Case report
Post-cardiac injury syndrome following transvenous pacing: Case report
Síndrome pós lesão cardíaca após pacing transvenoso – a propósito de um caso clínico
Carla Sousa
, Elisabete Martins, Manuel Campelo, Inês Rangel, Pedro B. Almeida, Maria Júlia Maciel
Corresponding author
Serviço de Cardiologia, Centro Hospitalar São João, E.P.E., Porto, Portugal
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array:1 [ 0 => array:4 [ "autoresLista" => "Carla Sousa, Elisabete Martins, Manuel Campelo, Inês Rangel, Pedro B. Almeida, Maria Júlia Maciel" "autores" => array:6 [ 0 => array:4 [ "nombre" => "Carla" "apellidos" => "Sousa" "email" => array:1 [ 0 => "cmcsousa@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Elisabete" "apellidos" => "Martins" ] 2 => array:2 [ "nombre" => "Manuel" "apellidos" => "Campelo" ] 3 => array:2 [ "nombre" => "Inês" "apellidos" => "Rangel" ] 4 => array:2 [ "nombre" => "Pedro B." "apellidos" => "Almeida" ] 5 => array:2 [ "nombre" => "Maria Júlia" "apellidos" => "Maciel" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Serviço de Cardiologia, Centro Hospitalar São João, E.P.E., Porto, Portugal" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Síndrome pós lesão cardíaca após <span class="elsevierStyleItalic">pacing</span> transvenoso – a propósito de um caso clínico" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 884 "Ancho" => 3001 "Tamanyo" => 186819 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Echocardiographic subcostal views: (A) after permanent pacemaker implantation revealing a new moderate pericardial effusion (arrow); (B) at hospital discharge, after a few days of clinical surveillance with no evidence of pericardial effusion (arrow); and (C) at readmission, with a large pericardial effusion and ‘swinging heart’ (arrow).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Pacemaker implantation is a classic technique in cardiology. Materials have changed considerably in recent years, making the procedure safer and the indications broader. However, as in all invasive procedures, there is the risk of immediate and delayed intra and postoperative complications, such as system infection, lead displacement and post-cardiac injury syndrome (PCIS).</p><p id="par0010" class="elsevierStylePara elsevierViewall">We report a rare case of an iatrogenic cardiac rupture followed by PCIS with delayed pericardial effusion after a pacemaker implantation. A comprehensive literature review on this topic is provided.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0020" class="elsevierStylePara elsevierViewall">An 89-year-old woman was admitted for syncope. She had a history of hypertension and dyslipidemia.</p><p id="par0025" class="elsevierStylePara elsevierViewall">At admission, she reported a brief episode of loss of consciousness, without prodromes or head trauma and with spontaneous recovery. Her physical examination revealed bradycardia but no other relevant findings. The electrocardiogram showed advanced heart block with mean heart rate of 30 bpm. She was not under any negative chronotropic medication and laboratory tests showed no relevant electrolyte disturbances. Summary echocardiography revealed mild systolic dysfunction without pericardial effusion.</p><p id="par0030" class="elsevierStylePara elsevierViewall">A temporary pacemaker was inserted via the right femoral vein, without immediate complications, followed by implantation of a dual chamber permanent pacemaker the next day. During this procedure, the patient presented a brief period of hypotension and pleuritic chest pain. The echocardiogram showed moderate systolic dysfunction and new moderate pericardial effusion (16 mm), with no signs of hemodynamic compromise (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>). A diagnosis of iatrogenic right ventricle rupture was made and the patient was kept under clinical, electrical and echocardiographic monitoring. She presented progressive reduction of the pericardial effusion and was discharged by the 5th day, asymptomatic and without pericardial effusion (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Four weeks later, she was readmitted for pleuritic chest pain and asthenia. Physical examination revealed reduced heart sounds with no other significant alterations, including in the pacemaker scar, which presented no inflammatory signs. The electrocardiogram showed sinus rhythm with P-wave synchronous ventricular pacing. Blood tests showed leukocytosis (17×10<span class="elsevierStyleSup">9</span>/l) and elevated C-reactive protein (CRP) (110 mg/dl), with no evidence of systemic infection or fever. Blood cultures were negative and the chest X-ray showed cardiomegaly without pleural effusion. The echocardiogram revealed a large pericardial effusion (25 mm), with ‘swinging heart’ and signs of hemodynamic compromise (inferior vena cava dilatation, mitral and tricuspid flow variation >50%, abnormal septal motion, mild diastolic compression of right heart chambers), suggestive of incipient tamponade physiology (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>).</p><p id="par0040" class="elsevierStylePara elsevierViewall">Pericardiocentesis was performed, with drainage of 350 ml of light yellow fluid, which was found to be a sterile exudate (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Post-procedural echocardiography still showed moderate pericardial effusion (18 mm), but with no signs of hemodynamic compromise. Autoimmunity study was negative. There was no sign of pacemaker dysfunction, sensing and pacing thresholds being optimal.