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Intrapericardial echocardiographic images and cardiac constriction
Volume 121 Number 1, Part 1
Brief Communiculions
207
have associated with their use a variety of complications. These have included but are not limited to lead fracture, inappropriate shock delivery, infection, and atria1 and ventricular arrhythmias. 2,3 As the current device is activated through the application of a magnet, the manufacturer warns that a variety of devices, including microwave ovens, motors, transformers, arc welders, radio-frequency transmitters, as well as diathermy and electrocautery units may provide electromechanical interference resulting in inappropriate function of an automatic implantable defibrillator.4 The inadvertent inactivation of an AICD by the magnet in a stereo speaker has been recently reported.5 We conclude that the currently available AICD is sensitive to inadvertent inactivation by low-strength magnetic fields that can be produced by easily available “innocuous” devices. With the increasing use of the AICD in the management of patients with sustained ventricular arrhythmias, the potential for device inactivation needs to be recognized so that patients can be instructed how to minimize the risk of this occurrence. REFERENCES
1. Marchlinski FE, Flores BT, Buxton AE. The automatic implantable cardioverter defibrillator: efficacy, complications, and device failures. Ann Intern Med 1986;104:481-8. 2. Kelly PA, Cannom DS, Garan H, Mirabal GS, Harthorne JW, Hurvitz RJ, Vlahakes GJ, Jacobs L, Ilvento JP, Buckley MJ, Ruskin JN. The automatic implantable cardioverter defibrillator: efficacy, complications and survival in patients with malignant ventricular arrhythmias. J Am Co11 Cardiol 1988;11:1278-86. 3. Gabry MD, Brodman R, Johnston D, Frame R, Kim SG, Waspe L, Fisher JD, Furman S. Automatic implantable cardioverter defibrillator: patient survival, battery longevity, and shock deliverv analvsis. J Am Co11 Cardiol. 1987:9:1349-56. 4. Electra-magnetic, electrical, and magnetic interference. Physicians Manual for the automatic implantable cardioverter defibrillator. CPI Document #1650155 (Al St. Paul. Minn: 1986:ll. 5. Karson TH, Grace K, Denes P. Stereo speaker silences automatic implantable cardioverter defibrillator. N. Engl J Med 1989:320:1628-g.
lntrapericardial echocardiographic and cardiac constriction J. Al&Bosch, MD, J. Candell-Riera, MD, L. Monge-Rangel, MD, and J. Soler-Soler, Barcelona, Spain
images
MD.
Several intrapericardial echocardiographic images have been reported in patients with pericardial effusion,‘, 2; it has been suggested that their presence may indicate the likelihood of developing constrictive pericarditis3 As most From the Servicio de Cardiologia, Hospital General “Vail d’Hebron.” Reprint requests: Dra. J. Ali&Bosch, Servicio de Cardiologia, Hospital General “Vall d’Hebron,” Paseo Valle Hebron s/n, 08035 Barcelona, Spain. 4/4/25109
Fig. 1. Parasternal short-axis (A) and apical four-chamber (B) views. Large pericardial effusion and pericardial “bands” (arrows) can be seen. LV, Left ventricle; RV, right ventricle; LA, left atrium; RA, right atrium.
reports in the literature deal with isolated patients4 we thought that a wider study of the relationship between intrapericardial echocardiographic images and cardiac constriction would be of interest. The study included 64 consecutive patients (33 males, 31 females), aged between 6 and 91 years (mean age, 47 years) with moderate or large pericardial effusion (sum of the anterior and posterior echo-free spaces of 10 cm or more) as evaluated by two-dimensional echocardiography. The patients belonged to an already reported prospective series from our institution.5 The mean clinical and echocardiographic follow-up was 24 months, ranging between 3 and 72
208
January
Brief Communications
American
Table
Heart
1991
Journal
II. Echocardiographic findings and constriction
Group 1
No.
