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An Undiagnosed, Massive Pericardial Effusion With a Swinging Heart
An Undiagnosed, Massive Pericardial Effusion With a Swinging Heart Berthold Bein, MD, Jochen Renner, MD, Jens Scholz, MD, and Peter H. Tonner, MD
T
HE EFFECT OF transesophageal echocardiography (TEE) in noncardiac surgery is currently under debate.1,2 While TEE examinations in patients undergoing cardiac surgery are a standard procedure in most institutions around the world, the value of TEE for the management of patients outside cardiac surgical operating rooms has been questioned.2 The authors report an unusual case of a patient scheduled for pleurodesis in which TEE was used to help in the diagnosis of the cause of an acute hemodynamic problem and to guide adequate therapy. CASE REPORT A 46-year-old woman with end-stage metastatic ovarian cancer and recurrent pleural effusions had pleurodesis after pleural puncture. A preoperative chest x-ray study performed 2 days before surgery was cleared by the consultant radiologist, particularly with respect to pleural or pericardial effusions (Fig 1). On arrival in the anesthesia induction room, the patient had tachycardia (heart rate, 120 bpm), distended jugular veins, and hypotension (blood pressure, 80/50 mmHg). An echocardiogram showed a sinus rhythm with a low-voltage QRS complex. After establishing intravenous access, anesthesia was induced with 0.3 mg/kg of etomidate and 0.3 g/kg of sufentanil. Immediately after administration of etomidate and sufentanil, the heart rate increased to 150 bpm and blood pressure decreased to 60/30 mmHg. Norepinephrine, 10 g, was administered, and after ensuring adequate mask ventilation, rocuronium, 0.6 mg/kg, was given and the trachea was intubated. Despite repeated vasopressor administration, heart rate and blood pressure remained unchanged. On bilateral chest auscultation, heart sounds appeared to be muffled, but breaths sounds were normal. Hydroxyethylstarch, 500 mL, was administered, and norepinephrine and epinephrine were started at 0.1 g/kg/ min each, without improvement. A multiplane echo probe was inserted (5 MHz; Philips Medical Systems, Best, The Netherlands). During TEE examination, a massive pericardial effusion was seen, with a swinging heart (Fig 2). Collapse of the right atrium during inspiration and a concomitant shift of the interventricular septum to the right were observed (Fig 3); cardiac chamber filling was largely impeded. Left ventricular function was judged to be in the normal range (ejection fraction, ⬎50%). Pericardiocentesis was performed with an 18-gauge Seldinger cannula advanced subxiphoid under echocardiographic guidance. A 6F pigtail catheter was then inserted via a 7F introducer, and subsequently 1,000 mL of fluid were removed and found to be cytologically positive for pericarditis carcinomatosa. Immediately after removal of the pericardial fluid the patient’s hemodynamic condition improved dramatically (blood pressure, 160/100 mmHg; heart rate, 110 bpm). Epineph-
From the Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany. Address reprint requests to Berthold Bein, MD, Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Schwanenweg 21, D-24105 Kiel, Germany. E-mail: [email protected] © 2006 Elsevier Inc. All rights reserved. 1053-0770/06/2002-0022$32.00/0 doi:10.1053/j.jvca.2005.01.040 Key words: cardiac tamponade, echocardiography, transesophageal, cancer, metastasis, pericardial effusion 242
rine and norepinephrine administration was stopped, and an additional 500 mL of hydroxyethylstarch were given. The pleurodesis yielded 250 mL of clear fluid, and the case was completed uneventfully. After 2 hours in the postanesthesia care unit, the patient was discharged to the ward in stable hemodynamic condition (heart rate, 90 bpm; blood pressure, 110/70 mmHg). The pigtail intrapericardial catheter was removed on the following day, without complications. DISCUSSION
