Tuberculosis in circulation system

Tuberculous pericarditis develops either via hematogenous or lymphangeal spread, or directly from pulmonary lesions. Tuberculous pericarditis begins with fibrin deposits, granuloma formation, and the presence of live acid-fast bacilli. A pericardial effusion, which is serous but often contains some blood with a high level of protein. Recently, PCR technology has been employed to amplify M. Tuberculosis DNA from pericardial fluid. The elevation of ADA (> 45 U/l) is supportive of the diagnosis. Tuberculous pericarditis is detected clinically either in the effusive stage by nonspecific systemic syndrome or after the development of constrictive pericarditis. The short-course treatment of tuberculous pericarditis should consist of three-drug regimen, such as INH, RFP, PZA, SM, EB. The use of prednisolone is controversial. Tuberculous myocarditis is extremely rare because of low affinity between M. Tuberculosis and myocardium. Most cases of tuberculous pericarditis are clinically silent and diagnosed at autopsy.     

Two cases of tuberculous constrictive pericarditis

Case 1 was a 79-year-old male suspected of tuberculous constrictive pericarditis. He was admitted to our hospital because of surgical treatment. His heart failure was NYHA IV. Culture of pleural effusion and pericardial effusion was negative. But ADA level in pericardial effusion was found to be increased. So tuberculosis was suspected. Cardiac catheterization date was compatible with constrictive pericarditis. Case 2 was a 73-year-old female. She was admitted because of heart failure (NYHA IV). As RVP wave indicated dip & platou at cardiac catheterization, she was diagnosed as constrictive pericarditis. ADA level in pleural effusion increased. So tuberculosis was suspected as etiology of constrictive pericarditis. In both cases, after pericardiectomy, heart failure improved to NYHA I. Results of pathological examination were tuberculous inflammation.     

Spontaneous cardiac tamponade due to sternotomy wire suture

The first case of spontaneous cardiac tamponade caused by wire suture for sternotomy closure is presented. The proper analysis of bloody pericardial fluid, including simultaneous aspirate and venous hematocrit, oxygen content, and coagulation studies, is emphasized. In addition, the causes of acute hemopericardium are reviewed. Spontaneous cardiac tamponade as a potential late complication of cardiac surgery should be considered in the postoperative patient who presents with pericarditis or a sudden change in cardiac status.     

An echocardiographic study of the interventricular septum in constrictive pericarditis

Ten patients with constrictive pericarditis were studied echocardiographically with specific reference to inter-ventricular septal dynamics. Abnormal movement of the interventricular septum was present in 8 patients and consisted of flattening in systole and unusual posterior motion in diastole. The aetiology of this type of movement is at present unknown but may be related to restriction of normal cardiac rotational dynamics. The interventricular septum also showed diminished degree of thickening (mean 21-2%). The amplitude of excursion was generally at the upper limit of or greater than normal. Left ventricular posterior wall amplitude of excursion was normal. Flattening of left ventricular posterior wall diastolic movement was seen in 4 patients. Right ventricular end-diastolic dimension was slightly increased (1-2 to 1-7 cm/m2) in 5 of 8 patients with abnormal septal motion, but no haemodynamic evidence of diastolic volume overload was found. Posterior pericardial thickening was noted echocardiographically when posterior calcification was present. We conclude that the most common though non-specific feature of the echocardiogram in patients with constrictive pericarditis is abnormal septal motion. Flattening of left ventricular posterior wall diastolic movement, posterior pericardial thickening, and epicardial-pericardial separation may also occur.     

