ABSTRAK
Perikarditis adalah peradangan perikardium parietalis, viseralis, atau keduanya. Etiologi terdiri dari infeksi, penyakit autoimun sistemik, sindrom
pasca infark miokard, kelainan metabolik, kehamilan, trauma, neoplasma, iatrogenik, obat-obatan. Prevalensinya 2 3,5% dari semua efusi
perikardium besar. Insidens tamponade jantung di Amerika Serikat adalah 2 kasus per 10.000 populasi. Gejala klinik tergantung dari jumlah
cairan dan kecepatan penimbunan cairan dalam kavum perikardium. Akumulasi cairan yang cepat dengan volume efusi kecil dapat memberikan
gejala tamponade, yaitu sianosis perifer, syok, dan perubahan status mental. Diagnosis ditegakkan berdasarkan gejala klinis, pemeriksaan fisik,
laboratorium, EKG, radiologi, dan ekokardiografi. Pengobatan disesuaikan dengan etiologi, dengan mengatasi penyakit dasarnya (misalnya
pemberian antibiotik, steroid). Jika terjadi tamponade, diperlukan drainase segera (perikardiosentesis). Dilaporkan kasus, pria 36 tahun dengan
diagnosis efusi perikardium kronik masif e. c. tuberculosis berdasarkan gejala klinis, pemeriksaan fisik, dan pemeriksaan penunjang. Dilakukan
perikardiosintesis, pemberian obat anti tuberkulosis, metilprednisolon dan rencana evaluasi ulang saat berobat jalan.
Kata kunci: efusi perikardium kronik masif, tuberkulosis, perikardiosentesis
ABSTRACT
Pericarditis is an inflammation of parietal pericard, visceral pericard or both, caused by infection, systemic autoimmune disease, post-myocardial
infarction syndrome, metabolic abnormalities, pregnancy, traumatic, neoplastic, iatrogenic, or drugs.1,2 The prevalence is 2 to 3.5% of all large
pericardial effusion. The incidence of cardiac tamponade in the United States is 2 per 10,000 population. Clinical symptoms depend on the
amount and rate of fluid accumulation in the pericardial cavity, rapid accumulation of fluid can result in tamponade with peripheral cyanosis,
shock, mental status changes. Diagnosis is established based on clinical symptoms, physical examination, laboratory, ECG, radiology and echocardiography. Treatment is directed to the underlying disease (eg antibiotics, steroids). Drainage (pericardiocentesis) is needed immediately if
tamponade occurs. The reported case is 36 year-old male diagnosed as chronic massive pericardial effusion ec tuberculosis based on clinical
symptoms, physical examination and other investigation. Treatment consist of pericardiocentesis, anti-tuberculosis drug and methylprednisolone. Eva Roswati, Zainal Safri. Pericardiocentesis for Massive Pericardial Effusion.
Key words: massive chronic pericardial effusion, tuberculosis, pericardiocentesis
PENDAHULUAN
Perikarditis adalah peradangan perikardium
parietalis, viseralis atau keduanya. Respons
perikard terhadap peradangan bervariasi dari
efusi perikardium, deposisi fibrin, proliferasi
jaringan fibrosa, pembentukan granuloma,
atau kalsifikasi.1 Efusi perikardium kronik
masif jarang ditemui, prevalensinya 2 - 3,5%
dari semua efusi perikardium besar. Insidens
tamponade jantung di Amerika Serikat adalah
2 kasus per 10.000 populasi. Lebih sering
pada anak laki-laki (7:3), sedangkan pada
dewasa tidak ada perbedaan bermakna (lakiAlamat korespondensi
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email: er2411@gmail
LAPORAN KASUS
yang menderita sakit yang sama tidak
dijumpai.
Pada saat masuk, dijumpai kesan sakit berat,
kesadaran kompos mentis, tekanan darah
130/90 mmHg, nadi 90 x/menit, pernapasan 28
x/menit, suhu 36,9 C. Status gizi underweight
(IMT 19,1 kg/m2). Pada pemeriksaan fisik,
dijumpai konjungtiva anemis, sklera tidak
ikterik, peningkatan tekanan vena jugularis,
suara pernapasan menghilang pada lapangan
bawah kedua paru, ronkhi basah di tengah
kedua paru, suara jantung kesan menjauh,
dan edema pada kedua ekstremitas inferior.