Constriction
40
3 (7.5%, )
p < 0.01 Group 2 “Bands” “Coat-like”
13 11
5 (38.4%) 0 (0%)
developed constrictive pericarditis (12.5 % ). In three of these eight patients who developed constriction, intrapericardial images had not been shown in serial echocardiograms (3 of 40, 7.5%), whereas in the remaining five patients pericardial “bands” had been found (5 of 13,
38.4%) (p < 0.01) (Table II). The development of constrictive pericarditis was more common in tuberculous pericarditis (five of six patients) than in the patients with Fig.
2. Apical four-chamber view, showing large pericar-
dial effusion and intrapericardial “coat-like” echoes (arLV, Left ventricle; RV, right ventricle.
rows).
I. Echocardiographic findings and etiology of pericardial disease Table
Group 1 Group 2 “Bands” “Coat-like”
other types of pericardial disease (3 of 58) (p < 0.0001). Two-dimensional echocardiography may be very useful not only for the detection of pericardial effusion, but to investigate
possible
intrapericardial
images.l, 3 The “bands”
probably correspond to fibrinous exudate in the pericardial space, and may favor the development of constriction. It was noteworthy that in our study these images were found before the development of clinical findings of cardiac constriction, and always during the initial 3 months of admission. In addition, no patient with “coat-like” images devel-
No.
TBC
NE0
CHR
ID
Other
40
2
4
6
25
3*
oped cardiac constriction. We think therefore that the
2t 31
presence or development of intrapericardial bands in a pericardial effusion (which, in our series, was more common in tuberculous pericarditis) indicates a higher likelihood of
13 11
4 0
1 0
TBC, Tuberculous; NEO, neoplasia; CHR, chronic effusion; ID, acute idiopathic pericarditis. *Post cardiac surgery, hypereosinophilic syndrome, tTrauma, radiation. iUremia, trauma, Dressier’s syndrome.
0 2 idiopathic
6 6
pericardial
radiation.
months. The patients were divided in two groups depending on whether they had or did not have intrapericardial images within the pericardial effusion. Constriction was demonstrated by clinical, external cardiac recordings, and echocardiographic criteria6 in all patients and by catheterization criteria in four patients. The statistical analysis was carried out with Fisher’s exact test. In 40 of the 64 evaluated patients, the pericardial space was completely echo-free (group l), while it showed intrapericardial images in 24 (group 2). In these 24 patients, linear echoes crossing the pericardial cavity, which we call “bands” (Fig. l), were found in 13. In the remaining 11 patients we found echodense images surrounding the epicardium; these we call “coat-like” echoes (Fig. 2). In Table I the different etiologies of pericardial disease are distrib-
uted according to the echocardiographic findings. Pericardial “bands” were found in four of six patients with tuberculous pericarditis and in 9 of the 58 remaining patients (p < 0.02). Out of the 64 patients with pericardial effusion, eight
subsequent constrictive pericarditis. These patients should be more closely monitored, both with clinical and echocardiographic examinations, months of their clinical
particularly evolution.
during
the initial
3
The authors thank Dr. G. Permanyer-Miralda and Dr. J. Sagristh-Sauleda for their help in performing the study investigations. REFERENCES
1. Chandraratna PAN, Aronow WS. Detection of pericardial metastases by cross-sectional echocardiography. Circulation 1981;63:197. 2. Trouillet JL, Dahan M, Touche T, Kitzis M, Groussard 0, Cohen-Solal A, Gourgon R. Evaluation de 1’8chographie bidimensionnelle dans l’orientation 6tiologique des maladies du pbricarde. Arch Ma1 Coeur 1987;80:1238. 3. Martin RP, Bowden R, Filly K, Popp RL. Intrapericardial abnormalities in patients with pericardial effusion: findings by two-dimensional echocsrdiography. Circulation 1980;61:568. 4. Come PC, Miklozek CL, Riley MF, Carl LV, Morgan JP. Echocardiographic changes in rapidly developing pericardial constriction. AM HEART J 1985;109:1385. 5. Permanyer-Miralda G, Sagrista-Sauleda J, Soler-Soler J. Primary acute pericardial disease: a prospective series of 231 consecutive patients. Am J Cardiol 1985;56:623. 6. Candell-Riera J, Garcia de1 Castillo H, Permanyer-Miralda G, Soler-Soler J. Echocardiographic features of the interventricular septum in chronic constrictive pericarditis. Circulation 1978;57:1154.
