Percutaneous BalloonPericardiotomy for Patients withPericardial Effusionand Tamponade

Question 1

What does an elevated RV pressure with exaggerated respiratory variation indicate?

Answer 1

Pericardial tamponade

Echocardiographic evidence of right ventricular collapse lasting more than one-third of diastole is a specific sign of cardiac tamponade.

Question 2

Define pulsus paradoxus.

Answer 2

> 10-mm Hg drop in systolic arterial pressure during inspiration

It is an exaggeration of the normal respiratory variation in blood pressure.

Question 3

What happens to the Y descent in pericardial tamponade due to high intrapericardial pressures?

Answer 3

Blunted Y descent

This corresponds to the tricuspid valve opening and right atrial emptying.

Question 4

Which condition is a well-described cause of pulsus paradoxus?

Answer 4

Constrictive pericarditis

Pericardial tamponade may occur in the absence of pulsus paradoxus.

Question 5

What is a common occurrence after percutaneous balloon pericardiotomy?

Answer 5

Left pleural effusion within 24 to 48 hours

Occurs in up to 50% of patients.

Question 6

What is the recommended technique to confirm balloon position during percutaneous balloon pericardiotomy?

Answer 6

Biplane fluoroscopy

It is recommended to confirm the balloon’s position in two planes before inflation.

Question 7

What are relative contraindications for percutaneous balloon pericardiotomy?

Answer 7

Platelet or coagulation abnormalities

Excessive bleeding may require surgical intervention.

Question 8

What is the best hemodynamic parameter for distinguishing pericardial constriction from restrictive cardiomyopathy?

Answer 8

Dynamic respiratory variation

Right ventricular systolic pressure increases during inspiration while left ventricular systolic pressure decreases.

Question 9

What major complications are reported in cases of pericardiocentesis?

Answer 9

1.3% to 1.6%

Drainage of more than 1 L of pericardial fluid may lead to right ventricular dilatation.

Question 10

Which type of aortic dissection has the highest occurrence of tamponade?

Answer 10

DeBakey type II

Tamponade occurs in 18% to 45% of these cases.

Question 11

What percentage of malignancy-related pericardial effusions are associated with lung and breast cancer?

Answer 11

Approximately 88% freedom from recurrence at 4 months

Percutaneous balloon pericardiotomy is highly successful in these cases.

Question 12

What is the expected change in right and left atrial pressures during expiration in pericardial tamponade?

Answer 12

Both pressures fall

Right ventricular middiastolic pressures may equal the right atrial and pericardial pressures.

Question 13

What is the mortality rate for untreated tuberculous pericarditis?

Answer 13

Up to 85%

Constrictive pericarditis occurs in 30% to 50% of patients with this condition.

Question 14

What is the sensitivity and specificity of distinguishing constrictive pericarditis from restrictive cardiomyopathy?

Answer 14

> 90% sensitive and specific

The right and left ventricular end diastolic pressures usually differ by <5 mm Hg.

Question 15

What is a major risk associated with endomyocardial biopsy?

Answer 15

Right ventricular perforation

Complication rates are between 0.3% to 5% of cases.

Question 16

What is a pathognomonic sign of pericardial inflammation?

Answer 16

Pericardial friction rub

It is caused by contact between two layers of inflamed pericardium.

Question 17

What should be included in the differential diagnosis of clinical syndrome consistent with right heart failure in a patient with prior malignancy?

Answer 17

• Pericardial metastasis
• Pulmonary embolism
• Chemotherapy-induced cardiomyotoxicity

Metastatic pericardial effusion evolves gradually and presents with fluid overload.

Question 18

What genetic mutation is associated with TRAPS (tumor necrosis factor recurrent acute pericarditis syndrome)?

Answer 18

Mutations in the TNFRSF1A gene

Patients with TRAPS may have recurrent fever, skin rash, and polyserositis.

Question 19

What percentage of patients may experience transient constrictive physiology that resolves completely with medical therapy?

Answer 19

A subset of patients

This was observed more often in patients developing constriction after cardiac surgery.

Question 20

What are the approaches to pericardiocentesis?

Answer 20

• Subxiphoid
• Right xiphocostal
• Apical
• Parasternal

Echo-guided pericardiocentesis often favors the left chest wall approach.

Question 21

What percentage of cases of percutaneous balloon pericardiotomy may require thoracocentesis?

Answer 21

Approximately 10% to 15%

Continuous drainage of >100 mL in 24 hours indicates the need for further intervention.

Question 22

What is the incidence of pericardial effusion after coronary artery bypass surgery?

Answer 22

50%

This condition occurs commonly following the procedure.

Question 23

What indicates the need for a more definitive percutaneous or surgical procedure after balloon pericardiotomy?

Answer 23

Continuous drainage of >100 mL in 24 hours, 3 days post-procedure, and reaccumulation of an effusion with tamponade.

A primary surgical approach may be preferred if a loculated fibrinous effusion is present.

Question 24

What is the incidence of pericardial effusion after coronary artery bypass surgery?

Answer 24

50% to 85%

Cardiac tamponade occurs in approximately 1% to 2% of cases.

Question 25

When does cardiac tamponade typically occur postoperatively?

Answer 25

More than a week postoperatively.

It is typically insidious in onset.

Question 26

Does the use of NSAIDs reduce the size of pericardial effusion or the risk of tamponade?

Answer 26

No, evidence indicates that NSAIDs use neither reduces the size of the effusion nor reduces the risk of tamponade.

Reference: Meurin P, et al. Ann Intern Med 2010;152(3):137–143.

Question 27

What is the incidence of cardiac perforation by an implanted lead of a cardiac implantable electronic device?

Answer 27

Less than 1%.

Late perforation is defined as perforation of the lead through the myocardium more than 1 month after implantation.

Question 28

What are the common indicators of lead perforation?

Answer 28

Increase in lead impedance, failure to pace and sense, increase in pacing threshold.

Lead perforation is commonly associated with a pericardial effusion and is a recognized cause of pericardial tamponade.

Question 29

What should be considered as causes for chest pain and hypotension following PCI?

Answer 29

Stent thrombosis, pericardial effusion, severe hemorrhagic shock.

Pleuritic pain is highly suspicious for pericardial irritation from pericardial effusion.

Question 30

Why might TTE fail to detect localized effusion?

Answer 30

It often fails in the posterior location, behind the left atrium, and in the atrioventricular groove.

In high suspicion cases, a cardiac CT with contrast is recommended.

Question 31

What characterizes pericardial fluid in patients with rheumatoid arthritis?

Answer 31

Low glucose concentration and elevated rheumatoid factor titer.

Pericardial involvement can be symptomatic or asymptomatic.

Question 32

What is the most common cause of constrictive pericarditis in developing countries?

Answer 32

Tuberculosis.

Early treatment with antituberculous therapy and adjunctive steroids is recommended.

Question 33

What can cause pericardial scarring associated with constrictive pericarditis?

Answer 33

Mediastinal radiotherapy for malignancies like esophageal cancer or lymphoma.

Systemic lupus erythematosus and other autoimmune conditions are rarely associated with extensive pericardial scarring.