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">The patient was diagnosed with PCIS and medicated with aspirin (500 mg four times a day) and colchicine (1 mg twice a day). As there was no favorable clinical evolution or remission of the pericardial effusion, prednisolone was added on the seventh day (1 mg/kg/day), with eventual resolution of symptoms, laboratory parameters and pericardial effusion. She was discharged on the 15th day and remained asymptomatic at follow-up.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">PCIS is an inflammatory process involving the pleura (pleural effusion) and/or pericardium (pericarditis, pericardial effusion) secondary to cardiac injury.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It can develop after cardiac trauma, cardiac surgery, myocardial infarction and certain intravascular procedures, including transvenous pacemaker lead insertion, electrophysiological studies and percutaneous coronary interventions, even in the absence of obvious cardiac perforation.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Hence, the designation of PCIS covers post-myocardial infarction pericarditis (Dressler syndrome), post-pericardiotomy syndrome and post-traumatic pericarditis. In the setting of cardiac pacing, it appears to be a very rare condition, with only a few cases described in the literature.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Unlike acute myocardial rupture and acute pericarditis, which can both occur within 24 hours of transvenous pacing, PCIS typically occurs later on and represents an exclusion diagnosis.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Although the precise cause is not clear, it appears to be due to an immune reaction precipitated by pacemaker-induced myocardial injury (late autoimmune or inflammatory response to pericardial irritation by minimally protruding electrodes, by low-grade bleeding with hemorrhagic pericarditis or by acute cardiac perforation). The underlying molecular mechanism may be similar to that of Dressler syndrome.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> There is no known predisposing underlying cardiac disease and the only demographic predictor seems to be advanced age.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The potential role of technical factors (such as active fixation during lead positioning or previous temporary transvenous pacemaker use) in the development of PCIS has been postulated but needs further investigation.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,4</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Clinical presentation includes pleuritic chest pain, shortness of breath and low-grade fever, symptoms that generally occur within the first month after the procedure.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> A rub (pericardial or pleural) may be detected and non-specific ECG changes can be found.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">On admission, elevated sedimentation rates and CRP levels, sometimes with both pericardial and pleural effusions, are typically documented. Laboratory analysis usually reveals exudative effusions.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Other documented laboratory alterations include unexplained falls in hemoglobin, low complement levels, presence of immune complexes in the pleural fluid and elevated anti-myocardial antibody levels in both serum and pleural effusion.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Regarding differential diagnosis, clinical entities such as infectious pericardial effusion, viral pericarditis and delayed perforation must be ruled out. In this setting, clinical history, electrocardiography, pacemaker interrogation, cardiac imaging techniques and pericardial fluid analysis are crucial diagnostic tools. Previous history of viral infection and diffuse ST-segment elevation are highly suggestive of acute viral pericarditis. The presence of a light yellow pericardial effusion excludes delayed myocardial lead rupture. Echocardiography and computed tomography can show pericardial positioning of a pacemaker lead, which, as well as pacemaker dysfunction, suggests late cardiac rupture.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Finally, pericardial effusion associated with infection of the pacemaker implantation site suggests a bacterial etiology and endocarditis must be ruled out.</p><p id="par0085" class="elsevierStylePara elsevierViewall">If identified early, these patients will likely respond to NSAIDS, colchicine and/or prednisone, and medical treatment may eliminate the need for a surgical procedure.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> However, cases of large fluid volumes, recurrent fluid accumulation and/or tamponade physiology require pericardial fluid drainage and/or pericardial window at presentation.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Regardless of the possible need for an invasive strategy in the acute phase, the outcome after PCIS secondary to pacemaker implantation is favorable, as all the reported cases presented a good evolution, even though there may be recurrence. However, delayed diagnosis and treatment of PCIS, as well as unnecessary tests to screen for other causes of pericardial or pleural effusion and fever, may prolong hospital stay and increase medical costs.