Brief Communiculions
207
have associated with their use a variety of complications. These have included but are not limited to lead fracture, inappropriate shock delivery, infection, and atria1 and ventricular arrhythmias. 2,3 As the current device is activated through the application of a magnet, the manufacturer warns that a variety of devices, including microwave ovens, motors, transformers, arc welders, radio-frequency transmitters, as well as diathermy and electrocautery units may provide electromechanical interference resulting in inappropriate function of an automatic implantable defibrillator.4 The inadvertent inactivation of an AICD by the magnet in a stereo speaker has been recently reported.5 We conclude that the currently available AICD is sensitive to inadvertent inactivation by low-strength magnetic fields that can be produced by easily available “innocuous” devices. With the increasing use of the AICD in the management of patients with sustained ventricular arrhythmias, the potential for device inactivation needs to be recognized so that patients can be instructed how to minimize the risk of this occurrence. REFERENCES
1. Marchlinski FE, Flores BT, Buxton AE. The automatic implantable cardioverter defibrillator: efficacy, complications, and device failures. Ann Intern Med 1986;104:481-8. 2. Kelly PA, Cannom DS, Garan H, Mirabal GS, Harthorne JW, Hurvitz RJ, Vlahakes GJ, Jacobs L, Ilvento JP, Buckley MJ, Ruskin JN. The automatic implantable cardioverter defibrillator: efficacy, complications and survival in patients with malignant ventricular arrhythmias. J Am Co11 Cardiol 1988;11:1278-86. 3. Gabry MD, Brodman R, Johnston D, Frame R, Kim SG, Waspe L, Fisher JD, Furman S. Automatic implantable cardioverter defibrillator: patient survival, battery longevity, and shock deliverv analvsis. J Am Co11 Cardiol. 1987:9:1349-56. 4. Electra-magnetic, electrical, and magnetic interference. Physicians Manual for the automatic implantable cardioverter defibrillator. CPI Document #1650155 (Al St. Paul. Minn: 1986:ll. 5. Karson TH, Grace K, Denes P. Stereo speaker silences automatic implantable cardioverter defibrillator. N. Engl J Med 1989:320:1628-g.
lntrapericardial echocardiographic and cardiac constriction J. Al&Bosch, MD, J. Candell-Riera, MD, L. Monge-Rangel, MD, and J. Soler-Soler, Barcelona, Spain
images
MD.
Several intrapericardial echocardiographic images have been reported in patients with pericardial effusion,‘, 2; it has been suggested that their presence may indicate the likelihood of developing constrictive pericarditis3 As most From the Servicio de Cardiologia, Hospital General “Vail d’Hebron.” Reprint requests: Dra. J. Ali&Bosch, Servicio de Cardiologia, Hospital General “Vall d’Hebron,” Paseo Valle Hebron s/n, 08035 Barcelona, Spain. 4/4/25109
Fig. 1. Parasternal short-axis (A) and apical four-chamber (B) views. Large pericardial effusion and pericardial “bands” (arrows) can be seen. LV, Left ventricle; RV, right ventricle; LA, left atrium; RA, right atrium.
reports in the literature deal with isolated patients4 we thought that a wider study of the relationship between intrapericardial echocardiographic images and cardiac constriction would be of interest. The study included 64 consecutive patients (33 males, 31 females), aged between 6 and 91 years (mean age, 47 years) with moderate or large pericardial effusion (sum of the anterior and posterior echo-free spaces of 10 cm or more) as evaluated by two-dimensional echocardiography. The patients belonged to an already reported prospective series from our institution.5 The mean clinical and echocardiographic follow-up was 24 months, ranging between 3 and 72
208
January
Brief Communications
American
Table
Heart
1991
Journal
II. Echocardiographic findings and constriction
Group 1
No.
Constriction
40
3 (7.5%, )
p < 0.01 Group 2 “Bands” “Coat-like”
13 11
5 (38.4%) 0 (0%)
developed constrictive pericarditis (12.5 % ). In three of these eight patients who developed constriction, intrapericardial images had not been shown in serial echocardiograms (3 of 40, 7.5%), whereas in the remaining five patients pericardial “bands” had been found (5 of 13,
38.4%) (p < 0.01) (Table II). The development of constrictive pericarditis was more common in tuberculous pericarditis (five of six patients) than in the patients with Fig.
