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Chapter 12 Pericardial Diseases

CHAPTER 12 PERICARDIAL DISEASES

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This approach has markedly curtailed the rate of recurrent effusion and need for a sclerosing agent. Rapid drainage of large volumes of pericardial fluid should be avoided as a “pericardial decompression syndrome,” character- ized by hemodynamic deterioration, pulmonary edema, or ventricular dysfunction, can ensue (21). For recurrent malignant pericardial effusion, there are no uniform approaches, and options may include repeat pericardio- centesis and drainage, surgical creation of a pericardial window, percutaneous balloon pericardiotomy, intraperi- cardial sclerosis or steroid instillation, and local or sys- temic chemotherapy. Pericardial effusions are usually circumferential. If the echo-free space is found only anteriorly, it may represent epicardial fat rather than a pericardial effusion. Posteriorly, a pericardial effusion is anterior to the descending tho- racic aorta, whereas a left pleural effusion is posterior to the aorta (Fig. 12-13). Two-dimensional ultrasonographic imaging of a pleural effusion prior to thoracentesis is helpful in locating the optimal puncture site. A left pleu- ral effusion allows cardiac imaging from the back. PERICARDIAL FAT Pericardial fat is common and often mistaken for peri- cardial effusion. Fat is usually present anteriorly over the right ventricle, with no posterior echolucent space, unlike the typical posteriorly located small pericardial effusion. Less commonly, pericardial fat deposition may be more extensive. Other distinguishing features of pericardial fat include a stippled appearance (Fig. 12-14) and some y PERICARDIAL EFFUSION VERSUS PLEURAL EFFUSION

sternal or apical areas; the subxiphoid location is used less frequently. In 1,127 consecutive echocardiographically guided pericardiocentesis procedures in our laboratory (20), malignant effusion was the most common reason for the procedure (34% of cases), followed by a postoperative complication (25%), complication of a catheter-based pro- cedure (10%), and miscellaneous causes. The procedure was successful in 97% of patients. Major complications were rare (1.2%) and included death (1 patient), cardiac laceration (5), vessel laceration (1), pneumothorax (5), infection (1), and sustained ventricular tachycardia (1). Typically, a pigtail catheter (6F or 7F) is introduced and left in the pericardial sac for about 3 days, with intermit- tent drainage every 4 to 6 hours. Once daily fluid drainage is less than 50 mL and a repeat echocardiogram con- firms absence of reaccumulation, the catheter is removed. FIGURE 12-12 The appearance of agitated saline ( arrows ) in the pericardial sac. If agitated saline is seen in any car- diac chamber, surgical consultation should be obtained immediately before any attempt is made to remove the pericardiocentesis needle or catheter.

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FIGURE 12-13 Two-dimensional imaging of pleural effusion ( PL ) from the parasternal (A) and apical (B) long-axis views. A pericardial effusion is present between the descending thoracic aorta ( Ao ) and the posterior cardiac walls, whereas a pleural effusion is present behind the descending thoracic aorta. LA , left atrium; LV , left ventricle; RV , right ventricle.

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