An Unusual Case of Effusive-Constrictive Pericarditis in the Intensive Care Unit

Q: What is the clinical evidence from this study?

Study design: Case Report. Population: Acute myeloid leukemia with hemorrhagic cardiac tamponade and effusive-constrictive pericarditis (n=1). Intervention: Ultrasound-guided pericardiocentesis and invasive mechanical positive pressure ventilation during 3+7 induction chemotherapy. Primary outcome: Resolution of cardiac tamponade and clinical survival.

Q: What does this research mean for the field?

Effusive-constrictive pericarditis can cause persistent hemodynamic instability and fatal collapse despite successful pericardiocentesis for hemorrhagic cardiac tamponade in acute myeloid leukemia. Novelty: ClaimNovelty.CONFIRMATORY. Consensus alignment: ConsensusAlignment.NEUTRAL.

Wincy Wing‐Sze Ng; Kin-Bong Tang; Man‐Yee Man; Kin-Yan Hui; Hoi‐Ping Shum

doi:10.1016/j.case.2022.04.011

August 1, 2022CASEOpen Access

An Unusual Case of Effusive-Constrictive Pericarditis in the Intensive Care Unit

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Key result

Pericardiocentesis resolves tamponade but unmasks fatal effusive-constrictive pericarditis in acute myeloid leukemia.

n=1

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Graphical abstract published by CASE — Graphical abstract · Published by CASE · CC BY-NC-ND

Key Points

Highlight the diagnostic and therapeutic challenges of acute hemorrhagic cardiac tamponade complicated by effusive-constrictive pericarditis in a patient with acute myeloid leukemia.
Evaluated an intensive care unit patient with acute myeloid leukemia presenting with acute hemorrhagic pericardial effusion and cardiac arrest.
Performed point-of-care ultrasound and comprehensive transthoracic echocardiography before and after pericardiocentesis and mechanical ventilation.
Echocardiography after pericardiocentesis confirmed effusive-constrictive pericarditis by meeting all 5 noninvasive criteria, including respirophasic septal shift, medial e' ≥ 9 cm/sec, and hepatic vein expiratory flow reversal.
The initiation of invasive mechanical ventilation prior to pericardial drainage aggravated right ventricular preload reduction, contributing to cardiac arrest.

Study Design

Type

Case Report (n=1)

Multicenter

No

Structured PICO

P

Population

A 39-year-old man newly diagnosed with acute myeloid leukemia with hyperleukocytosis who developed acute hemorrhagic cardiac tamponade and effusive-constrictive pericarditis on day 4 of admission.

I

Intervention

Urgent apical ultrasound-guided pericardiocentesis (draining 500 mL heavily blood-stained fluid), invasive mechanical positive pressure ventilation (IMPPV), high-dose vasopressors (norepinephrine 1.6 ug/kg/min, epinephrine 0.1 ug/kg/min), and standard 3+7 induction chemotherapy (cytarabine 100 mg/m2/day IV for 3 days, daunorubicin 90 mg/m2/day IV for 2 days) with IV hydration and rasburicase.

O

Outcome

Echocardiographic diagnosis of effusive-constrictive pericarditis (ECP) post-pericardiocentesis (respirophasic ventricular septal shift, mitral inflow E-wave variation of 30%, annulus reversus with medial e' 12 cm/sec and lateral e' 8 cm/sec, and hepatic vein expiratory diastolic flow reversal) and clinical survival (fatal asystolic cardiac arrest within a few hours of diagnosis).hard clinical

This case highlights that effusive-constrictive pericarditis should be suspected via Doppler echocardiography when hemodynamic instability persists after pericardiocentesis in AML patients, and emphasizes that pericardial drainage should precede mechanical ventilation in cardiac tamponade to avoid fatal hemodynamic collapse.

Limitations

No immunostaining or cytogenetic studies were performed on pericardial fluid to confirm leukemic invasion
Histologic findings were unavailable because the family refused postmortem examination
Cardiac catheterization was not performed due to rapid clinical deterioration and severe thrombocytopenia
Electrocardiogram and respirometer recordings were not included in echocardiographic images due to urgent resuscitation
No immunostaining or cytogenetic studies performed on pericardial fluid to confirm extramedullary AML involvement
Postmortem histological examination refused by patient's family
Invasive hemodynamic assessment via cardiac catheterization was not performed due to clinical instability and severe thrombocytopenia
Electrocardiogram and respirometer recordings were omitted from echocardiographic images due to the urgent resuscitation setting

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Implication

Persistent instability after pericardiocentesis in AML may indicate effusive-constrictive pericarditis; case report leaves open optimal ventilation-drainage sequencing.

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Cite This Study

Ng et al. (2022) conducted a case report in Acute myeloid leukemia with hemorrhagic cardiac tamponade and effusive-constrictive pericarditis (n=1). Ultrasound-guided pericardiocentesis and invasive mechanical positive pressure ventilation during 3+7 induction chemotherapy was evaluated on Resolution of cardiac tamponade and clinical survival. Ultrasound-guided pericardiocentesis of 500 mL hemorrhagic fluid resolved tamponade in a 39-year-old man with AML, but effusive-constrictive pericarditis caused persistent shock and fatal arrest.

synapsesocial.com/papers/6a7b37a4a861e9f59932dd21 https://doi.org/10.1016/j.case.2022.04.011

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An Unusual Case of Effusive-Constrictive Pericarditis in the Intensive Care Unit

Figures

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

An Unusual Case of Effusive-Constrictive Pericarditis in the Intensive Care Unit

Figures

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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