Evaluation of non-surgical causes of cardiac tamponade in children at a cardiac surgery center

1

This article is protected by copyright. All rights reserved.

Title: Evaluation of nonsurgical causes of cardiac tamponade in children at a cardiac surgery

center1

Running title: cardiac tamponade in children

Institutions:

Department of Pediatric Cardiology, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery

Education and Research Hospital, Istanbul, Turkey

Authors: Erkut Ozturk, Ibrahim Cansaran Tanidir, Murat Saygi, Yakup Ergul, Alper Guzeltas, , Ender

Odemis

Affiliations:

Erkut Ozturk, MD, Pediatric Cardiology Fellow, Department of Pediatric Cardiology, İstanbul

Mehmet Akif Ersoy, Thoracic and Cardiovascular Surgery Center and Research Hospital, Istanbul,

Turkey

Ibrahim Cansaran Tanıdır , MD, Pediatric Cardiology Fellow, Department of Pediatric

Cardiology, İstanbul Mehmet Akif Ersoy, Thoracic and Cardiovascular Surgery Center and Research

Hospital, Istanbul, Turkey

Murat Saygı, MD, Pediatric Cardiology Fellow, Department of Pediatric Cardiology, İstanbul


Turkey

Yakup Ergul, MD, Pediatric Cardiologist, Department of Pediatric Cardiology, İstanbul


Turkey

This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/ped.12192 Acc

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Alper Guzeltas, MD, Associated Professor, Department of Pediatric Cardiology, İstanbul


Turkey

Ender Odemis, MD, Associated Professor, Department of Pediatric Cardiology, İstanbul


Turkey

Conflict of interest: none

Number of text pages: 15

Number of reference pages: 2

Number of tables: 3

Number of figures: 0

Corresponding author:

Ibrahim Cansaran Tanidir MD

Department of Pediatric Cardiology,

Istanbul Mehmet Akif Ersoy, Thoracic and Cardiovascular Surgery Center, Istanbul, Turkey

Address: İstanbul Mehmet Akif Ersoy Eğitim Araştırma Hastanesi, İstasyon Mahallesi İstanbul Caddesi

Bezirganbahçe Mevki 34303 KÜÇÜKÇEKMECE- İSTANBUL

Tel: +90 212 692 20 00

Fax: +90 212 471 94 94

Mobile Phone: +90 505 259 27 25

E-mail: [email protected]

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Evaluation of non-surgical causes of cardiac tamponade in children at a single tertiary cardiac

surgery center

Abstract

Objectives:

We examined the causes of cardiac tamponade in children who underwent percutaneous

pericardiocentesis.

Method:

We retrospectively investigated patients who presented with other complaints but were diagnosed with

cardiac tamponade based on clinical and echocardiographic findings between January 2010 and January

2013.

Electrocardiography, telecardiography and transthoracic echocardiography were performed.

Pericardiocentesis was performed percutaneously under continuous blood pressure and rhythm

monitoring with echocardiography and fluoroscopy. Pericardial fluid was analyzed by hemography and

biochemical tests.

Results:

Fourteen patients (six boys, eight girls; median age, 7 years) underwent pericardiocentesis for cardiac

tamponade. At presentation, 78% had dyspnea, 56% chest pain, and 49% fever. All had cardiomegaly,

and their cardiothoracic index was 0.56–0.72. Also, all patients had sinus tachycardia, 78% low QRS

voltage, 70% ST-T changes, and 50% QRS alternans. Echocardiography showed pericardial effusion as

the widest diameter is between 12 mm and 36 mm deepness around the heart. The pericardial fluid was

purulent in one, serohemorrhagic in seven, serofibrinous in two, and serous in four cases.

Pericardiocentesis was unsuccessful in two patients, who underwent open surgical drainage, with no

complications. Based on pericardial fluid characteristics and additional tests, cardiac tamponade was

caused by an infection in five patients, hypothyroidism in two, familial Mediterranean fever in two,

malignancy in one, acute rheumatic fever in one, collagen tissue disease (systemic lupus erythematosus) Acc

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in one, catheter placement-associated damage in one, and idiopathic pulmonary arterial hypertension in

one patient.

Conclusion

Pericardial effusion and cardiac tamponade in children have varied causes, and early treatment is life

saving.

