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\begin{document}

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



\author[1]{Mahmoud Abdelsalam}%
\author[1]{Cyril Nathaniel}%
\author[2]{Zeyad Elmarzouky}%
\author[2]{Subash Dulal}%
\author[1]{Usama Habib}%
\author[3]{Maram  Ahmed}%
\author[1]{Amir  Ashiq}%
\author[2]{Navin Nanda}%
\affil[1]{Conemaugh Health System}%
\affil[2]{University of Alabama at Birmingham}%
\affil[3]{Ain Shams University}%


\vspace{-1em}



  
  \date{June 10, 2024}


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\selectlanguage{english}
\begin{abstract}
We describe an adult patient who presented with purulent pericarditis in
whom two-dimensional transthoracic echocardiography demonstrated a
marked decrease in the area of the right ventricular wall together with
the overlying fibrin following intrapericardial administration of a
fibrinolytic agent. Documentation of this decrease by measurements
performed and illustrated on two-dimensional images have not been
reported previously in an adult patient with purulent pericarditis, to
the best of our knowledge.%
\end{abstract}%



\sloppy


\textbf{Introduction}

Purulent pericarditis (PP) is a devastating condition with a high
mortality rate of around 40\% even after appropriate medical and
surgical treatment.{[}1, 2{]} Surgical pericardiectomy can prevent
progression to the feared long-term complication of constrictive
pericarditis but carries high mortality of nearly 8\%.{[}3{]}
Intrapericardial administration of a fibrinolytic agent (IFA) such as
urokinase has been shown to be effective in preventing constriction in
one randomized clinical trial.{[}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.
These 2DTTE findings are consistent with a substantial decrease in
fibrin content following IFA. To the best of our knowledge, these
findings have not been documented before with illustrations of both pre
and post IFA 2DTTE measurements in an adult with PP.

\textbf{Case Description}

A 56-year-old white male with a previous medical history of stroke,
hyperlipidemia, hypertension, sacral decubitus ulcer and a long-term
indwelling Foley catheter presented with severe dyspnea. His vital
status was remarkable for a heart rate of 108 beats per minute,
respiratory rate of 22, blood pressure of 106/81mmHg and temperature of
37\textsuperscript{o}C. Physical exam was negative for murmurs, rub or
gallop. Initial workup was significant for elevated white blood cells at
36.6(10\textsuperscript{x3}/uL), elevated troponin level at 0.45ng/L and
positive urine and blood cultures for methicillin-resistant
staphylococcus aureus (MRSA). The ECG showed sinus tachycardia and
diffuse ST-elevations in leads I, II, III and V2-V6 with PR-elevation in
lead aVR suggestive of pericarditis. To rule out myocardial infarction,
coronary angiography was done and showed no significant coronary
stenosis. 2DTTE demonstrated a large circumferential pericardial
effusion measuring 23mm in maximum depth with echogenic material
consistent with fibrin overlying the cardiac walls.{[}9,10{]} Signs of
cardiac tamponade including pulsus paradoxus, plethoric inferior vena
cava, RV diastolic collapse and right atrial inversion were present.
Both left and right ventricular size and function were normal with no
valve abnormalities. Subcostal pericardiocentesis was performed and
490mL of cloudy purulent fluid was drained with relief of dyspnea. The
culture of pericardial fluid came back positive for MRSA. The patient
was begun on daptomycin and piperacillin/tazobactam. A repeat 2DTTE 2
days post pericardiocentesis showed only a small amount of residual
effusion, but continued presence of the fibrinous material over the RV
wall. Because of this and in an effort to prevent possible progression
to constrictive pericarditis, 2mg of fibrinolytic agent (tissue
plasminogen activator, alteplase) diluted in 10 ml of normal saline was
administered intrapericardially followed by 10ml normal saline flush.
The pericardial drain was clamped for 24 hours. The next day, the
patient drained 450mL of pericardial fluid. A repeat 2DTTE 2 days later
revealed trivial pericardial effusion (Figures 1A, 1B and 2A, 2B, Movies
1A, 1B and 2A, 2B). In the parasternal long axis view, the area of the
RV wall together with fibrin deposition measured by planimetry decreased
from 261.9mm\textsuperscript{2} to 155.48mm\textsuperscript{2}, a
substantial reduction of 40.6\%. In the apical four chamber view, the RV
wall plus fibrin area decreased from 270.82mm\textsuperscript{2} to
139.4mm\textsuperscript{2}, also a substantial reduction of 48.5\%.
Fibrin deposition on the RV wall could be recognized using 2DTTE by its
uneven irregular contour/localized bulging on the outer pericardial
aspect of the RV wall. However, the inner boundary of fibrin deposit
could not be distinguished from the contiguous RV wall and hence
planimetry included both the fibrin deposit and RV wall. These declines
in RV wall areas in our patient are indicative of marked decrease in the
amount of fibrinous material by dissolution following IFA.

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.

\textbf{Discussion and Conclusion}

Demonstration of reduction in fibrin content by pre and post IFA 2DTTE
images in PP has been clearly illustrated in pediatric
patients.{[}10-12{]} 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, 13-23{]}

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.

\textbf{Authors contributions:}

Mahmoud Abdelsalam contributed to the acquisition of and interpretation
of data, data analysis, writing the article, critical revision of the
article, and final approval of the article. Navin Nanda contributed to
data analysis, writing the article, critical revision of the article,
and final approval of the article. Cyril Nathanial contributed to
acquisition of and interpretation of data, data analysis, writing the
article, critical revision of the article, and final approval of the
article. Zeyad Elmarzouky contributed to data analysis, writing the
article, critical revision of the article, and final approval of the
article. Subash Dulal contributed to data analysis, writing the article,
critical revision of the article, and final approval of the article.
Usama Habib contributed to data analysis, writing the article, critical
revision of the article, and final approval of the article. Maram Ahmed
contributed to data analysis, writing the article, critical revision of
the article, and final approval of the article. Amir Ashiq contributed
to data analysis, writing the article, critical revision of the article,
and final approval of the article.

\textbf{References}

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3. Dybowska M, Kazanecka B, Kuca P, et al. Intrapericardial fibrinolysis
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\textbf{Figure and movie legends}

Figure 1 A, B. Two-dimensional transthoracic echocardiography.
Parasternal long axis view. A. The area of the right ventricular wall
together with the overlying fibrin (arrow) measured 261.90
mm\textsuperscript{2} by planimetry before intrapericardial injection of
fibrinolytic agent. B. Following injection, the same wall with fibrin
measured 155.48 mm\textsuperscript{2} in area, a reduction of 40.6\%.
Movies 1A, 1B. AO= aorta; LA= left atrium; LV=left ventricle; RA= right
atrium; RV= right ventricle.

Figure 2 A, B. Two-dimensional transthoracic echocardiography. A. Apical
four chamber view. The area of the right ventricular wall together with
the overlying fibrin (arrow) measured 270.82 mm\textsuperscript{2} by
planimetry before intrapericardial injection of fibrinolytic agent. B.
Following injection, the same wall with fibrin measured 139.95
mm\textsuperscript{2} in area, a reduction of 48.5\%. Movies 2A, 2B.
Abbreviations as in Figure 1 and Movies 1A, 1B.

Supplemental Information. Movies 1A, 1B, 2A, 2B.\selectlanguage{english}
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