According to the guidelines of the American Society of Echocardiography, indications for TEE use can be divided into 4 categories, each with a different level of evidence.3 Hemodynamic instability of unknown origin is considered a class 1 indication, most probably resulting in a life-threatening diagnosis with important therapeutic consequences. Class 1 indications are commonly present in cardiac surgery; however, the effect of TEE for noncardiac surgery is currently evolving. Recently, a beneficial effect of TEE as an additional monitor was demonstrated in patients with a class 2 indication undergoing noncardiac surgery; fluid and vasoactive drug administration both were influenced in a significant proportion of patients.4 Of note, these patients all were classified as American Society of Anesthesiologists physical status III and IV. In the present case, a preoperative chest x-ray study gave no hint of the massive pericardial effusion found; therefore, the poor clinical condition of the patient was thought to be a consequence of the underlying disease, and was attributed to tumor cachexia in an advanced state. Pericardial effusion is a rare but potentially life-threatening complication of metastatic cancer.5 The increasing fluid in the pericardial space impedes cardiac function in two ways. First, the ventricular concordance provokes preferential filling of the right or left cardiac chamber, depending on the breathing cycle.6 Second, transmural pressure, which is the key determinant of cardiac chamber filling, is reduced, with increasing pericardial pressure,7 because intrathoracic pressure variations affecting the pulmonary vasculature are not transmitted to the ventricles in a comparable fashion. This is reflected in the transmitral and transtricuspid Doppler flow profile, in which the ventilation-dependent change of filling velocity is particularly characteristic.8 To compensate for impaired ventricular diastolic filling, endogenous catecholamines increase, subsequently causing increases in heart rate, contractility, and systemic vascular resistance. Since most general anesthetics cause myocardial depression and systemic vasodilation, and positivepressure ventilation decreases venous return, induction of general anesthesia may result in cardiovascular collapse.9 A good therapeutic approach is pericardiocentesis, which should result in prompt restoration of cardiac function and hemodynamic stability, as seen in the present case. Pulmonary edema may arise as a consequence of rapid drainage; thus a stepwise relief of the pericardial fluid is recommended, and is easily monitored with echocardiography. TEE for the detection of pericardial effusion is not a new diagnostic approach. However, the unique feature of the case
Journal of Cardiothoracic and Vascular Anesthesia, Vol 20, No 2 (April), 2006: pp 242-244
MASSIVE PERICARDIAL EFFUSION WITH SWINGING HEART
Fig 1.
243
Chest x-ray obtained 2 days before surgery.
reported is the immediate life-saving diagnosis during cardiovascular collapse of a patient outside the cardiac operating room. In conclusion, massive pericardial effusion is a rare but potentially life-threatening complication of metastatic cancer. Cardiac tamponade should be considered if typical symptoms are present, regardless of the underlying disease.
Transesophageal echocardiography is a sensitive tool for detection of pericardial effusion. In this case, TEE helped to determine the cause of the acute, postinduction hemodynamic compromise and to guide therapy. This example provides strong evidence that TEE may be used as an important and potentially life-saving diagnostic tool even in noncardiac surgery.
Fig 2. Transgastric, short-axis view shows a pigtail catheter in the pericardial space.
Fig 3. Four-chamber view at the midesophageal level shows the collapsing right atrium.
244
BEIN ET AL
REFERENCES 1. Patteril M, Swaminathan M: Pro: intraoperative transesophageal echocardiography is of utility in patients at high risk of adverse cardiac events undergoing noncardiac surgery. J Cardiothorac Vasc Anesth 18:107-109, 2004 2. Collard CD: Con: intraoperative transesophageal echocardiography is not of utility in patients at high risk of adverse cardiac events undergoing noncardiac surgery. J Cardiothorac Vasc Anesth 18:110-111, 2004 3. Practice guidelines for perioperative transesophageal echocardiography: a report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography. Anesthesiology 84:986-1006, 1996 4. Hofer CK, Zollinger A, Rak M, et al: Therapeutic impact of intraoperative transoesophageal echocardiography during noncardiac surgery. Anaesthesia 59:3-9, 2004
5. Klatt EC, Heitz DR: Cardiac metastases. Cancer 65:1456-1459, 1990 6. Savitt MA, Tyson GS, Elbeery JR, et al: Physiology of cardiac tamponade and paradoxical pulse in conscious dogs. Am J Physiol 265:H1996-2008, 1993 7. Boltwood CM Jr: Ventricular performance related to transmural filling pressure in clinical cardiac tamponade. Circulation 75:941-955, 1987 8. Spodick DH: Acute cardiac tamponade. N Engl J Med 349:684690, 2003 9. Stoelting RK, Dierdorf SF (eds): Pericardial diseases, Anesthesia and Co-existing Disease (ed 4). New York, NY, Churchill Livingstone, 2002, pp 135-142
