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Spontaneous Echo Contrast in Massive Pericardial Effusion With Tamponade
Spontaneous Echo Contrast in Massive Pericardial Effusion With Tamponade* Kou-Ci Shyu , M .D .; [un -jack Ch eng M .D .; ftiliang Kuan , M.D .; and Wen-Pin Lien. M .D ., EC.C .P.
Spontaneous echo contrast is uncommon in pericardial effusion. We report the case of a patient with massive malignant pericardial effusion causing cardiac tamponade in which the intense spontaneous echo contrast was found in the effusion by echocardiography. It was suggested that both the heavy blood content and a large amount of pericardial effusion were needed to create the phenomenon of spontaneous echo contrast in the pericardial cavity. (Chest 1993; 103:1600-01) FIG UII E 3. A trunsesop lmgeal 2-D ech ocardiogrum of pati ent in d iastole . :"ote the mobil e e nd of th e thrumhus (arrow) b"nding toward II... hioprusthctlc mitral valve amI partially ohs tructim; it. BMV = hio p....sthe tic mit ral valve; 1 = len atrium : LV= len ve ntricle; RV= right ventricle .
with the patient but she refused. Intravenous thrombolysis was considered but not performed because of the largesized thrombus and the risk that the remnants of the lysed thrombus may result in systemic emboli. She was treated initially with intravenous heparin and later, warfarin plus aspirin, with prothrombin time twice the control range. At 8 months follow-up, the patient has sustained no clinical embolic event. A follow-up transthoracic 2-D echocardiogram now demonstrates no mass protruding through the bioprosthetic mitral valve. However, a nonmobile mass is still observed in the left atrium. In conclusion , a mobile left atrial ball valve thrombus should be considered in the differential diagnosis of a hioprosthetic mitral valve obstruction. Trunsesophageal ech ocurdiography is superior to trausthoracic imaging in dcm onstrating this finding . HEFEHE:-J( ;ES
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3
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5
6
Alam M. Madrazo AC. Magilliglm DJ, Goldstein S. Mvmode and two-dimensional echocurdlographic features of porcine valve dysfunction . Am J Cardlol HJ79: 43:502-(19 Alam M. Laki.. r JB. Pickard so . ( ;oldsl pill S. Echocurdiographic evaluation of porcine hiop ro sthetic valves: experience with 3
1600
S
pontaneous echo contrast , a smoke-like echo , is a wellknown phenomenon in patients with mitral stenosis' and has been found in various cardiac disea ses." However, it is rare in pericardial effusion.' We report the case of a patient with malignant pericardial effusion in which the intense spontaneous echo contrast was found by echocardiography. CASE REPORT
A50-year-old female patient pres ented in April 1990 with bilateral ingu inal lymphadenopathy and left cervical lymphadenopathy of 7 months' duration. A neck lymph nod e biopsy specimen showed poorly differentiated squamous cell carcinoma. Chemotherapy with fluorouracil and leucovorin was started. She had an uneventful life until one week prior to this hospital ad mission when progressive dyspn ea developed . On examination, she WaS orthopnic and diaphoretic . The blood pressure WaS 64/44 mm Hg with paradoxical pulse of 114 beats/min. Th e neck vein WaS distended . Th e heart sound was quiet . /1;0 beart murmur was audihle . The breathing sound was d ecreased over tho right lower chest. Other physical findings were unremarkable . The red hlood cell count was 410 X 10'/ mm ', hematocrit was 32.4 percent; hemoglobin level was 11.0 Wdl; white blood cell count was 13,500/mm 3 with neutrophil 91 percent, lymphocyte 5 percent , and monocyt e 4 percent; plat elet count was 69 ,300/mm 3 • Th e prothrombin time and partial thromboplastic tim e were normal. The elect rocard iogram revealed sinus tachycardia and low voltage ofQRS in limh leads. The chest radiograph showed cardiomegaly and right pleural effusion . Th e blood btochemistry and electrolytes were normal. Echocardiography revealed a massive amount of circumcardiac pericardia effusion with swin~in~ cardiac motion. Early diastolic right ventricular collapse was in keeping with the presence of cardiac tamponade . Dynamic clouds of intense echo-like smoke were moving slowly or swirling to and fro within the pericardial Huld (Fig 1). Th ese abnormal echoes were see n using a 2.5- Mliz transducer (Toshiba SSA-270A). No intrapericardial adhe sion, fibrin , or masses were visualized . Urgent pericard iocentes is was performed, and 360 ml of noncoagulable bloody Ruid was removed, and immediately, the blood pr essure rose to 118/60 mm lIg and the heart rate slowed to Il8 beats/min. Th e pericardia] Ruid had a red blood cell count of 231 x IO'/mm'; hemoglobin level was 7.3 wdl ; hematocrit was 22.6 percent; white blood cell count was 4.140/mm ' ; platelet count WaS 3Il,OOO/mm"; glut1lse level WaS 11 mg/dl: and cytologic findings wer e consistent with malignancy A *From the Department of Internal Medicine, National Taiwan University Hospital. Taipei , Taiwan. Republic of China. Re,Jr','t requests: Dr: Kuan , Department of Int ernal Medicine, Nati,» .al Taiwan Univ ersity Hospital , TclilJei 100, Taiwan , ROC Spontaneous Echo Contrast (Shyu
et all