Pemeriksaan laboratorium: Hb 10,9 g/dL,
leukosit 14.680/mm3, Ht 30,4%, trombosit
526.000/mm3, morfologi eritrosit normokrom
normositer, ureum 11,2 mg/dL, Cr 0,66 mg/dL,
bilirubin total 0,88 mg/dL, bilirubin direk 0,6
mg/dL, SGOT 169 U/L, SGPT 73 U/L, albumin
2,9 g/dL, KGD s 92,1 mg/dL. Elektrolit: Na 126
mEk/L, K 4,6 mEk/L, Cl 96 mEk/L. AGDA: pH
7,498, pCO2 24,2 mmHg, pO2 132,5 mmHg,
HCO3 18,4 mmol/L, BE -3,4, Sat O2 98,5%.
Serologi: HbsAg negatif, anti-HCV negatif,
tes HIV Elisa 3 metode: nonreaktif. Urinalisis:
dalam batas normal.
Pada pemeriksaan foto toraks, dijumpai
gambaran jantung membesar globuler
(water bottle appearance), infiltrat pada 2/3
medial kedua paru dan suspek efusi pleura
bilateral. EKG kesan: low voltage, sinus ritme.
Ekokardiografi: efusi perikard masif perkiraan
cairan >2.000 mL, disertai fibrin-fibrin.
Swinging heart (+). Tidak dijumpai tanda-tanda
RA/RV kolaps. Fungsi sistolik baik dengan EF:
55,2% (Teichhloz), 64% (Simpson).
Diagnosa kerja: Efusi perikardium masif e. c.
tuberculosis + TB paru dalam pengobatan
dengan efusi pleura bilateral dan infeksi
sekunder + anemia e. c. penyakit kronik.
Penderita diterapi dengan diet MB TKTP,
oksigen 1 liter/menit, IVFD NaCl 0,9% 10
tetes/menit, injeksi seftriakson 1 g/12
jam, injeksi furosemid 1 ampul/12 jam,
OAT, metilprednisolon 4-4-4 tab, dan
perikardiosentesis, keluar cairan 2.000 liter:
warna merah, total protein 5,4 g/dL, LDH
2.799 U/L, glukosa 13 mg/dL, pH 9,0, lekosit
1213, PMN 45,2 %, MN 54,8 % dan sitologi
kesan benign smears, radang kronis. Setelah
dirawat selama 18 hari, pasien dipulangkan
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LAPORAN KASUS
sirkulasi yang adekuat.
Clinical presentation
Precipitating factors
ECG
Can be normal or non-specifically changed (ST-T wave), electrical alternans (QRS, rarely T),
bradycardia (end-stage), Electromechanical dissociation (agonal phase)
Chest X-ray
M mode/2D echocardiogram Diastolic collapse of the (1) anterior RV-free wall, RA collapse,LA and very rarely LV
collapse, increased LV diastolic wall thickness pseudohypertrophy, VCI dilatation (no
collapse in inspirium), swinging heart
Doppler
Tricuspid flow increases and mitral flow decreases during inspiration (reverse in
expiration)
Systolic and diastolic flows are reduced in systemic veins in expirium and reverse flow
with atrial contraction is increased
Cardiac catheterisation
RV/LV angiography
Computer tomography
Jugular venous distension is less notable in hypovolemic patients or in surgical tamponade. An inspiratory increase or lack
of fall of the pressure in the neck veins (Kussmaul sign), when verified with tamponade, or after pericardial drainage, indicates
effusive-constrictive disease.
b
Heart rate is usually >100 beats/min, but may be lower in hypothyroidism and in uremic patients.
Pulsus paradoxus is absent in tamponade complicating atrial septal defect71 and in patients with significant aortic regur-
gitation.
d
Right ventricular collapse can be absent in elevated right ventricular pressure and right ventricular hypertrophy73 or in right
ventricular infarction.
g
Coronary angiography
LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle; VCI, inferior vena cava.
a
If after drainage of pericardial effusion intrapericardial pressure does not fall below atrial pressure, the effusive-constrictive
194
Tamponade Jantung
Merupakan komplikasi perikarditis yang paling
fatal dengan gambaran klinis tergantung
kecepatan akumulasi cairan perikardium;
akumulasi cairan dapat menyebabkan
kompensasi, seperti takikardia, peningkatan
resistensi vaskuler perifer dan peningkatan
volume intravaskular guna membantu sistem
3. Elektrokardiografi
(EKG):
takikardia,
gelombang QRS rendah, elevasi segmen ST
yang cekung, dan electrical alternans. Jika
kompleks QRS dipengaruhi, setiap kompleks
QRS lainnya tegangannya lebih kecil, sering
dengan polaritas terbalik. Dikombinasikan P
dan QRS, hampir spesifik untuk tamponade
(Gambar 3). Volume efusi yang dapat
menyebabkan tamponade adalah sedang
sampai besar (300 sampai 600 mL).
LAPORAN KASUS
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LAPORAN KASUS
2-3 menit, atau bleomisin 45 mg dalam 20 mL
salin normal.
