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J Thorac Cardiovasc Surg 1997;113:428
© 1997 Mosby, Inc.

LETTERS TO THE EDITOR

Purulent pericarditis

Thoracic Surgery and Intensive Care Units
Dandenong Hospital
Melbourne, Australia

To the Editor:

We thank Drs. Winkler, Karnik, and Slany for their interest in our work and are gratified by the increasing awareness of the role of fibrinolytic irrigation therapy in purulent pericarditis. With regard to their specific queries, no echocardiograms were performed during pericardial irrigation. Serial echocardiograms over the period did, however, demonstrate a gradual diminution in the size of the loculated collections until they disappeared entirely. The alterations in left ventricular function as indicated by echocardiography and clinical evidence were entirely beneficial, and no hemodynamic compromise occurred. No coagulopathies or arrhythmias developed during the course of treatment.

We agree that urokinase does have a theoretic advantage over streptokinase in that it is nonantigenic. Urokinase is far more expensive than streptokinase and is currently unavailable in Melbourne public hospitals. In addition, we are unaware of a commercially available combination of urokinase/streptodornase or streptodornase alone that could be added to urokinase. Streptodornase is advantageous in lavage therapy of loculated purulent pericarditis because it accelerates the depolymerization of desoxyribose nucleoprotein, thereby liquefying the viscous component of pus. As such, it can work synergistically with fibrinolytics, whether streptokinase or urokinase, to facilitate drainage. It should be noted that streptodornase, like streptokinase, is antigenic.

To date, all documentation regarding the treatment of purulent pericarditis with proteolytic and fibrinolytic enzyme lavage has involved small series of patients. Formation of antienzymes has not been documented in this context. Only a large prospective randomized trial will determine the efficacy of adding antibiotics to the lavage solution and the relative benefits and risks of adding streptodornase to urokinase or using urokinase instead of commercially available streptokinase/streptodornase. Our good fortune in seeing a decreased incidence of this disease over the years also means that such a study would have to be multicentered to obtain the numbers required to achieve statistically significant results.

Until now all reported cases have been from groups that have developed their own fibrinolytic regimen de novo. We hope that the growing awareness of fibrinolytic therapy in purulent pericarditis will provide treatment options for clinicians without the need for further empiric trials in isolation from the published literature.

12/8/77667

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Bruce Jones Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Mann-Segal, D. D. M. Articles by Ramasamy, D. Search for Related Content PubMed Articles by Mann-Segal, D. D. M. Articles by Ramasamy, D.