Clinical diagnosis
Case 189
【Progress】
He got drainage for pericardial effusion which revealed bloody fluids. Regrettably, five days later, he passed away.
【Discussion】
Pericardial effusion is produced by endothelium, approximately 50 ml which relieves friction of myocardial movement. Cardiac tamponade occurs when extraordinary pericardial effusion compress myocardium, and elevated intrapericardial pressure inhibits myocardium movement (1). Hemopericardium (pericardial hematoma) is the main cause of cardiac tamponade. The symptoms of cardiac tamponade are feeling chest pressure and rapid heart rate as well as difficulty breathing, rapid breathing and fatigue which are serious condition. Cardiac ultrasound and CT are useful to detect pericardial effusion. CT value of 35 HU or greater is a standard for presence of hemopericardium (2).
Hemopericardium arises in various cases; trauma such as motor vehicle collision; myocardial penetration by iatrogenic pacemaker; rupture of cardiac aneurysm; rupture of coronary aneurysm; rupture of Valsalva aneurysm; myocardial infarction; dissecting aortic aneurysm; leukemia; neoplasm; anticoagulants (1, 2). Of these, hemopericardium by anticoagulants is known to often occur after cardiac infarction (2-7). Namely, neovascular formation for granulation tissue after myocardial infarction causes hemopericardium during anticoagulation medicine (3-6). Further, it is reported that anticoagulant induces hemopericardium with tamponade in the absence of myocardial infarction and pericarditis (1, 2). Cease of anticoagulation medicine and administration of antihemorrhagic medicine are useful for these cases to decrease hemopericardium.
Aortic valve has three leaflets. Each leaflet forms cusp, dividing three sinus called Valsalva sinuses; left coronary Valsalva sinus branching left coronary artery; right coronary Valsalva sinus branching right coronary artery and noncoronary Valsalva sinus. These Valsalva sinuses can develop and rupture, causing hemopericardium.
Cardiac aneurysm occurs following myocardial infarction. In our case, enhanced CT using contrast medium showed no cardiac aneurysm but intra-myocardial hematoma probably following myocardial infarction. Hemopericardium is supposed to arise from leakages of myocardial hematoma. CT values of pericardial effusion was 49.2 ± 7.1HU, compatible with hemopericardium. Laboratory test revealed BNP 344.4 pg/mL and troponin 318.6 pg/mL, indicating cardiac failure and myocardial damage.
Pericardiocentesis revealed bloody pericardial effusion and catheter drainage were conducted but regrettably, he passed away four days later.
【Summary】
We present an eighty seven-year-old male for difficulty of breathing, appetite loss, edematous lower extremities and wheezing. Laboratory test revealed that BNP 265.2 pg/mL (< 18.4) troponin 233.9 pg/mL (< 26.2), implying myocardial infarction and cardiac failure. Enhanced CT using contrast medium revealed intra-myocardial hematoma and hemopericardium (pericardial fluid CT values = 49.2 ± 7.1). It is borne in mind that fluids with CT value, 35 HU or greater indicate to include blood. Hemopericardium occurs most often during anticoagulant therapy after myocardial infarction. However, it can cause irrespective of absence of myocardial infarction or pericarditis. Other causes of hemopericardium are listed as trauma such as motor vehicle collision; myocardial penetration by iatrogenic pacemaker; rupture of cardiac aneurysm; rupture of coronary aneurysm; rupture of Valsalva aneurysm; myocardial infarction; dissecting aortic aneurysm; leukemia; neoplasm.
【References】
1.Fell SC, et al. Anticoagulant-Induced Hemopericardium with Tamponade — Its Occurrence in the Absence of Myocardial Infarction or Pericarditis. N Engl J Med 1965; 272:670-67.
2.Yu-Cheng, H, et al. Cardiac tamponade secondary to haemopericardium in a patient on warfarin. Emergency Medicine Journal. 2007; 24 (9): 679–80.
3.Lawrence LT, et al. Hemopericardium Following Acute Myocardial Infarction. AMA Arch Intern Med. 1955;96(6):757-761
4.Cheng TO, et al. Hemopericardium Complicating Acute Myocardial Infarction. Tex Heart Inst J. 2003; 30(4): 345–346.
5.Mohammad S, Austin SM. Hemopericardium with cardiac tamponade after intravenous thrombolysis for acute myocardial infarction. Clin Cardiol 1996;19:432–4.
6.Renkin J, et al. Cardiac tamponade early after thrombolysis for acute myocardial infarction: a rare but not reported hemorrhagic complication. J Am Coll Cardiol 1991;17:280–5.
7.Katis, Peter G. Atraumatic hemopericardium in a patient receiving warfarin therapy for a pulmonary embolus. Canadian Journal of Emergency Medicine.2005; 7 (3): 168–70.
2020.5.13