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Death on stage: a 26-year old actress

Case presented by Working Group on Myocardial and Pericardial Diseases



The case

Presented by: Anna Neugebauer, Barbara Pfeiffer, Hubert Seggewiss, Angelos G. Rigopoulos

1st Department of Internal Medicine, Leopoldina Hospital, Schweinfurt, Germany

Authors picture

Case presentation

A 26-year old professional actress - healthy until then - collapsed suddenly while performing on stage due to a cardiac arrest. She was immediately resuscitated and finally was twice defibrillated because of ventricular fibrillation. After resuscitation of 10-15 min a stable haemodynamic status was achieved and the patient was transferred to our hospital.

After hospital admission she was neurologically examined and after exclusion of a subarachnoid hemorrhage as cause for the collapse by CCT the patient was then transferred to the ICU for further treatment. The patient was intubated and ventilated. Physical examination was unremarkable. Auscultation of lungs and heart revealed no pathologies.

Laboratory evaluation revealed slightly elevated white blood cell count, an elevated CPK-level (389 U/l) with CK-MB (38 U/l) within normal limits as well as elevated D-Dimers. The rest of the laboratory was unremarkable.

An ECG showed sinus tachycardia (103 bpm) along with an incomplete right bundle branch block without ST-Elevation (Figure 1).

Transthoracic echocardiography performed on admission revealed a moderate systolic dysfunction (ejection fraction 38%) with septal hypokinesia, no pericardial effusion and no right heart decompensation (Figure 2).

Arrhythmia monitoring in the ICU showed several times non-sustained ventricular tachycardia.

What is more, we got to know that the patient was pregnant in the 8th week of gestation.

Questions

  1. What could be the diagnosis and the cause for the cardiac arrest and low systolic function?
  2. Which further diagnostic measures are recommended?
  3. How should we treat the patient?
  4. How should we treat the baby?

Figure 1: ECG on admission (50mm/sec)

Picture 1

Figure 2: Transthoracic echocardiography soon after admission. A & B: Long axis parasternal view in diastole (A) and systole (B), C: Mmode view of the left ventricle showing septal hypokinesia, D+E: apical 4-chamber view in diastole (D) and systole (E).
Picture 2

The solution of the previous case of the month: Large chronic idiopathic pericardial effusion: to tap or not to tap.

Presented by Massimo Imazio, MD, FESC.  
Cardiology Department, Maria Vittoria Hospital and Department of Public Health and Pediatrics, University of Torino, Torino, Italy.

  1. What is your next diagnostic step?
  2. What medical therapy would you suggest?
  3. How would you plan the follow-up?

A large pericardial effusion (>20mm of telediastolic free-space) is defined chronic when lasting for > 3months. It is labelled “idiopathic” when the etiological evaluation is negative as in this case even after the analysis of the pericardial fluid.

In asymptomatic patients the finding may be incidental and the outcome is poorly known.
In the largest reported study from the Barcelona group (1), 28 cases were reported: 13 of 28 (46%) were asymptomatic. After a mean follow-up of 7 years cardiac tamponade developed in 8/28 (29%), pericardiocentesis was necessary in 24/28 (86%) and pericardiectomy was performed as final therapy in 20/28 (71%).

On this basis, the authors recommend to resort to pericardiectomy whenever a large pericardial effusion recurs after pericardiocentesis since cardiac tamponade may occur unexpectedly in about one third of cases.

This is a poorly studied condition with divergent opinions among experts since an alternative strategy of “wait and see” may be equally adopted (2,3).

In this case, since the patient was completely asymptomatic without any physical or echocardiographic sign of cardiac tamponade, we decided to wait and monitor the effusion within 3 months. Since it was unchanged we decided to perform another pericardiocentesis with prolonged drainage in order to check again the pericardial fluid and test the possible efficacy of prolonged drainage to prevent the reaccumulation of pericardial fluid.

The evolution of the pericardial effusion is reported in the figure below.

The effusion reappeared despite the pericardiocentesis and worsened after an episode of pericarditis. After this worsening the patient remained asymptomatic for > 1year.

Anti-inflammatory therapies, including colchicine,  have been shown not to be efficacious in the absence of inflammation and pericarditis (4) and thus were performed only to treat the episode of pericarditis.

This case shows that a chronic large effusion may be asymptomatic and stable for long period of time. Precipitating events such as pericarditis or trauma may be responsible of worsening and should be considered in the decision to treat. Careful echocardiographic follow-up are warranted every 3 to 6 months depending on symptoms, pericardial effusion size changes, and the management should be tailored to the single patient according to his/her preferences and evolution. Pericardiectomy is generally the last option to be carefully considered and offered in well-experienced surgical centres since it is a long and demanding cardiac surgery operation. A pericardial window is often an alternative option to be considered.

References


  1. Sagristà-Sauleda J, Angel J, Permanyer-Miralda G, Soler-Soler J. Long-term follow-up of idiopathic chronic pericardial effusion. N Engl J Med. 1999;341(27):2054-9.
  2. Imazio M, Mayosi BM, Brucato A, Markel G, Trinchero R, Spodick DH, Adler Y. Triage and management of pericardial effusion. J Cardiovasc Med (Hagerstown).2010;11(12):928-35.
  3. Imazio M, Adler Y. Management of pericardial effusion. Eur Heart J. 2013;34(16):1186-97.
  4. Adler Y, Guindo J, Finkelstein Y, Khouri A, Assali A, Bayes-Genis A, Bayes de  Luna A. Colchicine for large pericardial effusion. Clin Cardiol. 1998;21(2):143-4.
  5. Imazio M, Adler Y. Pharmacological therapy of pericardial diseases. Curr Pharm Des. 2015;21(4):525-30.
The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.