Fluid around the heart

Contents

Hydrops fetalis/erythroblastosis fetalis

Mirror Syndrome

In up to 50 percent of pregnancies complicated by hydrops, a condition call mirror syndrome (or Ballentine syndrome) will develop. This condition is thought to be a variant of a pregnancy-related blood pressure disease called preeclampsia and may result in life-threatening maternal hypertension (elevated blood pressures) or seizures. The only treatment for mirror syndrome is immediate delivery of the baby

How do you treat hydrops fetalis?

Treatment for hydrops depends on the determined cause, if any. Otherwise, the care of a baby born with complications of hydrops is primarily focused on comfort measures, if no therapy or treatment is available.

When the underlying cause is determined to be complications of low blood counts, one potential therapy is transfusion of blood products to the fetus, just as would be done for an adult with critically low blood. This procedure is called a PUBS (percutaneous umbilical blood sampling). A PUBS involved an amniocentesis where a needle is guided by ultrasound into the umbilical cord of the baby so that the blood can be sampled for testing and new blood may be transfused to restore the blood levels. Blood levels are expressed as hematocrit and the initial procedure goal is a hematocrit of 20-25 percent. A repeat procedure is likely necessary to achieve a final hematocrit of 45-50 percent within 48-72 hours. (Then, transfusions are done at two- to three-week intervals, with the last one done at 34 to 35 weeks gestation. These babies should improve before birth.

The treatment protocol for other cases of non-immune hydrops is aimed at the underlying cause. If the underlying cause is known, the benefits and risks of the treatment will be weighed against likelihood of survival.

Babies who have not shown improvement before birth should be delivered at a tertiary care center with a level III neonatal intensive care unit capable of extensive evaluation and complex care of the compromised newborn immediately after delivery. Because hydrops of uncertain causes are associated with such poor outcomes, you should expect your team of doctors to have very open and frank conversations with you and your family about options of palliative care versus aggressive resuscitation, prior to delivering your baby. A neonatologist will work with you to develop a plan of care for your baby once he or she is born.

For infants without any specific diagnosis, we offer supportive treatment as we give the baby time to reabsorb all the edema (fluid from swelling). Often, there are complications like infection, and sometimes the baby is unresponsive to the support provided.

Delivery method

The best method for delivery of babies with hydrops is uncertain and a Cesarean section may be advised. At delivery, most babies who are being aggressively resuscitated will require endotracheal intubation (the placement of a special tube in the windpipe) to help with breathing. Placing the breathing tube can be difficult because of the swelling from the excess fluid in the baby’s body. High-frequency ventilation and high airway pressure settings may also be required to provide the baby with enough oxygen. To help your baby breathe, we may need to place tubes in the chest to help remove fluid from the abdomen and around the lungs.

We may also place special IV lines. Normally, in the umbilical cord, there are two arteries and one vein. We also put an umbilical artery catheter in one of the arteries of the umbilical cord. With this special line, we can:

  • Provide fluids
  • Give medications
  • Monitor blood pressure
  • Remove blood for blood tests

What about surgery?

Under some circumstances, surgical treatment of the suspected cause of hydrops may be discussed. For example, congenital cystic adenomatoid malformation and bronchopulmonary sequestration may be responsive to surgical treatment, but will only be considered if hydrops is diagnosed at certain gestational ages. You can discuss this option with your perinatologist.

Will I be able to help care for my baby after birth?

Yes. Please ask your baby’s nurse about ways to interact with and care for your baby. These babies are typically very ill at birth and will require aggressive treatments. To help in your understanding about what is being done and why, ask questions about the treatments and procedures and visit often with your baby.

If you had planned to breastfeed your baby, you can begin to pump and freeze your breast milk while you are still in the hospital. A lactation consultant can assist in answering your questions. Your milk will be frozen and stored in the Neonatal Intensive Care Unit until your baby is ready for it. The NICU has breast pumps and private rooms available to you when you are visiting.

You can bring in pictures, small toys, booties and blankets for your baby while he or she is in the NICU.

When can my baby go home?

If the treatment leads to a reversal and the hydrops resolves, your infant may eventually go home. However, for an infant with non-immune hydrops, the prognosis is very poor. Your baby must be able to eat enough to maintain and gain weight and breathe effectively by himself or herself before going home. It is important to remember the complication of hydrops has a poor prognosis of survival except for those cases that have a definite cause with established fetal treatment.

What is my baby’s long-term prognosis?

Long-term prognosis is guarded. These babies are critically ill even if they do survive to birth. Of the fetuses diagnosed prenatally, only about 20 percent survive to delivery. Of this number, approximately half will survive the neonatal period. Long-term survival for those that make it through the newborn period is based on the underlying cause of the hydrops. The data currently shows an optimistic outlook for those babies who do survive.

