- Email: [email protected]
Clinical and echocardiographic characteristics of hemodynamically significant pericardial effusions in patients with systemic lupus erythematosus
plant coronary artery disease, or significantly abnormal echocardiograms were identified. We had preemptively chosen a threshold of 100 pg/ml based on the adultdeveloped normal values for identifying heart failure, although no normal value for either the adult or pediatric transplant population has been definitively established. There are conflicting studies regarding the normal range of BNP levels, even in healthy children, as well as the possibility of a persistent increase in BNP for years after a transplant.3,13–15 Therefore, our cutoff may underestimate the ideal normal value for BNP, and further research is needed to establish this, as well as to validate the high sensitivity of BNP to exclude the possibility of rejection. Currently, with the known shortcomings of angiogram and biopsy to diagnose rejection or transplant coronary artery disease, an elevated BNP should mandate closer follow-up of the pediatric OHT patient.16 –19 Eventually, increases in BNP may indicate that further studies are necessary, whereas normal values may allow less frequent screening with biopsy and angiography. 1. Bonow RO. New insights into the cardiac natriuretic peptides. Circulation 1996;93:1946 –1950. 2. Maisel AS, Koon J, Krishnaswamy P, Kazenegra R, Clopton P, Gardette N, Morisey R, Garcia A, Chiu A, De Maria A. Utility of B-natriuretic peptide as a rapid, point-of-care test for screen patients undergoing echocardiography to determine left ventricular dysfunction. Am Heart J 2001;141:367–374. 3. Ry SD. Measurement of brain natriuretic peptide in plasma samples and cardiac tissue extracts by means of an immunoradiometric assay method. Scand J Clin Lab Invest 2000;60:81–90. 4. Cowie MR, Struthers AD, Wood DA, Coats AJ, Thompson SG, Poole-Wilson PA, Sutton GC. Value of natriuretic peptides in assessment of patients with possible new heart failure in primary care. Lancet 1997;350:1349 –1353. 5. Geny B, Charloux A, Lampart E, Lonsdorfer J, Habery P, Piquard F. Enhanced brain natriuretic peptide response to peak exercise in heart transplant recipients. J Appl Physiol 1998;85:2270 –2276.
6. Dao Q, Krishnaswany D, Kazanegra R, Harrison A, Amirnovin R, Lenert L,
Clopton P, Alberto J, Hlavin P, Maisel AS. Utility of B-type natriuretic peptide in the diagnosis of congestive heart failure in an urgent care setting. J Am Coll Cardiol 2001;93:1946 –1950. 7. McDonagh TA, Robb SD, Murdoch DR, Morton JJ, Forn I, Morrison CE, Tunstall-Pedoe H, McMurray JJ, Dargie HJ. Biochemical detection of left ventricular systolic dysfunction. Lancet 1998;351:9–13. 8. Sehested J, Happe E, Ishino K, Hetzer R, Schifter S. Diurnal variation in blood pressure in patients with biventricular assist devices and retained, non pumping hearts. Circulation 1994;89:2601–2604. 9. Masters RG. Discoordinate modulation of natriuretic peptides during acute cardiac allograft rejection in humans. Circulation 1999;100:287–291. 10. Chin C, Akhtar MJ, Rosenthal DN, Bernstein D. Safety and utility of the routine surveillance biopsy in pediatric patients 2 years after heart transplantation. J Pedriatr 2000;136:238 –242. 11. Lan YT, Chang RKR, Alejos JC, Burch C, Wetzel GT. B-type natriuretic peptide in children after cardiac transplantation. J Heart Lung Transplant 2003; In press. 12. Billingham ME, Cary NRB, Hammond EH, Kemnitz J, Marboe C, McCallister HA, Snovar DC, Winters GI, Zerbe A. A working formulation for the standardization of nomenclature of Heart and Lung Rejection Study Group. J Heart Lung Transplant 1990;9:587–593. 13. Ationu A. Molecular forms of brain and atrial natriuretic peptides in transplanted human hearts. Br J Biomed Sci 1994;51:316 –320. 14. El Gamel A, Yonan NA, Keevil B, Warbuton R, Kakadellis J, Woodcock A, Campbell CS, Rahman AN, Deiraniya AK. Significance of raised natriuretic peptides after bicaval and standard cardiac transplantation. Ann Thorac Surg 1997;63:1095–1100. 15. Atinou A, Sorenson K, Whitehead B, Singer D, Burch M, Carter ND. Ventricular expression of brain natriuretic peptide gene following orthotopic cardiac transplantation in children—a three year follow up. Cardiovasc Res 1993;27:2135–2139. 16. Putzner GJB, Cooper D, Keehn C, Asante-Korang A, Boucek MM, Boucek RJ Jr. An improved echocardiographic rejection-surveillance strategy following pediatric heart transplantation. J Heart Lung Transplant 2000;19:1166 –1174. 17. Nakhleh RE, Jones J, Goswitz JJ, Anderson AE, Titus J. Correlation of endomyocardial biopsy findings with autopsy findings in human cardiac allografts. J Heart Lung Transplant 1992;11:179 –185. 18. Grauhan O, Muller J, Pfitzman R, Knosalla C, Siniawski H, Fietze E, Volk HD, Hetzer R. Humoral rejection after heart transplantation: reliability of intramyocardial electrogram recordings (IMEG) and myocardial biopsy. Transpl Int 1997;10:439 –445. 19. Fang JC, Rocco T, Jarcho J, Ganz P, Mudge GH. Noninvasive assessment of transplant-associated arteriosclerosis. Am Heart J 1998;135(6 pt 1):980 –987.
