Download The Presentation of Pericardial Decompression syndrome

The Presentation of
Pericardial Decompression
syndrome
Thomas Caranasos MD
James Bardes MD
Donnie Goodwin NP
Case Presentation
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38 year old female transferred from an referring hospital with a
diagnosis of pericardial effusion.
She presented to the referring facility with a 3 day history of
increasing shortness of breath and chest pain.
A Chest CT revealed a pericardial effusion and bilateral pleural
effusions.
She had no significant past medical or surgical history. She took no
medications. She was a non-smoker, with no significant family history
or occupational exposures.
Physical exam findings included midline trachea, decreased breath
sounds at the bases, muffled heart sounds, and increased JVP.
Case Presentation
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Labs revealed only a mild anemia.
EKG revealed tachycardia and incomplete right bundle branch
block.
Transthoracic echocardiogram revealed a large pericardial
effusion, without tamponade physiology.
The patient was taken to the OR for subxiphoid pericardial window
with placement of right pleural chest tube and two pericardial blake
drains. Initially 1400cc of hemorrhagic pericardial fluid and 800cc
of pleural fluid were drained. Pericardial biopsies were
taken. Post operatively the patient was transferred to the
cardiothoracic intensive care unit.
Case Presentation
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On postoperative day 0 the patient became hypotensive, requiring
Neo-Synephrine and Epinephrine drip to maintain a
MAP>60mmHg. She was intubated and placed on mechanical
ventillation.
An intra-aortic balloon pump was placed to assist with cardiac
perfusion.
The patient underwent emergent transesophageal echocardiogram
for poor visualization on TTE which showed an EF of 30-35% and
no underlying valvular disease.
A pulmonary embolus was ruled out by pulmonary
arteriography. Cardiac catheterization revealed poor left
ventricular function, approximately 25% with diffuse
hyopkineses. EKG revealed only sinus tachycardia.
Case Presentation
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The patient stabilized on inotropes and pressors. Over the
following three days she was able to wean off the drips, the intraaortic balloon pump was discontinued and the patient was
extubated.
Pathology results from the pericardial fluid revealed cells
consistent with adenocarcinoma. Pericardial biopsy showed
metastatic adenocarcinoma. Immunohistochemistry stains
identified lung as the most likely primary site.
A non-small cell lung cancer would be diagnosed later. Pleural
fluid was negative for malignant cells. The patient continued to
progress and was able to be discharge home on post-operative
day 9. Outpatient follow up echo at 1 month showed a EF of 5055%.
Pericardial Decompression Syndrome
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Pericardial decompression syndrome is a recognized phenomenon
after drainage of pericardial fluid.
Three main hypotheses for PDS have been presented in the
literature.
The hemodynamic hypothesis suggests that the sudden increase in
venous return and greater right ventricular output overwhelms the left
ventricle.
The ischemic hypothesis states that the myocardium is damaged due
to diminished coronary artery blood flow from compression by the
pericardial fluid (1).
The sympathetic overdrive hypothesis purports that the pericardial
fluid was a stimulus for the sympathetic nervous system. Once that
stimulus was removed any underlying dysfunction was revealed (2).
Pericardial Decompression Syndrome
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While reviewing literature for our case, a developing pattern was
noticed. We describe one case and find four more in the literature
where all of the patients had a malignant effusion drained from the
heart.
Subsequent drainage of that effusion led to cardiac failure and
pulmonary edema in all of these cases. Three were drained by
peridcadiocentesis and two by subxiphoid window. The patients
range in age from 38-56. Two of them had previously been given
chemotherapy for an identified primary cancer.
None received an agent that would be expected to cause myocardial
damage. All of these patients developed significant areas of left
ventricular hypokinesia within hours of their procedure. All would
return to baseline with just supportive measures.
Pericardial Decompression Syndrome
Time Post
Drainage
Volume
Removed
F
~12 hours
1400mL
subxiphoid window left ventricle hypokinesia
41
F
3 hours
1000mL
pericardiocentesis
akinesis of the anterior
wall, septum and apex
Ann Internal
Med
46
F
~12 hrs
650mL
pericardiocentesis
left ventricle hypokinesia
Wolfe
Ann Internal
Med
50
F
Never back to
baseline
650mL
pericardiocentesis
global left ventricular
systolic function
Shenoy
Chest
56
M
<1 hour
1000mL
subxiphoid window
IV septum hypokinesia
Author
Journal
Age Sex
WVU
Pt 1
38
Ligero
Eur J Heart
Failure
Wolfe
Type of Drainage
Type of Failure
*All patients presented had an underlying adenocarcinoma
Pericardial Decompression Syndrome
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While it is a recognized phenomenon, it is uncommon. Few have
published on the topic but there seems to be a fair number that have a
history of a primary adenocarcinoma.
In 1993 Wolfe noted that both of his patients had cancer and it could
not be excluded as a cause.
We feel that further investigation is warranted into the pathogenesis of
pericarial decompression syndrome. We have obtained IRB approval
for a retrospective review of all patients who underwent
pericardiocentesis.
There seems to be connection between adenocarcinoma, these
malignant effusions, and the presentation of pericaridal
decompression syndrome.
Until this phenomenon can be investigated further patients should be
monitored closely after draining a suspected malignant effusion. It’s
possible there are varying degrees of this condition that go
unrecognized.