Eur J Cardiothorac Surg 2002;22:373-376
© 2002 Elsevier Science NL
Intrapericardial fibrynolytic therapy in purulent pericarditis
Ha
im Üstünsoya*,
Mehmet Adnan Celkana,
Muammer Cumhur Sivrikoza,
Hakki Kazaza,
Metin Kilinçb
a Department of Cardiovascular and Thoracic Surgery, Gaziantep University School of Medicine, Gö
üs ve Kalp Damar Cerrahisi Anabilimdali, Kolejtepe, Gaziantep, Turkey
b Department of Paediatric Cardiology, Gaziantep University School of Medicine, Çocuk Hastaliklari Anabilimdali, Kolejtepe, Gaziantep, Turkey
Received 16 January 2002;
received in revised form 18 April 2002;
accepted 19 April 2002.
* Corresponding author. Tel.: +90-342-336-1217; fax: +90-342-336-5505
e-mail: hustunsoy{at}yahoo.com
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Abstract
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Objective: Purulent pericarditis is a rare disease that is being conventionally managed with intravenous antibiotics and pericardial drainage. In our study, we used intrapericardial fibrinolytic treatment together with pericardiocentesis and antibiotic therapy. We evaluated the role of intrapericardial fibrinolytic treatment in nine purulent pericarditis patients. Methods: Six children and three adult patients with purulent pericarditis, aged between 5 and 50 years, were treated with intrapericardial fibrinolysis by streptokinase. Intrapericardial drainage catheter was placed into the subxyphoidal localization under local anaesthesia and echocardiography guidance, streptokinase was infused into the pericardial sac as the fibrinolytic agent. Results: Repeat echocardiograms showed no reaccumulation of pericardial effusions, pericardial thickening or constrictions. No patients had systemic bleeding, arrhytmias, or hypotension. There was one death which was due to sepsis and congestive heart failure. Conclusion: We believe that early pericardial drainage and intrapericardial fibrinolysis appears to be safe and effective in the treatment of purulent pericarditis.
Key Words: Fibrinolytic • Purulent pericarditis
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1. Introduction
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Purulent pericarditis is a rare disease that is being conventionally managed with intravenous antibiotics and pericardial drainage [1]. Despite the lower incidence of purulent bacterial pericarditis in the antibiotic era, overall survival continues to be extremely poor, averaging about 30% in modern series [2]. Rapid diagnosis and treatment is essential to prevent the associated morbidity.
Bacterial pericarditis is usually frankly suppurative by the time it is detected clinically. Loculated effusions with fibrin accumulation cause problems in the drainage of the pericardial effusions as well as pleural effusions. When it occurs and the pericardial abscess is not loculated, pericardiocentesis with two-dimensional echocardiography guidance and antibiotic therapy are usually the initial treatment [2].
The major complication of the standard management for purulent pericarditis is constrictive pericarditis. In our study, we have utilized the fibrinolytic treatment together with pericardiocentesis and antibiotic therapy. We evaluated the role of intrapericardial fibrinolytic treatment in nine purulent pericarditis patients.
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2. Material and methods
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From September 2000 to September 2001, six consecutive children and three adult patients with purulent pericarditis, aged 5–50 years, were treated with intrapericardial fibrinolysis by streptokinase. Details of patients’ characteristics are shown in Table 1. In all of the pediatric patients, there was an extracardiac infection focus. Two out of six patients had thoracostomy tubes placed due to empyema, to other cases treatment had been administered because of pneumonia and osteomyelitis. In these cases, during clinical follow up there was dyspnea of sudden onset, tachypnea, tachycardia and high-grade fever refractory to treatment. Echocardiographic examinations showed the presence of purulent pericarditis with fibrin accumulation. In one case, there were findings of cardiac tamponade. The echocardiographic examination revealed the presence of fibrinous purulent pericarditis, one patient additionally had ventricular septal defect (VSD). Three adult cases received intrapericardial fibrinolytic treatment. In a case who was treated with the diagnosis of multiple myeloma, and empyema. One of the two other cases had been operated for atrial septal defect (ASD) 1 month ago, other was a 50 year old male with diabetes mellitus and hypertension. These patients also came with the initial complaints of dyspnea, chest pain, high-grade fever and echocardiographic examination revealed purulent pericarditis.
