AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

INTRODUCTION

Section 2 of 10  

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• Differentials
• Workup
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• Follow-up
• Miscellaneous
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Background

Percutaneous pericardiocentesis was introduced during the 19th century. Frank Schuh first described this procedure in 1840. By the 20th century, percutaneous pericardiocentesis became a preferred technique for the treatment of patients with pericardial effusion or for diagnostic purposes.

Before the advent of 2-dimensional echocardiography, the procedure used a blind-subxiphoid approach. Serious complications were not uncommon (eg, injury to liver, myocardium, coronary arteries, lungs). Because 2-dimensional echocardiography permits direct visualization of cardiac structures and adjacent vital organs, the procedure now is performed with minimal risk. Since 1979, echo-guided pericardiocentesis has been the preferred initial procedure for the diagnosis and treatment of most pericardial effusions. The technique has been modified and refined in the past 22 years. Percutaneous pericardiocentesis now is the procedure of choice for the safe removal of pericardial fluid. Whenever possible, this procedure should be performed by a surgeon or cardiologist trained in invasive technique.

Pathophysiology

An increase in production or a decrease in drainage of pericardial fluid can cause pericardial effusion. Increased production can be due to inflammation of the pericardium, usually the visceral pericardium. Typically, the amount of pericardial effusion is larger when caused by lymphatic or venous obstruction. Accumulation of more than 20-30 mL of fluid in the pericardial sac is usually abnormal, and an increase in the pericardiac/cardiac silhouette is detectable when at least 250 mL of fluid accumulates in the pericardial cavity.

The rate of pericardial fluid accumulation is critical. As the pericardium stretches, a large effusion that develops slowly produces no hemodynamic effects until it is massive. A case of subacute cardiac tamponade with 2000 mL of pericardial fluids has been reported with no significant hemodynamic effect because of the gradual accumulation of pericardial fluid.¹ Significant hemodynamic instability is produced by the rapid collection of even small amounts of fluid.

Hemopericardium can occur as a result of coagulation abnormalities, postsurgical complications, anticoagulation therapy, dissecting aortic aneurysm, or myocardial rupture (eg, in acute myocardial infarction [MI] or traumatic injury). Chylopericardium is a pericardial effusion of chyle, which is often associated with irritation of the pericardium as well (acute or chronic pericarditis). The primary form is rare, and the secondary chylopericardium may be due to radiation, subclavian thrombosis, infections (eg, tuberculosis), mediastinal tumors, following cardiac and aortopulmonary surgeries, or any process that damages the thoracic ducts. Chylopericardium has been reported even following minimally invasive mitral valve repair.²

Pneumopericardium is a rare finding, which has very broad etiologies such as chest trauma, following medical interventions, fistula formation, and a variety of gas-forming infections. Tension pneumopericardium is associated with tamponade and hemodynamic instability and needs immediate attention.

Frequency

United States

The common etiologic factors are acute idiopathic pericardial effusion, iatrogenic (eg, post surgical, drug induced), chronic idiopathic pericardial effusion, malignancy, post myocardial infarction (Dressler syndrome), uremia, infection, and radiation.

Mortality/Morbidity

Since the advent of 2-dimensional echocardiography, the morbidity and mortality rates have been reduced. A review of 1127 echocardiographic-guided pericardiocentesis that were performed during more than 20 years at a major tertiary care center showed a procedural success rate of 97% overall, with a total complication rate of 4.7% (major, 1.2%; minor, 3.5%). This rate may be different from one institute to another, but echocardiographic-guided pericardiocentesis is considered an overall safe procedure with minimum complication and mortality.

CLINICAL

Section 3 of 10  

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• Miscellaneous
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History

The signs and symptoms depend on the amount of pericardial fluid present and the duration of disease. A patient can be asymptomatic when fluid accumulates very slowly or symptomatic when it accumulates very rapidly (eg, trauma, rupture of myocardium after MI). An incidental finding of effusion may be found on 2-dimensional echocardiography images, chest CT scans, chest MRIs, or cardiogram results. Other symptoms of pericardial effusion include the following:

• Chest pain is a presenting symptom when inflammation is the cause or when effusion is severe. Patients with diseases such as malignancy or chronic renal failure may be pain free.
• Dyspnea commonly occurs with cardiac tamponade.
• Cough usually occurs with bronchial encroachment of the pericardium.
• Fever is associated with infectious or inflammatory causes.
• Hoarseness of the voice can occur from compression of the recurrent laryngeal nerve by the enlarging pericardial sac.
• Hiccups generally occur from esophageal compression or irritation of the vagus or phrenic nerves.