Pericardiectomy for pericardial constriction

Constrictive pericarditis is a pathologic condition that may lead to significant morbidity. Definitive management of constrictive pericarditis requires pericardiectomy. A retrospective review of pericardiectomy for constrictive pericarditis at the Ochsner Clinic was undertaken. Twenty-one patients (17 male, four female) underwent pericardiectomy for constrictive pericarditis between January 1969 and June 1994. Ages ranged from 15 to 66 years (mean 41.5 years). Pedal edema, dyspnea, fatigue, and chest pain were the most common symptoms. Fifteen patients had important comorbidities. Preoperative New York Heart Association (NYHA) class was I (2), II (8), III (6), IV (5). Mean preoperative catheterization data, available in 17 patients (81%), demonstrated elevated intracardiac pressures (right atrial 17.4 mm Hg, right ventricular end-diastolic 22.4 mm Hg, pulmonary artery 26.2 mm Hg, pulmonary capillary wedge 20.2 mm Hg, left ventricular end-diastolic 20.1 mm Hg). A total pericardiectomy was performed in nine patients (sternotomy 8, thoracotomy 1). Pericardiectomy limited anteriorly to the phrenic nerves was performed in 11 patients (sternotomy 9, thoracotomy 2). One partial pericardiectomy was performed through a sternotomy. Cardiopulmonary bypass was used in six patients (29%). Mean hospital stay was 12 days (preoperative 4.2, postoperative 7.67). All patients achieved NYHA Class I postoperatively. Sixteen patients were discharged in sinus rhythm. No early mortality (<30 days), or major postoperative complications were observed. Pericardiectomy for pericardial constriction can be performed safely low morbidity and mortality and can favorably impact the natural history of this debilitating condition.     

Rate-dependent hemodynamic responses during incremental atrial pacing in chronic constrictive pericarditis before and after surgery

Chronic constrictive pericarditis is a frequent cause of diastolic dysfunction, and results in impaired ventricular filling. Unlike in normal subjects, ventricular filling in constrictive pericarditis occurs almost entirely in the initial one third of diastole, and cardiac output is dependent predominantly on heart rate. Tachycardia impairs ventricular filling in normal subjects, but its effects in patients with constrictive pericarditis have not been studied. The effect of increasing heart rate alone with atrial pacing on the central and peripheral hemodynamics of patients with untreated chronic constrictive pericarditis before and after pericardiectomy was evaluated. Increased heart rate with atrial pacing increased cardiac output, whereas stroke volume remained unchanged up to heart rates of 140 beats/min. Further increases in heart rate resulted in reductions of cardiac output and stroke volume. There were no significant changes in ventricular filling pressures. Infusion of 300 ml of saline solution at peak pacing rates did not improve cardiac output. After successful surgical pericardiectomy, the hemodynamic effects of atrial pacing returned to normal. It is concluded that moderate tachycardia improves the hemodynamic profile of patients with constrictive pericarditis.     

Transatrial access to the normal pericardial space: a novel approach for diagnostic sampling, pericardiocentesis, and therapeutic interventions

BACKGROUND: A nonsurgical means to access the normal pericardial space could provide opportunities for diagnostic sampling and therapeutic interventions. Because there are currently no approved nonsurgical methods to accomplish this, we tested a new approach in large animals. METHODS AND RESULTS: A catheter system was employed in a percutaneous approach from a femoral vein to pierce the right atrial appendage. Pericardial access was confirmed by placement of a radiopaque guidewire visible under fluoroscopy (6 dogs, 13 pigs). In 7 of the pigs, pericardial tamponade, produced by injection of saline or heparinized blood into the pericardial space through this route, was confirmed by fluoroscopy and hemodynamic evidence. The feasibility and safety of this access route were tested with multiple repetitions in all 19 animals. At the end of each of the 17 acute experiments, direct inspection after thoracotomy revealed no hemopericardium, laceration, or bleeding on catheter withdrawal. In 24-hour survival studies performed in 2 of the 6 dogs, the animals exhibited no behavioral signs of discomfort or untoward consequences on recovery from anesthesia. Histology revealed only a small (approximately 1-mm) fibrinous plug at the site of puncture. CONCLUSIONS: The percutaneous approach via the right atrial appendage provides a rapid, safe route to access the normal pericardial space for diagnostic sampling and to alleviate high-volume and low-volume (<200 mL) pericardial effusions. The access route is potentially useful for selective administration of therapeutic agents, growth factors, gene vectors, and cardioactive and vasoactive agents to the heart.     

Porphyria cutanea tarda with constrictive pericarditis in a family

Two cases of familial porphyria cutanea tarda (PCT) with constrictive pericarditis are described. A 50-year-old woman and her 48-year-old younger brother were admitted because of right ventricular heart failure. Constrictive pericarditis was diagnosed by RV pressure waveform and echocardiogram. The patients were diagnosed as PCT based on clinical symptoms, histologic findings and elevated urinary excretion levels of uroporphyrin. Even to this day, over 40% of the etiology of constrictive pericarditis remains unknown. There is a possibility of overlooking porphyria cutanea tarda in constrictive pericarditis patients. This report describes the first documented cases of familial PCT with constrictive pericarditis.     

