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Pericardial Disease (Drs. Klein and Johnston 3/14/13)

Thursday, March 14, 2013 - Noon


Pericarditis develops suddenly and may last up to several months. Sometimes excess fluid develops in the space between the pericardial layers and causes a pericardial effusion, a potentially life threatening condition. Dr. Klein, Director of the Center for Diagnosis and Treatment of Pericardial Diseases and Director of Cardiovascular Imaging Research and cardiac surgeon, Dr. Johnston answers your questions about pericarditis as well as other pericardial diseases.

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Question: I had chest pain and shortness of breath. I had an echo and my doctor put me on colchicine and prednisone. Near the end of my prednisone taper I started having some palpitations and a heavy feeling along with discomfort in my chest . So my doctor put me on the prednisone again. But someone told me - maybe the palpitations were a result of the prednisone? Is that possible?

Dr. Allan Klein: The palpitations are most likely related to the inflammation from the pericarditis. A key recommendation would be to be on triple therapy including colchicine, ibuprofen and prednisone. The prednisone should be tapered very slowly. At the Cleveland Clinic, we have a Pericardial Center that sees your type of pericardial syndrome very often and we are very successful in managing these cases.

Question: Hi - Thank you for considering my questions. I'm a 69 year old female who underwent a radio frequency ablation for atrial fib in Aug 2011. At that time the dome of the left atrium just next to the right pulmonary artery was punctured with cardiac tamponade physiology. A catheter was placed in the pericardial space until repair surgery could be performed. Even with continuous drainage prior to surgery, bright red blood ejected out of the pericardial sac under a great deal of pressure when the sac was opened. The surgeon performed a bilateral pulmonary vein isolation with bipolar Cardioblate device on the right and left sided pulmonary veins as the catheter ablation was not completed. A pericardial friction rub developed 2-3 days after surgery and is persisting to this date. I can hear it with my stethoscope. It was never treated. My cardiologist stated a piece of the pericardium was "stuck" but "not to worry about it". Can the pericardium have a 'rub' and a 'squeak' and still be 'stuck'? It seems contradictory. I've had 2 echo cardiograms (2 months and 8 months after ablation) neither of which showed any thickening or calcification or pericardial effusion. However, I do not feel my heart is working as well as it did before the surgery because -My exercise tolerance is low and I feel like at times I'm not getting enough air. I start to breathe harder even with mild exercise like walking. All my life I've been an active person. -I have a heaviness or pressure feeling in my chest and back. -After the ablation, when I'm in NSR, I never feel as well as I did in NSR before the ablation. My questions are: 1. What is causing the friction rub to persist? 2. If there is a fibrosis causing constriction, why doesn't it show on the echo's? 3. Is it possible to have an effusion from inflammation or rubbing which resolves and then returns? 4. If there is an effusion from inflammation from a fibrosis, can it lead to tamponade and sudden death? 5. If I do not have a pericarditis problem, is it possible that the puncture and tamponade itself caused damage to the heart muscle or valves? I'm trying to understand why my heart isn't working better.

BACKGROUND INFO MRI prior to ablation showed 5 pulmonary veins entering the left atrium. The right middle pulmonary vein enters the left atrium. An echo in Oct 2011 (2 months after ablation) - No thickening or calcification of the pericardium. No pericardial effusion. Ejection fraction normal. 6 months after ablation, a 30 day monitoring revealed 6 episodes of atrial fib, episodes of atrial flutter, ectopic atrial tach, and non conducted PAC's. 6 months after the ablation, a treadmill test using standard Bruce protocol for 6 min and 45 sec. Maximum heart rate was 133, 88% of maximum rate predicted. Test discontinued due to fatigue. Max BP was 166/90. Non specific ST changes inferolateral leads that were nondiagnostic for ischemia. An echo in April 2012 (8 months after ablation) revealed no pleural effusion. Peak mitral valve filling velocities decrease >25% with inspiration. No thickening or calcification of the pericardium. Ejection fraction normal. My AFib episodes have decreased and do not feel as severe as prior to the ablation, but I have some irregularity and palpations every day. CURRENT MEDS Metoprolol Succ ER 25 mgm daily Metoprolol tartrate 12-25 mgm as needed for palpitations Pradaxa 150 mgm twice daily ASA 325 mgm daily What I found that has really helped me is an extract of Hawthorn Berry and Arjuna and COQ10. Again, thank you and I appreciate any help you can be.

Dr. Douglas Johnston: The fact that you have a persistent friction rub suggests that you have some ongoing inflammation in the pericardium. The fact that your exercise tolerance is low and you feel that you are having more symptoms now when in sinus rhythm indicates that there may be some early constriction. A definitive evaluation would include an echocardiogram specifically looking at constriction, an MRI, and possibly a cardiac catheterization.