Physical

Findings upon physical examination depend on the size of the effusion and the accumulation rate of pericardial fluid. Generally, no physical findings exist if the effusion is very small. Large effusions can cause significant hemodynamic instability by impairing ventricular filling. Patients may have generalized discomfort from a large effusion. Other findings include the following:

• Tachycardia usually occurs due to increased venous pressure and decreased blood pressure, which indicates hemodynamically significant pericardial effusion.
• Tachypnea may develop in acute situations (eg, cardiac tamponade).
• Jugular venous distention is visible in large pericardial effusion and loculated effusion compressing the right atrium or ventricle.
• Narrow pulse pressure can occur in patients with significant pericardial effusion.
• Although pulsus paradoxus is a classic finding in patients with pericardial effusion, pulsus paradoxus also can occur in patients with obstructive lung diseases.
• Pericardial friction rub with a small effusion is most suggestive of pericarditis with secondary effusion.
• Elevated central venous pressure occurs from increased pressure in the pericardial space and the ventricles. This condition usually is associated with hypotension.
• The Ewart sign is another potential finding. In the late 1800s, William Ewart described a different method of identifying pericardial effusion by physical examination. Pericardial fluid compresses the adjacent lung, producing dullness to percussion, tactile fremitus, and egobronchophony at the angle of the left scapula. This is termed the Ewart sign. Massive cardiomegaly and left pleural effusion can produce a similar finding with dullness in the left axillary area. Most clinicians use chest radiographs and 2-dimensional echocardiography findings for diagnosis of pericardial effusion and to differentiate between pericardial effusion and massive cardiomegaly and left pleural effusion. This sign is only of historic importance.
• Of note, posterior pericardial effusions can occur following cardiothoracic surgery and can be difficult to detect clinically (see below).

Causes

A small asymptomatic effusion may be found incidentally in 8-15% of asymptomatic patients and in as many as 43% of healthy pregnant patients. In general, most of the causes of pericarditis can also cause the accumulation of fluid in the pericardial sac. In addition to these etiologies, other conditions, such as rupture of a left ventricular (LV) aneurysm, may give a large pericardial effusion with minimum or no inflammation of the pericardium.

In the Mayo Clinic registry with 1127 echocardiographic-guided pericardiocenteses, cardiothoracic surgery together with malignancy and perforation from catheter-based procedures accounted for nearly 70% of all therapeutic pericardiocenteses performed.³ Obviously, this pattern can be different in other institutes depending on the number of cardiothoracic surgeries performed at the institute, number and type of cancer patients, and many other factors. The pattern of etiologies of moderate-to-large pericardial effusion is not the same as pericarditis. For example, hypothyroidism is not a common cause of pericarditis, but it is a known etiology of large chronic pericardial effusion.⁴ The etiology of pericarditis is idiopathic, viral, or autoimmune in most cases.

Most of the causes of pericardial effusion are as follows:

• Idiopathic
• Infectious
• • Bacteria (eg, staphylococci, streptococci, pneumococci, Haemophilus influenzae, Mycoplasma species, Neisseria species, Borrelia burgdorferi, Chlamydia species, Legionella species, Salmonella species, Mycobacterium tuberculosis, Mycobacterium avium).
  • Viral (eg, coxsackievirus, adenovirus, Epstein-Barr virus, echovirus, cytomegalovirus, infectious mononucleosis, parvovirus B19, influenza, mumps, varicella, hepatitis B, HIV)
  • Fungal (eg, histoplasmosis, aspergillosis, blastomycosis, coccidioidomycosis, Candida species, Nocardia species)
  • Rickettsial organisms
  • Parasitic (toxoplasmosis, amebiasis)
• Neoplasm
• • Metastatic (eg, lung or breast carcinoma, lymphoma, leukemia, melanoma)
  • Primary (eg, rhabdomyosarcoma, lipoma, teratoma, fibroma, fibrosarcoma, angioma, angiosarcoma, mesothelioma)
• Early and late post-MI, rupture of ventricular aneurysm, dissecting aortic aneurysm
• Drugs
• • Procainamide
  • Hydralazine
  • Warfarin
  • Heparin
  • Thrombolytics
  • Methysergide
  • Isoniazid
  • Cyclosporine
• Autoimmune disorders
  • Systemic lupus erythematosus (SLE)
  • Rheumatoid arthritis (RA)
  • Scleroderma
  • Polyarteritis nodosa (PAN)
  • Temporal arteritis
  • Mixed connective tissue disorder (MCTD)
  • Inflammatory bowel diseases (IBD)
  • Sarcoidosis
  • Behçet disease
  • Myasthenia gravis
• Trauma
  • Blunt
  • Penetrating
  • Iatrogenic (eg, perforation caused by catheter insertion or pacemaker implantation, status post cardiopulmonary resuscitation)
• Other
• • Hypothyroidism
  • Amyloidosis and autoimmune diseases
  • Chylopericardium
  • Uremia
  • Radiation
  • Pneumopericardium
  • Postcardiothoracic surgery
  • Idiopathic thrombocytopenic purpura
  • Postpericardiotomy syndrome

DIFFERENTIALS

Section 4 of 10  

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Other Problems to be Considered

Postpericardiotomy syndrome

WORKUP

Section 5 of 10  

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Lab Studies

• Routine laboratory studies indicated include CBC count with differential, prothrombin time/International Normalized Ratio, activated partial thromboplastin time, and basal metabolic panel.
• Specific tests such as cardiac enzymes, thyroid-stimulating hormone, autoantibodies, and viral or rickettsial serologic tests are indicated depending on the clinical information and differential diagnosis.
• Routine tests on pericardial fluid are often indicated including cell count with differential, lactate dehydrogenase (LDH), protein, glucose, Gram stain, and routine bacterial cultures. Smear for acid-fast bacilli staining, adenosine deaminase, tuberculosis culture, viral cultures, and cytology are indicated depending on the degree of suspicion of tuberculosis, specific viral, or cancer etiology. Further specific tests on pericardial fluid usually depend on the results of the initial test.

Imaging Studies

• Chest radiographs usually show a large bilaterally distended cardiopericardial silhouette. Lungs usually are clear, unless the patient is in heart failure or has significant lung disease. Absence of vascular congestion in the lungs in patients with pericardial effusion and tamponade is an important radiographic clue to differentiate these conditions from congestive heart failure when in both conditions the heart size in the chest radiograph is higher than the normal range.
• Two-dimensional echocardiography is the best method of obtaining the diagnosis of pericardial effusion. The 2003 Task Force of the American College of Cardiology (ACC), the American Heart Association (AHA), and the American Society of Echocardiography (ASE) have given class 1 recommendation to use echocardiography for the evaluation of all patients with suspected pericardial disease.
• • This imaging study is highly sensitive and specific. It can detect a pericardial effusion as small as 30 mL and show characteristic findings of a pericardial effusion larger than 100 mL.
  • Small nonloculated pericardial effusions usually present in the posterior part of the pericardial space while the patient is in the supine position. As the amount of fluid increases, it starts to accumulate anteriorly and laterally. A significant large effusion usually is circumferential. It allows free motion of the heart within the fluid (swinging of the heart). A small loculated effusion can produce a hemodynamically significant problem depending on the location of the effusion and the structure that is compressed by that.
  • Echocardiographic findings may include swinging of the heart within the effusion, right atrial collapse, early right ventricular collapse, reciprocal changes in right and left ventricular volume, and motion of the chamber wall with breathing (see Media files 1-2).
• CT scan and MRI are reliable methods for helping detect pericardial fluid or pericardial thickening. They are not the diagnostic modality of choice to evaluate the pericardial effusion. However, they give useful information about the other structures in the chest, and they are helpful when echocardiography is inconclusive.