Keywords: cardiac tamponade, children, etiology, pericardiocentesis

Introduction

Cardiac tamponade (CT) is a clinical problem characterized by pericardial fluid accumulation; it

results in an increase in intrapericardial pressure and restriction of ventricular diastolic filling and,

subsequently, a decrease in stroke volume and cardiac output 1, 2. Unless immediate intervention is given,

it can be fatal. Correct and complete differential diagnosis of CT and pericardial effusion is crucial:

pericardial effusion is an anatomical diagnosis that does not cause hemodynamic instability, while CT is a

physiologic diagnosis associated with hemodynamic instability 3.

CT is especially noted in cases of infection and also heart failure, malignancies, collagen tissue

diseases, trauma, hypothyroidism, uremia, and rarely acute rheumatic fever (ARF) 1, 3, 4. It usually

presents with sudden, precordial or retrosternal chest pain which may radiate to the back, neck and arm;

fever; dyspnea; cough; dysphagia; anxiety; and mental changes. In patients who present with these

symptoms, distant heart sounds, hypotension, venous distension and pulsus paradoxus may indicate CT,

and a definitive diagnosis is made by echocardiographic assessment 3, 4. CT is usually treated using

pericardiocentesis or urgent surgical drainage to prevent cardiac compression. Currently, the preferred

first-line treatment is percutaneous pericardiocentesis under the guidance of echocardiography and/or

fluoroscopy 5.

There is not much information on the causes and findings of CT in children. To address this gap,

we evaluated the cases of children who presented to the emergency department or were referred to our

clinic and were consequently diagnosed with CT, for which they underwent percutaneous

pericardiocentesis as the first-line treatment.Acc

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Materials and Methods

Patient selection and diagnostic tools

We retrospectively investigated patients who presented with complaints such as chest pain,

dyspnea, and fever, and were diagnosed with CT based on clinical and echocardiographic evidence

between January 2010 and January 2013. We excluded cases in which the patients had had recent cardiac

surgery or those in which the CT occurred secondary to chest trauma.

Symptoms and detailed physical examination findings were recorded. The cardiothoracic index

(CTI) was calculated using telecardiography. The patients also underwent 12-lead electrocardiography

(ECG), the findings for which were evaluated in terms of low voltage, tachycardia, ST segment changes,

T wave inversion and electrical alternans. Low voltage on electrocardiogram was defined as 5 mm or less

in all limb leads and < 10 mm in all precordial leads. If some of the P and T-U waves were high and some

of them were short in QRS complexes we defined it as QRS alternans. Tachycardia was defined as a heart

rate that exceeds normal range for age. If ST segment was higher than 1mm in all limb leads and higher

than 2 mm in all precordial leads according to isoelectric line we defined this as ST-T segment change 1-

3.

All patients were diagnosed with CT based on the results of echocardiography. The amount of

effusion, the cardiac walls with the highest amount of effusion, and presence of pressure on the cardiac

chambers were examined in the echocardiogram. The diagnostic criteria were as follows: early diastolic

collapse in the right ventricle, pressure over the right ventricle outlet, late diastolic collapse in the right or

left atrium, and lack of respiratory changes in the inferior vena cava.

Based on the primary symptoms, history and physical examination findings, hemography,

peripheral smear, C-reactive protein (CRP), sedimentation, biochemical tests (urea, creatinine, glucose,

lactate dehydrogenase (LDH), cholesterol, albumin, free T4, thyroid-stimulating hormone (TSH)),

purified protein derivative(PPD) skin test for tuberculosis , viral serology, and collagenase and other

serologic tests were conducted.

Pericardial fluid was drained during pericardiocentesis, and the results of hemography, glucose,

albumin, LDH, cholesterol, culture, cytology, Ehrlich-Ziehl-Neelsen (EZN) and Gram staining, density Acc

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and adenosine deaminase were recorded. According to modified Light’s criteria, if the fluid total protein

was >3 g, fluid/serum protein ratio >0.5, fluid/serum LDH > 0.6 6, the fluid was considered as an exudate;

if these criteria were not met, it was considered as a transudate.

Moreover, in the case of some patients, advanced studies such as bone marrow aspiration,

Familial Mediterranean Fever (FMF) mutation panel, and Quantiferon Tb gold tests were required. ARF

was diagnosed based on Jones’ criteria 7, and FMF was diagnosed based on the Tel Hashimer criteria8.