Dr. Allan Klein: In addition, care must be taken with the anticoagulation of Pradaxa in such a setting of ongoing inflammation. Markers of inflammation should be checked and, if appropriate, should be treated with aggressive anti-inflammatory. Otherwise, you may need surgery to remove the pericardium. It is recommended that you see a specialist in pericardial diseases at the Cleveland Clinic Pericardial Diseases Center for optimal management of your complex situation.

Recurrent Pericarditis

Question: I have had symptoms of pericarditis since October of 2011. I have been on prednisone, trying to taper, but every time we get to 7mg, symptoms return, inflammatory markers go up, and I end up back on a larger dose of prednisone, starting over again. I feel like I am on a treadmill. I have no idea what caused this problem, although I was diagnosed with a pericardial effusion in July of 2011 and had a pericardial window done in September of 2011. My doctor and I are at a loss.

Dr. Allan Klein: You have a common clinical pericardial syndrome that of recurrent pericarditis. The tapering of the prednisone has to be very slow, such as tapering between 2.5 and 5 mg every two weeks to a month. While the tapering is occurring, the patient should be on steroids as well as other anti-inflammatories such as ibuprofen and colchicine. It is a very long process, but slow is better than fast. You should consider seeing a pericardial specialist.

Question: I had acute Pericarditis a year and a half ago. I was doing great for about 6 months. But now all the old symptoms are back - I feel terrible. I am very frustrated. what to do?

Dr. Allan Klein: It is important to continue the anti-inflammatories for longer period of time, and then gradually taper. Often, you may have to take one of them for example colchicine, for at least 6 months. You should see a pericardial specialist in managing the recurrent pericarditis.

Chronic Pericarditis

Question: Hello and thank you for allowing me to participate. I am a 65 year old woman. I was diagnosed with chronic pericarditis in September, 2012. At that time I had a pericardial effusion, which became tamponade. I had a heart tap followed a week later by a window in the pericardium. Presently, I am taking 4 mg of prednisone and 1800 mg of ibuprofen daily. My last echocardiogram was in January, 2013, showing that I still have a pericardial effusion. I understand the next step may be removal of part of the pericardium. My question is: Can removal of a section of the pericardium be done before an effusion becomes tamponade as a preventive? Also, what is the down side of having a section of the pericardium removed? Could this be controlled with different medication? I much appreciate your advice.

Dr. Douglas Johnston: Certainly a partial pericardiectomy can be performed in order to facilitate drainage of fluid into the chest cavity. This can usually be done with low risk and a very reasonable recovery. There are a few long term consequences of such a procedure.

Dr. Allan Klein: You can continue to taper the prednisone very slowly while leaving the ibuprofen and adding colchicine to the regimen.

Question: Typically how long does chronic pericarditis last?

Dr. Allan Klein: It depends on the cause, and it can last for years. We would be happy to offer you another opinion at the Pericardial Center.

Pericardial Effusion

Question: I was diagnosed with a moderate pericardial effusion three years ago at the Clinic. Four subsequent echos have been unchanged and I do not have symptoms. What are the chances that this could get worse over time? I do not know how long I have had the effusion.

Dr. Allan Klein: You have evidence of idiopathic moderate pericardial effusion. You should have serial echo's as you are doing; if the effusion gets larger or you get symptoms, a more definitive procedure such as pericardiocentesis or pericardial window can be considered. Often, there is a previous history of viral syndrome which can account for the pericardial effusion. In the meantime, you can think of the fluid as an extra cushion around the heart without major consequence.

Question:I am 59 years old male with a past history of 6000 rads of mantle field radiation for Hodgkin's (38 years ago). I recently have had 2 sudden and unexplained large pericardial effusions, the first relieved with a pericardiocentesis and the second with a 50 cent size window to my chest cavity. Could these effusions be radiation related? What are my options for #3, when it occurs?

Dr. Allan Klein: It is possible that the effusions could be related to radiation damage to the heart. If the effusions are large enough, it would be important to further analyze the contents to see whether they are a transudate or exudate. A key concern is to make sure there is an ongoing malignancy.

Dr. Douglas Johnston: One option, should the effusion recur, is to perform a more extensive resection of the pericardium, allowing the fluid to drain around the lung.

Causes of Pericarditis

Question: I have had three episodes of acute pericarditis. These are believed to be related to my rheumatoid arthritis (I am 67 y/o). I do not have joint disease. My CRP has been elevated during these episodes, values have been from 6 to 123 to even higher. I have no other risk factors for pericardial disease. Can we be sure the etiology of the pericarditis is the RA or should my cardiologist search for another cause? Thank you.

