444 3rief Communication.

Fig. 2. Apical two-chamber view showing shaggy projections (arr0r.u) bridging across the pericardial
effusion (PE) .

arthritis. Two-dimensional echocardiographic findings of RJ. Pericardial web Extensive pericardial adheaiona associ-
pericardial effusion with intrapericardial bands, presum- ated with idiopathic pericarditis. AM HEART J 19Sf$lll:60’2-
ably adhesive, are of striking interest. 603.
6. Chia BL, Choo M, Tan A, Ee B. Echocardiographic abnor-
These intraperic~di~ abnormahties have been malities in tuberculous pericardial effusion. AM R-T J
described by Martin et aLz in patients who have received 198~107:1034-1035.
mediastina1 radiation for malignancy and in pericardial 7. Chandraratna PAN, Aronow WS. Detection of per&did
effusions associated with uremia, pneumococcal infection, metastasea by cross-sectional echocardiography. Circulation
1981;6&197-199.
and trauma. Intrapericardial fibrinous bands have also
been described in idiopathic pericarditiss and in associa-
tion with tuberculous pericardial effusion.6 These findings Hydropneumopericardium with tampcwde
are thought to signify the presence of adhesions and have
been confirmed pathologically in a few cases? Some
as a late complication of surgtcal rapair of
authors have suggested that the presence of fibrinous hiatus hernia
bands may be a harbinger of constrictive pericardial
disease. Indeed, there was a high prevalence of pericardial Bernard de Bruyne, M.D., Thierry Dugernier, M.D.,
constriction and tamponade among the patients reported Louis Goncette, MD., Marc Reynaert, M.D.,
by Martin et al? Altered hem~yn~i~s resulting either Jean-Baptism Otte, M.D., and Jacques Co& M.D.
from constrictive pericarditis or from cardiac tamponade Brussels,II&&m
are not uncommon complications of rheumatoid pericardi-
tis3 Two-dimensional echocardiographic findings of intra-
pericardial adhesions may alert the clinician to the possi-
bility of an effusive-constrictive process. The occurrence of pneumopericardium is rare. Two hun-
dred fifty-two observations were recently collected in the
literature and reviewed.l Tamponade occurred in 37% of
REFERENCES
the cases, most frequently in trauma patients and new-
1. Martin RP, Rakowaki H, French J, Fopp RL. Local&&ion of borns under positive-pressure ventilation. We recently
pericardial elusion with wide angle phased array echocardio-
graphy. Am J Cardiol 197&42:904-912. observed two cases of hydropneumopericardium with
2. Martin RP, Bowden R, Filly JS, Popp R. Intrapericardial tamponade as a late complication of surgical repair of
abnormalities in patients with pericardial effusion: Findings hiatus hernia.
in ho-Dimensions ech~rdio~aphy. Circulation 198861: Case 1. A S-year-old woman was h~pi~z~ for chest
568-572.
3. Thandani U, Iveson JMI, Wright V. Cardiac tamponade,
constrictive pericarditia and per&.rdial resection in r-heurna”
toid arthritis. Medicine 1975;54:261-270. From the Inten&e Care Department and the Departments of Radiology
4* Kirk J, Coah J. The pericarditis of rheumatoid arthritis. Q J and Surgew, University of Louvain Me&al S&o&
Med 198@38397-423. Reprint requests: Jacques Cc& M.D., Soins lntensifs, Avenue Hippocrate,
5. Kessler KM, Bilsker MS, Manasa M, Laignhold M, MyerburS 10, 1200 Bmxelles, Belgium.
Fig. 1. Chest x-ray film of case 1 shows the parietal
peric~dium separated from the heart by a large amount
of air.
pain and hypotension. Three years earlier she had under-
gone transthoraeic repair by fundoplication of a sliding
hernia with esophagitis. On the fifth postoperative day she
complained of pain localized in the left shoulder and arm.
This pain was provoked by cough, deep breathing, and
eating. It lasted a few days and reappeared 2 years later.
