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
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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
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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.