Pericardiocentesis

Pericardiocentesis was performed percutaneously under continuous blood pressure and rhythm

control; echocardiography and fluoroscopy were performed in the catheter laboratory. A small incision

was made with a surgical lancet, following which the subxiphoidal area was sterilized and local

anesthesia was induced with 2% lidocaine. A puncture needle was slowly advanced with negative

pressure from under the xiphoid process with a 30°–45° slope towards the left shoulder. Once aspiration

fluid appeared, a 0.038-inch guide wire was passed through the needle. Under fluoroscopic guidance, we

made sure that the guide wire could easily move around the pericardium. If hemorrhagic fluid was found,

we assessed it to determine whether it coagulates, without withdrawal of needle. If it seemed like arterial

blood or extrasystole occurred in the patient or the aspirated fluid was clotting, the needle was withdrawn

and the puncture was repeated. Since pericardial pressure might be increased in these patients, in case

hemorrhagic fluid was observed with pulsation, we checked whether the pulsation persisted for a while.

When the pulsation declined, the procedure was resumed at all cases. We made sure that the guide wire

was in the pericardium during fluoroscopy, and a pigtail catheter was passed into the pericardium over the

guide wire. Some amount of fluid was drained to prevent cardiac decompensation, and some more fluid

was drained to eliminate tamponade. Improvement of symptoms after fluid drainage was considered to

indicate success. The catheter was withdrawn when the drainage was less than 20 ml in a day and/or a

significant amount of fluid was not found in echocardiography5.

Statistical analysis

The SPSS Software 12 program was used for statistical analysis. Continuous variables were

expressed as median (minimum-maximum); categorical variables were expressed as a percentage. Acc

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Results

During the 3-year period studied, we performed pericardiocentesis on 14 patients who presented

to our emergency department or were referred to us for causes other than CT. The median age of the

patients was 7 years (0.1–18); eight were female and six were male. Between them, 78% had dyspnea,

56% chest pain, and 49% fever at the time of presentation. The main characteristics of the included cases

are summarized in Table 1.

The results of cardiovascular evaluation of the patients were shown in Table 2. All patients had

cardiomegaly according to the results of telecardiography, and the CTI values were between 0.56 and

0.72. In the electrocardiographic assessment, while all patients (100%) had sinus tachycardia, 78% had

low QRS voltage, 70% ST-T changes and 50% QRS alternans. Echocardiography in the case of one

patient showed 12–36 mm deep pericardial effusion around the heart. Significant aorta and mitral valve

insufficiency was detected in one patient, and pulmonary arterial hypertension was detected in another.

In pericardiocentesis analysis, pericardial fluid was found to be purulent in one case,

serohemorrhagic in seven, serofibrinous in two and serous in four cases. Biochemical studies showed that

pericardial fluid was present as exudate in all patients. The volume of pericardial fluid drained was 160–

750 ml. In two patients, the pericardiocentesis was unsuccessful and they underwent open surgical

drainage, which was conducted by the pediatric cardiovascular surgery team; no complications occurred.

Based on pericardial fluid characteristics and additional test results, it was concluded that in the case of

five patients, CT was caused by an infection; two patients, hypothyroidism; two, FMF; one, malignancy;

one, ARF; one, collagen tissue disease systemic lupus erythematosus (SLE); one, catheter-associated

damage; and one, idiopathic pulmonary arterial hypertension. The pericardial fluid content and additional

test results used for definitive diagnosis of CT are summarized in Table 3.

No patient had cardiac perforation or severe arrhythmia, and no patients died during

pericardiocentesis. Only three patients had sudden hypotension during drainage of pericardial fluid, and it

improved by isotonic fluid replacement. The average hospital stay was 3–18 days. Following withdrawal Acc

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of pericardial fluid catheters, the patients were referred to appropriate subspecialties for treatment and

follow-up.

Among the patients in whom CT was detected secondary to infection (cases 1–5), bacterial

infection was detected in three patients, viral in one, and tuberculosis in one. In two of the patients with

bacterial infection, pneumonic infiltration was observed in their chest radiograph and streptococcus

pneumoniae and hemophilus influenza were found in their hemocultures. Staphylococcus aureus was

detected in the pericardial fluid of the third patient. In the patient with CT secondary to viral infection,

adenovirus was detected by PCR. The PPD results for the patient with tuberculosis showed a 15 mm × 18

mm induration. Moreover, the results of the Quantiferon Tb gold test were positive. Chest computerized

tomography for this patient showed nodular infiltration and a family history of lung tuberculosis.