Clinical and Echocardiographic Characteristics of Hemodynamically Significant Pericardial Effusions in Patients With Systemic Lupus Erythematosus Sanderson A. Cauduro,
MD,
Kevin G. Moder, MD, Teresa S.M. Tsang, James B. Seward, MD
MD,
and
Echocardiographic-guided pericardiocentesis was found to be safe and efficacious in treating 11 patients with systemic lupus erythematosus who had hemodynamically significant pericardial effusions. These patients tended to present early in their disease course, and men were more often affected. 䊚2003 by Excerpta Medica, Inc. (Am J Cardiol 2003;92:1370 –1372)
ardiac tamponade is rare in patients with systemic lupus erythematosus (SLE). In a review series of C ⬎1,300 patients with SLE, tamponade was only seen
From the Department of Internal Medicine and the Divisions of Cardiovascular Diseases and Rheumatology, Mayo Clinic and Foundation, Rochester, Minnesota. Dr. Moder’s address is: Division of Rheumatology and Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905. E-mail: [email protected]. Manuscript received February 19, 2003; revised manuscript received and accepted August 13, 2003.
Therapeutic pericardiocentesis is occasionally necessary.1 Indications for pericardiocentesis include patients with impending tamponade or for symptomatic relief of large effusions. Echocardiographic-guided pericardiocentesis has been shown to be safe and effective in this clinical setting2,3; surgical pericardectomy is infrequently
in ⬍1%. Symptoms and signs of pericardial effusion and tamponade are related to the size of the effusion and the rapidity in which it accumulates. Treatment of underlying SLE with nonsteroidal anti-inflammatory agents and corticosteroids, together with other steroidsparing agents, is often effective. •••
1370
©2003 by Excerpta Medica, Inc. All rights reserved. The American Journal of Cardiology Vol. 92 December 1, 2003
0002-9149/03/$–see front matter doi:10.1016/j.amjcard.2003.08.036
FIGURE 1. Kaplan-Meier plot of survival curve in patients with SLE after pericardiocentesis.
