Concept: Pericardial effusion
A 58-year-old woman presented with intermittent, nonexertional chest pain. She had been admitted for similar symptoms 2 months earlier; a coronary angiogram had revealed normal anatomy. A transthoracic echocardiogram revealed a pericardial effusion. A video is available at NEJM.org.
A 56-year-old woman with a history of stage II cancer of the left breast presented with progressive shortness of breath and fatigue. Transthoracic echocardiography revealed a large pericardial effusion with the heart freely swinging in an anterior-posterior fashion, shown in a video.
Intrapericardial teratoma is a rare, lethal tumor often detected in fetal life. Tumor mass and pericardial effusion cause cardiac tamponade, which if relieved, could be life-saving. Optimal timing of intervention and methods for effective fetal treatment are unknown.
OBJECTIVES: The purpose of the study was to determine the efficacy and safety of left atrial appendage (LAA) closure via a percutaneous LAA ligation approach. BACKGROUND: Embolic stroke is the most devastating consequence of atrial fibrillation. Exclusion of the LAA is believed to decrease the risk of embolic stroke. METHODS: Eighty-nine patients with atrial fibrillation were enrolled to undergo percutaneous ligation of the LAA with the LARIAT device. The catheter-based LARIAT device consists of a snare with a pre-tied suture that is guided epicardially over the LAA. LAA closure was confirmed with transesophageal echocardiography (TEE) and contrast fluoroscopy immediately, then with TEE at 1 day, 30 days, 90 days, and 1 year post-LAA ligation. RESULTS: Eighty-five (96%) of 89 patients underwent successful LAA ligation. Eighty-one of 85 patients had complete closure immediately. Three of 85 patients had a ≤2-mm residual LAA leak by TEE color Doppler evaluation. One of 85 patients had a ≤3-mm jet by TEE. There were no complications due to the device. There were 3 access-related complications (during pericardial access, n = 2; and transseptal catheterization, n = 1). Adverse events included severe pericarditis post-operatively (n = 2), late pericardial effusion (n = 1), unexplained sudden death (n = 2), and late strokes thought to be non-embolic (n = 2). At 1 month (81 of 85) and 3 months (77 of 81) post-ligation, 95% of the patients had complete LAA closure by TEE. Of the patients undergoing 1-year TEE (n = 65), there was 98% complete LAA closure, including the patients with previous leaks. CONCLUSIONS: LAA closure with the LARIAT device can be performed effectively with acceptably low access complications and periprocedural adverse events in this observational study.
Autoantibodies against several aminoacyl-transfer-RNA synthetases have been described in patients with myositis; anti-threonyl-tRNA synthetase (anti-PL-7) is one of the rarest. We describe the clinical and laboratory characteristics of a cohort of European anti-PL-7 patients, and compare them with previously reported cases. This multicenter study of patients positive for anti-PL-7, identified between 1984 and 2011, derives from the EUMYONET cohort. Clinical and serologic data were obtained by retrospective laboratory and medical record review, and statistical analyses were performed with chi-squared and Fisher exact tests. Eighteen patients, 15 women, were anti-PL-7 antibody positive. Median follow-up was 5.25 years (interquartile range, 2.8-10.7 yr), and 4 patients died. All patients had myositis (12 polymyositis, 5 dermatomyositis, and 1 amyopathic dermatomyositis), 10 (55.6%) had interstitial lung disease, and 9 (50%) had pericardial effusion. Occupational exposure to organic/inorganic particles was more frequent in patients with interstitial lung disease than in the remaining patients (5 of 10 vs. 1 of 7; p = 0.152), although the difference was not significant. Concurrent autoantibodies against Ro60 and Ro52 were seen in 8 of 14 (57%) patients studied. In the literature review the most common manifestations of anti-PL-7 antisynthetase syndrome were interstitial lung disease (77%), myositis (75%), and arthritis (56%). As in other subsets of the antisynthetase syndrome, myositis and interstitial lung disease are common features of the anti-PL-7 antisynthetase syndrome. In addition, we can add pericarditis as a possible manifestation related to anti-PL-7 antibodies.
