Correspondence

Idiopathic Chronic Pericardial Effusion

N Engl J Med 2000; 342:1449-1450May 11, 2000

Article

To the Editor:

Sagristà-Sauleda et al. (Dec. 30 issue),1 in their report on the long-term follow-up of patients with idiopathic chronic pericardial effusion, conclude that pericardiectomy should be considered whenever a large effusion recurs after pericarditis. This recommendation is based on the findings among the 28 patients in the study, 20 of whom eventually underwent pericardiectomy because of the presence of cardiac tamponade. We would like to emphasize two points that we feel were not adequately addressed by the authors.

Constrictive pericarditis did not develop in any patient during follow-up. This is surprising, since in the majority of cases effusive–constrictive pericarditis is preceded by idiopathic pericardial effusion.2 This has been demonstrated in the study by Haycock and Jordan of five children in whom pericardial constriction developed after nontuberculous effusion.3 It may be that the high rate of pericardiectomy prevented the development of constrictive pericarditis in the study by Sagristà-Sauleda et al.

The other issue that was not addressed was the use of antiinflammatory medications. It is not stated whether antiinflammatory medication was given at any stage of the follow-up and, if so, for how long. Colchicine has been found to be useful in preventing the recurrence of pericarditis, although there is a paucity of data regarding chronic pericardial effusion.4 We have treated two patients with large chronic pericardial effusions with long-term colchicine therapy, after repeated pericardiocentesis. These patients had no clinical or laboratory signs of an active inflammatory process. There was a resolution of the clinical symptoms and a decrease in the amount of pericardial fluid. We suggest that there may be a place for considering a trial of antiinflammatory therapy before proceeding to the more invasive pericardiectomy.

Sorel Goland, M.D.
Avraham Caspi, M.D.
Stephen D.H. Malnick, M.B., B.S.
Kaplan Medical Center, Rehovot 76100, Israel

4 References

1
Sagrista-Sauleda J, Angel J, Permanyer-Miralda G, Soler-Soler J. Long-term follow-up of idiopathic chronic pericardial effusion. N Engl J Med 1999;341:2054-2059
Full Text | Web of Science | Medline

2
Hancock EW. Subacute effusive-constrictive pericarditis. Circulation 1971;43:183-192
Web of Science | Medline

3
Haycock GB, Jordan SC. Chronic pericardial constriction with effusion in childhood. Arch Dis Child 1979;54:890-895
CrossRef | Web of Science | Medline

4
Adler Y, Zandman-Goddard G, Ravid M, et al. Usefulness of colchicine in preventing recurrences of pericarditis. Am J Cardiol 1994;73:916-917
CrossRef | Web of Science | Medline

To the Editor:

Sagristà-Sauleda et al. have provided a much-needed look into the natural history of a disease that has been well recognized clinically, but about which little is known. Although there are several case reports and an occasional small case series1 in the literature about chronic idiopathic pericardial effusions, only a few reports2-4 mention the very simple biochemical and cellular characteristics of these effusions (except for protein levels). It would be good to know about the basic properties of the pericardial fluid, such as cell count and differential count, glucose level, lactate dehydrogenase level, and pH. One would then be able to see if there are any differences between the group in which effusion recurred and the group in which it did not.

Kamal Gupta, M.D.
University of Texas Medical School at Houston, Houston, TX 77030

4 References

1
Colombo A, Olson HG, Egan J, Gardin JM. Etiology and prognostic implications of a large pericardial effusion in men. Clin Cardiol 1988;11:389-394
CrossRef | Web of Science | Medline

2
Barker PS, Johnston FD. Chronic pericarditis with effusion. Circulation 1950;2:134-138
Web of Science | Medline

3
Bedford DE. Chronic effusive pericarditis. Br Heart J 1964;26:499-512
CrossRef | Web of Science | Medline

4
Contro S, De Giuli G, Ragazzini F. Chronic effusive pericarditis. Circulation 1955;11:844-848
Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: No patient in our study of idiopathic chronic pericardial effusion had features of constrictive pericarditis. However, we think that this is not surprising since, in marked contrast to the patients with effusive–constrictive pericarditis described by Hancock,1 active inflammatory features (pericardial pain, fever, and pericardial friction rub) were, as a rule, not present in our patients. On the other hand, most, if not all, of the patients in the study by Hancock did not meet our criteria for idiopathic chronic pericardial effusion. In fact, the syndromes of idiopathic chronic pericardial effusion and effusive–constrictive pericarditis are quite different from each other and do not have similar patterns of clinical evolution.

There are no solid data for or against the use of antiinflammatory drugs in idiopathic chronic pericardial effusion. Our study was not a randomized clinical trial, and its purpose was not to demonstrate the efficacy of a given therapy as compared with other forms of therapy. We found, however, that pericardiocentesis and pericardiectomy can be useful in most patients. To our knowledge, there is no such information about antiinflammatory drugs. However, it is worth mentioning that some patients in our series had been given corticosteroids or other antiinflammatory drugs by their referring physicians, without any apparent response. With regard to the two patients described by Goland et al., we are uncertain whether the favorable course of these patients could be related to the administration of colchicine or to the repeated pericardiocentesis.

The basic properties of pericardial fluid that we investigated in our patients (protein concentration, activity of adenosine deaminase, and cell count) were nonspecific. A formal comparison between the pericardial-fluid measurements in the patients with recurrence of effusion and those without recurrence was not made. However, our clinical impression was that there were no major differences between the two groups. Accordingly, we think that important diagnostic or prognostic data cannot be drawn from the examination of pericardial fluid in this condition.

Jaume Sagristà-Sauleda, M.D.
Gaietà Permanyer-Miralda, M.D.
Jordi Soler-Soler, M.D.
Hospital General Universitari Vall d'Hebron, 08035 Barcelona, Spain

1 References