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Presented by: Massimo Imazio, MD, FESC.
Cardiology Department, Maria Vittoria Hospital and Department of Public Health and Pediatrics, University of Torino, Torino, Italy.
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A 69-year-old Caucasian female patient, with a previous diagnosis of Rheumatoid Arthritis (RA) and Sjogren Syndrome (SS), was referred for a second opinion. She has a known large chronic idiopathic pericardial effusion since 2010.
In March 2011 and September 2011 she underwent 2 diagnostic pericardiocentesis without pericardial drainage. The pericardial effusion always reappeared after few days. She also attempted empiric anti-inflammatory therapies with NSAID and colchicine without significant changes of the size of the pericardial effusion. The aetiological testing was negative and the final diagnosis was large idiopathic pericardial effusion. She was always asymptomatic and the pericardial effusion was detected incidentally following a chest-x-ray and a transthoracic echocardiogram.At the visit she is asymptomatic without evidence of distended neck veins. The ECG shows sinus rhythm with low QRS voltages (Figure 1).
Figure 1. Low QRS voltages on ECG.
On transthoracic echocardiography a large pericardial effusion (maximal telediastolic echo-free space of 36mm) is detected without clinical and echocardiographic signs of cardiac tamponade.
Figure 2. Large pericardial effusion (>20mm) without significant changes of mitral E velocities with respiratory phases and maintained changes of inferior vena cava size with respiration.
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.
Angelica Peritore1, Massimo Imazio2, Alberto Roghi3 and Patrizia Pedrotti31 Bicocca University, Milano, Italy; 2 Ospedale Maria Vittoria, Cardiology, Torino, Italy; 3 Ospedale Niguarda Cà Granda, Cardiac Magnetic Resonance Laboratory, Milano, Italy
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