Clinical Pearls & Morning Reports
Published October 18, 2023
Percutaneous cardiac procedures, such as pacemaker implantation, coronary angioplasty, procedures that involve interatrial septostomy, and transcatheter valve interventions, can cause hemorrhagic pericardial effusion. Read the NEJM Case Records of the Massachusetts General Hospital here.
Q: Name an infection that can cause hemorrhagic pericardial effusion.
A: Although uncommon in the United States, tuberculous pericarditis can occur in patients with tuberculosis and could cause hemorrhagic pericardial effusion. A clue to assist in the diagnosis of tuberculous pericarditis would be a lymphocytic and monocytic cell predominance in the pericardial fluid. Diagnosis of tuberculous pericarditis can be challenging because a mycobacterial (acid-fast bacilli) smear of the pericardial fluid can be negative in up to 60% of patients with this condition. Additional testing of adenosine deaminase activity in the pericardial fluid could be performed.
Q: Metastatic disease associated with which cancers are most often the cause of symptomatic hemorrhagic pericardial effusion in the United States?
A: In the United States, metastatic disease is a common cause of symptomatic hemorrhagic pericardial effusion. Lung, breast, and esophageal cancers are the most common, whereas melanoma, lymphoma, leukemia, and acquired immunodeficiency syndrome–related Kaposi’s sarcoma are less common. It is important to perform cytologic analysis of pericardial fluid in all patients with hemorrhagic effusion.
A: Device erosion is a very rare but serious complication of percutaneous transcatheter closure of ASDs. The true incidence of device erosion is unknown; however, it has been estimated to occur after 0.05 to 0.3% of all procedures. The following risk factors have been associated with an increased risk of device erosion: deficient anterior (aortic) and superior (superior vena cava) tissue rims abutting the ASD (<5 mm thick), an oversized device (defined as a device measuring >5 mm larger than the ASD diameter or the presence of a higher ratio of patient weight to device size or a higher ratio of patient age to device size), and the use of aggressive balloon sizing for device selection (an increased difference in size between the balloon and the static defect).
A: By far, the most common clinical presentation is hemopericardium or cardiac tamponade, with a minority of patients presenting with a fistula between the atrium and the aorta without pericardial fluid accumulation. The median time from device placement to device erosion is 14 days, with 30% of cases occurring within 1 day after the procedure and only 5% of cases occurring beyond 5 years after the procedure. Device erosion can be fatal; death occurs within the first day after diagnosis in half of affected patients and is more common in adults or in patients with an aortoatrial fistula. Surgical intervention is the standard of care for patients presenting with device erosion after percutaneous transcatheter closure of any cardiac defect and should be performed urgently in patients with pericardial tamponade.