T
HE EFFECT OF transesophageal echocardiography (TEE) in noncardiac surgery is currently under debate.1,2 While TEE examinations in patients undergoing cardiac surgery are a standard procedure in most institutions around the world, the value of TEE for the management of patients outside cardiac surgical operating rooms has been questioned.2 The authors report an unusual case of a patient scheduled for pleurodesis in which TEE was used to help in the diagnosis of the cause of an acute hemodynamic problem and to guide adequate therapy. CASE REPORT A 46-year-old woman with end-stage metastatic ovarian cancer and recurrent pleural effusions had pleurodesis after pleural puncture. A preoperative chest x-ray study performed 2 days before surgery was cleared by the consultant radiologist, particularly with respect to pleural or pericardial effusions (Fig 1). On arrival in the anesthesia induction room, the patient had tachycardia (heart rate, 120 bpm), distended jugular veins, and hypotension (blood pressure, 80/50 mmHg). An echocardiogram showed a sinus rhythm with a low-voltage QRS complex. After establishing intravenous access, anesthesia was induced with 0.3 mg/kg of etomidate and 0.3 g/kg of sufentanil. Immediately after administration of etomidate and sufentanil, the heart rate increased to 150 bpm and blood pressure decreased to 60/30 mmHg. Norepinephrine, 10 g, was administered, and after ensuring adequate mask ventilation, rocuronium, 0.6 mg/kg, was given and the trachea was intubated. Despite repeated vasopressor administration, heart rate and blood pressure remained unchanged. On bilateral chest auscultation, heart sounds appeared to be muffled, but breaths sounds were normal. Hydroxyethylstarch, 500 mL, was administered, and norepinephrine and epinephrine were started at 0.1 g/kg/ min each, without improvement. A multiplane echo probe was inserted (5 MHz; Philips Medical Systems, Best, The Netherlands). During TEE examination, a massive pericardial effusion was seen, with a swinging heart (Fig 2). Collapse of the right atrium during inspiration and a concomitant shift of the interventricular septum to the right were observed (Fig 3); cardiac chamber filling was largely impeded. Left ventricular function was judged to be in the normal range (ejection fraction, ⬎50%). Pericardiocentesis was performed with an 18-gauge Seldinger cannula advanced subxiphoid under echocardiographic guidance. A 6F pigtail catheter was then inserted via a 7F introducer, and subsequently 1,000 mL of fluid were removed and found to be cytologically positive for pericarditis carcinomatosa. Immediately after removal of the pericardial fluid the patient’s hemodynamic condition improved dramatically (blood pressure, 160/100 mmHg; heart rate, 110 bpm). Epineph-
From the Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany. Address reprint requests to Berthold Bein, MD, Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Schwanenweg 21, D-24105 Kiel, Germany. E-mail: [email protected] © 2006 Elsevier Inc. All rights reserved. 1053-0770/06/2002-0022$32.00/0 doi:10.1053/j.jvca.2005.01.040 Key words: cardiac tamponade, echocardiography, transesophageal, cancer, metastasis, pericardial effusion 242
rine and norepinephrine administration was stopped, and an additional 500 mL of hydroxyethylstarch were given. The pleurodesis yielded 250 mL of clear fluid, and the case was completed uneventfully. After 2 hours in the postanesthesia care unit, the patient was discharged to the ward in stable hemodynamic condition (heart rate, 90 bpm; blood pressure, 110/70 mmHg). The pigtail intrapericardial catheter was removed on the following day, without complications. DISCUSSION
According to the guidelines of the American Society of Echocardiography, indications for TEE use can be divided into 4 categories, each with a different level of evidence.3 Hemodynamic instability of unknown origin is considered a class 1 indication, most probably resulting in a life-threatening diagnosis with important therapeutic consequences. Class 1 indications are commonly present in cardiac surgery; however, the effect of TEE for noncardiac surgery is currently evolving. Recently, a beneficial effect of TEE as an additional monitor was demonstrated in patients with a class 2 indication undergoing noncardiac surgery; fluid and vasoactive drug administration both were influenced in a significant