Dr. Allan Klein: The most common cause of acute pericarditis would be viral or often idiopathic. However, with the history of rheumatoid arthritis, it is more likely that there is a link with this autoimmune process. Therefore, I would seek the help of a rheumatologist for proper treatment of the autoimmune process.

Question: Have you encountered instances of pericarditis resulting from the use of surgically implanted devices? (Harrington Rods, Breast Implants, Pedical Screws, etc.)

Dr. Allan Klein: I have seen a number of patients with breast implants with pericarditis but is not known whether there is any causal relationship.

Question: Is pericarditis considered an autoimmune disease? If so how does one ever really rid themselves of this condition?

Dr. Allan Klein: Autoimmune diseases can be a common cause of pericarditis, such as Systemic lupus erythematosus (SLE) or Rheumatoid Arthritis (RA).

Medications to treat Pericarditis

Question: What options for Pericarditis are there if you develop a troublesome rash while taking Colcrys? I have had 5 episodes of acute Pericarditis since last August.

Dr. Allan Klein: The first thing would be to see a dermatologist to assess whether the rash is related to the Colchicine. that particular medicine is crucial for treating recurrent pericarditis, otherwise, you would be limited to NSAID'S and occasionally oral prednisone.

Question: I am taking colcrys for pericarditis. What is the usual dose that would help with relieving the pain?

Dr. Allan Klein: Usually 0.6 mg twice a day.

Question: What do you think about using Plaquenil as part of treatment for chronic pericarditis?

Dr. Allan Klein: It is not unusual to be put on Plaquenil by rheumatologists if the traditional anti-inflammatory medications are not enough. Plaquenil may help. Other medicines that may be used include Imuran and Methotrexate. Also, there is interest in using -DMARDS such as Kineret ( anakinra).

Question: I use Fentanyl and Oxycodone for chronic pain associated with previous multiple back surgeries. I am fused from T3 to her sacrum. When I apply a new Fentanyl patch (50 mcg) I feel much better and less winded. Could the use of the narcotics for pain in anyway be slowing down the recovery from the pericarditis?

Dr. Allan Klein: We don’t recommend the narcotics to treat pericardial pain, however, I doubt that the narcotics are slowing down recovery.

Pericardial Window

Question: If you have a pericardial window - does it eventually heal over or is it there permanently?

Dr. Douglas Johnston: If the pericardial window is done via the subxiphoid approach, then often scar tissue will grow over the opening, sometimes very soon after the surgery. If the window is done into the chest cavity, and the opening is large enough, these can persist for a long time.


Question: How many pericardiectomies do you perform each year? What are other options.

Dr. Douglas Johnston: We perform about 40 pericardiectomies at the Cleveland Clinic per year. For pericardial constriction, pericardiectomy is the best option. However, a number of patients may be successfully treated with medication before the constriction is severe.

Dr. Allan Klein: When the onset is relatively short there may be a component of inflammation which can be treated medically– this syndrome is called transient constriction. You should go to a center that has expertise in managing these patients.

Post-Pericardiectomy Syndrome

Question: I'm a 46 year-old male who had bypass surgery and then after had a pericardial effusion with chest pain. Was treated by draining the effusion and then with NSAIDs and prednisone. Six months ago had a pericardial window cut in my pericardium. I have no more fluid but continue to have a constant chest discomfort. All EKGs and lab work say it is not the bypass but I still have the pain. Could I still have the pericarditis and inflammation even with a window? Very frustrated and wondering if I will have this pain forever or if there is something that can help me.

Dr. Allan Klein: You have a condition called post-pericardiectomy syndrome or Dressler’s Syndrome. You have to continue your anti-inflammatories much longer to allow healing from the inflammation. You may want to be evaluated by a pericardial specialist.

Pericardial Cysts

Question: Can you tell me about pericardial cysts? When should they be treated? What type of doctors?

Dr. Douglas Johnston: Pericardial cysts are most often asymptomatic, and are discovered because of an imaging test looking for something else. They only need to be removed if they are causing symptoms or if they are enlarging. Both cardiac and thoracic surgeons treat pericardial cysts.

This information is provided by Cleveland Clinic as a convenience service only and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. Please remember that this information, in the absence of a visit with a health care professional, must be considered as an educational service only and is not designed to replace a physician's independent judgment about the appropriateness or risks of a procedure for a given patient. The views and opinions expressed by an individual in this forum are not necessarily the views of the Cleveland Clinic institution or other Cleveland Clinic physicians.

Reviewed: 3/13

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