required. Pericardial fluid is typically inflammatory with a high leukocyte count, low glucose levels, and complement compared with sera. There is often a positive antinuclear antibody also in the fluid. We reviewed the Mayo Clinic echocardiographic database, and, to date, virtually all consecutive pericardiocenteses have been directed by echocardiography since 1979. We specifically investigated (1) clinical and echocardiographic presentation, (2) the efficacy of managing symptomatic pericardial effusion with echocardiographic-guided pericardiocentesis, and (3) how pericardial effusion affects clinical course (outcome). We identified 11 patients (7 men and 4 women) with SLE who underwent 12 pericardiocenteses for clinically or hemodynamically significant pericardial effusion from 1979 to 1997. All other causes of pericardial effusion not related to SLE were not included. Charts were abstracted by a cardiologist and a rheumatologist. All met American College of Rheumatology classification criteria for SLE.4 A comprehensive review of medical records and an echocardiographic database was performed after approval of the institutional review board. Details of pericardiocentesis, and the clinical, demographic, and hemodynamic status of the patients were examined. The clinical presentation at the time of pericardiocentesis was considered unstable when the patient presented with signs of clinical tamponade (pulsus paradoxus, increased jugular venous pressure, hypotension, tachycardia, and echocardiographic characteristics of cardiac chamber compression on bidimensional or Doppler echocardiography). Pre-tamponade was diagnosed by echocardiographic criteria in the absence of combined clinical characteristics of tamponade. Bidimensional echocardiographic characteristics of tamponade included swinging heart, lack of inspiratory collapse of the dilated inferior vena cava, and right chamber compression during early diastole (ventricle) and late diastole (atrium). Doppler echocardiographic patterns of tamponade included marked respiratory variations of ventricular inflow of pulmonary and hepatic venous flow velocities.5
Echocardiographic-guided pericardiocentesis has been performed at the Mayo Clinic since 1979, and has been extensively described.6 Eleven patients (7 men and 4 women, mean age 52 years [range 20 to 81]) underwent 12 pericardiocenteses (1 man had 2 procedures) between 1979 and 1997. Significant pericardial effusion was the initial manifestation in 3 of 11 patients, and in 4 other patients, pericardiocentesis was performed ⬍1 year after the initial diagnosis of SLE. All patients were alert and ambulatory; the most frequent clinical symptoms were shortness of breath (83%), fatigue (58%), and chest pain (42%). Tachycardia (67%), elevated jugular venous pressure (50%), tachypnea (50%), and pulsus paradoxus (33%) were the most frequent physical findings. Pericardial friction rub and fever were each documented in 50% of patients. Mean systolic blood pressure was 120 mm Hg (range 80 to 150); diastolic pressure was 74 mm Hg (range 60 to 90). The average heart rate was 106 beats/ min (range 76 to 175). Nine of 11 patients were receiving prednisone (21 ⫾ 16 mg). Five patients were alive at the time of data collection. The average age of patients at death was 65 ⫾ 16 years and the average of time of SLE diagnosis to death was 12 ⫾ 11 years. Figure 1 shows the survival curve of this series and Table 1 depicts the correlation between mortality and pericardial effusion values. All patients in this series underwent Doppler and bidimensional echocardiographic evaluation before and immediately after pericardiocentesis. Left ventricular systolic function was reduced in 2 patients (ejection fraction 35% and 43%). At pericardiocentesis, valvular vegetations were not present. Echocardiographic Doppler physiology was documented in 50% of patients. Two patients presented with atrial fibrillation and atrial flutter that reverted to normal sinus rhythm after pericardiocentesis. In 10 patients, the fluid was dispersed circumferentially; fluid was loculated in the 1 remaining patient. Pericardial fluid presented as serosanguineous in 7 patients, serous in 3, and bloody in 2. The thoracic wall (63%) was the main access site. Pericardiocentesis required 1 needle passage in 83% of patients. Extended catheter drainage was used in 5 of 12 procedures, for an average of 2.2 days (range 1 to 3). After extended catheter placement, 84 ml (range 0 to 300) of additional fluid was drained. There were no minor or major complications related to pericardiocentesis. The erythrocyte sedimentation rate (median 58 ⫾ 34 mm [range 1 to 105] in the first hour) was measured in 10 of 11 patients. Median leukocyte levels in the pericardial effusion fluid was 6,785/mm3 (range 11 to 15,900). In 9 of 12 patients, the fluid had inflammatory characteristics (⬎2,000 leukocytes/mm3), and polymorphonuclear leukocytes (⬎70%) were predominantly present in 8 of 12 patients. Antidouble strand deoxyribonucleic acid was positive in the serum of 5 of 10 observations. Serum glucose levels were elevated to 88 mg/dl (range 70 to 185) compared with pericardial levels (68 mg/dl [range 50 to 101]). Table 2 lists the serum and pericardial laboratory results. ••• BRIEF REPORTS
1371
TABLE 1 Echocardiographic and Mortality Data
Patient
Age (yrs) & Sex
Year of PCT
Volume of Effusion (ml)
Time of Initial Symptoms to PCT (yrs)
Clinical or Echo Tamponade
Alive
1 2 3 4 5 6 7 8 9 9a* 10 11
M 21 M 80 M 57 F 20 M 64 M 43 F 73 M 60 M 55 M 55 F 50 F 43
1984 1997 1992 1981 1997 1997 1982 1990 1989 1989 1990 1988
650 600 600 200 625 500 400 550 800 1,100 130 980
– 0.1 0.1 0.3 0.6 0.7 1 3 4 4 20 27
⫹ 0 ⫹ 0 ⫹ 0 ⫹ 0 0 ⫹ 0 ⫹
⫹ 0 ⫹ 0 0 ⫹ 0 ⫹ 0 0 0 ⫹
*Second time drainage. PCT ⫽ pericardiocentesis.