2. Apical four-chamber view, showing large pericar-
dial effusion and intrapericardial “coat-like” echoes (arLV, Left ventricle; RV, right ventricle.
rows).
I. Echocardiographic findings and etiology of pericardial disease Table
Group 1 Group 2 “Bands” “Coat-like”
other types of pericardial disease (3 of 58) (p < 0.0001). Two-dimensional echocardiography may be very useful not only for the detection of pericardial effusion, but to investigate
possible
intrapericardial
images.l, 3 The “bands”
probably correspond to fibrinous exudate in the pericardial space, and may favor the development of constriction. It was noteworthy that in our study these images were found before the development of clinical findings of cardiac constriction, and always during the initial 3 months of admission. In addition, no patient with “coat-like” images devel-
No.
TBC
NE0
CHR
ID
Other
40
2
4
6
25
3*
oped cardiac constriction. We think therefore that the
2t 31
presence or development of intrapericardial bands in a pericardial effusion (which, in our series, was more common in tuberculous pericarditis) indicates a higher likelihood of
13 11
4 0
1 0
TBC, Tuberculous; NEO, neoplasia; CHR, chronic effusion; ID, acute idiopathic pericarditis. *Post cardiac surgery, hypereosinophilic syndrome, tTrauma, radiation. iUremia, trauma, Dressier’s syndrome.
0 2 idiopathic
6 6
pericardial
radiation.
months. The patients were divided in two groups depending on whether they had or did not have intrapericardial images within the pericardial effusion. Constriction was demonstrated by clinical, external cardiac recordings, and echocardiographic criteria6 in all patients and by catheterization criteria in four patients. The statistical analysis was carried out with Fisher’s exact test. In 40 of the 64 evaluated patients, the pericardial space was completely echo-free (group l), while it showed intrapericardial images in 24 (group 2). In these 24 patients, linear echoes crossing the pericardial cavity, which we call “bands” (Fig. l), were found in 13. In the remaining 11 patients we found echodense images surrounding the epicardium; these we call “coat-like” echoes (Fig. 2). In Table I the different etiologies of pericardial disease are distrib-
uted according to the echocardiographic findings. Pericardial “bands” were found in four of six patients with tuberculous pericarditis and in 9 of the 58 remaining patients (p < 0.02). Out of the 64 patients with pericardial effusion, eight
subsequent constrictive pericarditis. These patients should be more closely monitored, both with clinical and echocardiographic examinations, months of their clinical
particularly evolution.
during
the initial
3
The authors thank Dr. G. Permanyer-Miralda and Dr. J. Sagristh-Sauleda for their help in performing the study investigations. REFERENCES
1. Chandraratna PAN, Aronow WS. Detection of pericardial metastases by cross-sectional echocardiography. Circulation 1981;63:197. 2. Trouillet JL, Dahan M, Touche T, Kitzis M, Groussard 0, Cohen-Solal A, Gourgon R. Evaluation de 1’8chographie bidimensionnelle dans l’orientation 6tiologique des maladies du pbricarde. Arch Ma1 Coeur 1987;80:1238. 3. Martin RP, Bowden R, Filly K, Popp RL. Intrapericardial abnormalities in patients with pericardial effusion: findings by two-dimensional echocsrdiography. Circulation 1980;61:568. 4. Come PC, Miklozek CL, Riley MF, Carl LV, Morgan JP. Echocardiographic changes in rapidly developing pericardial constriction. AM HEART J 1985;109:1385. 5. Permanyer-Miralda G, Sagrista-Sauleda J, Soler-Soler J. Primary acute pericardial disease: a prospective series of 231 consecutive patients. Am J Cardiol 1985;56:623. 6. Candell-Riera J, Garcia de1 Castillo H, Permanyer-Miralda G, Soler-Soler J. Echocardiographic features of the interventricular septum in chronic constrictive pericarditis. Circulation 1978;57:1154.