Other Tests

• Electrocardiography may show some evidence of the pericardial diseases, but often the ECG findings are nonspecific. However, because ECG is a noninvasive and widely available test, it is usually indicated in evaluation of suspected pericardial diseases.
• • The electrocardiographic hallmark of pericardial effusion is low-voltage QRS complexes, which occur as the fluid surrounds the heart. Definition of low voltage is the QRS amplitude less than 0.5 mV in limb leads and less than 1 mV in precordial leads. Low QRS voltage is neither a sensitive nor a very specific sign for pericardial effusion, and therefore it should not be used to confirm the suspected diagnosis of pericardial effusion or to rule it out.
  • A variety of other cardiac conditions (eg, constrictive pericarditis, amyloidosis, scleroderma, cardiac neoplasm, myocardial fibrosis in chronic ischemic heart disease) and a variety of noncardiac conditions (eg, COPD, pneumothorax, pleural effusion, obesity) may present with low QRS voltage on the ECG. No strong correlation exists between the degree of decrease in QRS voltage and the amount of fluid in the pericardial sac. Although an increase in QRS voltage is expected following the pericardiocentesis, it may not happen immediately if some degree of fibrin has deposited.
  • Electrical alternans, which is beat-to-beat variation of the amplitude of QRS voltage, is another ECG finding suggestive of large pericardial effusion or cardiac tamponade. With large pericardial effusion and no clinical tamponade, the heart has some freedom of movement and therefore small variation in QRS amplitude can be seen in many of these cases. However, significant alternans in p wave, QRS complex, and T wave, which is called total electrical alternans, is a specific finding for cardiac tamponade.
  • The pressure produced by fibrin or fluid may induce a current of injury, which may appear as ST-segment changes on 12-lead surface ECG. Acute pericarditis typically appears with diffuse ST-segment elevation and PR depression on ECG.

Procedures

• As the fluid increases in the pericardial space, the right atrial and central venous pressure increase correspondingly. Ideally, right heart catheterization shows high pressure during ventricular diastole and equal pressure in the right atrium and ventricular diastolic pressure.

TREATMENT

Section 6 of 10  

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Medical Care

Aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), steroid, and colchicine are used to treat the inflammation associated with pericardial effusion. The treatment of choice for primary symptomatic moderate-to-large amount of pericardial effusion is pericardiocentesis. A surgical approach is not only preferable but is the treatment of choice for recurrent or chronic pericardial effusions.