This is the largest published series on patients with SLE who underwent echocardiographic-guided pericardiocentesis to manage symptomatic pericardial effusion. Data suggest that symptomatic pericardial effusion predicts reduced survival of patients with SLE. This study also demonstrates how safe and effective echocardiography is in diagnosing and managing this situation. Symptomatic pericardial effusion is an uncommon manifestation of SLE. This study demonstrated that effusion can occur early in the course of SLE. In 7 of 11 patients, it occurred within the first year of the diagnosis of SLE. Moreover, serositis (i.e., pericardial involvement) occurs more frequently in men with SLE, as shown in other series and as confirmed in our study.7,8 Because our study was not a population-based study, it is difficult to quantify the exact risk for the development of hemodynamically significant pericardial effusion in men. However, it is known from investigators’ unpublished data that approximately 150 patients/year are seen at the Mayo Clinic who meet the American College of Rheumatology classification criteria for SLE, and about 15% of these patients are men. Over an 18-year period, approximately 360 men with SLE were seen in our institution. Because 7 men were found to have hemodynamically significant pericardial effusion that required pericardiocentesis, this would suggest that the risk to men with SLE is very small, certainly ⬍5%. Symptomatic pericardial effusion appears to be an indicator of decreased survival despite acute management with echocardiographic-guided pericardiocentesis and treatment with prednisone. Compared with recent prospective SLE clinical studies in which significant pericardial effusion was not investigated, 5-year survival rates were an average of 92%.9 Our series demonstrated 5-year survival of only 46%. Two patients died as a result of malignancy, 1 due to renal insufficiency and cardiac arrhythmias, and 3 of unknown causes. We could not find a correlation between gender, size, or early onset of effusion in disease course and survival, possibly because of the sample size. Because pericardial effusion and other cardiac manifestations are prevalent, potentially serious, yet treatable, manifestations of SLE, it is appropriate to 1372 THE AMERICAN JOURNAL OF CARDIOLOGY姞
VOL. 92
TABLE 2 Laboratory Results (positive values/cases analyzed)
Pericardial Serum
ANA Positive
C3 ng/dl
C4 ng/dl
CH50 U
4/4 8/10
3/5 4/10
2/4 4/8
4/4 3/9
Results are considered positive if ANA is ⬎1:40, C3 is ⬍75 ng/dl, C4 is ⬍14 ng/dl, and CH50 is ⬍9 U. ANA ⫽ antinuclear antibody; C3 ⫽ C3 complement; C4 ⫽ C4 complement; CH50 ⫽ total hemolytic complement.
perform echocardiography to access all symptomatic patients. Management of symptomatic pericardial effusions in SLE using echocardiographic-guided pericardiocentesis appears to be a reasonable approach, alleviating patient’s symptoms with no clinical complications and minimal discomfort. This method, based on a large series, can be used in varied clinical scenarios.10 In our series, it verified a decrease of symptoms in all patients without requiring a surgical procedure. 1. Moder KG, Miller TD, Tazelaar HD. Cardiac involvement in systemic lupus erythematosus. Mayo Clin Proc 1999;74:275–284. 2. Callahan JA, Seward JB, Nishimura RA, Miller FA Jr, Reeder GS, Shub C, Callahan MJ, Schattenberg TT, Tajik AJ. Two-dimensional echocardiographically guided pericardiocentesis: experience in 117 consecutive patients. Am J Cardiol 1985;55:476 –479. 3. Tsang TS, El-Najdawi EK, Seward JB, Hagler DJ, Freeman WK, O’Leary PW. Percutaneous echocardiographically guided pericardiocentesis in pediatric patients: evaluation of safety and efficacy. J Am Soc Echocardiogr 1998;11:1072–1077. 4. Tan EM, Cohen AS, Fries JF, Masi AT, McShane DJ, Rothfield NF, Schaller JG, Talal N, Winchester RJ. The 1982 revised criteria for the classification of systemic lupus erythematosus. Arthritis Rheum 1982;25:1271–1277. 5. Burstow DJ, Oh JK, Bailey KR, Seward JB, Tajik AJ. Cardiac tamponade: characteristic Doppler observations. Mayo Clin Proc 1989;64:312–324. 6. Tsang TS, Freeman WK, Sinak LJ, Seward JB. Echocardiographically guided pericardiocentesis: evolution and state-of- the-art technique. Mayo Clin Proc 1998;73:647–652. 7. Camilleri F, Mallia C. Male SLE patients in Malta. Adv Exp Med Biol 1999;455:173–179. 8. Mok CC, Lau CS, Chan TM, Wong RW. Clinical characteristics and outcome of southern Chinese males with systemic lupus erythematosus. Lupus 1999;8: 188 –196. 9. Trager J, Ward MM. Mortality and causes of death in systemic lupus erythematosus. Curr Opin Rheumatol 2001;13:345–351. 10. Tsang TS, Enriquez-Sarano M, Freeman WK, Freeman WK, Barnes ME, Sinak LJ, Gersh BJ, Bailey KR, Seward JB. Consecutive 1127 therapeutic echocardiographically guided pericardiocenteses: clinical profile, practice patterns, and outcomes spanning 21 years. Mayo Clin Proc 2002;77:429 –436.