FIGURE lA (/eft) . Modified parasternal long axis view showing a massive pericardial effusion. Some echo contrasts were seen in the pericardia] cavity (arrowheads). There was acoustic artifact in the top of the fih'ure (arrows). B (right) . Modified apical view showing only pericardial effusion with diffuse and intense spontaneous echo contrast in the pericurdial cavity. In the real-time image, these dynamic echoes showed a slow swirling motion. LV = left ventricle; RV = right ventricle; PE = pericardial effusion. pericardial drainage tuhe was left in place and another 1,000 ml of intrapericardial echo patterns. Artifacts could he easily bloody fluid was drained off in 2 days. After removal of the drain, differentiated from blood stasis, since the latter presents echocardiogruphy revealed a minimalamount of pericardial effusion characteristic circular movement in successive cardiac cvcles and no more spontaneous echo contrast was found. with clear changes in acoustic configuration. Other intr~pcrDISCUSSION icardial echoes such as metastatic pericardial mass of varying Spontaneous contrast, described as smoke-like discrete size and intrapericardial clots could not be drained out by pericardiocentesis and have echocardiographic morphologic reflectance in intracardiac blood, is most commonly seen in features different from the spontaneous echo contrast patclinical settings resulting in low-flow states, such as severe tern visualized in the effusion. Microbubbles resulting from left ventricular dysfunction or in the presence of mitral pyopneumopericardiurn" could also produce the similar echo diseases. 1.2 This unique finding is uncommon in the pericardial effusion. To our knowledge , only two cases of spontaappearance; however, the effusion was purulent and a chest neous echo contrast in pericardial effusion have been radiograph revealed the presence of pericardial air. reported in the English literature ." There were some similar REFERENCES features between those two cases and our patient. The Daniel we, Nellessen U, Schroder E, Nonnast-Daniel B, pericardial effusion was malignant and had a heavy blood Bednarski P, Nikulta P, et a!' Left atrial spontaneous echo contrast content. The amount of effusion was large causing cardiac in mitral valve disease: an indicator for an increased thromhoemtamponade . However, the spontaneous echo contrast was holic risk.] Am Coli Cardioll988; 11:1024-11 not the same . The echo contrast in our patient was markedly 2 Milell FL, Asinger R\V, Elsperger KL, Anderson WR, lIodes M. intense and diffuse, while in the case of D'Cruz et al,' the Regional stasis of hlood in the dysfnnctional left ventricles: echo contrast before drainage was focal and low in intensity. echocardiogaphic detection and differentiation from early thromhosis. Circulation 1982; 66:755-63 The mechanism of spontaneous echo contrast remains 3 Panidis Ip, Kotler MN, Mitz CS, Ross] . Intracavitary echoes in unclear. An increased blood echogenicity during stasis or the aortic arch in type II aortic dissection. Am ] Cardiol 1984; slow-flow rate has been demonstrated in in vivo and in vitro 54:1159-60 studies." The pericardial fluid with spontaneous echo con4 Castello R, Pearson AC, Labovitz A]. Prevalence and clinical trast has a heavy blood content that made the aggregation implications ofatrial spontaneous contrast in patients undergoing of red blood cells into clump possible and was responsible transesophageal echocurdiography, Am] Cardiol 1990; 6,'}:1149for this pattern. The large amount of effusion created a large 53 dead space that made sluggish fluid motion and slow shear 5 D'Cruz lA, Holman MS, Childers LS. Spontaneous mobile rate possible . Thus, we postulate that both the heavy blood contrast echoes in pertcardial effusion . Am lIeart ] 1990; content and a large amount of the pericardial effusion were 120:1472-75 needed to create the phenomenon of spontaneous echo 6 Sigel B, Coelho ]CU, Spigos DC , Flanigan Dp, Schuler J], Kasprisin DO, et a!' Ultrasonography of blood during stasis and contrast in the pericardial cavity. The significance of this coagulation. Invest Radio11981; 16:71-6 uncommon phenomenon in pericardial effusion requires 7 Miller ML, Osborn M], Sinak L], Westbrook BM. Pyropneumofurther clarification. pericardium attributed to an esophagopericardial fistula. report The intrapericardial echoes described previously must be of a survivor and review of the literature. MayoClin Proc 1991; differentiated from artifacts and other known types of 66:1041-45 CHEST I 103 I 5 I MAY, 1993
1601
Spontaneous echo contrast is uncommon in pericardial effusion. We report the case of a patient with massive malignant pericardial effusion causing cardiac tamponade in which the intense spontaneous echo contrast was found in the effusion by echocardiography. It was suggested that both the heavy blood content and a large amount of pericardial effusion were needed to create the phenomenon of spontaneous echo contrast in the pericardial cavity. (Chest 1993; 103:1600-01) FIG UII E 3. A trunsesop lmgeal 2-D ech ocardiogrum of pati ent in d iastole . :"ote the mobil e e nd of th e thrumhus (arrow) b"nding toward II... hioprusthctlc mitral valve amI partially ohs tructim; it. BMV = hio p....sthe tic mit ral valve; 1 = len atrium : LV= len ve ntricle; RV= right ventricle .