What is peripartum cardiomyopathy?

Peripartum cardiomyopathy (PPCM), also known as postpartum cardiomyopathy, is an uncommon form of heart failure that happens during the last month of pregnancy or up to five months after giving birth. Cardiomyopathy literally means heart muscle disease.

PPCM is a dilated form of the condition, which means the heart chambers enlarge and the muscle weakens. This causes a decrease in the percentage of blood ejected from the left ventricle of the heart with each contraction. That leads to less blood flow and the heart is no longer able to meet the demands of the body’s organs for oxygen, affecting the lungs, liver, and other body systems.

PPCM is rare in the United States, Canada, and Europe. About 1,000 to 1,300 women develop the condition in the U.S. each year. In some countries, PPCM is much more common and may be related to differences in diet, lifestyle, other medical conditions or genetics.

How is it diagnosed?

PPCM may be difficult to detect because symptoms of heart failure can mimic those of third trimester pregnancy, such as swelling in the feet and legs, and some shortness of breath. More extreme cases feature severe shortness of breath and prolonged swelling after delivery.

During a physical exam, doctors will look for signs of fluid in the lungs. A stethoscope will be used to listen for lung crackles, a rapid heart rate, or abnormal heart sounds. An echocardiogram can detect the cardiomyopathy by showing the diminished functioning of the heart.

PPCM is diagnosed when the following three criteria are met:

  1. Heart failure develops in the last month of pregnancy or within 5 months of delivery.
  2. Heart pumping function is reduced, with an ejection fraction (EF) less than 45% (typically measured by an echocardiogram). EF is how much blood the left ventricle pumps out with each contraction. A normal EF can be between 55 and 70.
  3. No other cause for heart failure with reduced EF can be found.

Laboratory blood tests are a standard part of the evaluation. This includes tests to assess kidney, liver and thyroid function; tests to assess electrolytes, including sodium and potassium; and a complete blood count to look for anemia or evidence of infection. In addition, markers of cardiac injury and stress can be used to assess level of risk.

Symptoms of the condition include:

  • Fatigue
  • Feeling of heart racing or skipping beats (palpitations)
  • Increased nighttime urination (nocturia)
  • Shortness of breath with activity and when lying flat
  • Swelling of the ankles
  • Swollen neck veins
  • Low blood pressure, or it may drop when standing up.

The severity of symptoms in patients with PPCM can be classified by the New York Heart Association system:

  • Class I – Disease with no symptoms
  • Class II – Mild symptoms/effect on function or symptoms only with extreme exertion
  • Class III – Symptoms with minimal exertion
  • Class IV – Symptoms at rest

What are the causes?

The underlying cause is unclear. Heart biopsies in some cases show women have inflammation in the heart muscle. This may be because of prior viral illness or abnormal immune response. Other potential causes include poor nutrition, coronary artery spasm, small-vessel disease, and defective antioxidant defenses. Genetics may also play a role.

Initially thought to be more common in women older than 30, PPCM has since been reported across a wide range of age groups. Risk factors include:

  • Obesity
  • History of cardiac disorders, such as myocarditis (inflammation of the heart muscle)
  • Use of certain medications
  • Smoking
  • Alcoholism
  • Multiple pregnancies
  • African-American descent
  • Poor nourishment

How can PPCM be treated?

The objective of peripartum cardiomyopathy treatment is to keep extra fluid from collecting in the lungs and to help the heart recover as fully as possible. Many women recover normal heart function or stabilize on medicines. Some progress to severe heart failure requiring mechanical support or heart transplantation.

There are several classes of medications a physician can prescribe to treat symptoms, with variations that are safer for women who are breastfeeding.

  • Angiotensin converting enzyme, or ACE, inhibitors – Help the heart work more efficiently
  • Beta blockers – Cause the heart to beat more slowly so it has recovery time
  • Diuretics – Reduce fluid retention
  • Digitalis – Derived from the foxglove plant, it has been used for more than 200 years to treat heart failure. Digitalis strengthens the pumping ability of the heart
  • Anticoagulants – To help thin the blood. Patients with PPCM are at increased risk of developing blood clots, especially if the EF is very low.

Doctors may recommend a low-salt diet, fluid restrictions, or daily weighing. A weight gain of 3 to 4 pounds or more over a day or two may signal a fluid buildup.

Women who smoke and drink alcohol will be advised to stop, since these habits may make the symptoms worse.

A heart biopsy may help determine if the underlying cause of cardiomyopathy is a heart muscle infection (myocarditis). However, this procedure is uncommon.

How can women minimize their risk?

To develop and maintain a strong heart, women should avoid cigarettes and alcohol, eat a well-balanced diet and get regular exercise. Women who develop peripartum cardiomyopathy are at high risk of developing the same condition with future pregnancies.