Needle embolus causing cardiac puncture and chronic constrictive pericarditis

We present a case in which a needle broke off during intravenous injection and embolized to the right heart. After cardiac perforation, the needle entered the pericardial space and ultimately caused chronic constrictive pericarditis, which presented as congestive heart failure. Pericardectomy and removal of the foreign body via a median sternotomy were successful. Early surgical removal of contaminated intrapericardial foreign bodies remains a safe and effective approach to preventing such complications.     

Intrapericardial fibrinolysis: a useful treatment in the management of purulent pericarditis

Since the introduction of antibiotics into clinical practice, purulent pericarditis has become a rare disease. The major complication of the standard management for this condition is constrictive pericarditis. We report two cases of purulent pericarditis in which intrapericardial fibrinolysis was performed in order to minimize this complication. The first case was a 38-year-old man admitted to our intensive care unit (ICU) for management of constrictive pericarditis complicating purulent pericarditis diagnosed 17 days previously. The patient was treated with four intrapericardial injections of streptokinase (250,000 IU each). Fluid drainage and cardiac output were improved. No change in clotting parameters was noted. Pericardiectomy and esophagectomy were then performed for a diagnosis of esophageal neoplasm. The postoperative course was uneventful. The second case was a 16-year-old boy admitted with loss of consciousness due to cardiac tamponade. Percutaneous pericardiocentesis drained 900 ml of cloudy fluid. Two intrapericardial injections were performed (day 1 and day 5) without any complication. Pericardial drainage was withdrawn on day 13 and the patient was discharged from ICU on the same day. Six months later, there was no evidence of constrictive pericarditis. Intrapericardial fibrinolysis appears to be safe and effective when prescribed rapidly in the course of purulent pericarditis.     

Constrictive pericarditis after coronary artery bypass surgery as a cause of unexplained dyspnea: a report of five cases

Constrictive pericarditis after coronary artery bypass grafting (CABG) is rare and can present as unexplained dyspnea. We report five consecutive cases of post-CABG constrictive pericarditis seen within a period of 17 months at our institution. All patients presented with heart failure of unknown etiology within a period of 8-84 months after surgery. During the initial post-CABG period, two patients had developed postcardiotomy syndrome that was successfully treated with steroids. They were all assessed noninvasively and invasively. In all patients, the diagnosis of constriction was initially suspected clinically (symptoms, high jugular venous pressure with deep "X" and "Y" descents, pericardial knock). Echocardiography showed transmitral flow typical of constriction in all patients and hepatic venous flow in two. Two patients showed rapid left ventricular relaxation. In all patients, hemodynamic assessment showed diastolic equalization of pressures in all chambers, "W" shape waveform in right atrial pressure, and "dip and plateau" configuration in right and left ventricular pressure waveforms. Diagnosis was confirmed surgically in four patients who were subjected to pericardiectomy-pericardial stripping (three survived, one died). One patient refused surgery. We conclude that constrictive pericarditis, although rare, should be suspected in every case of unexplained dyspnea post CABG. It can appear early or late after surgery, and clinical examination plays an important role in its early recognition. It requires a full noninvasive and invasive assessment in case of clinical suspicion.     

Computed tomography screens stable patients at risk for penetrating cardiac injury

OBJECTIVE: To determine the accuracy of CT of the chest in diagnosing the presence of cardiac injury in stable patients with penetrating chest injuries. METHODS: A retrospective chart review of a convenience sample of stable patients with penetrating thoracic wounds evaluated for hemopericardium using chest CT at an urban level I trauma center. RESULTS: 60 stable patients with penetrating wounds in proximity to the heart underwent CT. Three patients had radiographic evidence of pericardial fluid, and 1 had an equivocal study. These 4 patients underwent subxiphoid pericardial window exploration: 2 had only clear fluid present, the other 2 had hemopericardium. The latter patients had a total of 3 cardiac and 1 diaphragmatic injuries, which were repaired at subsequent sternotomy. None of the 56 patients who had negative CTs had further clinical evidence of cardiac injury. The sensitivity, specificity, and accuracy of CT in this setting for hemopericardium are 100% (95% CI 18-100%), 96.6% (95% CI 88-100%), and 96.7% (95% CI 89-100%), respectively. CONCLUSION: Chest CT may be a useful test for diagnosing the presence of hemopericardium in the setting of penetrating thoracic injury. With the caveat that the patient must be removed from a closely monitored environment, the authors the use of CT in stable patients with penetrating chest wounds whenever echocardiography is unavailable.     