Routine laboratory tests and blood cultures were performed in all patients, immediately after the first examination. The chest radiograms were useful instruments to the diagnosis but definitive diagnosis was reached with transthoracic echocardiography. Anteroposterior chest X-rays showed the enlargement of cardiac contours and the increase in the density of the lung shadows and pneumonic infiltration. In the echocardiographic examination, pericardial fluid rich from fibrin was observed in all patients (Fig. 1)
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Fig. 1. Thick fibrinous intrapericardial effusion before fibrinolytic treatment. PE, pericardial effusion; LV, left ventricle; and RV, right ventricle.
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In all the patients, pericardiocentesis was performed after echocardiographic detection of the pericardial effusion. 7F of intrapericardial drainage catheter (Pleuracan (Pleuracath), B. Braun Melsungen AG) was placed into the subxyphoidal localization under local anaesthesia and under echocardiographic guidance (Fig. 2)
. It was also placed into using of needle/guidewire as seldinger technique. The diagnosis of purulent pericarditis was confirmed by the examination of the pericardial aspirate. In patients, who have been previously administered antibiotics, same treatment was continued until culture and antibiogram results arrived. For the patients who will be receiving antibiotics for the first time, 3rd generation cephalosporins+aminoglicosides were administered ampirically.
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Fig. 2. View of the intrapercardial catheter during fibrinolytic treatment. PE, pericardial effusion, LV, left ventricle; and RV, right ventricle.
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In three pediatric patients, lower extremity drainage was performed because of osteomyelitis. And culture samples were obtained from drainage material.
2.1. Streptokinase protocol
Normal coagulation status was documented with prothrombin time, activated partial thromboplastin and thrombin time before the first treatment. Daily 2000 U/kg streptokinase was diluted in 50 ml of physiological saline which was administered into the pericardial sac through a catheter. Patients were monitored for anaphylaxis, arrhythmias, bleeding and hypotension. Duration of streptokinase treatment was controlled with daily clotting parameters (activated coagulation time, prothrombin time, activated partial thromboplastin and thrombin time Table 2), serial radiographs, haemoglobin measurements and echocardiography.
During follow up, echocardiography evaluation was performed prior to discharge, and at 1st and 6th months after discharge.
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3. Results
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No patients had systemic bleeding, arrhytmias, or hypotension. An average of 250±50 ml purulent fluid was obtained at first step. Only one adult patient did not have any growth in culture, all others had Staphylococcus aureus in their pericardial fluid. In cultures obtained from patients who had drainage due to osteomyelitis, S. aureus also grew. Antibiotic therapy (Vancomycin 20–30 mg/kg) was planned according to the antibiogram results. The biochemical examination of the fluid showed an increase in lactic dehydrogenase, and a decrease in glucose concentrations.
Drainage containing fibrin particles continued for 1 day in two cases, 2 days in one case, 3 days in four cases, 4 days in one case and 6 days in one case. Average daily drainage volume was 50±20 ml. The amount of drainage decreased continuously in all patients. Pericardial catheters were withdrawn after that and the drainage was stopped, the sequential cultures were negative, the cardiac contours had returned to normal on telecardiograms and echocardiography showed the absence of pericardial fluid and thickening (Fig. 3)
. One patient died on the 4th day. In this patient, the clinical course got better with pericardial drainage, fibrinolytic treatment and antibiotic treatment. On the 3rd day of the treatment, drainage was performed on the osteomyelitic leg under general anesthesia. On the first post-operative day, the patient died of sepsis, respiratory failure and congestive heart failure.