What’s next?

Investigations are underway to understand the cause of PPCM and to develop new treatments. Treatments that alter the immune system such as intravenous γ-globulin and immunoabsorption have been tried but are not proven. Investigators also have focused on the role of prolactin in PPCM. Prolactin is a hormone released from the pituitary gland late in pregnancy and after delivery that stimulates breast milk production. Prolactin, however, may have adverse effects on the heart muscle by limiting its blood supply and causing cell death. Bromocryptine is a medication that inhibits the pituitary secretion of prolactin. Early studies suggest it helps treat PPCM, but more research is needed.

A Rough Pregnancy – Read Rebecca Stewart’s PPCM story featured in Heart Insight Magazine.

Heart Disease & Pregnancy

If you have a prosthetic valve and are taking an anticoagulant medication, it is very important to be evaluated by a cardiologist before planning a pregnancy. The cardiologist will talk to you about your potential risks and determine the best anticoagulant therapy routine for you.

In addition, ask your doctor what precautions you should continue to follow to prevent endocarditis.

Aorta Disease and pregnancy

Women who have conditions that affect the aorta, such as aortic aneurysm, dilated aorta, or connective tissue disorders such as Marfan syndrome, are at increased risk during pregnancy.

Pressure in the aorta increases during pregnancy and when bearing down during labor and delivery. This extra pressure increases the risk of an aortic dissection or rupture, which can be life-threatening.

It is very important for women who have aorta disease to be evaluated by a cardiologist before planning a pregnancy. A thorough evaluation of your condition will provide the physician with information about the potential risks of pregnancy. It is also important to note that some conditions, such as Marfan syndrome, are genetic and can be passed down to children, so genetic counseling may be recommended.

After you become pregnant

Congratulations on your pregnancy! During pregnancy, it’s important to:

  • Continue following a heart-healthy diet.
  • Exercise regularly, as recommended by your cardiologist.
  • Quit smoking!

In addition to keeping your follow-up appointments with your obstetric provider throughout pregnancy, schedule regular follow-up visits with your cardiologist and follow the recommendations carefully. Your cardiologist can evaluate your heart condition throughout your pregnancy so symptoms and/or potential complications can be detected and treated early. This will help ensure a safe outcome for you and your baby.

Some conditions may require a team approach that involves you and your obstetrician, cardiologist, anesthesiologist and pediatrician. Depending on your heart condition, special arrangements may be needed for labor and delivery.

Cardiovascular disorders that may develop during pregnancy

Peripartum cardiomyopathy

Peripartum cardiomyopathy is a rare condition. It is when heart failure develops in the last month of pregnancy or within five months after delivery. The cause of peripartum cardiomyopathy remains unknown. Certain patients, including those with multiple pregnancies and those of African descent, are at greatest risk. Women with peripartum cardiomyopathy have symptoms of heart failure. After pregnancy, the heart usually returns to its normal size and function. But, some women continue to have poor left ventricular function and symptoms. Women with peripartum cardiomyopathy have an increased risk of complications during future pregnancies, especially if the heart dysfunction continues.

Hypertension (high blood pressure)

About 6% to 8% of women develop high blood pressure, also called hypertension, during pregnancy. This is called pregnancy-induced hypertension (PIH) and is related to preeclampsia, toxemia, or toxemia of pregnancy. Symptoms of PIH include high blood pressure, swelling due to fluid retention, and protein in the urine. Pregnancy-induced hypertension can be harmful to the mother and the baby. To learn more about who is at risk for PIH, symptoms of PIH, and how PIH is diagnosed and treated, click on the following links:

  • Cleveland Clinic – Pregnancy-Induced Hypertension
  • Cleveland Clinic – Preeclampsia and Eclampsia
  • American Heart Association – Pregnancy and High Blood Pressure

Myocardial infarction

Heart attack (myocardial infarction) is fortunately a very rare but potentially deadly complication that can occur during pregnancy or during the first few weeks afterwards. A heart attack can be caused by many things. Patients with coronary artery disease (“hardening of the arteries”) can have a myocardial infarction if the plaque inside their arteries ruptures. This problem is becoming more common, since many women wait until later in life to become pregnant. Other causes of a heart attack include a spontaneous blood clot inside a coronary vessel (because pregnancy increases the risk of blood clots) and coronary dissection (a weakening of the vessel wall that leads to a spontaneous tear and clotting). If you have a heart attack, it is critical to get emergency help. Treatment will be focused on ensuring your survival.

Heart Murmur

Sometimes, the increase in blood volume during pregnancy can cause a heart murmur(an abnormal “swishing” sound). In most cases, the murmur is harmless. But in rare cases, it could mean there’s a problem with a heart valve. Your doctor can evaluate your condition and determine the cause of the murmur.