Value of radionuclide ventriculography and magnetic resonance imaging in the diagnosis of constrictive pericarditis

In suggestive clinical presentations, the diagnosis of constrictive pericarditis is confirmed by the haemodynamic findings of impaired ventricular filling (diastole). In this study of 15 patients with pure constrictive pericarditis, the diagnosis value of two non-invasive techniques little used in this indication until now was examined: radionuclide ventriculography (RV) and magnetic resonance imaging (MRI). The RV provides a "functional" diagnosis through the analysis of global and segmental left ventricular filling whilst MRI provides anatomical details of the pericardial thickening. Diastolic dysfunction on RV presented as an increased early diastolic filling time as shown by a shortening of the interval to third filling T1/3R (p < 0.0001), an increased peak diastolic E wave velocity (p < 0.01) and early onset (p < 0.001), increased one third (FR 1/3) and mid (FR 1/2) diastolic filling fractions (p < 0.01) and of the E wave velocity to maximal systolic ejection velocity (S) ration (p < 0.01). The atrial contribution to filling in end diastole decreased (NS). Asynchronous filling, shown by dispersion of the times of onset of segmental early diastolic E peak velocities (delta tE) or of one third diastolic filling delta T1/3R, decreased. Seven patients underwent MRI. Pericardial thickening was present in all patients. The pericardium varied from 6 to 14 mm thick (normal 2.5 +/- 0.7 mm), without any systolo-diastolic variation. The thickening was seen as a dark low intensity signal, indicating the fibro-calcific character of the tissues. Sagittal and coronal views clearly demonstrated the non-uniformity of pericardial thickening.(ABSTRACT TRUNCATED AT 250 WORDS)     

Cardiac amyloidosis, contrictive pericarditis and restrictive cardiomyopathy

Cardiac amyloidosis is not characterized by a single hemodynamic pattern. Some of the cases present the clinical findings of restrictive cardiomyopathy and in these differentiation from constrictive pericarditis remains difficult in spite of the introduction of techniques designed to assess myocardial contractility and ventricular diastolic compliance. The clinical features and the demonstration of left ventricular diastolic pressure greater than right remain the most useful means of distinguishing restrictive cardiomyopathy from constrictive pericarditis. In other cases of cardiac amyloidosis the diastolic pressure is elevated throughout diastole and ventricular ejectile ability is lost. These cases do not simulate constrictive pericarditis and should not be classified as restrictive cardiomyopathy.     

Catheter lavage and drainage of pneumococcal pericarditis

An 88 year old woman with streptococcal pneumonia developed purulent pericarditis and cardiac tamponade despite treatment with antibiotics. Percutaneous pericardial drainage was effected with a 6 French pigtail catheter inserted via the subxyphoid approach. Catheter drainage was continued for 7 days in conjunction with systemic antibiotics. Catheter patency was maintained with antibiotic lavage. Immediate hemodynamic improvement followed the initial pericardial drainage. Fever, leukocytosis, and sepsis resolved during the course of therapy. The patient recovered fully from the closed space bacterial infection without additional surgical drainage. There has been no recurrence of streptococcal infection and no echocardiographic evidence of recurrent pericardial effusion after 3 months of follow-up. Indwelling catheter drainage combined with antibiotics may be an effective substitute for surgical drainage in the treatment of streptococcal pericarditis.     

Comparison of PCR, culture, and histopathology for diagnosis of tuberculous pericarditis

