A case of tuberculous pericarditis treated by video-assisted thoracoscopic pericardial fenestration and steroid therapy

Abstract

An 83-year-old man with appetite and weight loss was referred to our hospital for further examination. Chest computed tomography (CT) showed pericardial effusion and bilateral pleural effusions. An echocardiogram demonstrated a decreased left ventricular diastolic function due to the pericardial effusion. Despite conservative treatment, cardiogenic shock due to cardiac tamponade developed 9 days after admission, and pericardial drainage was performed immediately. Polymerase chain reaction detected Mycobacterium tuberculosis DNA in the pericardial effusion, confirming the diagnosis of tuberculous pericarditis and bilateral tuberculous pleuritis. Because pericardial effusion at about 100 mL daily had continued even after drainage and the administration of anti-tubercular agents, video-assisted thoracoscopic pericardial fenestration with a left-sided transthoracic approach was performed under general and epidural anesthesia 20 days after admission. The parietal pericardium was markedly thickened with fibrinous adhesion to the visceral pericardium, and the parietal pericardium could be dissected from the edematous visceral pericardium. A pericardial window was created with a size of 4×3 cm. For residual multiple loculated pericaridial effusions, many incisions were made in the pericardium. Corticosteroid was also administered after the operation, and the thickness of the parietal pericardium had normalized on chest CT one month after the operation. The anti-tubercular agents were administered for 12 months, and no recurrence of pericardial effusion has been observed. Video-assisted thoracoscopic pericardial fenestration is a safe and effective technique for pericardial drainage and biopsy. Moreover, this procedure with the administration of corticosteroids for tuberculous pericarditis might prevent progression to constrictive pericarditis.