Multiple x-ray investigations were then carried out and
the radiologic digestive status was found to be normal
except that a large part of the stomach was situated in the
thorax. She continued to complain and 3 months later she
developed, over a few hours, severe dyspnea and chest
pain radiating to the left shoulder. Theee acute symptoms
followed a night during which the patient exerted severe
and unproductive vomiting efforts. On clinical examina-
tion she appeared to be acutely ill and cyanotic. Pulse rate
was 104 bpm, and blood pressure was 90/~ mm Hg with a
20 mm Hg pulsus paradoxus. Respiratory rate was 20 and
temperature was 37.3’ C. A loud harsh pericardial rub was
heard with decreased heart sounds. ECG showed atrial
fibrillation and evidence of pericarditis. A chest x-ray film
demonstrated a pneumoperic~di~ (Fig. 1). Echocardi-
ography revealed a “swinging heart” with an anterior and
posterior free space and other signs of cardiac tamponade.
A pericardial drainage was performed with a No, 4 French
catheter inserted by Seldinger technique under pressure
control. The in~aperic~di~~ capillary wedge, and right
atrial pressure were all 14 mm Hg. A large amount of air
and a few milliliters of fluid were aspirated with immedi-
Fig. 2. Gastrografin swallow (case 21 demonstrates a
large quantity of contrast material in the pericardial
cavity. (F = fistula; E = esophagus; S = intra-abdominal
part of the stoma& S = intrathoracic part of the stomach
P = pericardml cavity.)
ate improvement of hemodynamic symptoms. The culture
and histologic analysis of the pericardial fluid were not
contributory. A Gastrogratin swallow failed to reveal any
abnormality 2 days after admission to the hospital, except
for a late emptying of the herniated stomach. The opaci-
fication of the pericardium through the drainage catheter
showed irregularities of the pericardial sac. In view of this
abnormality a second Gastrografin swallow was carried
out immediately and showed the fistula between the
herniated stomach and the pericardium. The pericardium
wes drained by a saline solution, a gastric tube was placed
in the herniated stomach, and the patient received intra-
venous feeding. Ten days later, at surgery, the fistula was
excluded, a pleuropericardial window was made, and
the postoperative period was uneventful. The patient
was discharged without medication and neither chest
nor left shoulder pain reappeared during an 18-month
follow-up.
Cuse 2. A 57-year-old plumber was admitted to the
hospital with the chief complaints of chest pain and
dyspnea. One and a half years before he had undergone a
Nissen operation for hiatus hernia. After a few days he
had complained of pain in the left shoulder, and a left

446 Brief Communications
pleural effusion was evidenced. The diagnosis of pulmo-
nary embolism was made on the basis of an abnormal
perfusion scan scintigram. Symptoms cleared after treat
ment with heparin. Six months later he complained of
episodic pain in the left shoulder and slight breathless-
ness. Chest x-ray film showed a moderately enlarged heart
shadow. No inflammatory syndrome was evidenced at that
time. On physical examination, breath sounds were
decreased at the left base. No pericardial rub was heard.
Blood pressure was 100/65 mm Hg, pulse was 120 bpm,
and temperature was 36.3’ CL P&us paradoxus was
noted. Echocardiography confirmed cardiac tamponade.
Two hundred fifty milliliters serohemorrhagic sterile peri-
cardial fluid was aspirated with immediate improvement
of symptoms. Histologic and bacteriologic analysis was
negative and cortisone therapy was administered for a few
days. Symptoms reappeared a few days later, Chest x-ray
film showed an enlarged heart with gas in the pericardial
cavity. The patient was then referred to our institution.
Pericardial drainage evidenced a purulent &id. After
drainage, contrast medium was injected but did not reveal
any abnormality. Gastrografin swallow demonstrated a
large amount of contrast material passing through a
fist&a between the large intrathoracic tuberosity and the
pericardium (Fig. 2). Irrigation of the pericardial cavity
was carried out for 10 days with a 0.1% solution of
polyvidone-iodine, under general antibiotic cover and pa-
renteral nutrition. The fistula was ligated and pericardec-
tomy was performed. The postoperative period was
uneventful and the patient did well until the present
follow-up of 12 months.