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Fig. 3. Pericardial space view on the 4th day of fibrinolytic treatment. Echocardiography showed the minimal pericardial effusion with complete clearing of the echodense masses and the absence of pericardial thickening. PE, pericardial effusion; LV, left ventricle; RV, right ventricle; VSD, ventricular septal defect; and AO, aort.
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During follow up, repeat echocardiograms showed no reaccumulation of pericardial fluid and pericardial constrictions in any of the patients. Routine laboratory tests and telecardiographic evaluation did not demonstrate any pathological findings either. The control echocardiography in the 1st and 3rd months after discharge were not showing any pathologic findings. All patients are still alive and healthy.
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4. Comment
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Pericardial effusions can be caused by several etiological factors including infectious agents. The inflammation may result in organization and dense adhesions with a loculated pericardial effusion followed by obliteration of the pericardial space, thickening and eventual calcification of the pericardium [2].
Microorganisms may invade the pericardial space by spreading from the heart, lung, or diaphragm. Septicemia may seed in the pericardial space, especially in immunosuppressed patients with concurrent burns or neoplastic disease [3].
Although the clinical spectrum of bacterial purulent pericarditis has changed over the past four decades, S. aureus is still the most commonly detected microorganism in purulent pericarditis [2]. In infants and children, development of purulent pericarditis is associated with pharyngitis, pneumonia, meningitis, otitis media, impetigo, endocarditis, bacterial arthritis and osteomyelitis [4]. Purulent pericarditis tends to occur in adults via contiguous spread from an early postoperative infection after cardiothoracic surgery or trauma, infection related to infective endocarditis, extension from subdiaphragmatic suppurative source, and hematogenous spread during bacteremia [2]. Acute self-limited pericarditis has also been observed in young adults with acute streptococcal tonsillitis in the absence of rheumatic fever [5]. In all the pediatric patients in our series, there was additional infectious focus together with purulent pericarditis. The most common coexistence was that of pneumonia and osteomyelitis. Pleural empyema was only detected in one adult patient.
Constrictive pericarditis may develop long after the treatment of the acute episode of purulent pericarditis and pericardiectomy might still be required for the treatment of this entity.
Pericardiocentesis is recommended as the first line of treatment. Pericardiosentesis was first performed by Schuh in 1840 [6] for cases, in which complete drainage could not be achieved due to loculated foci and fibrin deposition. In the cases we present, although there was severe intrapericardial fibrin accumulation, application of streptokinase resulted in effective drainage.
Streptokinase has been used intrapleurally for over 30 years to aid the drainage of loculated emphyema [7,8], without inducing any systemic fibrinolytic effects [9]. Streptokinase, an enzyme with proteolytic activity, converts plasminogen to plasmin. Plasmin degrades fibrin clots as well as fibrinogen [10].
In patients with a thick purulent effusion and dense adhesions with loculations, we could not establish sufficient drainage by pericardiocentesis. Under the light of the limited number of literature on pericardial fibrinolytic therapy [11,12], our data also demonstrates that instillation of streptokinase dramatically increases the volume of pericardial drainage consistent with clinical improvement. We thought that intrapericardial fibrin accumulation that was preventing an effective drainage could be cleared by the enzymatic effect of streptokinase. We had an effective drainage after this approach. Intrapericardial streptokinase can effectively enhance the removal of material that would otherwise be too viscous or particulate to be removed by tube drainage. This may prevent the need for more invasive therapy without jeopardizing any subsequent intervention if required.
There are several adverse effects of fibrinolytic therapy including allergic reactions, yet no systemic side effects have been reported due to the absorption of the substance from pleural and pericardial tissues [13]. Although no serious complications were seen in our patients, a rare complication which is the submitral pseudoaneurysm was reported by Juneja et al. [12].
In conclusion, we believe that early pericardial drainage and intrapericardial fibrinolysis appears to be safe and effective in the treatment of purulent pericarditis. Fibrinolytic therapy is a treatment alternative that should be tried before surgery.
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References
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Abstract
1. Introduction
