering a covered stent across the pericardial space  into  peritoneal space like a VP shunt done by  Neurosurgeons.(If no body has done this , Can I claim the patency  for this  !)

The procedure

 

percutaneous balloon pericarditomy

Image used from Daniel A. Jones & Ajay K. Jain, Journal of thoracic Oncology , 2011

Risk of procedure

The procedure carries a definite risk especially  if done in an  emergency fashion. The aim of  procedure is two fold one to drain pericardial effusion second to prevent recurrence of effusion  .Since procedure carries  considerable risk  its to be performed  only in malignant effusion that are documented to be recurrent.

Surgical vs Balloon window  and other alternatives

Surgical window  creation is well known procedure , ever since Palacios (Ref 1) in 1991 described this per cutaneous approach as an alternative to surgery has become less popular. The risk of anesthesia and co-morbidity makes balloon pericardiotomy attractive. But surgical window creation still may have a role. A video  assisted pericardiotomy by thoracoscopy is also possible .Another option is injecting sclerosing agents into pericardial space .This time tested simple modality probably requires  more attention.

Need for subsequent pleural tapping

It should be realised this procedure may just  shift the  fluid from pericardium to pleural space. Some of them become significant effusion that requires pleural space drainage.

Concern of risk of dissemination of malignancy

Its a real issue , there has been instances of accelerated death after the procedure. Hence this procedure is a trade-of  between patient comfort and quality of life with a  potential risk of dissemination impacting  the longevity of life .

1.Palacios IF, Tuzcu EM, Ziskind AA, Younger J, Block PC. Percoutaneous balloon pericardial window for patients with malignant pericardial effusion and tamponade. Cathet Cardiovasc Diagn 1991: 22;244-249.

 3.Percutaneous Balloon Pericardiotomy in Patients with Recurrent Pericardial Effusion Luis Felipe Navarro del Amoa, Manuel Córdoba Poloa, Miguel Orejas Oreja Rev Esp Cardiol. 2002;55:25-8. – Vol. 55 s
4.Ziskind AA, Pearce AC, Lemon CC, Burstein S, Gimple LW, Herrmann HC, Mc Kay R, Block PC, Waldman H, Palacios IF. Percutaneous balloon pericardiotomy for the treatment of cardiac tamponade and large pericardial effusions: description of technique and report of the first 50 cases. J Am Coll Cardiol 1993; 21 (1): 1-5..
5.

Balloon pericarditomy mechanism6.Percutaneous Balloon Pericardiotomy for Recurrent Malignant Pericardial Effusion Daniel A. Jones, Ajay K. Jain, Journal of thoracic oncology December 2011Volume 6, Issue 12, Pages 2138–2139

 

 

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