Arrhythmias and pregnancy

Abnormal heartbeats (arrhythmias) during pregnancy are common. Women who have never had an arrhythmia or heart problem may first develop an arrhythmia during pregnancy. When an arrhythmia develops during pregnancy, it can be a sign of a heart condition you didn’t know you had. Most of the time, the arrhythmia causes little in the way of symptoms and does not require treatment. If you have symptoms, your doctor may order tests to determine the type arrhythmia you have and attempt to determine its cause.

  • Learn more about arrhythmia and pregnancy

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Pericarditis refers to inflammation of the pericardium, two thin layers of a sac-like tissue that surround the heart, hold it in place and help it work. A small amount of fluid keeps the layers separate so that there’s no friction between them.

A common symptom of pericarditis is chest pain, caused by the sac’s layers becoming inflamed and possibly rubbing against the heart. It may feel like pain from a heart attack.

If you have chest pain, call 911 right away because you may be having a heart attack. Learn about warning signs for a heart attack.

Overview

Pericarditis can be attributed to several factors, including viral, bacterial, fungal and other infections. Other possible causes of pericarditis include heart attack or heart surgery, other medical conditions, injuries and medications.

Pericarditis can be acute, meaning it happens suddenly and typically doesn’t last long. Or the condition may be “chronic,” meaning that it develops over time and may take longer to treat.

Both types of pericarditis can disrupt your heart’s normal rhythm or function. In rare cases, pericarditis can have very serious consequences, even leading to death.

Outlook

Most of the time, pericarditis is mild and clears up on its own with rest or simple treatment. Sometimes, more intense treatment is needed to prevent complications.

Recovery from pericarditis may take a few days to weeks or even months.

Other names for pericarditis

  • Idiopathic pericarditis (no known cause)
  • Acute pericarditis
  • Chronic pericarditis
  • Chronic effusive pericarditis and chronic constrictive pericarditis (forms of chronic pericarditis)
  • Recurrent pericarditis

Causes of pericarditis

The cause of pericarditis is often unknown, though viral infections are a common cause. Pericarditis often occurs after a respiratory infection.

Chronic, or recurring pericarditis is usually the result of autoimmune disorders such as lupus, scleroderma and rheumatoid arthritis. These are disorders in which the body’s immune system makes antibodies that mistakenly attack the body’s tissues or cells.

Other possible causes of pericarditis are:

  • Heart attack and heart surgery
  • Kidney failure, HIV/AIDS, cancer, tuberculosis and other health problems
  • Injuries from accidents or radiation therapy
  • Certain medicines, like phenytoin (an anti-seizure medicine), warfarin and heparin (both blood-thinning medicines), and procainamide (a medicine to treat irregular heartbeats)

Who is at risk for pericarditis?

Pericarditis affects people of all ages, but men 20 to 50 years old are more likely to develop pericarditis than others.

Among those treated for acute pericarditis, 15 to 30 percent may experience the condition again, with a small number eventually developing chronic pericarditis.

Also in this section:

  • Symptoms and diagnosis of pericarditis
  • Prevention and treatment of pericarditis

Source:

Tests for heart and circulatory conditions

What are the symptoms of pericarditis?

Symptoms of pericarditis include:

  • chest pain that feels like a stabbing sensation
  • pain in the neck that may spread across the shoulders and/or arms
  • a fever
  • nausea (feeling like you want to vomit)
  • feeling light headed
  • a sudden shortness of breath (if you experience this get urgent medical help).

The pain can sometimes get worse when you’re lying down and better when you’re leaning forward.

What causes pericarditis?

The cause of pericarditis is not always known (idiopathic). It is a complex condition that can have many causes.

Pericarditis can be caused by:

  • a virus or bacterial infection
  • another inflammatory condition (such as rheumatoid arthritis)
  • inflammation of the myocardium (the heart muscle) rubbing against the pericardium. This can happen after a heart attack or heart surgery.

How is pericarditis diagnosed?

Pericarditis is a complex condition which can be hard to diagnose. You will need to be examined by a doctor. Your doctor will need to look at your medical history in order to diagnose the condition.

Tests for diagnosing pericarditis include:

  • an electrocardiogram (ECG)
  • an echocardiogram (echo)
  • a chest X-ray.

How is pericarditis treated?

Treatments for pericarditis depend on the cause and may include:

  • anti-inflammatory medication such as colchicine
  • painkillers
  • pericardial window – surgery that’s done only if symptoms persist. This drains the sac surrounding the heart.

Recovery from pericarditis

Most people recover from pericarditis quickly, but for some it can take several months or have longer effects.

