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Pericardial Disease: The authors reply
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LETTERS
Mayo Clln Proc, February 1992, Vol 67
therapeutic taps (as in this case) for diagnosis versus "diagnostic" taps, which provide minimal diagnostic information. The authors quote me (theirreference 1) as stating"...as little as 250 ml during rapid accumulation" will cause tamponade. Actually, in that study, I noted that as little as 150 ml is capable of compressing the heart in acute injuries to the heart and brisk bleeding. In contrast, a 200- to 250-ml increase in pericardial contents may be the threshold for roentgenographic recognition of fluid-provoked enlargement of the cardiac silhouette. In the case report, bacterial infections are listed among the most common causes of tamponade, but actually in the United States, viral infections are much more common. Indeed, the commonality of etiologic factors depends on the patient population, a point that is worth emphasizing. For example, in pericardial disease, as in many other diseases, Mayo Clinic physicians encounter patients who have been referred not only because of a difficult condition but also because of an unusual cause or pathogenesis of a condition. Finally, the statement that" ...the overall survival rate of patients was not significantly improved by more extensive resections" probably applies strictly to patients with malignant tumors and other life-threatening conditions. My comments are meant only to supplement and emend an otherwise excellent report of an unusual case associated with many "pearls" for clinicians (for example, the importance of intermittent rather than steady drainage of the pericardium with use of a catheter). DavidH. Spodick, M.D., D.Sc. Cardiology Division Saint Vincent Hospital Worcester, Massachusetts
The authors reply We appreciate Dr. Spodick's comments and questions. In regard to the first question, the patient's chief complaints on admission were generalized fatigue and minimal shortness of breath; however, the most outstanding physical finding was the absence of palpable pulses-the unusual aspect of the patient's condition. Pulsus paradoxus was detected by auscultation of the patient's right brachial artery. Nonetheless, a pulse was not palpable over that site. Furthermore, the patient did not have an arterial line at the time of this measurement. Dr. Spodick's other comments including the utility of a therapeutic tap in diagnosis, the volumes of fluid necessary to cause tamponade, and the fact that viral rather than bacterial infections are more common causes of tamponade in the United States are salient points. Additionally, his suggestion that the limited benefits of more extensive resections refer "to patients with malignant tumors and other life-threatening conditions" is well taken. Kevin G. Moder, M.D. David N. Mohr, M.D. JamesB. Seward, M.D.
The Editor welcomes letters and comments, particularly pertaining to recently published articles in the Mayo Clinic Proceedings. A letter should be no longer than 500 words and contain no more than 5 references. The letter should be signed. It is assumed that appropriate letters may be published, at the discretion ofthe Editor, unless the writer indicates otherwise. The Editor reserves the right to edit letters in accordance with the Mayo Clinic Proceedings style and to abridge them if necessary.
LETTERS
Mayo Clln Proc, February 1992, Vol 67
therapeutic taps (as in this case) for diagnosis versus "diagnostic" taps, which provide minimal diagnostic information. The authors quote me (theirreference 1) as stating"...as little as 250 ml during rapid accumulation" will cause tamponade. Actually, in that study, I noted that as little as 150 ml is capable of compressing the heart in acute injuries to the heart and brisk bleeding. In contrast, a 200- to 250-ml increase in pericardial contents may be the threshold for roentgenographic recognition of fluid-provoked enlargement of the cardiac silhouette. In the case report, bacterial infections are listed among the most common causes of tamponade, but actually in the United States, viral infections are much more common. Indeed, the commonality of etiologic factors depends on the patient population, a point that is worth emphasizing. For example, in pericardial disease, as in many other diseases, Mayo Clinic physicians encounter patients who have been referred not only because of a difficult condition but also because of an unusual cause or pathogenesis of a condition. Finally, the statement that" ...the overall survival rate of patients was not significantly improved by more extensive resections" probably applies strictly to patients with malignant tumors and other life-threatening conditions. My comments are meant only to supplement and emend an otherwise excellent report of an unusual case associated with many "pearls" for clinicians (for example, the importance of intermittent rather than steady drainage of the pericardium with use of a catheter). DavidH. Spodick, M.D., D.Sc. Cardiology Division Saint Vincent Hospital Worcester, Massachusetts
The authors reply We appreciate Dr. Spodick's comments and questions. In regard to the first question, the patient's chief complaints on admission were generalized fatigue and minimal shortness of breath; however, the most outstanding physical finding was the absence of palpable pulses-the unusual aspect of the patient's condition. Pulsus paradoxus was detected by auscultation of the patient's right brachial artery. Nonetheless, a pulse was not palpable over that site. Furthermore, the patient did not have an arterial line at the time of this measurement. Dr. Spodick's other comments including the utility of a therapeutic tap in diagnosis, the volumes of fluid necessary to cause tamponade, and the fact that viral rather than bacterial infections are more common causes of tamponade in the United States are salient points. Additionally, his suggestion that the limited benefits of more extensive resections refer "to patients with malignant tumors and other life-threatening conditions" is well taken. Kevin G. Moder, M.D. David N. Mohr, M.D. JamesB. Seward, M.D.
The Editor welcomes letters and comments, particularly pertaining to recently published articles in the Mayo Clinic Proceedings. A letter should be no longer than 500 words and contain no more than 5 references. The letter should be signed. It is assumed that appropriate letters may be published, at the discretion ofthe Editor, unless the writer indicates otherwise. The Editor reserves the right to edit letters in accordance with the Mayo Clinic Proceedings style and to abridge them if necessary.