Intrapericardial treatment of autoreactive pericardial effusion with triamcinolone
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European Heart Journal (2002) 23, 1503–1508
doi:10.1053/euhj.2002.3152, available online at http://www.idealibrary.com on
Intrapericardial treatment of autoreactive pericardial
effusion with triamcinolone
The way to avoid side effects of systemic corticosteroid therapy
B. Maisch, A. D. Ristić and S. Pankuweit
Department of Internal Medicine-Cardiology, Philipps University, Marburg, Germany
Aims To evaluate efficacy and safety of intrapericardial in groups 1 and 2, respectively (P>0·05). There were no
treatment with the crystalloid corticosteroid triamcinolone treatment-related acute complications. During the follow-
in autoreactive pericardial effusion. up, 29·6% of the patients developed transitory iatrogenic
Cushing syndrome in group 1 in contrast to 13·3% in group
Methods and Results Two hundred and sixty consecutive 2 (P1504 B. Maisch et al.
Figure 1 Autoreactive myopericarditis: (A) pericardioscopy findings and aimed biopsy, (B) epicardial
histology, (C) cytology of pericardial effusion, (D) epicardial immunofluorescence.
Methods excluded by PCR and/or cultures; (5) neoplastic cells
absent in cytology of pericardial effusion and no neo-
Patients and the design of the study plastic changes in the biopsy samples; (6) exclusion of
systemic and metabolic disorders, as well as uraemia.
Two hundred and sixty consecutive patients with peri- The intrapericardial instillation of triamcinolone was
carditis or myopericarditis and pericardial effusion were applied in 84 patients with autoreactive pericardial
studied over 12 years. All patients underwent a compre- effusion in two different regimens (group 1: 54 patients,
hensive initial clinical, laboratory, and echocardiogra- 50% males, mean age 48·914·3 years, triamcinolone
phy assessment. Furthermore, in patients with signs of 600 mg . m 2 . 24 h 1; group 2: 30 patients, 46·7%
possible myocardial involvement, cardiac catheteriz- males, mean age 52·512·7 years, triamcinolone
ation and endomyocardial biopsy were carried out. 300 mg . m 2 . 24 h 1). Colchicine 0·5 mg t.i.d. was
Finally, all patients underwent pericardiocentesis, peri- used as adjuvant oral treatment for the first 6 months of
cardioscopy (flexible endoscope AF 1101 B1, Karl follow-up.
Storz, Germany), and epicardial biopsy with peri- Instillation of crystalloid suspension of triamcinolone
cardial fluid and tissue analyses by PCR for causative in 100 ml of 0·9% NaCl was performed as a single slow
viruses and bacteria, immunohistochemistry and injection over a 7F pigtail catheter introduced after
immunocytochemistry. pericardiocentesis. Instillation may be painful and
The diagnosis of chronic autoreactive pericarditis appropriate analgesic premedication was routinely given
(Fig. 1) was established in 84/260 patients (32·3%) using (morphine 5 mg i.v.). The triamcinolone solution was
the following criteria[4,6]: (1) increased number of lym- kept intrapericardially for 24 h and then evacuated.
phocytes and mononuclear cells, as well as the presence After aspiration of excessive residual fluid the pigtail
of antibodies against heart muscle tissue (antisarco- catheter was removed. Patients were followed clinically
lemmal) in the pericardial fluid; (2) signs of myocarditis and echocardiographically for 12 months.
(>14 cells . mm 2) on epicardial or endomyocardial The study was approved by the local ethical com-
biopsies; (3) exclusion of active viral infection both in mittee and all patients have signed an informed consent
pericardial effusion and endomyocardial/epimyocardial before the procedure.
biopsies (no virus isolation, no IgM-titre against cardio-
tropic viruses in pericardial effusion, and negative Pericardiocentesis
polymerase chain reaction (PCR) for major cardio-
tropic viruses); (4) tuberculosis, Borrelia burgdorferi, Pericardiocentesis was performed in the cardiac
Chlamydia pneumoniae, and other bacterial infection catheterization laboratory using the subxiphoid route
Eur Heart J, Vol. 23, issue 19, October 2002Intrapericardial treatment with triamcinolone 1505
Table 1 Patients population: Baseline clinical data, treatment, and side effects
Duration of Colchicine Complete Time to
Age PE volume Iatrogenic
N 7 (%) the disease 0·5 mg t.i.d. 12-months follow-up PE relapse
(years) (ml) Cushing
(months) per os (%) (%) (months)
Group 1 54 50·0 48·914·3 7·71·6 88·9 309·2130·6 92·6 4·93·8 29·6
Group 2 30 46·7 52·512·7 7·11·0 86·7 328·4205·5 93·3 3·02·9 13·3*
Group 1: intrapericardial instillation of triamcinolone 600 mg . m 2 . 24 h 1; Group 2: intrapericardial instillation of triamcinolone
300 mg . m 2 . 24 h 1; PE – pericardial effusion; *P1506 B. Maisch et al.