• Indications for pericardiocentesis can be summarized as follows:
  • Pericardiocentesis is indicated in patients with pericardial tamponade and in those with large recurrent pericardial effusion.
  • Symptomatic pericardial effusion is an indication for pericardiocentesis.
  • Pericardial fluid drainage is indicated in patients with suspicion of purulent pericarditis.⁵
  • Pericardiocentesis can be used for diagnostic purposes, ie, effusion of unclear etiology.
  • It can be used to obtain a biopsy specimen of pericardium.
  • Pericardiocentesis is indicated for large pericardial effusions that compress other organs (eg, trachea, lung).
• Conservative treatment is as follows:
  • Many pericardial effusions can be managed conservatively if there is no evidence of hemodynamic compromise or need for diagnosis based on pericardial fluid. Ultimately, the patient may require removal of the fluid for definitive treatment.
  • The patient can be treated medically, which includes support of blood pressure with vascular volume expansion.
  • Inotropic agents have no significant role in the management of hypotension due to effusion. Treatment of the underlying cause is important.
  • An idiopathic large pericardial effusion occasionally occurs, usually without tamponade. Pericardiocentesis may not be part of the initial management if the effusion does not have any hemodynamic and clinical consequence. Colchicine may be effective for treating these patients; however, sometimes, removal of the fluid is required for definitive treatment.
• Preparation is as follows:
  • Elective or urgent pericardiocentesis should be performed by a specialist or other experienced individuals; otherwise, the surgical approach should be pursued.
  • Obtain an echocardiogram before the pericardiocentesis procedure to prove the presence of the effusion and to confirm that the effusion is at least of moderate size and is not loculated. Perform this procedure in a place equipped with monitors and 2-dimensional echocardiography or fluoroscopy. Although fluoroscopic guidance has been used more commonly, echocardiographic guidance is becoming more popular, partially because with echocardiography the shortest route to the pericardial sac can be easily identified. Echocardiographic-guided pericardiocentesis can be performed at the bedside, and no exposure to the x-ray occurs in this technique.
  • A needle aspiration should not be performed on patients with small, organized, or loculated effusions.
  • Pericardiocentesis is indicated for large pericardial effusions when evidence of symptoms and/or signs of hemodynamic compromise are present (ie, pericardial tamponade). The presence of a significant pericardial effusion should be confirmed by echocardiography and hemodynamic status ascertained by assessment of vital signs and related findings. Hematologic abnormalities that might increase the risk of bedside pericardiocentesis (aPTT, PTT, platelet count) are also indicated prior to pericardiocentesis.
  • If time permits, any clotting abnormality should be corrected. Fresh frozen plasma should be administered if the effusion occurs from thrombolytics, and pericardiocentesis should not be performed unless the tamponade is life threatening. Administration of heparin should be discontinued if the condition is caused by anticoagulation. Pericardiocentesis should be delayed until the clotting profile is normal or protamine is administered, unless the patient is unstable.
  • An electrocardiogram should be obtained before the procedure, and electrocardiographic monitoring should be continued during the procedure. If the needle touches the myocardium, the current of injury causes ST-segment elevation on the electrocardiographic monitor.
  • Pericardiocentesis tray and other equipment should include the following:
    • An 18- to 20-gauge cardiac needle or long central venous catheter with needle introducer
    • A 3-way stopcock
    • Syringes (10, 20, and 60 mL)
    • Antiseptic chlorhexidine and alcohol or povidone-iodine solution
    • ECG monitor
    • Specimen collection tubes for fluid analysis and cultures; fluid receptacle (1-L vacuum bottle)
    • Manometer (for pericardial pressure measurement)
    • Small-gauge needle for local anesthesia and 1-2% lidocaine
    • Sterile gloves, mask, gown, dressing materials (sterile transparent plastic drape, eg, 1030 Drape, Baxter), and gauze (4 X 4 in)
    • Surgical blade (#11)
    • Multiple 16- to 18-gauge (5.1-8.3 ctn) polytef sheathed venous Intracath needles (Deseret)
    • Sterile isotonic sodium chloride solution (for flushing catheter)
    • Emergency medications (eg, atropine, lidocaine, epinephrine)
    • Sedating medications
    • Frequent vital signs sheet
    • Defibrillator with monitor
• The pericardiocentesis procedure is as follows:
• • Ensure that the patient is sitting at 30-45° head elevation, which increases pooling of fluid toward the inferior and anterior surface, thus maximizing fluid drainage.
  • Select a site that is closest to the pericardial space, avoiding vital structures, such as the internal mammary artery, lungs, myocardium, liver, and vascular bundle at the inferior margin of each rib.
  • Shave the skin carefully to avoid any trauma. Anesthetize the local site with lidocaine (1-2%). Make a small incision (approximately 5 mm) to decrease the resistance during needle insertion. Separate the subcutaneous tissue with mosquito grasping forceps.
  • Connect the needle with a 3-way stopcock. Ensure that the syringe with 1% lidocaine is connected to the 3-way stopcock on the opposite side of the needle connection. Connect the transducer on the side of the 3-way stopcock. Attach a sterile ECG recorder to the metal part of the needle.
  • Insert the needle through the subxiphoid approach on the left side under fluoroscopy. Advance the needle and syringe until the needle tip is posterior to the rib cage. The needle should be advanced toward the shoulder at an angle 15-20° from the abdominal wall. While advancing the needle toward the pericardial space, aspirate the syringe and inject lidocaine for a better analgesic effect. Continue to advance the needle until fluid is aspirated in the syringe or the ECG monitor shows ST elevation.
  • Withdraw the needle slowly with negative pressure on the syringe if the ECG shows ST elevation after clearing the needle with lidocaine. Reinsert the needle in a different direction very slowly until fluid is aspirated in the syringe.
  • If hemorrhagic fluid is aspirated, a few milliliters of contrast medium are injected, which can be observed surrounding the cardiac silhouette, indicating that the needle tip is in the pericardial space. If the contrast material immediately disappears, then the needle is in one of the cardiac chambers.
  • The position of the needle is confirmed by injecting agitated saline through the needle, termed saline echocontrast medium for confirmation of position. This procedure is particularly important when bloody fluid has been aspirated or when confirming the needle position. If contrast appears in the pericardial space, the procedure can be continued.
  • When the needle tip is inside the pericardial space, a soft floppy-tip guidewire is passed through the needle. Wrap this guidewire around the heart. Remove the needle, and insert a soft catheter with multiple side holes over this wire. Remove the guidewire. Connect the catheter hub with the transducer and syringe with a 3-way stopcock. Place the dressing, and secure the catheter to prevent displacement. Ensure that the catheter is flushed with 1-2 mL of fluid to prevent blockage.
  • Two different types of catheters are used commonly, the pigtail catheter and the straight catheter. A pigtail catheter is curved and has a soft tip. A straight catheter has side holes, which help to increase drainage and reduce the chances of blockage. The type of catheter selected depends on the surgeon's preference. A more flexible catheter that allows continuous drainage may be preferable.
  • The pericardial catheter can be left in the space for 24 hours with continuous closed drainage occurring, using gravity to increase drainage. The catheter should be removed after 24 hours, if possible, because it increases the chances of infection in the pericardial space. However, keeping the catheter in the pericardial space often is necessary to maintain drainage for longer periods. Negative suction should not be used to maximize the drainage.
  • Echocardiographic-guided procedure has the same principles as the fluoroscopic guided. When echocardiography is used as the guide, the operator has more choices regarding the approach to the effusion. One of the most commonly used approaches is the apical approach with inserting the needle along the long axis and toward the aortic valve. In echocardiographic-guided procedure no contrast media is injected to the pericardium and instead the presence of the needle in the pericardial space can be confirmed by using air bubbles.
  • CT-guided pericardiocentesis is a new approach that is indicated specifically for patients in whom ultrasound-guided or radiograph-guided pericardiocentesis is unsuccessful. For example, echocardiographic-guided procedure may have some technical difficulties in obese patients.
  • It is recommended to perform the pericardiocentesis (even the echocardiographic-guided procedure) in a cardiac catheterization laboratory where appropriate equipment are available for hemodynamic monitoring and interventions, except under the most urgent conditions.
  • Pericardiocentesis with intrapericardial sclerotherapy also is effective in treating patients with malignant pericardial effusion.