Stenum
Pericardium
To electrocardiogram
Xyphoid
Three-way
stopcock
Transducer
Aspiration
syringe with
1% xylocaine
Fluid-filled short
connecting tubing
2. Pericardial window.
Tindakan ini memerlukan torakotomi dan
dilakukan drainase dari kavum perikardium
ke kavum pleura. Angka kekambuhan sekitar
5-20%.
3. Perikardiodesis
Dilakukan pemberian tetrasiklin, tiotepa, atau
bleomisin ke dalam kavum perikardium untuk
melengketkan perikardium. Tetrasiklin 500 mg
dalam 25 mL salin normal dimasukkan dalam
DAFTAR PUSTAKA
1.
Guberman BA, Fowler NO, Engel PJ, Gueron M, Allen JM. Cardiac tamponade in medical patients. Circulation. 1981;64:633-8.
2.
Colombo A, Olson HG, Egan J, Gardin JM. Etiology and prognostic implications of a large pericardial effusion in men. Clin Cardiol. 1988;11:389-94.
3.
Shabetai R. Disease of the pericardium. In: Hurst J, editor. The heart. New York: McGraw-Hill; 1986. p. 1249-50.
4.
Darsee R. Diseases of the pericardium. In: Braunwald E, Ed. Heart disease. New York: Saunders Publishing Co; 1987. p. 1415-8.
5.
Brodie HR. Marchessault V. Acute benign pericarditis caused by Coxsackie virus group B. N Engi J Med. 1960;262:1278-83.
6.
Hageman JH, DEsopo ND, Glenn WW. Tuberculosis of the pericardium: A long term analysis of 44 proved cases. N Engl J Med. 1964;270:327-31.
7.
Flannery EP, Gregoratos G, Corder ME. Pericardial effusion in patients with malignant diseases. Arch Intern Med. 1975;135:976-82.
8.
Goldstein DH, Nagar C, Srivastava N, Schact R, Ferris FZ, Flowers NC. Clinically silent pericardial effusions in patients on long-term hemodialysis. Chest. 1977;72:744-54.
9.
Lksner MR, Cohen GI, Skarin AT. Pericardial disease in patients with cancer: The differentiation of malignant from radiation-induced pericarditis. Am J Med. 1981;7:407-12.
10. Crandell-Riera J, Del Castillo G, Frmanyer, Miralth G, Soler-Soler A. Pericardial effusion: Diagnostic value of the subcostal acoustic window (inferior vena cava right atrial projection). Clin
Cardiol. 1987;10:262-9.
11. Horowitz MS, Schhultz CS, Stinson EB. Sensitivity and specificity of echocardiographic diagnosis of pericardial effusion. Circulation. 1974;50:239-44.
12. Friedman MJ, Sahn DJ, Haber K. Two-dimensional echocardiography and B-mode ultnasonography fur the diagnosis of loculated pericardial effusion. Circulation. 1979;60:1644-51.
13. Fowler NO. Physiology of cardiac tamponade and pulsus pamdoxus: physiological, circulatory, and pharmacologic response in cardiac tamponade. Mod Conc Cardiovasc Dis.
1978;47:115-9.
14. Spodick DH. The normal and diseased pericardium: Current concepts of pericardial physioIogy diagnosis and treatment. J Am Coll Cardiol. 1983;1:241-4.
15. Shabetai R, Fowler NO, Guntheroth WG. The hemodynamics of cardiac tamponade and constrictive pericarditis. Am J Cardiol. 1970;26:480-5.
16. Frank MN, Nadimi M, Lesniak U, Hilmi K, Levinson GE. Effects ofcarduac tamponade on myocardial performance, blood flow and metabolism. Am J Physiol. 1971;220:79-86.
17. Spodick DH. Acute cardiac tamponade: Pathologic physiology, diagnosis and management. Progr Cardiovasc Dis. 1967;10:64-73.
18. Kronzon I, Cohen MJ, Wmer HE. Contribution of echocardiography to the understanding of the pathophysiology of cardiac tamponade. J Am Coil Cardiol. 1983;1:1180-6.
19. Armstrong NF, Feigenbaum H, Dillon JC. Acute right ventricular dilation and echocardiographic volume overload following pericardiocentesis fur relief of cardiac tamponade. Am Heart
J. 1984;107:1266-71.
20. Shenoy MM, Char 5, Gittin R, Sinha AK, Sabado M. Pulmonary edema following pericardiectomy fur cardiac tamponade. Chest. 1984;86:647-53.
21. The Task Force on the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology. Guidelines on the diagnosis and management of pericardial diseases. Eur
Heart J. 2004. doi:10.1016/j.ehj.2004.02.001.
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