The two patients with CT secondary to hypothyroidism (cases 6 and 7) had Down syndrome

(TSH, >100 µIU/ml; free T4, 0.001–0.009 ng/dl). Levothyroxine administration was started after the first

diagnosis. In the second week of treatment, the thyroid function tests for both patients showed

improvement.

The two patients with FMF (cases 8 and 9) had a history of frequent fever and abdominal pain.

Besides, one of these patients had had an appendectomy. Gene analysis showed that one of them had a

homozygous M694V mutation while the other had a heterozygous M680I mutation. These two patients

were under colchicine treatment, and they did not report any complaints during the 12-month follow-up

period.

The patient with ARF was a 7-year-old boy (case 10) who presented with fever, chest pain,

cough and dyspnea for 3 days. He had an upper respiratory infection 2 weeks before and joint pain for a

week. Echocardiography showed marked mitral and aorta valve insufficiency in addition to CT findings;

ASO was 508 Todd/U. Since he had one major (carditis) and 3 minor findings (high acute phase

reactants, arthralgia and fever) in addition to high ASO levels, he was diagnosed with ARF, and steroid

treatment for carditis was started. His symptoms improved in the first week of treatment.

One patient (case 11) had marked leukocytosis and anemia, but no thrombocytopenia was

detected. This patient had Down syndrome, and was diagnosed with transient leukemia based on the Acc

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results of pericardial fluid, peripheral smear and bone marrow aspiration analysis. This patient showed

improvement after treatment and has been followed up for 10 months. The patient is still receiving

treatment at a pediatric hematology clinic.

Another patient (case 12) had leucopenia and anemia. This patient was positive for antinuclear

antibody (ANA). This patient was diagnosed with SLE and has been followed up at the pediatric

nephrology and rheumatology department.

One patient (case 13) was referred to us with respiratory difficulty. Echocardiography indicated

CT. Pericardiocentesis was unsuccessful, so surgical tube pericardiostomy was performed. The content of

pericardial fluid was found to be consistent with the total parenteral nutrition (TPN) solution of the

patient. CT in this case was associated with percutaneous central catheter placement that the patient had

undergone 10 days before. The patient was successfully treated and discharged.

The patient in case 14 was under treatment for pulmonary hypertension at another clinic and was

referred to us with sudden cardiac arrest and respiratory distress. Pericardiocentesis was performed for

CT, and the angiographic assessment was consistent with IPAH. The patient was followed up at the

intensive care unit; despite intensive treatment with bosentan, nitric oxide and prostaglandin analogues,

the patient died because of pulmonary hypertensive crisis at the 16th day of admission.

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Discussion

There are limited studies about CT cases in children presented to the emergency room without a

history of cardiac surgery or trauma. The studies published are mostly in the form of case reports 5-7.

Thus, to our knowledge, this is the largest groups of patients with CT reported so far in our country.

Pericardial effusion is not an often application reason to the pediatric emergency units. It should

be carefully evaluated because it can lead to cardiac tamponade. Cardiac tamponade can develop due to

fluid accumulation blood, clot, pus, air deposition in the pericardial cavity and may also develop due to

cardiac trauma or rupture. Depending on the increase of the content in the pericardial cavity cardial

chambers are compressed and cardiac filling reduces for this reason cardiac tamponade is a life-

threatening condition 3-5.

Many diseases may cause pericardial fluid accumulation. It may be caused by bacterial (S.

Aureus, meningococcus, H. Influenza, pneumococcus, streptococcus, mycobacterium tuberculosis, etc.),

viral (coxsackie B5-6, echo, adenovirus, Epstein Barr, influenza, HIV, etc.) or fungal (aspergillus

spp.etc.) infections as well as congestive heart failure, collagen vascular disease (SLE, scleroderma,

dermatomyositis, etc), chest wound and trauma, rheumatic fever, uremia, myxedema, tumor, trauma and

iatrogenic catheterization complications. In rare cases it can develop due to pericardial cysts and masses

and this condition often progresses to tamponade. The most important factor that affects the formation of

tamponade is accumulation rate of the fluid. 1-4. In literature there are many different etiologic factors that

cause CT and frequencies of these causes vary between studies 3-6. In a study on 25 adult patients with

large pericardial effusion, Colombo et al. found the causes to be neoplastic in 36% of them; idiopathic,

32%; uremic, 20%; post-myocardial infarct, 8%; and ARF, 4% 9.