Surgical Care

A surgical approach is not only preferable but is the treatment of choice for recurrent or chronic pericardial effusions. Several surgical options are available including subxiphoid pericardial window (SPW), thoracotomy with a pleuropericardial window, and pericardiectomy.

Postcardiothoracic surgery, pericardial effusions may occur early (within 24 h of surgery) or late (within weeks of surgery). Often, postsurgical effusions are located posteriorly and may consist of coagulated blood. For these reasons, detection and percutaneous aspiration can be difficult. This diagnosis should be suspected in postcardiothoracic surgical patients with otherwise unexplained hemodynamic compromise. Surgical drainage is often required in this circumstance.

FOLLOW-UP

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Further Inpatient Care

• Assess for the following in the postoperative period:
• • Patency of the pericardial catheter: The catheter can be connected to the suction continuously or urokinase can be used in the catheter with intermittent opening of the catheter for drainage.
  • Hypotension
  • Ventricular puncture
  • Cardiac arrest
  • Pulseless electrical activity
  • Pneumothorax
  • Liver laceration
  • Clinical correlation with previous physical finding

Complications

• Laceration of coronary artery
• Laceration of coronary vein
• Pericardial tamponade
• Acute left ventricular failure with pulmonary edema
• Puncture or laceration of any cardiac chamber
• Bleeding
• Ventricular ectopic beats
• Atrial ectopic beats
• Arrhythmias
• Hypotension
• Pneumothorax
• Pulmonary edema

Prognosis

• With the advent of 2-dimensional echocardiography, the morbidity and mortality rate have been significantly reduced. Blind pericardiocentesis, which has significantly higher risk of complications compared to echocardiographic-guided or fluoroscopic-guided procedure should be left for emergency situations in a patient with cardiac tamponade and significant hemodynamic instability.

