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Aortic Rupture and Concomitant Transection of the Left Bronchus After Blunt Chest Trauma
selected reports Aortic Rupture and Concomitant Transection of the Left Bronchus After Blunt Chest Trauma* Miralem Pasic, MD, PhD; Ralf Ewert, MD; Marcus Engel, MD; Norbert Franz; Peter Bergs, MD; Hermann Kuppe, MD, PhD; and Roland Hetzer, MD, PhD
We report a patient with traumatic aortic rupture and preoperatively unrecognized complete disruption of the bronchus for the left lower lobe. Preoperative state was complicated by inadequate oxygenation due to total atelectasis of the unventilated collapsed left lower lobe with consequent significant shunting of the unoxygenated blood. The patient had no massive pneumothorax because the intact peribronchial tissue and pleura covered the injured place, preventing important air leakage. The suspicion of possible concomitant tracheobronchial injury and early diagnostic bronchoscopy are important in patients with aortic rupture after blunt chest trauma. (CHEST 2000; 117:1508 –1510) Key words: aortic rupture; bronchial rupture
trauma is often obscured by the presence of other A ortic serious injuries. However, if the diagnosis is made, it can overshadow the presence of other severe but rare injuries. We report a patient with traumatic aortic rupture and preoperatively unrecognized complete disruption of the bronchus to the left lower lobe, a possibly catastrophic complication.
Case Report A 34-year-old man was transferred to our institution because of rupture of the descending thoracic aorta after a fall from the sixth floor (about 20 m height) onto the ground in an alcoholic state. He had been intubated and placed on mechanical ventilation because of head trauma and unconsciousness. Bilateral chest tubes were inserted in order to drain small hemothoraces with apical pneumothoraces, and multiple fractures of both legs were stabilized using external fixation. The other concomitant injuries were bilateral serial rib fractures and fractures of both clavicles, scapula, humerus, and pelvis. Despite these injuries, the patient *From the Deutsches Herzzentrum Berlin, Berlin, Germany. Manuscript received June 9, 1999; revision accepted October 10, 1999. Correspondence to: Miralem Pasic, MD, PhD, Deutsches Herzzentrum Berlin, Klinik fu¨r Herz-, Thorax- and Gefa¨sschirurgie, Augustenburger Platz 1, D-13353 Berlin, Germany; e-mail: [email protected] 1508
maintained stable respiratory status and an adequate blood pressure. A chest roentgenogram performed after admission at our institution revealed full expansion of the lungs without pneumothoraces. While the patient was being prepared to be transferred into the operating room, the blood gas analysis worsened abruptly, with a Po2 value of 50 mm Hg. A new chest roentgenogram showed a small left-sided apical pneumothorax, and an additional chest tube was inserted immediately, with consequent minimal air leak and full expansion of the lungs. However, ventilation became increasingly difficult and insufficient, and peripheral oxygen saturation values dropped to 70% despite administration of 100% oxygen. Repeated tracheal toilette was not followed by improvement of oxygenation. His hemodynamic state worsened progressively with tachycardia and hypotension. Because of worsening of the cardiopulmonary status, the patient was immediately transported to the operating room. Although a standard endotracheal tube was replaced with a double-lumen tube, there was no improvement in the respiratory and hemodynamic state. This situation demanded an emergency thoracotomy. When turning the patient to the right lateral decubitus position for the left thoracotomy, the peripheral pulse oximetry revealed an abrupt improvement of peripheral oxygen saturation from 70 to 100% and ventilation became increasingly normal. Immediately taken blood gas analyses showed a Po2 value of 300 mm Hg and oxygen saturation of 100% that allowed reduction of the inspired oxygen from 100 to 50%. Thereafter, the surgical procedure was straightforward. A left posterolateral thoracotomy incision was made, the left lung was deflated, and some liquid blood was evacuated from the left pleural space. Acute aortic disruption was found at the posteromedial half of the aortic circumference, distal to the origin of the left subclavian artery, with a localized mediastinal hematoma and an extravasation of blood into the periaortic area. The rupture involved all layers of the aortic wall, but the mediastinal pleura remained intact. An 18-mm Dacron gelatine-impregnated prosthesis was interposed in the proximal part of the descending thoracic aorta in a standard manner using inclusion technique and normothermic femorofemoral partial cardiopulmonary bypass. Then, the left lung was inflated and ventilation of the left lung was started and some air leak was noted. The exact site of the leakage could not be identified immediately. After visual inspection and palpation, it was noted that the bronchus to the left lower lobe was injured. There was no overt communication of the airway injury with the pleural space because intact peribronchial tissue and pleura prevented the development of a larger air leakage. Opening of the visceral pleura revealed unexpectedly a major bronchial injury with a significant loss of ventilated air. After close inspection, it was seen that the bronchus to the left lower lobe was totally transected and the lobe hung on the lobar vessels (Fig 1). End-to-end anastomosis of the disrupted bronchus was performed with absorbable polydioxanone 5-0 suture, using continuous suture for the pars membranacea and interrupted sutures for the cartilaginous part. There was no air leakage from the anastomosis, and no additional covering of the anastomosis with pleural or muscle flap was attempted. After femoral decannulation, the chest was closed in a standard way after placing two chest tubes. Intraoperative bronchoscopy showed a normal anastomotic relationship, and postoperative esophagoscopy excluded Selected Reports
Figure 1. Artistic view of the combined aortic rupture (arrowhead) and bronchial injury of the bronchus for the left lower lobe (arrow). The bronchial defect was identified by palpation and visible pleural bubbles in the interlobar fisura. The bronchial disruption encompassed complete diagonal transection of three bronchial rings.
esophageal lesions. After a prolonged postoperative course, the patient was discharged in a good general condition.