DECEMBER 1, 2003
6. Dao Q, Krishnaswany D, Kazanegra R, Harrison A, Amirnovin R, Lenert L,
Clopton P, Alberto J, Hlavin P, Maisel AS. Utility of B-type natriuretic peptide in the diagnosis of congestive heart failure in an urgent care setting. J Am Coll Cardiol 2001;93:1946 –1950. 7. McDonagh TA, Robb SD, Murdoch DR, Morton JJ, Forn I, Morrison CE, Tunstall-Pedoe H, McMurray JJ, Dargie HJ. Biochemical detection of left ventricular systolic dysfunction. Lancet 1998;351:9–13. 8. Sehested J, Happe E, Ishino K, Hetzer R, Schifter S. Diurnal variation in blood pressure in patients with biventricular assist devices and retained, non pumping hearts. Circulation 1994;89:2601–2604. 9. Masters RG. Discoordinate modulation of natriuretic peptides during acute cardiac allograft rejection in humans. Circulation 1999;100:287–291. 10. Chin C, Akhtar MJ, Rosenthal DN, Bernstein D. Safety and utility of the routine surveillance biopsy in pediatric patients 2 years after heart transplantation. J Pedriatr 2000;136:238 –242. 11. Lan YT, Chang RKR, Alejos JC, Burch C, Wetzel GT. B-type natriuretic peptide in children after cardiac transplantation. J Heart Lung Transplant 2003; In press. 12. Billingham ME, Cary NRB, Hammond EH, Kemnitz J, Marboe C, McCallister HA, Snovar DC, Winters GI, Zerbe A. A working formulation for the standardization of nomenclature of Heart and Lung Rejection Study Group. J Heart Lung Transplant 1990;9:587–593. 13. Ationu A. Molecular forms of brain and atrial natriuretic peptides in transplanted human hearts. Br J Biomed Sci 1994;51:316 –320. 14. El Gamel A, Yonan NA, Keevil B, Warbuton R, Kakadellis J, Woodcock A, Campbell CS, Rahman AN, Deiraniya AK. Significance of raised natriuretic peptides after bicaval and standard cardiac transplantation. Ann Thorac Surg 1997;63:1095–1100. 15. Atinou A, Sorenson K, Whitehead B, Singer D, Burch M, Carter ND. Ventricular expression of brain natriuretic peptide gene following orthotopic cardiac transplantation in children—a three year follow up. Cardiovasc Res 1993;27:2135–2139. 16. Putzner GJB, Cooper D, Keehn C, Asante-Korang A, Boucek MM, Boucek RJ Jr. An improved echocardiographic rejection-surveillance strategy following pediatric heart transplantation. J Heart Lung Transplant 2000;19:1166 –1174. 17. Nakhleh RE, Jones J, Goswitz JJ, Anderson AE, Titus J. Correlation of endomyocardial biopsy findings with autopsy findings in human cardiac allografts. J Heart Lung Transplant 1992;11:179 –185. 18. Grauhan O, Muller J, Pfitzman R, Knosalla C, Siniawski H, Fietze E, Volk HD, Hetzer R. Humoral rejection after heart transplantation: reliability of intramyocardial electrogram recordings (IMEG) and myocardial biopsy. Transpl Int 1997;10:439 –445. 19. Fang JC, Rocco T, Jarcho J, Ganz P, Mudge GH. Noninvasive assessment of transplant-associated arteriosclerosis. Am Heart J 1998;135(6 pt 1):980 –987.