As this rare condition can’t be seen or linked with an unhealthy lifestyle, it can be challenging to understand the effects of living with pericarditis. Because of this people with pericarditis may often feel isolated, causing them to experience other effects such as anxiety, palpitations and panic attacks.

Is Fluid Around the Heart Dangerous?

Q1. My neighbor was recently diagnosed with fluid around the heart. What does this mean? Is it dangerous?

— Madeline, Florida

There are many reasons why fluid can build up around the heart, a condition that is medically known as pericardial effusion. It is often associated with pericarditis, which is an inflammation of the pericardium, a double-layered membrane sac that surrounds the heart and protects it. One layer of the pericardial tissue is fibrous, connecting the heart to surrounding tissues; the other layer is serous, meaning it normally contains a small amount of pale yellow fluid that prevents friction as the heart pumps.

Are you doing everything you can to manage your heart condition? Find out with our interactive checkup.

Problems can arise when, for some reason, too much fluid starts to accumulate in this covering, also known as the pericardial lining. When that happens, the fluid can put pressure on the heart, affecting blood circulation and the body’s oxygen supply.

Just to be clear, pericardial effusion and/or pericarditis are not the same as congestive heart failure, which people sometimes mistakenly describe as “fluid around the heart.” In congestive heart failure, fluid builds up in the lungs, causing the lungs to be heavy and making it difficult to breathe; in pericardial effusion or pericarditis, fluid builds up in the lining around the heart.

Q2. My dad is 99 and will be 100 this year. His heart rate is slow, in the 54 to 40 range. It’s been like that for several years. It was stated that he has bradycardia. Do you think he should have a pacemaker at his age? What are the risks? Thank you!

— Faye, California

Even though your father is nearly 100 years old, there is no specific reason why he shouldn’t be able to get a pacemaker if he is otherwise healthy. A pacemaker can be a life-saving device in the event of heart failure, which is a risk for patients with slow heart rhythms (bradyarrythmias). Since your father has been diagnosed with bradycardia (a resting heart rate of fewer than 60 beats per minute), he could certainly be a candidate for a pacemaker, though it is not clear from your description whether his heart rate has been at that level for some time or if this is a more recent issue. Your father’s doctor can determine, based on his overall health and his specific heart condition, whether a pacemaker would be right for him. It would, of course, also be important for your father to have a cardiologic workup before considering a pacemaker to make sure that his body is capable of handling the surgery required to insert the device. Generally speaking, the insertion of a pacemaker is a safe procedure, but since your father is nearly 100 years old there are some additional risks involved, as there would be with any type of surgery at that age. Should he choose to go through with getting a pacemaker, it is important that your father seek out a very skilled and knowledgeable cardiologist and team who can monitor his health throughout the process.

Learn more in the Everyday Health Heart Health Center.

Pericardial Effusion

Pericardial effusion, sometimes referred to as “fluid around the heart,” is the abnormal build-up of excess fluid that develops between the pericardium, the lining of the heart, and the heart itself.

Who is affected by pericardial effusions?

Since pericardial effusions are a result of many different diseases or conditions, anyone who develops one of the many conditions that can produce an effusion may be affected. Pericardial effusions can be acute (comes on quickly) or chronic (lasting more than 3 months).

Is pericardial effusion serious?

The seriousness of the condition depends on the primary cause, size and rate of growth of the effusion — and whether it can be treated effectively. Causes that can be treated or controlled, such as an infection due to a virus or heart failure, allows the patient to be effectively treated and remain free of pericardial effusions.

Pericardial effusion caused by other conditions, such as cancer, is very serious and should be diagnosed and treated promptly.

Additionally, rapid fluid accumulation in the pericardium can cause cardiac tamponade, a severe compression of the heart that impairs its ability to function. Cardiac tamponade resulting from pericardial effusion can be life-threatening.

What are the symptoms of pericardial effusion?

Many patients with a small pericardial effusion have no symptoms. The condition is often discovered on a chest x-ray, CT scan or echocardiogram that was performed for another reason. Initially, the pericardium may stretch to accommodate excess fluid build-up. Therefore, signs and symptoms may not occur until a large amount of fluid has collected over time.If symptoms do occur, they may result from compression of surrounding structures, such as the lung, stomach or phrenic nerve (a nerve that connects to the diaphragm). Symptoms also may occur due to diastolic heart failure (heart failure that occurs because the heart is unable to relax normally between each contraction due to the added compression).Symptoms of pericardial effusion include:

  • Chest pressure or pain
  • Shortness of breath
  • Nausea
  • Abdominal fullness
  • Difficulty in swallowing

Symptoms that pericardial effusion is causing cardiac tamponade include:

  • Blue tinge to the lips and skin
  • Shock
  • Change in mental status

Cardiac tamponade is a severe compression of the heart that impairs its ability to function. Cardiac tamponade resulting from pericardial effusion can be life-threatening and is a medical emergency, requiring urgent drainage of the fluid.