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">In the reported case an iatrogenic cardiac rupture immediately after permanent pacemaker implantation was followed by a hemodynamically significant pericardial effusion requiring urgent pericardiocentesis. Bacterial infection of the pacemaker implantation site and infective endocarditis were excluded, as was delayed myocardial perforation. The clinical features, investigation and response to steroids indicated a diagnosis of PCIS.</p><p id="par0100" class="elsevierStylePara elsevierViewall">This case highlights the need for a high suspicion index in the diagnosis of this rare entity after interventional procedures. Early recognition is crucial, both in order to proceed to the appropriate therapy and to prevent catastrophic complications, as well as to avoid prolonged hospital stay and increased medical costs.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0105" class="elsevierStylePara elsevierViewall">PCIS after pacemaker implantation is a rare situation with potentially serious complications. It constitutes an exclusion diagnosis in which a high suspicion index is necessary. The case described highlights the need to keep this entity in mind in patients who have undergone invasive cardiac procedures.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Ethical disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Protection of human and animal subjects</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Confidentiality of data</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Right to privacy and informed consent</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflicts of interest</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:2 [ "identificador" => "xres350693" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec332250" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres350694" "titulo" => "Resumo" ] 3 => array:2 [ "identificador" => "xpalclavsec332251" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusion" ] 8 => array:3 [ "identificador" => "sec0025" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-09-08" "fechaAceptado" => "2013-12-31" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec332250" "palabras" => array:3 [ 0 => "Post-cardiac injury syndrome" 1 => "Cardiac rupture" 2 => "Pacemaker implantation" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec332251" "palabras" => array:3 [ 0 => "Síndrome pós-lesão cardíaca" 1 => "Rotura cardíaca" 2 => "Implantação de <span class="elsevierStyleItalic">pacemaker</span>" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Post-cardiac injury syndrome (PCIS) is an inflammatory process involving the pericardium secondary to cardiac injury. It can develop after cardiac trauma, cardiac surgery, myocardial infarction, and, rarely, after certain intravascular procedures. We report a rare case of an iatrogenic cardiac rupture followed by PCIS with delayed inflammatory pericardial effusion after pacemaker implantation. A comprehensive literature review on this topic is provided.</p>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A síndrome pós-lesão cardíaca (SPLC) corresponde a um processo inflamatório envolvendo o pericárdio, secundário à lesão cardíaca. Pode desenvolver-se após traumatismo cardíaco, cirurgia cardíaca, enfarte agudo do miocárdio, e, raramente, após alguns procedimentos intravasculares. Os autores apresentam o caso invulgar de uma rotura cardíaca iatrogénica após implantação de um <span class="elsevierStyleItalic">pacemaker</span>, seguida pelo desenvolvimento de um derrame pericárdico retardado, inflamatório, correspondendo a SPLC. A propósito do referido caso clínico, é efetuada uma revisão compreensiva da literatura acerca desta entidade.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 884 "Ancho" => 3001 "Tamanyo" => 186819 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Echocardiographic subcostal views: (A) after permanent pacemaker implantation revealing a new moderate pericardial effusion (arrow); (B) at hospital discharge, after a few days of clinical surveillance with no evidence of pericardial effusion (arrow); and (C) at readmission, with a large pericardial effusion and ‘swinging heart’ (arrow).</p>" ] ] 1 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">ADA: adenosine deaminase; LDH: lactate dehydrogenase.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Appearance \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Light yellow \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nucleated cell count, 10<span class="elsevierStyleSup">9</span>/l \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Neutrophils, % \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">66 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lymphocytes, % \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">26 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total protein, g/dl \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">49.20 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LDH, U/l \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">781 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ADA, U/l \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">28.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">pH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Microbiology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sterile \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab524493.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Analysis of pericardial fluid.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Post-cardiac injury syndrome following transvenous pacemaker insertion: a case report and review of the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "C. 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