Figure 2 Proportion of patients free of pericardial effusion 3 and 12
months after intrapericardial treatment with 600 mg . m 2 . 24 h 1 or
300 mg . m 2 . 24 h 1 of triamcinolone. Both regimens are highly efficient,
without significant advantage for the higher dosage (P>0·05).
and the size of pericardial effusion of the patients None of the patients have developed signs of constric-
selected for treatment groups 1 or 2 (Table 1). Both tion and none had to undergo surgical pericardiectomy.
therapeutic regimens were successful in all patients
regarding the immediate result of the procedure, i.e.
after the drainage of the effusion and triamcinolone
instillation all patients would be promptly discharged
Discussion
with only minimal or no residual effusion. Autoreactive pericarditis is a newly recognized form of
All patients were available for the 3 months follow-up idiopathic pericarditis with increased number of lym-
and 78/84 patients were available for the 12 months phocytes and mononuclear cells, as well as the presence
follow-up (50/54 patients in group 1 and 28/30 patients of antisarcolemmal antibodies in the pericardial fluid,
in group 2). There was no cardiovascular mortality in signs of myocarditis on epicardial or endomyocardial
either group during the follow-up. The intrapericardial biopsies and exclusion of any other specific aetiology of
administration of crystalloid triamcinolone resulted in pericardial disease. Identification of this form of peri-
symptomatic improvement and prevented effusion carditis was enabled by comprehensive diagnostic evalu-
recurrence in 92·6% vs 86·7% of the patients after ation of patients, including early pericardiocentesis,
3 months and in 86·0% vs 82·1% after 1 year in groups 1 pericardioscopy, epicardial biopsy as well as molecular
and 2, respectively (P>0·05 for both comparisons) and immunological evaluation of obtained fluid and
(Fig. 2). Patients with relapses of pericardial effusion in tissue samples. To the best of our knowledge, this is the
group 1 were asymptomatic in 100% (4/4) and 71·4% first study that evaluated long-term efficacy and safety of
(5/7) after 3 and 12 months of follow-up, respectively. intrapericardial treatment with triamcinolone in a large
Patients with effusion relapses in group 2 were asymp- group of patients with autoreactive pericardial effusion.
tomatic in 75% (3/4) and 60% (3/5) after 3 and
12 months of follow-up, respectively (mean time to
relapse 4·93·8 vs 3·02·9 months in group 1 vs group
2, respectively; P>0·05). The higher dose of triamci- Therapeutic value of intrapericardial
nolone was successfully instilled for the treatment of treatment with triamcinolone
symptom recurrence in two patients and also in two
patients in group 2. For recurrence of small, asymp- Intrapericardial drug delivery has been performed for
tomatic pericardial effusion intrapericardial treatment decades in patients with neoplastic and uraemic peri-
was not repeated. carditis. Apart from our pilot studies[4,5], there are no
There were no treatment-related acute complications published data on intrapericardial treatment of chronic
in either group. However, during the follow-up, a sig- idiopathic or autoreactive pericardial effusion. There are
nificantly larger proportion of the patients developed also no publications demonstrating the minimal effective
transitory iatrogenic Cushing syndrome in group 1 dose for this kind of treatment.
(29·6%) in contrast to 13·3% in group 2 (PIntrapericardial treatment with triamcinolone 1507
emphasized that in patients with large uraemic peri- Intrapericardial application of corticosteroid therapy
cardial effusion, elective pericardial drainage with instil- avoids major side effects of systemic treatment as well as
lation of triamcinolone hexacetonide is the treatment of compliance problems. However, the systemic absorption
choice, according to their experience in 22 patients. and iatrogenic Cushing’s syndrome cannot be com-
However, for small pericardial effusion they recom- pletely avoided, as noted in the report by Grubb
mended a trial of non-steroidal antiinflammatory drugs et al.[19]. Our study has shown that the effect is dose-
and/or intensive dialysis. dependent and that side effects could be significantly
Buselmeier et al[11] have treated 45 patients with diminished with the application of a lower dose of
uraemic pericardial effusion, instillating 200 mg of triamcinolone, as applied in most of the studies in
methylprednisolone and 80–1250 mg of triamcinolone uraemic pericarditis[11,12,14,15,20] and in our pilot
intrapericardially for an average of 50 h. Triamcinolone studies[4,5]. Further clinical studies are necessary if the
doses were administered in 4–6 h intervals until the same therapeutic effect is to be achieved with even lower
pericardial drainage was stopped. Before the removal of dose than 300 mg . m 2.
the catheter a final dose of 50 mg of triamcinolone was In conclusion, this study presents the first large group
instilled. The procedure had an immediate success rate of consecutive patients with chronic autoreactive peri-
of 97·8% regarding both pericardial pain and effusion cardial effusion treated successfully with triamcinolone
production. During the follow-up of 1 to 54 months intrapericardially. The treatment regimen of
(mean 14 months) there was no recurrence of symptoms 300 mg . m 2 . 24 h 1 of triamcinolone prevented
or pericardial effusion in 95·6% of patients. Notably, recurrence of symptoms and relapses of pericardial
our treatment regimen in autoreactive pericarditis had effusion as effectively as the 600 mg . m 2 . 24 h 1 regi-
similar efficacy despite single administration of men, but with a significantly lower incidence of iatro-
triamcinolone and shorter duration of treatment. genic Cushing syndrome. According to the results of this
Reversal of intractable uraemic pericarditis by triam- study a single dose of 300 mg . m 2 . 24 h 1, followed
cinolone hexacetonide was also achieved in a small by 6 months of oral colchicine, could be recommended
group of patients by Fuller et al[12] and Quigg et al.[13]. for further treatment of these patients.
In all patients prompt haemodynamic and symptomatic
improvement was maintained during the long-term The authors greatly appreciate the grant from the German
Science Foundation (Deutsche Forschunggemeinschaft – DFG) for
follow-up. Prof Dr B. Maisch, and the research fellowship grant from the
Instillation of triamcinolone after surgical peri- European Society of Cardiology, as well as the Twin Centres Grant
cardiotomy in uraemic patients was also highly effi- from the World Heart Federation for Dr A. D. Ristic.
cient[14,15] with only one recurrence in 16 patients during
the median follow-up of 4·2 years[15].
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