MISCELLANEOUS

Section 8 of 10  

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Medical/Legal Pitfalls

• Contraindications to pericardiocentesis include the following:
• • Myocardial rupture
  • Aortic dissection
  • Skin infection at site
  • Severe bleeding disorder

MULTIMEDIA

Section 9 of 10  

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Media file 1:  Subcostal view of 2-dimensional echocardiography shows pericardial effusion.
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Media type:  Image

Media file 2:  Subcostal view of 2-dimensional echocardiography shows pericardial effusion.
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Media type:  Image

REFERENCES

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1. Sovari AA, Moazemi K, Bodine CK. Subacute cardiac tamponade with very large pericardial effusion in a postpartum woman. Heart. Sep 2006;92(9):1218. [Medline].
2. Mood G, Shaaraoui M, Allareddy R, Smith D, Rodriguez L, Hammer D. Chylous pericardial effusion after minimally invasive mitral valve repair. Ann Thorac Surg. Nov 2006;82(5):1892-4. [Medline].
3. Tsang TS, Enriquez-Sarano M, Freeman WK, Barnes ME, Sinak LJ, Gersh BJ. Consecutive 1127 therapeutic echocardiographically guided pericardiocenteses: clinical profile, practice patterns, and outcomes spanning 21 years. Mayo Clin Proc. May 2002;77(5):429-36. [Medline].
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5. Soler-Soler J, Sagrista-Sauleda J, Permanyer-Miralda G. Management of pericardial effusion. Heart. Aug 2001;86(2):235-40. [Medline].
6. Bastian A, Meissner A, Lins M, et al. Pericardiocentesis: differential aspects of a common procedure. Intensive Care Med. May 2000;26(5):572-6. [Medline].
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8. Cheitlin MD, Armstrong WF, Aurigemma GP. ACC/AHA/ASE 2003 guideline for the clinical application of echocardiography. Accessed October 22, 2006. [Full Text].
9. Girardi LN, Ginsberg RJ, Burt ME. Pericardiocentesis and intrapericardial sclerosis: effective therapy for malignant pericardial effusions. Ann Thorac Surg. Nov 1997;64(5):1422-7; discussion 1427-8. [Medline].
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11. Kocheril AG, Luttmann C, Sadaniantz A. Pneumococcal pericarditis successfully treated with catheter drainage and intravenous antibiotics. Cathet Cardiovasc Diagn. 1991;24(4):286-7. [Medline].
12. Little WC, Freeman GL. Pericardial disease. Circulation. Mar 28 2006;113(12):1622-32. [Medline].
13. Lorell BH. Pericardial diseases. In: Braunwald E, Zipes DP, Libby P, eds. Heart Disease: A Textbook of Cardiovascular Medicine. 6^th ed. Philadelphia, Pa: WB Saunders; 2001:1823-76.
14. Lorell BH, Grossman W. Profile in constrictive pericarditis, restrictive cardiomyopathy and cardiac tamponade. In: Grossman W, ed. Cardiac Catherterization and Angiography. 3^rd ed. Philadelphia, Pa: Lea & Febiger; 1986:434-41.
15. Marcy PY, Bondiau PY, Brunner P. Percutaneous treatment in patients presenting with malignant cardiac tamponade. Eur Radiol. 2005;15(9):2000-9. [Medline].
16. Sairam S, Goel N, Lisse J, McNearney T. Pericardial effusion and cardiomyopathy following arthritis with parvovirus B19 infection: response to intravenous immunoglobulin. J Clin Rheumatol. Oct 2001;7(5):346-9. [Medline].
17. Shabetai R. Diseases of the pericardium. In: Alexander RW, Schlant RC, Fuser V, et al, eds. Hurst's The Heart. 10^th ed. New York, NY: McGraw-Hill; 2001:2169-204.
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Article Last Updated: Jan 10, 2007