What causes pericardial effusion?

Pericardial effusion, and the possible inflammation of the pericardium resulting from it (called pericarditis), can have many possible causes, including:

  • Infection such as viral, bacterial or tuberculous
  • Inflammatory disorders, such as lupus and rheumatoid arthritis
  • Cancer that has spread (metastasized) to the pericardium
  • Kidney failure with excessive blood levels of nitrogen
  • Heart surgery

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Pericardiocentesis

What is pericardiocentesis?

Pericardiocentesis is a procedure done to remove fluid that has built up in the sac around the heart (pericardium). It’s done using a needle and small catheter to drain excess fluid.

A fibrous sac known as the pericardium surrounds the heart. This sac is made of two thin layers with a small amount of fluid between them. This fluid reduces friction between the layers as they rub against each other when the heart beats. In some cases, too much fluid builds up between these two layers. This is called pericardial effusion. When this happens, it can affect the normal function of the heart. Pericardiocentesis drains this fluid and prevents future fluid buildup.

During pericardiocentesis, a doctor inserts a needle through the chest wall and into the tissue around the heart. Once the needle is inside the pericardium, the doctor inserts a long, thin tube called a catheter. The doctor uses the catheter to drain excess fluid. The catheter may come right out after the procedure. Or it may stay in place for several hours or overnight. This is to make sure all the fluid has drained, and to prevent fluid from building up again.

Why might I need pericardiocentesis?

Many medical conditions can cause fluid to build up around the heart. This fluid buildup can cause shortness of breath and chest pain. This may be treatable with medicine. In other cases, this fluid buildup is life threatening and needs draining right away.

Pericardiocentesis can help drain the fluid around the heart. And it can help diagnose the cause of the extra fluid. Conditions that can cause pericardial effusion include:

  • Infection of the heart or pericardial sac
  • Cancer
  • Inflammation of the pericardial sac due to a heart attack
  • Injury
  • Immune system disease
  • Reactions to certain drugs
  • Radiation
  • Metabolic causes, like kidney failure with uremia

Sometimes the cause of fluid buildup is unknown.

Pericardiocentesis is not the only method to remove fluid around the heart. However, it is preferred because it is less invasive than surgery. Sometimes doctors surgically drain the fluid. This may be done in people who have had chronic fluid buildup or inflammation, in people who might need part of the pericardium removed, or in people whose fluid has certain characteristics.

What are the risks of pericardiocentesis?

All procedures have some risks. The risks of pericardiocentesis include:

  • Puncturing the heart, which may require surgery to repair
  • Puncturing the liver
  • Excess bleeding, which might compress the heart and affect its normal function
  • Air in the chest cavity
  • Infection
  • Abnormal heart rhythms (which can cause death in rare instances)
  • Heart failure with fluid in the lungs (rare)

There is also a chance that the fluid around the heart will come back. If this happens, you might need to repeat the procedure, or you might eventually need all or part of your pericardium removed.

Your own risks may vary according to your age, your general health, and the reason for your procedure or type of surgery you have. They may also vary depending on the anatomy of the heart, fluid, and pericardium. Talk with your healthcare provider to find out what risks may apply to you.

How do I get ready for pericardiocentesis?

Ask your doctor how to prepare for pericardiocentesis. You will probably need to avoid eating and drinking for 6 hours or more before the procedure. Ask the doctor whether you need to stop taking any medicines before the procedure.

The doctor may want some extra tests before the surgery. These might include:

  • Chest X-ray
  • Electrocardiogram (ECG), to check the heart rhythm
  • Blood tests, to assess general health
  • Echocardiogram, to view blood flow through the heart and the fluid around the heart
  • CT or MRI, if the doctor needs more information about the heart
  • Heart catheterization, to measure the pressure within the heart

What happens during pericardiocentesis?

Talk to your doctor about what will happen during your procedure. A cardiologist and a surgical team will do the procedure. The following is a description of catheter-based pericardiocentesis, the most common form. In general:

  • You will be awake. An IV will be inserted in your hand or arm. You will most likely be given medicine to make you sleepy before the procedure starts.
  • Your vital signs will be closely watched.
  • The procedure should take around an hour.
  • Your doctor will do an echocardiogram to view the fluid around your heart and your heart anatomy. This will help determine the best place to insert the needle.
  • The doctor will apply a local anesthetic at the needle insertion site, below the breastbone.
  • The doctor will insert the needle through the skin. You might feel this as pressure or slight pain. You can have pain medicine if needed.
  • The needle will be guided to the fluid in the pericardial sac with the help of an echocardiogram or X-ray imaging (fluoroscopy).
  • Once the needle is in the correct area, it will be removed and replaced with a catheter. Fluid will drain out through the catheter. In some cases, this catheter may stay in place for several hours or even days. In other cases, it may come out sooner.
  • The catheter will be removed when enough fluid has drained. Pressure will be applied to the catheter insertion site to prevent bleeding.

