Intrapericardial Fibrinolytic Therapy in Purulent Pericarditis: A Review of Two Cases

Abstract

Purulent pericarditis is the infection of the pericardial space with pus formation. High mortality and morbidity can be explained by cardiac tamponade and septic shock in the acute phase, while chronically, it can lead to recurrent purulent pericarditis and constrictive pericarditis. We present two cases of purulent pericarditis treated with intrapericardial recombinant tissue plasminogen activator (r-tPA) for three consecutive days in addition to surgical pericardial drainage. In both instances, loculated effusions and reaccumulation of pericardial fluid persisted despite adequate antibiotic coverage and surgical drainage. Intrapericardial fibrinolysis was considered a less invasive alternative to extensive surgery to prevent constrictive pericarditis and improve clinical outcomes. Both patients had complete clinical recovery and there was no evidence of constrictive pericarditis during follow-up. There is scant literature regarding r-tPA therapy for purulent pericarditis, most of which is limited to case reports or case series. The most commonly used regimen is three doses of tPA administered into the pericardial space over three days. It is a safe and potentially effective therapy in preventing constrictive pericarditis and need of pericardiectomy.

Purulent Streptococcus intermedius Pericarditis in the Setting of Histoplasma Mediastinal Lymphadenitis: A Case Report and Literature Review

“…We suspect the reason this patient presented again so quickly after his initial discharge was because he had persistent purulent pericarditis inadequately treated with pericardiocentesis and drain placement alone. This has been documented in prior case reports, especially when loculations and fibrinous material are present in pericardial fluid [19]. As seen on this patient's TEE, both fibrin and loculations were observed in the pericardial space before pericardial drain removal and had an increased burden on readmission echocardiography.…”