Bloody Pericardial Effusion in Patients With Cardiac Tamponade: Is the Cause Cancerous, Tuberculous, or Iatrogenic in the 1990s?

doi:10.1378/chest.116.6.1564

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Volume 116, Issue 6, December 1999, Pages 1564-1569

https://doi.org/10.1378/chest.116.6.1564 Get rights and content

Study objectives

The decrease in incidence of tuberculosis, along with the increase in invasive cardiovascular procedures, may have changed the frequency of causes of bloody pericardial effusion associated with cardiac tamponade, although this is not yet recognized by medical textbooks. We analyzed the causes of bloody pericardial effusion in the clinical setting of cardiac tamponade in the 1990s; patients’ survival; the effect of laboratory results on discharge diagnosis; and how often bloody pericardial effusion is a presenting manifestation of a new malignancy or tuberculosis.

Design

Retrospective, observational, single-center study.

Setting

A community hospital.

Patients

The charts of all patients who underwent pericardiocentesis for cardiac tamponade and had bloody pericardial effusion were retrospectively reviewed.

Results

Of 150 patients who had pericardiocentesis for relieving cardiac tamponade, 96 patients (64%) had a bloody pericardial effusion. The most common cause of bloody pericardial effusion was iatrogenic disease (31%), namely, secondary to invasive cardiac procedures. The other common causes were malignancy (26%), complications of atherosclerotic heart disease (11%), and idiopathic disease (10%). Tuberculosis was detected as a cause of bloody pericardial effusion in one patient and presumed to be the cause in another patient. Bloody pericardial effusion was found to be a presenting manifestation of a newly diagnosed malignancy in two patients. The patients in the idiopathic and iatrogenic groups were all alive and had no recurrence of pericardial effusion at 24 ± 27 and 33 ± 21 months after hospital discharge, respectively, whereas 80% of patients with malignancy-related bloody effusions died within 8 ± 6 months.

Conclusions

In a patient population that is reasonably representative of that in most community hospitals in the United States, the most common cause of bloody pericardial effusion in patients with signs or symptoms of cardiac tamponade is now iatrogenic disease. Of the noniatrogenic causes, malignancy, complications of acute myocardial infarction, and idiopathic disease predominated. Hemorrhagic tuberculous pericardial effusions are uncommon and may likely reflect a low incidence of cardiac tuberculosis in community hospitals in the United States.

Section snippets

Materials and Methods

The Institutional Review Board approved the study. The charts of patients who were admitted to Cedars-Sinai Medical Center between May 1, 1991, and August 31, 1997, were identified by a computer search for pericardiocentesis and cardiac tamponade. One hundred fifty cases with sufficient data to determine the gross appearance and the cause of the pericardial effusion were identified. Pericardial fluid had been routinely analyzed for gross appearance, cell count, glucose, total protein, lactate

Results

Of the 150 patients with pericardiocentesis and cardiac tamponade, 54 (36%) had nonhemorrhagic pericardial effusions, and 96 (64%) had hemorrhagic effusions. In each case, pericardiocentesis was performed because of signs or symptoms of pericardial tamponade. In this report, we analyzed in detail the 96 patients with bloody pericardial effusions. The group included 47 women, aged 59 ± 20.5 years (range, 24 to 90 years), and 49 men, aged 61 ± 21.5 years (range, 24 to 87 years).

Discussion

The principal finding of our study is that the cause of bloody pericardial effusion associated with cardiac tamponade has changed substantially in the past decade. The most common cause is now iatrogenic disease. In the noniatrogenic group, malignancy, complications of atherosclerotic heart disease and idiopathic causes account for three fourths of the cases. Nonetheless, as presented in Table 3, the most widely referenced textbooks still regard malignancy and TB as the primary causes of