What happens after pericardiocentesis?

Ask your doctor about what to expect after the procedure. In general, after your pericardiocentesis:

  • You may be groggy and disoriented upon waking.
  • Your vital signs, such as your heart rate, breathing, blood pressure, and oxygen levels, will be carefully watched.
  • If the catheter that was used to drain the fluid is left in place, it will be checked to make sure it’s not blocked before it can be safely removed.
  • You may have an echocardiogram to confirm the absence of fluid re-accumulation.
  • You may have a chest X-ray to make sure the needle did not puncture your lung during the procedure.
  • A sample of the drained fluid may be sent to a lab for testing.
  • You will probably need to stay in the hospital for one or more days. This may partly depend on the reason for your pericardiocentesis.

After you leave the hospital:

  • You should be able to resume normal activities relatively soon, but avoid vigorous exercise until your doctor says it’s OK.
  • Make sure you keep all of your follow-up appointments.
  • Call the doctor if you have fever, increased draining from the needle insertion site, chest pain, or any severe symptoms.
  • Follow all the instructions your healthcare provider gives you for medicines, exercise, diet, and wound care.

Many people note improvements in their symptoms right after having pericardiocentesis.

Next steps

Before you agree to the test or the procedure make sure you know:

  • The name of the test or procedure
  • The reason you are having the test or procedure
  • What results to expect and what they mean
  • The risks and benefits of the test or procedure
  • What the possible side effects or complications are
  • When and where you are to have the test or procedure
  • Who will do the test or procedure and what that person’s qualifications are
  • What would happen if you did not have the test or procedure
  • Any alternative tests or procedures to think about
  • When and how will you get the results
  • Who to call after the test or procedure if you have questions or problems
  • How much will you have to pay for the test or procedure

PMC

Discussion

Since the introduction of antibiotics, pyopneumopericarditis is a rarely seen complication of pneumococcal infection. In a 14-year period (1960–1974) the Massachusetts General Hospital found 26 cases of purulent pericarditis, with two cases due to Streptococcus pneumonia.1 Between 6 and 7.5% of purulent pericarditis is due to a bacterial infection, most commonly S. aureus. Nowadays, this clinical problem is mostly seen in immune-compromised patients, after oesophageal interventions, thoracic surgery or thoracic trauma.2 Spreading mechanisms consist of direct spread from infected tissue into the pericardial space, or indirect haematogenous spread.3

Pneumococcal pericarditis is a serious illness with a high mortality of up to 30%. Cardiac tamponade is usually the cause of death, mainly because of delayed or missed diagnosis.4

The diagnosis is made based on purulent pericardial fluid or positive cultures after pericardiocentesis.4

We did not find any previous cases in the literature in which the Streptococcus pneumonia antigen test was used for pericardial effusion. This test is a rapid in vitro immunochromatographic assay for the detection of S. pneumoniae antigen in the urine of patients with pneumonia and in the cerebral spinal fluid (CSF) of patients with meningitis. The sensitivity of the test for urine is 86 and 97% for CSF, with specificities of 94 and 99%, respectively.5 We believe that, because the concentration of antigen after lysis of the Streptococcus pneumonia in the pericardial effusion has to be higher than in urine, the sensitivity and specificity of this test is increased in pericardial effusion.

Surgical drainage of the pericardium in conjunction with systemic antibiotic administration results in the best therapeutic results.6 Early surgical drainage could prevent the complication of constrictive pericarditis.4

We believe, especially because of the positive pneumococcal antigen test, that our patient was suffering from pyopneumopericarditis, secondary to a pneumococcal pneumonia. Based on the results of the sputum culture, H. influenzae pericarditis would be the differential diagnosis. H. influenza is not uncommon in the paediatric population, but can also be found in adults.7

After pericardiocentesis intravenous treatment was started with antibiotics (first penicillin and, after the positive sputum culture, amoxicillin/clavulanic acid). Over the next few days the patient developed signs of haemodynamic compromise for which he was transferred to a thoracic surgery centre. First, a pericardial window was created by a subxiphoid approach followed by inserting a drain for adequate drainage. At a later stage, pericardiectomy was necessary because of the development of constrictive pericarditis.

In summary, although quite rare nowadays, the diagnosis of pyopneumopericarditis should be considered if a respiratory tract infection is complicated by haemodynamic instability. We would recommend using the Streptococcus pneumoniae antigen test to confirm the aetiology.

