Letters to the Editor Department of Cardiovascular Surgery, Chungbuk National University Hospital, Cheong/u, Korea References [1] Rubin RH, Moellering RC. Clinical, microbiologic and therapeutic aspects of purulent pericarditis. Am J Med 1975; 59: 68-78. [2] Sagrista-Sauleda J, Barrabes JA, Permanyer-Miralda G, Soler-Soler J. Purulent pericarditis: Review of a 20year experience in a general hospital. J Am Coll Cardiol 1993; 22: 1661-5. [3] Cheatham JE, Grantham RN, Peyton MD el al. Hemophilus influenza purulent pericarditis in children: Diagnostic and therapeutic considerations. J Thorac Cardiovasc Surg 1980; 79: 933-6. [4] Cameron EWJ. Surgical management of staphylococcal pericarditis. Thorax 1975; 30: 678-81. [5] Majid AA, Omar A. Diagnosis and management of purulent pericarditis: Experience with pericardiectomy. J Thorac Cardiovasc Surg 1991, 102: 413-7. Figure 1 (A) Transoesophageal examination, four-chamber-view with large, hypermobile mass in the right atrium. (B) Transgastric short-axis view of right ventricle and left ventricle showing the diastolic prolapse through the tricuspid valve. (C and D) same transducer position as in (A) and (B) 15 h after systemic lysis; complete resolution of the right atrial mass. cardiopulmonary resuscitation over 40 min. In all four cases transoesoSuccessful lysis of mobile right heart phageal echocardiography clearly and pulmonary artery thrombi, identified the extensive, hypermobile, diagnosis and monitoring by worm-shaped thrombus formation in transoesophageal echocardiography theright-sidedcavities of the heart and Right-atrial and/or ventricular in the central pulmonary artery in two thrombi are precursors of pulmonary cases. All patients were treated with embolism (PE) and are associated with 100 mg rt-PA, three patients in a a poor clinical outcome1' 31. Due to front-loaded regimen over 90 min, and the high rate of consecutive massive due to the life-threatening situation in pulmonary embolism with anticoagu- one case, a bolus injection as ultimalation therapy only, the mortality rate ratio was performed with no is high and ranges from 40—50%[l). intracerebral bleeding complications. The recommended therapeutic regi- Regression of thromboembolic masses men has changed within the last after fibrinolytic therapy was demondecade. Before thrombolysis, surgical strated by transthoracic and transembolectomy was the treatment of oesophageal echocardiography after choice121. Current therapeutic strate- 1 to 15 h. All patients survived and gies favour fibrinolytic therapy with were put on coumadine; one patient developed an intracerebral bleeding consecutive anticoagulation[4]. with persistent hemiplegia. We assessed the value of transoesophageal echocardiography In the majority of cases, right for diagnosis and follow-up of a atrial or ventricular thrombi represent mobile right heart and pulmonary pulmonary emboli in transit. These artery thrombi under thrombolysis may be fatal in patients treated conwith recombinant tissue-type plas- servatively with anticoagulation only. M. C. CHO minogen activator (rt-PA). In four In the literature, the incidence of right D. W. KIM patients (4 men, 55-74 years old) with heart thrombi in patients with proven J. H. EARM suspected PE diagnosis and regression pulmonary embolism ranges from S. J. YOON of right heart and pulmonary throm- of 3-4°/^. Extremely mobile, long, boemboli following a systemic intra- worm-shaped masses in the right heart S. T. KIM venous, lysis therapy with rt-PA cavities carry an especially high early Department of Internal Medicine was documented by transoesophageal thrombus-related mortality rate which echocardiography (e.g. Fig 1 A-D). A ranges from 40-50%"]. The present J. M. HONG submassive PE occurred in three therapeutic strategies favour fibrinoJ. H. AHN patients. One patient had a massive lytic therapy with consecutive antiwith heparin and J. S. HONG PE with cardiac arrest followed by coagulation Eur Heart J, Vol. 17, October 1996 Downloaded from by guest on November 10, 2014 roentgenogram. An electrocardiogram showed sinus tachycardia and elevation of ST segment in leads I, II, aVL, and Vj^. Ultrasonography revealed a 10 x 6 x 5 cm sized relatively wellmarginated mass with heterogeneous internal echoes in the left lobe of liver. Echocardiography demonstrated a swinging heart and massive pericardial effusion with diastolic collapse of both the right atrial and ventricular wall. Pus drainage of the liver abscess and pericardiotomy were performed. A small perforation, 1 cm, with an irregular border was observed on the posterior aspect of right diaphragm. The pericardium was thickened and 600 ml of foul odorous pus and necrotic debris were drained. Fibrin clots were firmly attached to the underlying myocardium. Histological examination of the pericardium showed acute inflammation with microabscess and Escherichia coli was cultured from both blood and pericardial pus. He was discharged after 4 weeks on antibiotics, but Doppler echocardiography revealed a slightly thickened pericardium with a mild constrictive physiology. Early diagnosis of pericardial abscess is difficult because usual symptoms and signs of pericarditis may be absent and diagnosis may not be made until a significant degree of cardiac compression has occurred. Despite medical progress, pericardial abscess is a serious, life-threatening illness and still carries a high mortality rate. If surgical treatment is combined with medical therapy, the mortality rate decreases to 20% or less[3>4]. Even though drainage of pus and removal of fibrin clots in the pericardium is necessary, controversy still exists about which method of surgical treatment is optimal to obtain the best immediate result and to prevent pericardial constriction12'31. Although clinical features are lacking, physicians should be alert to the possibility of pericardial abscess if there is fever, an infective focus, and some signs of cardiac tamponade. 