In a recent review, Cummings et aLI reported 252 cases
of pneumopericardium, some of them associated with
effusion. Tamponade complicated 37% of cases of pneu-
mopericardi~. In this review the etiology has been
classified into four major groups: trauma (62 % ), iatrogen-
ic origin (9%), spontaneous gas production from infected
pericardial fluid (4%) and, less infrequently, disease
processes with contiguous organ systems (25%). In this
late category, occurrence of pneumopericardium has been
reported as a complication of hiatus hernia,z esogastrosto-
my,3 perforated gastric ulcer,4 and eroding gastric carcino-
mas.5 Only one instance of pneumopericardium observed 6
years after transthoracic repair of hiatus hernia has been
published.~ The clinical presentation of our two observa-
tions was very similar. In both cases chronic scapula&a
preceded the acute cardiac symptoms during a very long
period of time. This chronology was likely the result of a
chronic inflammatory nonspecific process contiguous to
the diap~agm, Since infection and neoplasia were ruled
out, the chronic inflammation was probabIy secondary to
a process on the gastric site of the fistula, likely chemical
in nature. How this could be initiated remains unanswered
because operation was considered successful in both cases.
The early onset of the first scapulalgia soon after surgery
(a few days) suggests surgical trauma of the gastric wall
and diaphragm,
The acute symptoms of tamponade were the result of
the presence of a fistula created between the stomach and
August lgg7
American tIeart JownaI
pericardium. The tamponade in case 1 occurred as a result
of sudden entry of air in the pericardial sac, This was
made possible by means of a pressure gradient between
the intrathoracic gastric cavity and the pericardial sac
with a one-way valve mechanism at the level of the fistula.
Since the two structures are located in the thorax, tran-
sient pressure increase of the intrathoracic gastric cavity
above pericardial pressure could not be generated by
coughing. Transfer of air from the intra-abdominal into
the intrathoracic stomach was most likely produced by
efforts of vomiting. When one knows that eructation is
made impossible after such an operation, it is not surpris-
ing to note that vomiting efforts were very strong during
the entire night before hospitalization for tamponade. In
case 2 the accumulation of gastric &id and air in the
pericardial cavity was much more progressive. The occur-
rence of pneumopericardium complicated by effusion,
especially when purulent, seems to have an exceptionally
bad prognosis, but all these reported cases proved to be
septic.’ The favorable outcome of our two cases is certain-
ly related to the absence of infection but also to the
therapeutic management: drainage and lavage of the
pericardial cavity, general antibiotic therapy, and paren-
teral nutrition permitted surgical repair under good hemo-
dynamic and metabolic conditions.
REFERENCES
1. Cummings RG, Wesly RLR, Adams DH, Lowe JE. Pneumo-
pericardium resulting in cardiac tamponade. Ann Thorac
Surg 19%37:511.
2. Monro JL, Nicholls RJ, Hately W, Murray RS, Flavell G.
Gastronericardial fistula-a complication of hiatus hernia. Br
J Surg-197$61:445.
3. Gago 0, Choppra PS, Ellison LH, Silverman PL. Pyopneu-
mopericardium as a complication of oesophagogastrostomy.
Thorax 1973;2&250.
4. Dassel PM, Kirsh IE. Non-traumatic pneumo~~cardinm
and pyopneumopericardium: report of two cases. Radiology
1954;63:346.
5. Beaugie JM, Eadie DGA, Dyer NH. Pneumopericardium
complicating carcinoma of the stomach. Br J Surg 1966;
53645.
6. Wegryn RL, Zaroff LI, Weiner RS. Spontaneous tansion
pneumopericardium. N Engl J Med 19%$279:1440.
Calcification of patent ductus arteriosus
detected by two-dimensional
echocardiography
Jesus Vargas-Barron, M.D., Tomas Sancho-Undo,
M.D., Candace Keirns, M.D.,
Angel Gonzalez-Medina, M.D., and
Jesus Vazquez-Sanches, M.D.* Mexico City, Mexico
From the Departmenti of Ech~~diography and *Radiology, Institute
N&ma1 de Cardiologia “Ignacio Chavez.”
Reprint reqwsts: Jesus Vargas-Barron, M.D., Dept. of Echocafdiography,
Institute National de Csrdiologia “Ignacio Chavez,” Juan Badiano No. 1,
Mexico, D.F., Mexico.