with the patient but she refused. Intravenous thrombolysis was considered but not performed because of the largesized thrombus and the risk that the remnants of the lysed thrombus may result in systemic emboli. She was treated initially with intravenous heparin and later, warfarin plus aspirin, with prothrombin time twice the control range. At 8 months follow-up, the patient has sustained no clinical embolic event. A follow-up transthoracic 2-D echocardiogram now demonstrates no mass protruding through the bioprosthetic mitral valve. However, a nonmobile mass is still observed in the left atrium. In conclusion , a mobile left atrial ball valve thrombus should be considered in the differential diagnosis of a hioprosthetic mitral valve obstruction. Trunsesophageal ech ocurdiography is superior to trausthoracic imaging in dcm onstrating this finding . HEFEHE:-J( ;ES
2
3
4
5
6
Alam M. Madrazo AC. Magilliglm DJ, Goldstein S. Mvmode and two-dimensional echocurdlographic features of porcine valve dysfunction . Am J Cardlol HJ79: 43:502-(19 Alam M. Laki.. r JB. Pickard so . ( ;oldsl pill S. Echocurdiographic evaluation of porcine hiop ro sthetic valves: experience with 3
1600
S
pontaneous echo contrast , a smoke-like echo , is a wellknown phenomenon in patients with mitral stenosis' and has been found in various cardiac disea ses." However, it is rare in pericardial effusion.' We report the case of a patient with malignant pericardial effusion in which the intense spontaneous echo contrast was found by echocardiography. CASE REPORT
A50-year-old female patient pres ented in April 1990 with bilateral ingu inal lymphadenopathy and left cervical lymphadenopathy of 7 months' duration. A neck lymph nod e biopsy specimen showed poorly differentiated squamous cell carcinoma. Chemotherapy with fluorouracil and leucovorin was started. She had an uneventful life until one week prior to this hospital ad mission when progressive dyspn ea developed . On examination, she WaS orthopnic and diaphoretic . The blood pressure WaS 64/44 mm Hg with paradoxical pulse of 114 beats/min. Th e neck vein WaS distended . Th e heart sound was quiet . /1;0 beart murmur was audihle . The breathing sound was d ecreased over tho right lower chest. Other physical findings were unremarkable . The red hlood cell count was 410 X 10'/ mm ', hematocrit was 32.4 percent; hemoglobin level was 11.0 Wdl; white blood cell count was 13,500/mm 3 with neutrophil 91 percent, lymphocyte 5 percent , and monocyt e 4 percent; plat elet count was 69 ,300/mm 3 • Th e prothrombin time and partial thromboplastic tim e were normal. The elect rocard iogram revealed sinus tachycardia and low voltage ofQRS in limh leads. The chest radiograph showed cardiomegaly and right pleural effusion . Th e blood btochemistry and electrolytes were normal. Echocardiography revealed a massive amount of circumcardiac pericardia effusion with swin~in~ cardiac motion. Early diastolic right ventricular collapse was in keeping with the presence of cardiac tamponade . Dynamic clouds of intense echo-like smoke were moving slowly or swirling to and fro within the pericardial Huld (Fig 1). Th ese abnormal echoes were see n using a 2.5- Mliz transducer (Toshiba SSA-270A). No intrapericardial adhe sion, fibrin , or masses were visualized . Urgent pericard iocentes is was performed, and 360 ml of noncoagulable bloody Ruid was removed, and immediately, the blood pr essure rose to 118/60 mm lIg and the heart rate slowed to Il8 beats/min. Th e pericardia] Ruid had a red blood cell count of 231 x IO'/mm'; hemoglobin level was 7.3 wdl ; hematocrit was 22.6 percent; white blood cell count was 4.140/mm ' ; platelet count WaS 3Il,OOO/mm"; glut1lse level WaS 11 mg/dl: and cytologic findings wer e consistent with malignancy A *From the Department of Internal Medicine, National Taiwan University Hospital. Taipei , Taiwan. Republic of China. Re,Jr','t requests: Dr: Kuan , Department of Int ernal Medicine, Nati,» .al Taiwan Univ ersity Hospital , TclilJei 100, Taiwan , ROC Spontaneous Echo Contrast (Shyu
et all