Atrial fibrillation (AF) increases by fivefold a patient’s risk for thromboembolic stroke. The main source of emboli in AF is the left atrial appendage (LAA). Therefore, LAA closure could reduce the risk for thromboembolic events in AF. The investigators report the first United States experience with a novel percutaneous LAA closure device, the Lariat snare device, and its outcomes in 21 patients with AF, CHADS(2) scores ≥2, and contraindications to anticoagulation. The LAA was closed with a snare containing suture from within the pericardial space. The intraoperative success of the procedure was confirmed by left atrial angiography and transesophageal echocardiographic color Doppler flow. The effectiveness of the procedure was evaluated by follow-up transesophageal echocardiography. The incidence of periprocedural and short-term complications was assessed by reviewing medical records. Twenty patients (100%) had successful LAA exclusion that was preserved at 96 ± 77 days. No patient had a stroke during an average of 352 ± 143 days of follow-up. One patient had right ventricular perforation and tamponade that required surgical exploration and repair. Two patients required prolonged hospitalization: 1 because of pericardial effusion that required repeat pericardiocentesis and 1 because of noncardiac co-morbidities. Three patients developed pericarditis <1 month after the procedure, of whom 1 had associated pericardial effusion that required drainage. In conclusion, percutaneous LAA exclusion can be achieved successfully and with an acceptable incidence of periprocedural and short-term complications. Further studies are needed to determine whether LAA exclusion lowers the long-term risk for thromboembolic events in patients with AF and contraindications to anticoagulation.
Key Clinical Points Acute Pericarditis The diagnosis of acute pericarditis requires at least two of the following symptoms or signs to be present: typical chest pain, pericardial friction rub, typical electrocardiographic changes, and pericardial effusion. In developed countries, 80 to 90% of cases are idiopathic and presumed to be viral. Evaluation includes a medical history and laboratory tests to help determine whether a specific cause is present, a chest radiograph, and an echocardiogram to determine whether there is an effusion. In response to treatment with a combination of a nonsteroidal antiinflammatory drug (NSAID) and colchicine, 70 to 90% of cases resolve completely; treatment with glucocorticoids should be avoided, if possible, because they increase the risk of recurrence. Patients with recurrent pericarditis should be treated with repeated courses of an NSAID and colchicine; if treatment with glucocorticoids cannot be avoided, moderate initial doses followed by gradual tapering provide the best outcomes.
Patient: Female, 30 Final Diagnosis: Nocardiosis Symptoms: Cardiac tamponade • cough • dyspnea • hoarseness • mediastinal mass • pericardial effusion • short of breath Medication: - Clinical Procedure: - Specialty: Transplantology.
The primary objective of this study was to describe the frequency of the most common presenting signs and symptoms of pericardial effusions, particularly with relation to the size of the effusion. The secondary objective was to review the final etiology of the pericardial effusion in those patients who had presented to a tertiary care pediatric emergency department.
We report the first case of Nocardia beijingensis pericarditis in a 32-year-old HIV-infected patient. He presented with cardiac tamponade after failing to respond to treatment for smear-negative pulmonary and pericardial tuberculosis (TB). The pericardial fluid was examined several times before it eventually revealed filamentous branching organisms in Gram and modified acid-fast bacilli stain. The culture grew Nocardia spp. and was identified by 16s rRNA sequencing as N. beijingensis. Eight previously reported cases of Nocardia pericarditis in HIV-infected patients were caused by Nocardia asteroides. All patients had low CD4 cell count (range: 17-239 cells/mm3) and 50% of patients were treated for tuberculous pericarditis prior to making the correct diagnosis of Nocardia pericarditis. This report revisits the issue of nocardiosis as a great TB mimicker. It should always be considered in the differential diagnosis among HIV-infected patients suspected of having pericardial TB that is failing treatment.