proportion of patients.4 Of note, these patients all were classified as American Society of Anesthesiologists physical status III and IV. In the present case, a preoperative chest x-ray study gave no hint of the massive pericardial effusion found; therefore, the poor clinical condition of the patient was thought to be a consequence of the underlying disease, and was attributed to tumor cachexia in an advanced state. Pericardial effusion is a rare but potentially life-threatening complication of metastatic cancer.5 The increasing fluid in the pericardial space impedes cardiac function in two ways. First, the ventricular concordance provokes preferential filling of the right or left cardiac chamber, depending on the breathing cycle.6 Second, transmural pressure, which is the key determinant of cardiac chamber filling, is reduced, with increasing pericardial pressure,7 because intrathoracic pressure variations affecting the pulmonary vasculature are not transmitted to the ventricles in a comparable fashion. This is reflected in the transmitral and transtricuspid Doppler flow profile, in which the ventilation-dependent change of filling velocity is particularly characteristic.8 To compensate for impaired ventricular diastolic filling, endogenous catecholamines increase, subsequently causing increases in heart rate, contractility, and systemic vascular resistance. Since most general anesthetics cause myocardial depression and systemic vasodilation, and positivepressure ventilation decreases venous return, induction of general anesthesia may result in cardiovascular collapse.9 A good therapeutic approach is pericardiocentesis, which should result in prompt restoration of cardiac function and hemodynamic stability, as seen in the present case. Pulmonary edema may arise as a consequence of rapid drainage; thus a stepwise relief of the pericardial fluid is recommended, and is easily monitored with echocardiography. TEE for the detection of pericardial effusion is not a new diagnostic approach. However, the unique feature of the case
Journal of Cardiothoracic and Vascular Anesthesia, Vol 20, No 2 (April), 2006: pp 242-244
MASSIVE PERICARDIAL EFFUSION WITH SWINGING HEART
Fig 1.
243
Chest x-ray obtained 2 days before surgery.
reported is the immediate life-saving diagnosis during cardiovascular collapse of a patient outside the cardiac operating room. In conclusion, massive pericardial effusion is a rare but potentially life-threatening complication of metastatic cancer. Cardiac tamponade should be considered if typical symptoms are present, regardless of the underlying disease.
Transesophageal echocardiography is a sensitive tool for detection of pericardial effusion. In this case, TEE helped to determine the cause of the acute, postinduction hemodynamic compromise and to guide therapy. This example provides strong evidence that TEE may be used as an important and potentially life-saving diagnostic tool even in noncardiac surgery.
Fig 2. Transgastric, short-axis view shows a pigtail catheter in the pericardial space.
Fig 3. Four-chamber view at the midesophageal level shows the collapsing right atrium.
244
BEIN ET AL
REFERENCES 1. Patteril M, Swaminathan M: Pro: intraoperative transesophageal echocardiography is of utility in patients at high risk of adverse cardiac events undergoing noncardiac surgery. J Cardiothorac Vasc Anesth 18:107-109, 2004 2. Collard CD: Con: intraoperative transesophageal echocardiography is not of utility in patients at high risk of adverse cardiac events undergoing noncardiac surgery. J Cardiothorac Vasc Anesth 18:110-111, 2004 3. Practice guidelines for perioperative transesophageal echocardiography: a report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography. Anesthesiology 84:986-1006, 1996 4. Hofer CK, Zollinger A, Rak M, et al: Therapeutic impact of intraoperative transoesophageal echocardiography during noncardiac surgery. Anaesthesia 59:3-9, 2004
5. Klatt EC, Heitz DR: Cardiac metastases. Cancer 65:1456-1459, 1990 6. Savitt MA, Tyson GS, Elbeery JR, et al: Physiology of cardiac tamponade and paradoxical pulse in conscious dogs. Am J Physiol 265:H1996-2008, 1993 7. Boltwood CM Jr: Ventricular performance related to transmural filling pressure in clinical cardiac tamponade. Circulation 75:941-955, 1987 8. Spodick DH: Acute cardiac tamponade. N Engl J Med 349:684690, 2003 9. Stoelting RK, Dierdorf SF (eds): Pericardial diseases, Anesthesia and Co-existing Disease (ed 4). New York, NY, Churchill Livingstone, 2002, pp 135-142