Effusive-Constrictive Pericarditis After Pericardiocentesis

Study Questions:

What are the incidence, associated findings, and natural history of effusive-constrictive pericarditis (ECP) after pericardiocentesis?

Methods:

The investigators analyzed 205 consecutive patients undergoing pericardiocentesis at Mayo Clinic, Rochester, MN, who were divided into two groups (ECP and non-ECP) based on the presence or absence of post-centesis echocardiographic findings of constrictive pericarditis. Clinical, laboratory, and imaging characteristics were compared. In order to assess the prevalence of ECP in cardiac tamponade related to cardiac surgery/percutaneous interventions versus tamponade unrelated to procedures, the authors used Poisson regression models with sandwich estimators before and after adjustment for baseline covariates.

Results:

ECP was subsequently diagnosed in 33 patients (16%) after pericardiocentesis. Overt clinical cardiac tamponade was present in 52% of ECP patients and 36% of non-ECP patients (p = 0.08). Post-procedure hemopericardium was more frequent in the ECP group (33% vs. 13%; p = 0.003), and a higher percentage of neutrophils and lower percentage of monocytes were noted on pericardial fluid analysis in those patients. Clinical and laboratory findings were otherwise similar. Baseline early diastolic mitral septal annular velocity was significantly higher in the ECP group. Before pericardiocentesis, respiratory variation of mitral inflow velocity, expiratory diastolic flow reversal of hepatic vein, and respirophasic septal shift were significantly more frequent in the ECP group. Fibrinous or loculated effusions were also more frequently observed in the ECP group. Four deaths occurred in the ECP group; all four patients had known malignancies. During a median follow-up of 3.8 years (interquartile range, 0.5-8.3), only two patients required pericardiectomy for persistent constrictive features and symptoms.

Conclusions:

The authors concluded that in a cohort of unselected patients undergoing pericardiocentesis, 16% were found to have ECP.

Perspective:

This cohort study reports that effusive-constrictive pericarditis post-pericardiocentesis is common and that constrictive pericarditis features usually resolve either spontaneously or with medical management. These observations suggest a reversible, inflammatory cause for the hemodynamic abnormality and support a conservative approach to management, reserving pericardiectomy for only patients refractory to adequate anti-inflammatory therapy. Pre-pericardiocentesis, high mitral medial e′ velocities, and respirophasic septal shift were seen more frequently in the group that developed ECP, suggesting that these patients have distinct echo-Doppler features before pericardiocentesis is performed and may need closer monitoring post-pericardiocentesis.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Pericardial Disease, Prevention, Cardiac Surgery and Arrhythmias, Interventions and Imaging, Echocardiography/Ultrasound

Keywords: Cardiac Surgical Procedures, Cardiac Tamponade, Echocardiography, Echocardiography, Doppler, Hemodynamics, Incidence, Monocytes, Neoplasms, Neutrophils, Paracentesis, Pericardial Effusion, Pericardiectomy, Pericardiocentesis, Pericarditis, Constrictive, Prevalence, Primary Prevention


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