In a study on adult patients, pericardial effusion was observed in 136 patients, 34 of whom had

tamponade; the most common causes were malignancy and tuberculosis infection10. In our study, the

most common causes of CT were infections, hypothyroidism and FMF. This may be related to the type of

hospital (specialty or reference hospital), and the age and choice of the patient population. Acc

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Guven et al. evaluated 10 patients aged 1.5 to 17 years who presented with a large CT, and

detected tuberculosis in three patients, non-Hodgkin lymphoma in two, uremic infection in one, bacterial

infection in one and postpericardiotomy syndrome in one; the cause was unknown in two cases11.

In the case of CT caused by infections, the infection is mostly bacterial or viral and rarely fungal.

The most common infectious agents are Staphylococcus, meningococcus, H. influenza and coxsakievirus.

Tuberculosis is a particularly important cause, especially in Turkey. In this study, we reported 5 patients

in whom infection was the cause of CT: it was bacterial in three cases and viral in one case, and one

patient had tuberculosis.

ARF is a non-suppurative complication following group A beta hemolytic streptococcus

infection that affects many systems, especially the cardiovascular and skeletal systems. The most

common cause of mortality and morbidity is carditis. Cardiac involvement associated with ARF can

present as pancarditis, which affects all three layers of the heart. While valve insufficiency associated

with endocardial involvement and valve stenosis is seen in later stages and is an important cause of

morbidity and mortality, in acute cases, myocardial and pericardial involvement may be fatal. Pericardial

involvement associated with ARF mostly presents as mild pericardial effusion; it rarely presents as fatal

severe pericardial effusion and tamponade7.

FMF is an autoimmune disease characterized by frequent fever and inflammation of serous

membranes such as the peritoneum, synovium and pleura. Common symptoms of this disease are

generalized peritonitis, pleuritis and monoarthritis. CT in association with this disease is quite rare 10.

Pleural effusion is also frequent in the progression of SLE, which is another rheumatologic disease. In

SLE patients with unexplained venous congestion, a CT investigation is suggested. Some SLE cases have

also been reported in which CT is the first clinical finding 12. RF and ANA are commonly used for

screening for collagen vascular diseases, and ANA has a very high negative predictive value in SLE

(95%)12. In our study, in a case in which CT was the first clinical finding, we later found the patient to be

positive for SLE and ANA.

Hypothyroidism is a clinical condition with multi-organ involvement. In patients with

hypothyroidism, 30–80% were reported to have pericardial fluid effusion13, 14. In hypothyroidism, Acc

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increased capillary permeability and protein transport into the interstitial area due to insufficient

lymphatic drainage are responsible for pericardial fluid accumulation. Since fluid accumulation is slow,

tamponade is seen rarely. In this study, 2 patients with CT also had hypothyroidism.

Percutaneous central venous catheters (PCVCs) are commonly used in newborn intensive care

units, especially for very-low-birth-weight premature neonates in recent years. During catheter placement,

infusion fluid may leak into the pericardial space as a result of direct myocardial perforation. If the

catheter repeatedly strikes the myocardial wall, it results in endothelial disruption and subsequently local

thrombosis and myosclerosis. The risk of pericardial effusion/CT development due to percutaneous

central venous catheter placement was reported in 1.8 out of 1000 cases, with the mortality being 0.7

among 1000 cases15. In this study, we detected CT within 12 days following PCVC placement.

The prevalence of malignant disease in children diagnosed with CT at the first presentation is not

known. There are a few cases of acute lymphoblastic leukemia (ALL). We detected malignant disease in

one case. This patient was a 2-month-old with Down syndrome. After unsuccessful pericardiocentesis,

surgical tube pericardiostomy was performed. The tests results were indicative of transient leukemia. The

patient’s clinical conditions improved after steroid treatment, and the patient was followed up for 10

months16.

Symptoms vary with the acuteness and underlying cause of the tamponade. Patients with acute

tamponade may present with dyspnea, tachycardia, and tachypnea. Cold and clammy extremities from

hypoperfusion are also observed in some patients. A comprehensive review of the patient's history usually

helps in identifying the probable etiology of a pericardial effusion 1-5. The most frequent complaints in

our study were dyspnea (78%), chest pain (56%) and fever (49%).