FIGURE lA (/eft) . Modified parasternal long axis view showing a massive pericardial effusion. Some echo contrasts were seen in the pericardia] cavity (arrowheads). There was acoustic artifact in the top of the fih'ure (arrows). B (right) . Modified apical view showing only pericardial effusion with diffuse and intense spontaneous echo contrast in the pericurdial cavity. In the real-time image, these dynamic echoes showed a slow swirling motion. LV = left ventricle; RV = right ventricle; PE = pericardial effusion. pericardial drainage tuhe was left in place and another 1,000 ml of intrapericardial echo patterns. Artifacts could he easily bloody fluid was drained off in 2 days. After removal of the drain, differentiated from blood stasis, since the latter presents echocardiogruphy revealed a minimalamount of pericardial effusion characteristic circular movement in successive cardiac cvcles and no more spontaneous echo contrast was found. with clear changes in acoustic configuration. Other intr~pcrDISCUSSION icardial echoes such as metastatic pericardial mass of varying Spontaneous contrast, described as smoke-like discrete size and intrapericardial clots could not be drained out by pericardiocentesis and have echocardiographic morphologic reflectance in intracardiac blood, is most commonly seen in features different from the spontaneous echo contrast patclinical settings resulting in low-flow states, such as severe tern visualized in the effusion. Microbubbles resulting from left ventricular dysfunction or in the presence of mitral pyopneumopericardiurn" could also produce the similar echo diseases. 1.2 This unique finding is uncommon in the pericardial effusion. To our knowledge , only two cases of spontaappearance; however, the effusion was purulent and a chest neous echo contrast in pericardial effusion have been radiograph revealed the presence of pericardial air. reported in the English literature ." There were some similar REFERENCES features between those two cases and our patient. The Daniel we, Nellessen U, Schroder E, Nonnast-Daniel B, pericardial effusion was malignant and had a heavy blood Bednarski P, Nikulta P, et a!' Left atrial spontaneous echo contrast content. The amount of effusion was large causing cardiac in mitral valve disease: an indicator for an increased thromhoemtamponade . However, the spontaneous echo contrast was holic risk.] Am Coli Cardioll988; 11:1024-11 not the same . The echo contrast in our patient was markedly 2 Milell FL, Asinger R\V, Elsperger KL, Anderson WR, lIodes M. intense and diffuse, while in the case of D'Cruz et al,' the Regional stasis of hlood in the dysfnnctional left ventricles: echo contrast before drainage was focal and low in intensity. echocardiogaphic detection and differentiation from early thromhosis. Circulation 1982; 66:755-63 The mechanism of spontaneous echo contrast remains 3 Panidis Ip, Kotler MN, Mitz CS, Ross] . Intracavitary echoes in unclear. An increased blood echogenicity during stasis or the aortic arch in type II aortic dissection. Am ] Cardiol 1984; slow-flow rate has been demonstrated in in vivo and in vitro 54:1159-60 studies." The pericardial fluid with spontaneous echo con4 Castello R, Pearson AC, Labovitz A]. Prevalence and clinical trast has a heavy blood content that made the aggregation implications ofatrial spontaneous contrast in patients undergoing of red blood cells into clump possible and was responsible transesophageal echocurdiography, Am] Cardiol 1990; 6,'}:1149for this pattern. The large amount of effusion created a large 53 dead space that made sluggish fluid motion and slow shear 5 D'Cruz lA, Holman MS, Childers LS. Spontaneous mobile rate possible . Thus, we postulate that both the heavy blood contrast echoes in pertcardial effusion . Am lIeart ] 1990; content and a large amount of the pericardial effusion were 120:1472-75 needed to create the phenomenon of spontaneous echo 6 Sigel B, Coelho ]CU, Spigos DC , Flanigan Dp, Schuler J], Kasprisin DO, et a!' Ultrasonography of blood during stasis and contrast in the pericardial cavity. The significance of this coagulation. Invest Radio11981; 16:71-6 uncommon phenomenon in pericardial effusion requires 7 Miller ML, Osborn M], Sinak L], Westbrook BM. Pyropneumofurther clarification. pericardium attributed to an esophagopericardial fistula. report The intrapericardial echoes described previously must be of a survivor and review of the literature. MayoClin Proc 1991; differentiated from artifacts and other known types of 66:1041-45 CHEST I 103 I 5 I MAY, 1993
1601