1603 1604 Letters to the Editor [2] Farfel Z, Schechter M, Vered Z, Rath S, Goor D, Grafni J. Review of echocardiographically diagnosed right heart entrappment of pulmonary emboli-in-transit with emphasis on management. Am Heart J 1987; 113: 171-8. [3] Kinney EL, Wright RJ. Efficacy of treatment of patients with echocardiographically detected right-sided heart thrombi. Eur Heart J 1989; 10: 104659. [4] Cuccia C, Campana M, Franzoni P et al. Effectiveness of intravenous rTPA in the treatment of massive pulmonary embolism and right heart thromboembolism. Am Heart J 1993; 126: 468^472 [5] Kasper W, Geibel A, Tiede N, Hofmann T, Meinertz T, Just H. Die Echokardiographie in der Diagnostik der Lungenembohe. Herz 1989; 14: 82-101. Biphasic P wave masquerading as a retrograde positive P wave during atriovenrricular nodal reentrant tachycardia Retrograde impulses exiting from the atrioventricular (AV) node and spreading to the atria generally result in an inverted, negative P wave in leads II, III and aVF'1"31. We report a patient with AV nodal reentrant tachycardia who, during tachycardia, exhibited apparently positive retro- grade P wave in inferior leads occurring immediately after the QRS complexes'41. A 51-year-old woman with a history of recurrent sustained supraventricular tachycardia was referred to our hospital to undergo radiofrequency catheter ablation. A pseudo r' deflection in lead V, (Fig. 1A) suggests AV nodal reentry as a mechanism of tachycardia'2- '. It should also be noted in Fig. 1A that in leads II, III and aVF each QRS complex is followed by an apparently 'positive' retrograde P wave'41, as indicated by an arrow. Sustained supraventricular tachycardia with a cycle length of 315 ms (AH=265 ms, HA = 50 ms) was reproducibly induced by atrial extrastimulation and rapid atrial pacing. AV nodal reentrant tachycardia was diagnosed based on standard electrophysiologic diagnostic criteria. Application of radiofrequency current at a site where the so-called slow pathway potential was recorded abolished the tachycardia. Apparently positive P waves during AV nodal reentrant tachycardia will be explained in three ways: (1) the whole positive deflection represents a truly positive retrograde P wave14', and is preceded by a small 'S' deflection of the QRS complex; the occurrence of an S wave may be B) Sinus rhythm A) AVNRT C) RV extrodnalns i -V'_-W' ! til I JAUI I II in J J J •' v. AJA'A1, v, —JLA. ,^A/_ SI SI S2 W. LEPPER JJ J J . V, I I U. JANSSENS V. -4 H. G. KLUES 51F P. HANRATH Medical Clinic I. Figure 1 12-lead ECGs. Each panel indicates AV nodal reentrant RWTH Aachen, tachycardia (Panel A), sinus rhythm (Panel B) and ventricular Aachen, Germany extrastimulus testing (basic cycle length, 600 ms) at the extrastimulus coupling interval of 400 ms (Panel C). In Panel C, the biphasic ( - + ) nature of retrograde P wave is more clearly characterized during S2 stimulation as compared with SI stimulation. AVNRT=AV nodal References [1] Cameron J, Pohlner P, Stafford G et al. reentrant tachycardia; RV=right ventricle; SI = basic drive stimulus Right heart thrombus: recognition, during ventricular extrastimulus testing; S2=extrastimulus during diagnosis and management. J Am Coll ventricular extrastimulus testing. Paper speed is 25 mm . s ~ ' in each panel. Cardiol 1985; 5: 1239-41. Eur Heart J, Vol. 17, October 1996 Downloaded from by guest on November 10, 2014 coumadine. Pulmonary embolectomy and complete exploration of the right heart as an alternative treatment strategy has an extremely high mortality rate and should only be performed in patients with contraindications for fibrinolytic therapy or after ineffective lysis. The efficacy of intravenous thrombolytic therapy in the lysis of right-sided heart thrombi has only been documented in a few cases without significant complications''^*1. Based on these experiences, we chose intravenous thrombolytic therapy in all four cases as the primary treatment. In contrast to surgery, this strategy has the advantage that it also resolves the origin of the thrombus formation, which is most often located in the deep venous system of lower extremities. The echo findings, in context with the clinical symptoms, allowed immediate initiation of thrombolytic therapy without pulmonary angiography, thus preventing a potentially fatal diagnostic procedure in these patients, namely right heart catheterization with consecutive embolization of thrombotic material into the pulmonary artery. Although we cannot rule out the occurrence of embolization of the thrombotic masses or parts thereof into the peripheral pulmonary circulation, absence of clinical signs of embolization suggest that most of the thrombi underwent local lysis. In summary, the use of thrombolytic therapy is highly efficacious for the therapy of patients with pulmonary embolism and concomitant right atrial or ventricular thrombus formation, if there are no contraindications for such a therapy. Transthoracic and especially transoesophageal echocardiography, is a powerful bedside diagnostic tool for the immediate diagnosis and follow-up of successful treatment in this life-threatening condition.
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