Cardiac tamponade can be defined clinically by Beck triad; hypotension, muffled heart sounds,

and jugular venous distension but only one third of the patients with cardiac tamponade has these

symptoms. Also 10 % of the patients does not present with these symptoms. Telecardiography

(cardiomegaly), electrocardiography (sinus tachycardia, ST-T wave changes, low voltage and QRS

alternans) and echocardiography (the most useful test for detecting the amount of effusion and Acc

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tamponade) are helpful in diagnosis 1-5. In this study CTI of the patients were 0.56-0.78 and they had

ECG abnormalities in varying degrees.

Treatment approaches for pericardial effusion/cardiac compression vary according to the centers

at which patients are treated. In patients with life-threatening compression, pericardial fluid drainage and

elimination of cardiac compression are performed. For this purpose, pericardial tube placement with the

surgical subxiphoidal approach has been used for years. Surgical treatment is certainly life saving in cases

of acute pericardial tamponade that develop due to penetrant cardiac trauma or cardiac rupture. This

method also allows for easy diagnosis via pericardial biopsy. However, a disadvantage of this method is

that because drainage is via a percutaneously placed catheter, it may not always be possible to obtain a

pericardial biopsy sample 1-3. In our study, 12 out of 14 pericardiocentesis procedures were successful;

surgical tube pericardiostomy was performed in the remaining two cases. No complications associated

with the procedure were observed.

Conclusion: pericardial effusion and CT in children are associated with many causes and early treatment

is life saving. When CT is suspected, echocardiography and, if required, pericardiocentesis should be

performed for quick diagnosis and treatment without loss of time.

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References:

1 Chetcuti S. Pericardial effusion. In: Marso SP, Griffin BP, Topol EJ (eds.). Manual of

Cardiovascular Medicine. 1st edn. Lippincott Williams Wilkins, Philadelphia, 2000; 363-73.

2 Spodick DH. Acute cardiac tamponade. N Engl J Med. 2003; 349: 684-90.

3 Chang AC. Cardiac tamponade. In: Hanley F (ed.). Pediatric Cardiac Intensive Care.

Lippincot Williams Wilkins, Philedelphia, 1998; 510-1.

4 Klein LW. Diagnosis of cardiac tamponade in the presence of complex medical illness.

Crit Care Med. 2002; 30: 721-3.

5 Önem G, Baltalarlı A, V. ÖA, Evrengül H, Gökşin İ, Saçar M. Subxiphoid pericardial

window and percutaneous catheter drainage for treatment of cardiac tamponade. The

Turkish Journal of Thoracic and Cardiovascular Surgery. 2006; 14: 107-9.

6 Light RW. Diagnostic principles in pleural disease. Eur Respir J. 1997; 10: 476-81.

7 Bland EF, Duckett Jones T. Rheumatic fever and rheumatic heart disease; a twenty

year report on 1000 patients followed since childhood. Circulation. 1951; 4: 836-43.

8 Medlej-Hashim M, Loiselet J, Lefranc G, Megarbane A. [Familial Mediterranean Fever

(FMF): from diagnosis to treatment]. Sante. 2004; 14: 261-6.

9 Colombo A, Olson HG, Egan J, Gardin JM. Etiology and prognostic implications of a

large pericardial effusion in men. Clin Cardiol. 1988; 11: 389-94.

10 Zimand S, Tauber T, Hegesch T, Aladjem M. Familial Mediterranean fever presenting

with massive cardiac tamponade. Clin Exp Rheumatol. 1994; 12: 67-9.

11 Guven H, Bakiler AR, Ulger Z, Iseri B, Kozan M, Dorak C. Evaluation of children with a

large pericardial effusion and cardiac tamponade. Acta Cardiol. 2007; 62: 129-33.

12 Manresa JM, Gutierrez L, Viedma P, Alfani O. [Cardiac tamponade as a clinical

symptom of systemic lupus erythematosus]. Rev Esp Cardiol. 1997; 50: 600-2. Acc

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13 Kabadi UM, Kumar SP. Pericardial effusion in primary hypothyroidism. Am Heart J.

1990; 120: 1393-5.

14 Kerber RE, Sherman B. Echocardiographic evaluation of pericardial effusion in

myxedema. Incidence and biochemical and clinical correlations. Circulation. 1975; 52: 823-7.

