The Presentation of Pericardial Decompression syndrome

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The Presentation of Pericardial Decompression
syndrome

• Thomas Caranasos MD
• James Bardes MD
• Donnie Goodwin NP

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Case Presentation

• 38 year old female transferred from an referring
  hospital with a diagnosis of pericardial
  effusion.  
• She presented to the referring facility with a 3
  day history of increasing shortness of breath and
  chest pain.  
• A Chest CT revealed a pericardial effusion and
  bilateral pleural effusions.  
• She had no significant past medical or surgical
  history.  She took no medications.  She was a
  non-smoker, with no significant family history or
  occupational exposures.  
• Physical exam findings included midline trachea,
  decreased breath sounds at the bases, muffled
  heart sounds, and increased JVP.   

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Case Presentation

• Labs revealed only a mild anemia.  
• EKG revealed tachycardia and incomplete right
  bundle branch block.  
• Transthoracic echocardiogram revealed a large
  pericardial effusion, without tamponade
  physiology.  
• The patient was taken to the OR for subxiphoid
  pericardial window with placement of right
  pleural chest tube and two pericardial blake
  drains.  Initially 1400cc of hemorrhagic
  pericardial fluid and 800cc of pleural fluid were
  drained.  Pericardial biopsies were taken.  Post
  operatively the patient was transferred to the
  cardiothoracic intensive care unit.  

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Case Presentation

• On postoperative day 0 the patient became
  hypotensive, requiring Neo-Synephrine and
  Epinephrine drip to maintain a MAPgt60mmHg.  She
  was intubated and placed on mechanical
  ventillation.  
• An intra-aortic balloon pump was placed to assist
  with cardiac perfusion.  
• The patient underwent emergent transesophageal
  echocardiogram for poor visualization on TTE
  which showed an EF of 30-35 and no underlying
  valvular disease.
• A pulmonary embolus was ruled out by pulmonary
  arteriography.  Cardiac catheterization revealed
  poor left ventricular function, approximately 25
  with diffuse hyopkineses.  EKG revealed only
  sinus tachycardia.  

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Case Presentation

• The patient stabilized on inotropes and pressors.
  Over the following three days she was able to
  wean off the drips, the intra-aortic balloon pump
  was discontinued and the patient was extubated.  
• Pathology results from the pericardial fluid
  revealed cells consistent with adenocarcinoma.
   Pericardial biopsy showed metastatic
  adenocarcinoma.  Immunohistochemistry stains
  identified lung as the most likely primary site.
   
• A non-small cell lung cancer would be diagnosed
  later.  Pleural fluid was negative for malignant
  cells.  The patient continued to progress and was
  able to be discharge home on post-operative day
  9.   Outpatient follow up echo at 1 month showed
  a EF of 50-55.  

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Pericardial Decompression Syndrome

• Pericardial decompression syndrome is a
  recognized phenomenon after drainage of
  pericardial fluid.  
• Three main hypotheses for PDS have been presented
  in the literature.  
• The hemodynamic hypothesis suggests that the
  sudden increase in venous return and greater
  right ventricular output overwhelms the left
  ventricle.  
• The ischemic hypothesis states that the
  myocardium is damaged due to diminished coronary
  artery blood flow from compression by the
  pericardial fluid (1).  
• The sympathetic overdrive hypothesis purports
  that the pericardial fluid was a stimulus for the
  sympathetic nervous system.  Once that stimulus
  was removed any underlying dysfunction was
  revealed (2).  

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Pericardial Decompression Syndrome

• While reviewing literature for our case, a
  developing pattern was noticed.  We describe one
  case and find four more in the literature where
  all of the patients had a malignant effusion
  drained from the heart.  
• Subsequent drainage of that effusion led to
  cardiac failure and pulmonary edema in all of
  these cases.  Three were drained by
  peridcadiocentesis and two by subxiphoid window.
   The patients range in age from 38-56.  Two of
  them had previously been given chemotherapy for
  an identified primary cancer.  
• None received an agent that would be expected to
  cause myocardial damage.  All of these patients
  developed significant areas of left ventricular
  hypokinesia within hours of their procedure.  All
  would return to baseline with just supportive
  measures.
•  

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Pericardial Decompression Syndrome
Author Journal Age Sex Time Post Drainage Volume Removed Type of Drainage Type of Failure
WVU Pt 1 38 F 12 hours 1400mL subxiphoid window left ventricle hypokinesia
Ligero Eur J Heart Failure 41 F 3 hours 1000mL pericardiocentesis akinesis of the anterior wall, septum and apex
Wolfe Ann Internal Med 46 F 12 hrs 650mL pericardiocentesis left ventricle hypokinesia
Wolfe Ann Internal Med 50 F Never back to baseline 650mL pericardiocentesis global left ventricular systolic function
Shenoy Chest 56 M lt1 hour 1000mL subxiphoid window IV septum hypokinesia
All patients presented had an underlying
adenocarcinoma
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Pericardial Decompression Syndrome

• While it is a recognized phenomenon, it is
  uncommon.  Few have published on the topic but
  there seems to be a fair number that have a
  history of a primary adenocarcinoma.  
• In 1993 Wolfe noted that both of his patients had
  cancer and it could not be excluded as a cause.  
• We feel that further investigation is warranted
  into the pathogenesis of pericarial decompression
  syndrome. We have obtained IRB approval for a
  retrospective review of all patients who
  underwent pericardiocentesis.
•  There seems to be connection between
  adenocarcinoma, these malignant effusions, and
  the presentation of pericaridal decompression
  syndrome.  
• Until this phenomenon can be investigated further
  patients should be monitored closely after
  draining a suspected malignant effusion.  Its
  possible there are varying degrees of this
  condition that go unrecognized.

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