Clinical and Echocardiographic Characteristics of Hemodynamically Significant Pericardial Effusions in Patients With Systemic Lupus Erythematosus Sanderson A. Cauduro,
MD,
Kevin G. Moder, MD, Teresa S.M. Tsang, James B. Seward, MD
MD,
and
Echocardiographic-guided pericardiocentesis was found to be safe and efficacious in treating 11 patients with systemic lupus erythematosus who had hemodynamically significant pericardial effusions. These patients tended to present early in their disease course, and men were more often affected. 䊚2003 by Excerpta Medica, Inc. (Am J Cardiol 2003;92:1370 –1372)
ardiac tamponade is rare in patients with systemic lupus erythematosus (SLE). In a review series of C ⬎1,300 patients with SLE, tamponade was only seen
From the Department of Internal Medicine and the Divisions of Cardiovascular Diseases and Rheumatology, Mayo Clinic and Foundation, Rochester, Minnesota. Dr. Moder’s address is: Division of Rheumatology and Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905. E-mail: [email protected]. Manuscript received February 19, 2003; revised manuscript received and accepted August 13, 2003.
Therapeutic pericardiocentesis is occasionally necessary.1 Indications for pericardiocentesis include patients with impending tamponade or for symptomatic relief of large effusions. Echocardiographic-guided pericardiocentesis has been shown to be safe and effective in this clinical setting2,3; surgical pericardectomy is infrequently
in ⬍1%. Symptoms and signs of pericardial effusion and tamponade are related to the size of the effusion and the rapidity in which it accumulates. Treatment of underlying SLE with nonsteroidal anti-inflammatory agents and corticosteroids, together with other steroidsparing agents, is often effective. •••
1370
©2003 by Excerpta Medica, Inc. All rights reserved. The American Journal of Cardiology Vol. 92 December 1, 2003
0002-9149/03/$–see front matter doi:10.1016/j.amjcard.2003.08.036
FIGURE 1. Kaplan-Meier plot of survival curve in patients with SLE after pericardiocentesis.
required. Pericardial fluid is typically inflammatory with a high leukocyte count, low glucose levels, and complement compared with sera. There is often a positive antinuclear antibody also in the fluid. We reviewed the Mayo Clinic echocardiographic database, and, to date, virtually all consecutive pericardiocenteses have been directed by echocardiography since 1979. We specifically investigated (1) clinical and echocardiographic presentation, (2) the efficacy of managing symptomatic pericardial effusion with echocardiographic-guided pericardiocentesis, and (3) how pericardial effusion affects clinical course (outcome). We identified 11 patients (7 men and 4 women) with SLE who underwent 12 pericardiocenteses for clinically or hemodynamically significant pericardial effusion from 1979 to 1997. All other causes of pericardial effusion not related to SLE were not included. Charts were abstracted by a cardiologist and a rheumatologist. All met American College of Rheumatology classification criteria for SLE.4 A comprehensive review of medical records and an echocardiographic database was performed after approval of the institutional review board. Details of pericardiocentesis, and the clinical, demographic, and hemodynamic status of the patients were examined. The clinical presentation at the time of pericardiocentesis was considered unstable when the patient presented with signs of clinical tamponade (pulsus paradoxus, increased jugular venous pressure, hypotension, tachycardia, and echocardiographic characteristics of cardiac chamber compression on bidimensional or Doppler echocardiography). Pre-tamponade was diagnosed by echocardiographic criteria in the absence of combined clinical characteristics of tamponade. Bidimensional echocardiographic characteristics of tamponade included swinging heart, lack of inspiratory collapse of the dilated inferior vena cava, and right chamber compression during early diastole (ventricle) and late diastole (atrium). Doppler echocardiographic patterns of tamponade included marked respiratory variations of ventricular inflow of pulmonary and hepatic venous flow velocities.5