15 Beardsall K, White DK, Pinto EM, Kelsall AW. Pericardial effusion and cardiac

tamponade as complications of neonatal long lines: are they really a problem? Arch Dis Child

Fetal Neonatal Ed. 2003; 88: F292-5.

16 Vaitkus PT, Herrmann HC, LeWinter MM. Treatment of malignant pericardial

effusion. JAMA. 1994; 272: 59-64.

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Tables:

Table 1: Patient characteristics

Table 2: Telecardiographic, ECG findings, pericardial effusion amounts (echocardiographic

measurements)

Table 3: Pericardiocentesis fluid characteristics and other features

Table 1: Patient characteristics

Characteristics N %

Gender (Male/ Female) 6/8

Age,year,median(range) 7(0.1-18)

Weight,kg,median(range) 26(3-64)

Symptoms

Dyspnea

Chest pain

Fever

Abdominal pain

Vomiting

Cough

Palpitation

11

8

7

4

4

4

3

80

56

49

28

28

28

22

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Table 2: Telecardiographic, ECG findings ,pericardial effusion amounts (echocardiographic measurements)

Case Diagnosis Telecardiogram

CTI

ECG Changes Pericardial effusion

Tachycardia Low voltage

ST- T

changes

QRS

Alternans

1 Bacterial 0.72 + - - - 28 mm

2 Bacterial 0.58 + - + + 18 mm

3 Bacterial 0.65 + + + + 24 mm

4 Viral 0.56 + + + - 18 mm

5 Tuberculosis 0.70 + + + - 36 mm

6 Hypothyroidism 0.61 + + + - 27 mm

7 Hypothyroidism 0.64 + - + - 24 mm

8 FMF 0.67 + + + - 30 mm

9 FMF 0.58 + - - - 20 mm

10 SLE 0.59 + + + + 35 mm

11 ALL 0.66 + - - - 11mm

12 ARF* 0.65 + + + + 14 mm

13 Catheter associated

0.62 + - + - 12 mm

14 IPAH† 0.60 + + - - 15 mm

* Significant aorta and mitral valve insufficiency

† Pulmonary artery end diastolic pressure: 40 mmHg

FMF: Familial Mediterranean fever, ARF: Acute rheumatic fever, ECG: Electrocardiography, CTI: Cardiothoracic index, IPAH: Idiopathic pulmonary arterial hypertension

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Table 3: Pericardiocentesis fluid characteristics and other features

Case Diagnosis Fluid type Amount Procedure success

Other features

1 Bacterial Exudate 750 ml Successful Pericardial culture

(S.aureus)

2 Bacterial Exudate 400 ml Successful Pneumonia+ S.pneumonia (HC)

3 Bacterial Exudate 340 ml Successful H.influenza (HC)

4 Viral Exudate 160 ml Successful Adenovirus

5 Tuberculosis Exudate 500 ml Successful PPD 15x16 mm

TBC gold (+)

6 Hypothyroidism

Exudate 200 ml Successful TSH>100

Down Syndrome

7 Hypothyroidism

Exudate 200 ml Successful TSH>100

Down Syndrome

8 FMF Exudate 450 ml Successful M694V

Repeated fever+ abdominal pain

9 FMF Exudate 330 ml Successful M680I

Arthritis+ abdominal pain+ appendectomy

10 SLE Exudate 450 ml Successful ANA (+)

11 ALL Exudate 180 ml Unsuccessful Down syndrome

Blast (BMA)

12 ARF Exudate 400 ml Successful ASO>600, fever+ arthritis+ ECHO(MI+AI)

13 Catheter associated*

Exudate 160 ml Unsuccessful Newborn

14 IPAH Exudate 180 ml Successful No etiology found

*Fluid content was consistent with TPN solution. Acc

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FMF: Familial Mediterranean fever, ARF: Acute rheumatic fever, ALL: acute lymphoblastic leukemia, SLE: systemic lupus erythematosus, HC: Hemoculture, TSH: thyroid-stimulating hormone, PPD: purified protein derivative. BMA: bone marrow aspirate, ECHO: Echocardiography, IPAH: Idiopathic pulmonary arterial hypertension

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Evaluation of non-surgical causes of cardiac tamponade in children at a cardiac surgery center

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Transcript of Evaluation of non-surgical causes of cardiac tamponade in children at a cardiac surgery center