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A CASE OF ATYPICAL CARDIAC TAMPONADE WITH ISOLATED LEFT VENTRICULAR COMPRESSION
2409 JACC March 21, 2017 Volume 69, Issue 11
FIT Clinical Decision Making A CASE OF ATYPICAL CARDIAC TAMPONADE WITH ISOLATED LEFT VENTRICULAR COMPRESSION Poster Contributions Poster Hall, Hall C Saturday, March 18, 2017, 3:45 p.m.-4:30 p.m. Session Title: FIT Clinical Decision‐Making: Heart Failure and Pulmonary Hypertension Abstract Category: Pulmonary Hypertension and Pulmonary Thrombo-embolic Disease Presentation Number: 1257-427 Authors: Eliany Mejia Lopez, Sula Mazimba, University of Virginia, Charlottesville, VA, USA
Background: Pericardial effusion (PE) in patients with severe pulmonary hypertension (PH) is associated with significant morbidity and mortality, and its pathogenesis is complex and poorly understood. In these patients PE worsens the paradoxical interventricular septal motion, which impairs left ventricular filling. This is also called atypical cardiac tamponade because right atrial and ventricular diastolic collapse, pulsus paradoxus, and hypotension are usually absent. Treatment is controversial and it represents a therapeutic challenge. Case: 55 year-old female with history of chronic thromboembolic pulmonary hypertension (WHO class IV) presented with worsening dyspnea and edema. She had low voltage on EKG while echocardiogram showed a new large pericardial effusion with evidence of tamponade in association with severe RV dysfunction and elevated pulmonary artery pressure (66 mmHg). Physical exam revealed elevated JVD and tachycardia but no evidence of pulsus pardoxus or hypotension.
Decision‐Making: Patient was admitted to the CCU for closer observation. Risks and benefits of pericardiocentesis were discussed. Imminent death have been reported after drainage of large PE in patient with RV dysfunction and PH, the mechanism is unclear but has been postulated that rapid removal of the PE leads to the enlargement of the RV cavity, which further pushes the interventricular septum, compressing the left ventricle and leading to hypotension and death. Patient underwent pericardiocentesis with pericardial drain placement, gradual removal of pericardial fluid with close hemodynamic monitoring. Patient symptoms improved and she was discharged with diuresis and plan to start Ambrisentan and Riociguat after optimization of volume status.
Conclusions: Pericardial effusion in PH signals elevated right atrial pressures and right heart failure and is strongly associated with poor outcomes. The treatment of large PE remains controversial, early and aggressive treatment may be helpful after weighing risks and benefits of pericardiocentesis. Gradual removal of the effusion with close hemodynamic monitoring is recommended in these cases.
FIT Clinical Decision Making A CASE OF ATYPICAL CARDIAC TAMPONADE WITH ISOLATED LEFT VENTRICULAR COMPRESSION Poster Contributions Poster Hall, Hall C Saturday, March 18, 2017, 3:45 p.m.-4:30 p.m. Session Title: FIT Clinical Decision‐Making: Heart Failure and Pulmonary Hypertension Abstract Category: Pulmonary Hypertension and Pulmonary Thrombo-embolic Disease Presentation Number: 1257-427 Authors: Eliany Mejia Lopez, Sula Mazimba, University of Virginia, Charlottesville, VA, USA
Background: Pericardial effusion (PE) in patients with severe pulmonary hypertension (PH) is associated with significant morbidity and mortality, and its pathogenesis is complex and poorly understood. In these patients PE worsens the paradoxical interventricular septal motion, which impairs left ventricular filling. This is also called atypical cardiac tamponade because right atrial and ventricular diastolic collapse, pulsus paradoxus, and hypotension are usually absent. Treatment is controversial and it represents a therapeutic challenge. Case: 55 year-old female with history of chronic thromboembolic pulmonary hypertension (WHO class IV) presented with worsening dyspnea and edema. She had low voltage on EKG while echocardiogram showed a new large pericardial effusion with evidence of tamponade in association with severe RV dysfunction and elevated pulmonary artery pressure (66 mmHg). Physical exam revealed elevated JVD and tachycardia but no evidence of pulsus pardoxus or hypotension.
Decision‐Making: Patient was admitted to the CCU for closer observation. Risks and benefits of pericardiocentesis were discussed. Imminent death have been reported after drainage of large PE in patient with RV dysfunction and PH, the mechanism is unclear but has been postulated that rapid removal of the PE leads to the enlargement of the RV cavity, which further pushes the interventricular septum, compressing the left ventricle and leading to hypotension and death. Patient underwent pericardiocentesis with pericardial drain placement, gradual removal of pericardial fluid with close hemodynamic monitoring. Patient symptoms improved and she was discharged with diuresis and plan to start Ambrisentan and Riociguat after optimization of volume status.
Conclusions: Pericardial effusion in PH signals elevated right atrial pressures and right heart failure and is strongly associated with poor outcomes. The treatment of large PE remains controversial, early and aggressive treatment may be helpful after weighing risks and benefits of pericardiocentesis. Gradual removal of the effusion with close hemodynamic monitoring is recommended in these cases.