Echocardiographic-guided pericardiocentesis has been performed at the Mayo Clinic since 1979, and has been extensively described.6 Eleven patients (7 men and 4 women, mean age 52 years [range 20 to 81]) underwent 12 pericardiocenteses (1 man had 2 procedures) between 1979 and 1997. Significant pericardial effusion was the initial manifestation in 3 of 11 patients, and in 4 other patients, pericardiocentesis was performed ⬍1 year after the initial diagnosis of SLE. All patients were alert and ambulatory; the most frequent clinical symptoms were shortness of breath (83%), fatigue (58%), and chest pain (42%). Tachycardia (67%), elevated jugular venous pressure (50%), tachypnea (50%), and pulsus paradoxus (33%) were the most frequent physical findings. Pericardial friction rub and fever were each documented in 50% of patients. Mean systolic blood pressure was 120 mm Hg (range 80 to 150); diastolic pressure was 74 mm Hg (range 60 to 90). The average heart rate was 106 beats/ min (range 76 to 175). Nine of 11 patients were receiving prednisone (21 ⫾ 16 mg). Five patients were alive at the time of data collection. The average age of patients at death was 65 ⫾ 16 years and the average of time of SLE diagnosis to death was 12 ⫾ 11 years. Figure 1 shows the survival curve of this series and Table 1 depicts the correlation between mortality and pericardial effusion values. All patients in this series underwent Doppler and bidimensional echocardiographic evaluation before and immediately after pericardiocentesis. Left ventricular systolic function was reduced in 2 patients (ejection fraction 35% and 43%). At pericardiocentesis, valvular vegetations were not present. Echocardiographic Doppler physiology was documented in 50% of patients. Two patients presented with atrial fibrillation and atrial flutter that reverted to normal sinus rhythm after pericardiocentesis. In 10 patients, the fluid was dispersed circumferentially; fluid was loculated in the 1 remaining patient. Pericardial fluid presented as serosanguineous in 7 patients, serous in 3, and bloody in 2. The thoracic wall (63%) was the main access site. Pericardiocentesis required 1 needle passage in 83% of patients. Extended catheter drainage was used in 5 of 12 procedures, for an average of 2.2 days (range 1 to 3). After extended catheter placement, 84 ml (range 0 to 300) of additional fluid was drained. There were no minor or major complications related to pericardiocentesis. The erythrocyte sedimentation rate (median 58 ⫾ 34 mm [range 1 to 105] in the first hour) was measured in 10 of 11 patients. Median leukocyte levels in the pericardial effusion fluid was 6,785/mm3 (range 11 to 15,900). In 9 of 12 patients, the fluid had inflammatory characteristics (⬎2,000 leukocytes/mm3), and polymorphonuclear leukocytes (⬎70%) were predominantly present in 8 of 12 patients. Antidouble strand deoxyribonucleic acid was positive in the serum of 5 of 10 observations. Serum glucose levels were elevated to 88 mg/dl (range 70 to 185) compared with pericardial levels (68 mg/dl [range 50 to 101]). Table 2 lists the serum and pericardial laboratory results. ••• BRIEF REPORTS
1371
TABLE 1 Echocardiographic and Mortality Data
Patient
Age (yrs) & Sex
Year of PCT
Volume of Effusion (ml)
Time of Initial Symptoms to PCT (yrs)
Clinical or Echo Tamponade
Alive
1 2 3 4 5 6 7 8 9 9a* 10 11
M 21 M 80 M 57 F 20 M 64 M 43 F 73 M 60 M 55 M 55 F 50 F 43
1984 1997 1992 1981 1997 1997 1982 1990 1989 1989 1990 1988
650 600 600 200 625 500 400 550 800 1,100 130 980
– 0.1 0.1 0.3 0.6 0.7 1 3 4 4 20 27
⫹ 0 ⫹ 0 ⫹ 0 ⫹ 0 0 ⫹ 0 ⫹
⫹ 0 ⫹ 0 0 ⫹ 0 ⫹ 0 0 0 ⫹
*Second time drainage. PCT ⫽ pericardiocentesis.