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Chronic Pericardial Effusion: Causes and Management
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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.
L’épanchement péricardique chronique est un syndrome péricardique courant pour lequel l’approche a été normalisée ces dernières années. Le principal enjeu associé à cette maladie est l’évolution (parfois inattendue) vers une tamponnade cardiaque. L’épanchement péricardique peut se présenter de manière isolée ou découler d’une maladie auto-immune, néoplasique ou métabolique. Parmi les examens utilisés lors du bilan diagnostique, l’échocardiographie est très utile pour mesurer le degré de l’épanchement et évaluer en série son impact hémodynamique sur la fonction diastolique du cœur. En fonction du patient, il convient de procéder à une imagerie avancée, notamment une tomodensitométrie cardiaque et une imagerie par résonance magnétique cardiaque, en particulier si les tests de base sont non concluants. Le triage de ces patients selon les dernières lignes directrices 2015 de la Société européenne de cardiologie pour le diagnostic et la prise en charge des maladies péricardiques devrait d’abord reposer sur la présence d’un trouble hémodynamique ainsi qu'à une éventuelle péricardite maligne ou purulente, puis sur la mesure du taux sérique de protéine C-réactive, ensuite sur la recherche d’une affection associée à un épanchement péricardique, et enfin sur le degré et la durée de l’épanchement. Le traitement dépend de l’évaluation des paramètres susmentionnés et devrait idéalement être adapté à chaque patient. Le pronostic des épanchements péricardiques chroniques est en grande partie tributaire de l’étiologie sous-jacente, mais, à la lumière des plus récentes données, il est généralement favorable pour les personnes présentant un épanchement péricardique idiopathique chronique (> 3 mois), de grande taille (> 2 cm) et asymptomatique. Une stratégie de surveillance clinique semble donc plus raisonnable et moins coûteuse que le drainage habituel indiqué dans les recommandations précédentes.
The pericardium and its diseases
2022, Cardiovascular Pathology
The pericardium, as its Greek root suggests, is a double-walled sac which surrounds the heart and the roots of the great vessels. In health, the pericardium forms a lubricated sac which allows the heart to function normally within it. The pericardium can be affected by many diseases which affect the body as well by those that affect the heart. This chapter discusses the pathology of inflammatory diseases affecting the pericardium, both primarily and secondary to diseases in the rest of the body, the effects of diseases involving the myocardium, and the effects of other diseases. The chapter also discusses pericardial neoplasms, which while not common, do occur and may have significant impact on cardiac function.
Incidence and Management of Hemopericardium: Impact of Changing Trends in Invasive Cardiology
2018, Mayo Clinic Proceedings
Citation Excerpt :
The average fluid drained was more than 500 mL but rarely required further intervention when the pericardial catheter remained in place until less than 50 mL drained in a 24-hour period. Our findings compare favorably with previously reported “bloody effusions” in 96 patients in the 1990s where Atar et al3 demonstrated almost one-third of cases to occur in the setting of a recent percutaneous procedure or cardiovascular surgery. Hemopericardium results from myocardial, aortic, or coronary disruption, which may result from a cardiovascular interventional procedure/surgery and less often from malignancy or overt pericarditis.
As invasive cardiovascular care has become increasingly complex, cardiac perforation leading to hemopericardium is a progressively prevalent complication. We sought to assess the frequency, etiology, and outcomes of hemorrhagic pericardial effusions managed through a nonsurgical echo-guided percutaneous strategy.
Over a 10-year period (January 1, 2007, to December 31, 2016), 1097 unique patients required pericardiocentesis for clinically important pericardial effusions. Of these 411 had drainage of hemorrhagic effusions (defined as a pericardial hemoglobin level >50% of serum hemoglobin or frank blood in the setting of cardiac perforation). Clinical characteristics, echocardiographic data, details of the procedure, and outcomes were determined.
Median patient age was 67 years (interquartile range, 56-76 years), and 60% were men. The procedure was emergent in 83% and elective in 17%. The site of pericardiocentesis was determined by echo-guidance in all: 68% from the left para-apical region, 18% from the left or right parasternal areas, and 14% were subxyphoid. Half (n=215 [52%]) occurred after cardiac perforation with percutaneous interventional procedure (ablation, n=94; device lead implantation, n=65; percutaneous coronary intervention, n=22; other, n=34), whereas 30% followed cardiac or thoracic surgery. Pericardial fluid volume drained was 546±440 mL. In 94% of cases, echo-guided pericardiocentesis was the only treatment of the effusion needed, whereas definitive surgery was required in 25 (6%) cases for persistent bleeding or acute management of the underlying etiology. There was no procedural mortality. Late mortality was better for hemorrhagic effusions compared with a contemporary cohort with nonhemorrhagic effusions.
Echocardiographic guidance allows rapid successful pericardiocentesis in the setting of hemopericardium related to microperforation with interventional procedures, malignancy, or pericarditis, with most not requiring surgical intervention. Surgery should remain the first-line approach for aortic dissection or myocardial rupture.
Burkholderia cepacia–Associated Hemorrhagic Pericardial Effusion
2017, American Journal of the Medical Sciences
Beyond Beck's triad: A case report of cardiac tamponade in a “super-super” obese patient
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Recurrent pericardial effusion with pericardial amyloid deposition: a case report and literature review
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Pericardial amyloidosis is a rare cause of pericardial effusion. Here, we report a case of recurrent pericardial effusion because of pericardial amyloid deposition. The patient was a man in his 40s admitted for pulmonary embolism. During hospitalization, arterial fibrillation and cardiac tamponade were observed, and an initial pericardial puncture was performed. Thereafter, pericardial puncture was repeated nine times over the next two years. Cytological examination of the pericardial effusion suggested malignant mesothelioma. Afterward, pericardial fenestration and partial resection were performed. Intraoperatively, a thickened pericardium and hemorrhagic pericardial effusion were noted. Histologically, the surface of the pericardium was covered by an eosinophilic amorphous material. Congo red and DYLON stains, electron microscopy, and immunohistochemical findings revealed localized amyloidosis composed of an immunoglobulin lambda light chain. Although the patient did not receive further treatment for 5 years postoperatively, his renal and cardiac functions remained within normal limits. Based on these findings, the patient was diagnosed with localized amyloidosis. So far, hemorrhagic pericardial effusion has been reported in few cases with systemic amyloidosis. Because localized immunoglobulin light-chain–derived (AL) amyloidosis may progress to systemic disease (although it is a very rare occurrence), long-term follow-up is necessary to detect recurrence or progression to a systemic form.

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: Dr. Atar is a Save A Heart Foundation Harkham Industries fellow.

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Clinical InvestigationsCardiologyBloody Pericardial Effusion in Patients With Cardiac Tamponade: Is the Cause Cancerous, Tuberculous, or Iatrogenic in the 1990s?

Study objectives

Design

Setting

Patients

Results

Conclusions

Section snippets

Materials and Methods

Results

Discussion

Chest

J Am Coll Cardiol

Chest

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

Am J Med Sci

Pericardial disease

The heart

Diseases of the pericardium, cardiac tumors, and cardiac trauma

Pericardial disease

Pericardial and myocardial disease

The pericardium

Congestive heart failure and/or enlarged cardiac silhouette: approach to the patient and management

Clinical Investigations
Cardiology
Bloody Pericardial Effusion in Patients With Cardiac Tamponade: Is the Cause Cancerous, Tuberculous, or Iatrogenic in the 1990s?