How pneumonia bacteria can compromise heart health

Carlos Orihuela, from the University of Texas Health Science Center in San Antonio, USA, and colleagues initially studied the reasons for heart failure during invasive pneumococcal disease (when S. pneumoniae bacteria infect major organs such as the lungs, bloodstream, and brain) in mice, and subsequently confirmed some of their main findings in rhesus macaques and in heart tissue from deceased human patients.

Mice with severe invasive pneumococcal disease showed elevated levels of troponin, a marker for heart injury, in their blood. They also had abnormal EKGs. When the researchers examined the hearts of the mice, they found microscopic sites of injury (called microlesions) in the heart muscle. S. pneumoniae were found within these microlesions, indicating the bacteria were able to invade and multiply within the heart. Looking in more detail, the researchers identified dying heart muscle cells in the tissue surrounding microlesions.

At the molecular level, the researchers found that the S. pneumoniae toxin pneumolysin was present within the microlesions and responsible for heart muscle cell death. They also showed that S. pneumoniae requires a molecule called CbpA to exit the bloodstream and invade the heart. Moreover, an experimental vaccine formulation composed of CbpA and a non-toxic version of pneumolysin generated antibodies that protected mice against cardiac invasion and heart damage.

Having obtained tissues from three rhesus macaques that had died from pneumococcal pneumonia, the researchers found cardiac microlesions that were similar in size and appearance to those seen in mice, but without the presence of S. pneumoniae bacteria. The situation was similar in cardiac samples from human patients who had died from invasive pneumococcal disease. Two of the samples (they looked at a total of nine) showed microlesions, but the lesions did not contain bacteria.

As the macaques and the human patients had been treated with antibiotics, the researchers wondered whether the bacteria had caused the lesions but subsequently been killed by the treatment. To test this, they infected mice with S. pneumoniae and treated them with a high-dose antibiotic (ampicillin) when the lesions were first apparent. The hearts of these mice looked similar to the macaques and human samples, with clear presence of microlesions but devoid of bacteria. As the researchers discuss, ampicillin acts by breaking bacteria apart and releasing their contents, including pneumolysin, and this could exacerbate the death of heart muscle cells. Alternative antibiotics that do not spill their bacterial targets’ contents exist and might be advantageous.

Having shown for the first time that S. pneumoniae can directly damage the heart — which could help explain the link between pneumonia and adverse heart events — the researchers conclude that “research is merited to determine the true frequency of cardiac microlesions in patients hospitalized with invasive pneumococcal disease, if modifications in antibiotic therapy improve long-term outcomes, and if prevention of cardiac damage is an indication for vaccination.”

Heart attack risk rises after a bout of pneumonia

If you’re hospitalized with pneumonia,your heart attack risk may rise in the following month.

Image: Thinkstock

If you’re over 65, be sure to follow the latest pneumonia vaccine guidelines.

Published: March, 2015

Each year, about a million people in the United States end up in the hospital with pneumonia, a serious lung infection that can be caused by an array of different viruses, bacteria, and even fungi. New research suggests that older people hospitalized with pneumonia face four times their usual risk of a having a heart attack or stroke or dying of heart disease in the month following the illness.

The risk declines over the following year, according to the report, published in the Jan. 20, 2015, Journal of the American Medical Association. Infections put added stress on your heart, forcing it to work harder. Your body’s efforts to fight the infection also trigger unhealthy changes inside your arteries, such as releasing chemicals that can make blood more likely to clot, which can lead to a heart attack or stroke.

“Serious infections like pneumonia are linked to a higher risk of heart attack as well as worsening heart failure in people with that condition,” says Dr. Scott Solomon, a professor of medicine at Harvard Medical School. For older people, the pneumonia vaccine may help prevent these dangerous complications, but an annual flu shot is also important, he notes. The same virus that causes the flu can also cause viral pneumonia in some people and nudge others to develop bacterial pneumonia.

Pneumonia symptoms

The symptoms of pneumonia are similar to the flu: fever, muscle aches, and headache. But your cough is usually worse (sometimes producing yellow, green, or even bloody mucus), and you may have trouble breathing. For example, you may get winded going up just a few stairs, when you normally walk up two flights without a problem. Older people with pneumonia sometimes don’t have a fever or a cough, but they may be confused or complain of pain when taking a deep breath.

Two vaccines

The Centers for Disease Control and Prevention recommend that people ages 65 and older receive two different vaccines— PCV13 (Prevnar 13) and PPSV23 (Pneumovax). If you’re in that age group and have already had your one-time Pneumovax shot, the CDC recommends getting a Prevnar 13 inoculation a year later. If you haven’t had a pneumonia vaccine, you’re advised to get a Prevnar 13 shot first, followed by a Pneumovax injection six to 12 months later. 

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