This is the largest published series on patients with SLE who underwent echocardiographic-guided pericardiocentesis to manage symptomatic pericardial effusion. Data suggest that symptomatic pericardial effusion predicts reduced survival of patients with SLE. This study also demonstrates how safe and effective echocardiography is in diagnosing and managing this situation. Symptomatic pericardial effusion is an uncommon manifestation of SLE. This study demonstrated that effusion can occur early in the course of SLE. In 7 of 11 patients, it occurred within the first year of the diagnosis of SLE. Moreover, serositis (i.e., pericardial involvement) occurs more frequently in men with SLE, as shown in other series and as confirmed in our study.7,8 Because our study was not a population-based study, it is difficult to quantify the exact risk for the development of hemodynamically significant pericardial effusion in men. However, it is known from investigators’ unpublished data that approximately 150 patients/year are seen at the Mayo Clinic who meet the American College of Rheumatology classification criteria for SLE, and about 15% of these patients are men. Over an 18-year period, approximately 360 men with SLE were seen in our institution. Because 7 men were found to have hemodynamically significant pericardial effusion that required pericardiocentesis, this would suggest that the risk to men with SLE is very small, certainly ⬍5%. Symptomatic pericardial effusion appears to be an indicator of decreased survival despite acute management with echocardiographic-guided pericardiocentesis and treatment with prednisone. Compared with recent prospective SLE clinical studies in which significant pericardial effusion was not investigated, 5-year survival rates were an average of 92%.9 Our series demonstrated 5-year survival of only 46%. Two patients died as a result of malignancy, 1 due to renal insufficiency and cardiac arrhythmias, and 3 of unknown causes. We could not find a correlation between gender, size, or early onset of effusion in disease course and survival, possibly because of the sample size. Because pericardial effusion and other cardiac manifestations are prevalent, potentially serious, yet treatable, manifestations of SLE, it is appropriate to 1372 THE AMERICAN JOURNAL OF CARDIOLOGY姞
VOL. 92
TABLE 2 Laboratory Results (positive values/cases analyzed)
Pericardial Serum
ANA Positive
C3 ng/dl
C4 ng/dl
CH50 U
4/4 8/10
3/5 4/10
2/4 4/8
4/4 3/9
Results are considered positive if ANA is ⬎1:40, C3 is ⬍75 ng/dl, C4 is ⬍14 ng/dl, and CH50 is ⬍9 U. ANA ⫽ antinuclear antibody; C3 ⫽ C3 complement; C4 ⫽ C4 complement; CH50 ⫽ total hemolytic complement.
perform echocardiography to access all symptomatic patients. Management of symptomatic pericardial effusions in SLE using echocardiographic-guided pericardiocentesis appears to be a reasonable approach, alleviating patient’s symptoms with no clinical complications and minimal discomfort. This method, based on a large series, can be used in varied clinical scenarios.10 In our series, it verified a decrease of symptoms in all patients without requiring a surgical procedure. 1. Moder KG, Miller TD, Tazelaar HD. Cardiac involvement in systemic lupus erythematosus. Mayo Clin Proc 1999;74:275–284. 2. Callahan JA, Seward JB, Nishimura RA, Miller FA Jr, Reeder GS, Shub C, Callahan MJ, Schattenberg TT, Tajik AJ. Two-dimensional echocardiographically guided pericardiocentesis: experience in 117 consecutive patients. Am J Cardiol 1985;55:476 –479. 3. Tsang TS, El-Najdawi EK, Seward JB, Hagler DJ, Freeman WK, O’Leary PW. Percutaneous echocardiographically guided pericardiocentesis in pediatric patients: evaluation of safety and efficacy. J Am Soc Echocardiogr 1998;11:1072–1077. 4. Tan EM, Cohen AS, Fries JF, Masi AT, McShane DJ, Rothfield NF, Schaller JG, Talal N, Winchester RJ. The 1982 revised criteria for the classification of systemic lupus erythematosus. Arthritis Rheum 1982;25:1271–1277. 5. Burstow DJ, Oh JK, Bailey KR, Seward JB, Tajik AJ. Cardiac tamponade: characteristic Doppler observations. Mayo Clin Proc 1989;64:312–324. 6. Tsang TS, Freeman WK, Sinak LJ, Seward JB. Echocardiographically guided pericardiocentesis: evolution and state-of- the-art technique. Mayo Clin Proc 1998;73:647–652. 7. Camilleri F, Mallia C. Male SLE patients in Malta. Adv Exp Med Biol 1999;455:173–179. 8. Mok CC, Lau CS, Chan TM, Wong RW. Clinical characteristics and outcome of southern Chinese males with systemic lupus erythematosus. Lupus 1999;8: 188 –196. 9. Trager J, Ward MM. Mortality and causes of death in systemic lupus erythematosus. Curr Opin Rheumatol 2001;13:345–351. 10. Tsang TS, Enriquez-Sarano M, Freeman WK, Freeman WK, Barnes ME, Sinak LJ, Gersh BJ, Bailey KR, Seward JB. Consecutive 1127 therapeutic echocardiographically guided pericardiocenteses: clinical profile, practice patterns, and outcomes spanning 21 years. Mayo Clin Proc 2002;77:429 –436.
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