Intrapericardial recombinant tissue plasminogen activator in purulent pericarditis- case series

Abstract

Background: Pericardial constriction is one of the complications of purulent pericarditis (PP). Most difficult to treat, which may develop both in early and in the late period of the disease, resulting in a very poor prognosis. Case presentation: We present case series of 4 patients with purulent pericarditis, in whom direct intrapericardial administration of recombinant tissue plasminogen activator (r-tPA) was used. Management of PP requires a combined surgical and medical approach. The most important is complete drainage of the effusion by subxiphoid pericardiotomy connected with complementary use of broad-spectrum antibiotics. Despite the use of broad-spectrum antibiotics, in some patients a large volume of daily drainage is still present. Constrictive pericarditis as a complication of PP is observed in majority of patients. Intrapericardial administration of fibrinolytic agents, although not strongly recommended, can improve efficacy of antibiotic treatment especially in patients with loculation fluid and can prevent the development of constrictive pericarditis. r-tPA was applied at a dose of 20 mg dissolved in 100 ml of normal saline in a 100 ml syringe, administered by a large pericardial drain (Pezzer drain) installed into the pericardial cavity during pericardioscopy. The tube was closed and reopened after 24 h. No serious complications, such as bleeding, allergy or hypotension, were noted. Conclusion: We present case series of 4 patients with purulent pericarditis, in whom direct intrapericardial administration of recombinant tissue plasminogen activator (r-tPA), prevented the development of constrictive pericarditis, and increased efficacy of antibiotic treatment without any significant complications.

Two‐dimensional transthoracic echocardiographic demonstration of reduction in fibrin content in purulent pericarditis following intrapericardial fibrinolytic agent administration

“…[10][11][12] However, as far as we can find there is mention in the text but, unlike our patient, there is no documentation with measurements illustrated on pre and post IFA 2DTTE images or movies in any adults presenting with PP in the literature. 3,6,[13][14][15][16][17][18][19][20][21][22][23] In conclusion, we document for the first time to the best of our knowledge, a substantial decrease in fibrin content with measurements shown on 2DTTE images before and following IFA in an adult patient presenting with PP. The decrease in fibrin content following IFA is believed to prevent possible progression to fibrosis with subsequent development of constrictive pericarditis with its high morbidity and mortality in these patients.…”

“…previously. 3,6,9 Subsequently, intravenous vancomycin was substituted for daptomycin, and the patient was transferred to an acute care rehabilitation for further treatment and care. After 30 days of inpatient rehabilitation, the patient was discharged in stable condition with no clinical evidence of pericardial constriction.…”

“…4 A decrease in fibrin content which is commonly associated with infection with a consequent decrease in pericardial fibrosis is the suggested mechanism for a decrease in the incidence of pericardial constriction following IFA. 5,6 Because of this, IFA has been recommended by some in the management of PP. 7,8 In this report, we present an adult patient with PP in whom two-dimensional transthoracic echocardiography (2DTTE) demonstrated a marked decrease in the area of the right ventricular (RV) wall together with the overlying fibrin following IFA as compared to the baseline.…”

Large Pericardial Effusion—Diagnostic and Therapeutic Options, with a Special Attention to the Role of Prolonged Pericardial Fluid Drainage

“…Four patients diagnosed with purulent pericardial effusion were treated with pericardial fibrinolysis. Details of the therapy were described previously [ 10 ].…”

Two-Dimensional Transthoracic Echocardiographic Demonstration of Reduction in Fibrin Content in Purulent Pericarditis Following Intrapericardial Fibrinolytic Agent Administration

“…Our patient did not suffer from any side effects following IFA such as hemorrhage or cardiac tamponade which have been reported previously. [3,6,9] Subsequently, intravenous vancomycin was substituted for daptomycin, and the patient was transferred to an acute care rehabilitation for further treatment and care. After 30 days of inpatient rehabilitation, the patient was discharged in stable condition with no clinical evidence of pericardial constriction.…”