Nucleic acid amplification techniques for the diagnosis of tuberculosis (TB) are rapidly being developed. Scant work, however, has focused on pericardial TB. Using cryopreserved specimens from a prior study of pericarditis, we compared PCR to culture and histopathology for the diagnosis of tuberculous pericarditis in 36 specimens of pericardial fluid and 19 specimens of pericardial tissue from 20 patients. Fluid and tissue were cultured on Lowenstein-Jensen and Middlebrook solid media and in BACTEC radiometric broth. Tissue specimens were stained with hematoxylin-eosin, Ziehl-Neelsen, auramine O, and Kinyoun stains and were examined for granuloma formation and acid-fast bacilli. PCR was performed with both fluid and tissue with IS6110-based primers specific for the Mycobacterium tuberculosis complex by published methods. Sixteen of the 20 patients had tuberculous pericarditis and 4 patients had other diagnoses. TB was correctly diagnosed by culture in 15 (93%) patients, by PCR in 13 (81%) patients, and by histology in 13 of 15 (87%) patients. PCR gave one false-positive result for a patient with Staphylococcus aureus pericarditis. Considering the individual specimens as the unit of analysis, M. tuberculosis was identified by culture in 30 of 43 specimens (70%) from patients with tuberculous pericarditis and by PCR in 14 of 28 specimens (50%) from patients with tuberculous pericarditis (P > 0.15). The sensitivity of PCR was higher with tissue specimens (12 of 15; 80%) than with fluid specimens (2 of 13; 15%; P = 0.002). In conclusion, the overall accuracy of PCR approached the results of conventional methods, although PCR was much faster. Therefore, PCR merits further development in this regard. The sensitivity of PCR with pericardial fluid was poor, and false-positive results with PCR remain a concern.     

Fungal purulent constrictive pericarditis in a heart transplant patient

Purulent pericarditis caused by Candida species is rare and is associated with very high mortality. Immunosuppressed transplant patients are particularly susceptible to fungal infections. We report a case of Candida purulent constrictive pericarditis in an immunocompromised heart transplant patient who was treated successfully with antifungal agents, surgical drainage, and pericardiectomy.     

Cerebral haemorrhage triggered by calcium antagonist

On the basis of our reported experience with colchicine for recurrent pericarditis, we administered colchicine to two patients with large pericardial effusions complicating idiopathic pericarditis. The first was a 26-year-old male who showed clinical deterioration following emergency pericardiocentesis and aspirin (3 g/day) for 10 days; the second was a 2-year-old girl who was unsuccessfully treated with aspirin (100 mg/kg/day) for 2 weeks, followed by corticosteroids for 7 months. Administration of colchicine (1 mg/day) instead of aspirin in the first case, and with a rapid tapering-off of the corticosteroids in the second case, led to complete regression of the pericardial effusion on echocardiography within 1 week and 1 month, respectively. Colchicine was discontinued after 1 month in the first patient and was continued for 6 months in the child. Neither has had a recurrence at 24 and 6 months of follow-up, respectively. No side effects of colchicine were observed. We conclude that colchicine may be effective in the treatment of large pericardial effusion when therapy with nonsteroidal anti-inflammatory drugs and/or corticosteroids fails.     

Reversal of intractable uremic pericarditis by triamcinolone hexacetonide

Of 74 patients undergoing long-term hemodialysis who were observed during a 21-month period, seven developed uremic pericarditis. Five of these patients developed intractable pericarditis, unresponsive to intensive dialysis and pericardiocentesis, and were treated with prolonged pericardial drainage (16 to 60 hours) by an indwelling polyethylene catheter and instillation of triamcinolone hexacetonide. Evidence of intractability was based on either the recurrence of cardiac tamponade after pericardiocentesis (two patients) or progression in the size of the pericardial effusion despite four weeks of intensive dialysis (three patients). These five patients recovered and subsequently were observed from 1 to 15 months with no evidence of recurrent pericarditis. This procedure may be an effective alternative to the surgical management of intractable uremic pericarditis, particularly in the patient at high risk for anesthesia and major surgery.     

The evaluation of carcinoembryonic antigen determination in the pericardial fluid in the diagnosis of the cause of pericarditis

Pericardial fluid CEA level was measured with radioimmunoassay in 19 patients with large pericardial effusion of unknown origin. In 11 patients malignancy was diagnosed. In all of these patients pericardial fluid CEA levels were above 7 ng/ml (mean value 52.6 +/- 42.6 ng/ml). In 8 patients the etiology of pericarditis was non-malignant. In all of them pericardial fluid CEA levels were below 7 ng/ml (mean value 2.2 +/- 1.6 ng/ml). In 9 patients with malignant pericarditis serum CEA levels were also determined: they were found to be lower than pericardial fluid CEA values in 6 patients. It was concluded that pericardial fluid CEA elevation is a reliable criteria of neoplastic pericardial involvement.