Discussion The reported case emphasizes the importance of a suspicion of concomitant tracheobronchial injury in patients with aortic rupture after blunt chest trauma. Early recognition of tracheobronchial disruption is essential because if overlooked, it may have severe, life-threatening consequences.1 The clinical presentations of a bronchial injury may be overt or subtle, and usually present when they are least expected and are a challenge to manage.2 In a patient with massive air leak, the use of double-lumen endobronchial tube or selective endobronchial intubation
may be needed to achieve adequate pulmonary ventilation.3 Our patient had no massive pneumothorax because the intact peribronchial tissue and pleura covered the injured place, preventing important air leakage. Thus, the cause of inadequate oxygenation in this patient was total atelectasis of the unventilated collapsed left lower lobe with consequent significant shunting of the unoxygenated blood. The suspicion of possible concomitant tracheobronchial injury and early diagnostic bronchoscopy are important in patients with aortic rupture after blunt chest trauma. The possible causes of bronchial disruption after blunt injury are presumably similar to that of aortic rupture. Traumatic aortic rupture results most commonly from sudden high-speed deceleration or less frequently from chest compression. The typical point of injury is located in the most proximal descending thoracic aorta, at the site of insertion of the ligamentum arteriosum, just distal to the origin of the left subclavian artery, where a highly mobile region of the aorta is placed between two fixed aortic segments. The aortic arch is anchored with the neck vessels including the left subclavian artery, and the descending thoracic aorta is fixed to the thorax by the ligamentum arteriosum and by the intercostal arteries. The mobile part of the aorta—the distal part of the aortic arch and the most proximal part of the descending thoracic aorta—is only loosely fixed to the chest wall by the parietal pleura. With the abrupt deceleration of the thorax, as in our patients when the body crashed against the ground, the fixed portions decelerate with the chest but the loosely fixed part of the aorta continues to move forward until they finally decelerate. Aortic rupture occurs at the interface between these two parts. The similar principle can be applied for the transection of the bronchus, in which complete rupture occurs at the transition region between the fixed and nonfixed part of the tracheobronchial tree. The trachea and the proximal part of the bronchi are fixed, and sudden deceleration results in movement of the left lower bronchus around its fixed points of attachment. This movement may lead to shearing forces that may cause disruption. We report on an exceedingly rare4,5 combination of injuries with traumatic aortic disruption and concomitant left lower bronchial transection. The complete disruption of the bronchus—a possibly catastrophic complication— was not recognized preoperatively. Therefore, in a patient with traumatic aortic injury and similar clinical presentation of abrupt deterioration of pulmonary function without a clinicaly identifiable cause, we recommend emergency bronchoscopy to exclude a concomitant injury of the tracheobronchial tree. After blunt chest trauma, early diagnosis of possibly associated vascular, tracheobronchial, and esophageal injuries should be performed, because all these lesions may be caused by the same mechanism. Therefore, we suggest that patients with traumatic aortic injury should routinely undergo screening to exclude concomitant lesions of the tracheobronchial tree and esophagus regardless of the presence or absence of pulmonary symptomatology or signs of esophageal trauma. CHEST / 117 / 5 / MAY, 2000
1509
Bronchoscopy and esophagoscopy may be performed in the operating room prior to chest closure in these patients. Awareness of the possibility of these rare concurrent injuries could contribute to timely diagnosis and treatment.
References 1 Rossbach MM, Johnson SB, Gomez MA, et al. Management of major tracheobronchial injuries: a 28-year experience. Ann Thorac Surg 1998; 65:182–186 2 Devitt JH, Boulanger BR. Lower airway injuries and anaesthesia. Can J Anaesth 1996; 43:148 –159 3 Bishop MJ, Benson MS, Pierson DJ. Carbon dioxide excretion via bronchopleural fistulas in adult respiratory distress syndrome. Chest 1987; 91:400 – 402 4 Sadow SH, Murray CA III, Wilson RF, et al. Traumatic rupture of ascending aorta and left main bronchus. Ann Thorac Surg; 1988; 45:682– 683 5 Marzelle J, Nottin R, Dartevelle Ph, et al. Combined ascending aortic rupture and left main bronchus disruption from blunt chest trauma. Ann Thorac Surg 1989; 47:769 –771
incidence and variety of acupuncture-related adverse effects is not available up to now. Recently, a literature survey of acupuncture-related adverse effects was published, concluding that substantial evidence for the high degree of safety of this technique exists.1 However, a study from Norway that analyzed data of 135 randomly selected physicians and 197 acupuncturists revealed various adverse effects, among them pneumothorax as a major adverse event.2 Even fatal acupuncture-induced pneumothorax has previously been reported.3 Cardiac tamponade resulting from penetrating trauma represents a life-threatening emergency, for elevated intrapericardial pressure compromises diastolic filling and systolic stroke volume, leading to profound circulatory collapse and shock.4 Acupuncture-associated cardiac tamponade represents an extremely rare but serious event. Only three case reports of cardiac tamponade due to acupuncture were found in the literature.5–7
Case Report
Cardiac Tamponade Following Acupuncture* Andreas Kirchgatterer, MD; Christian D. Schwarz, MD; Eva Ho¨ller, MD; Christian Punzengruber, MD; Peter Hartl, MD; and Bernd Eber, MD
We present a rare complication of acupuncture in a 83-year-old woman who developed syncope and cardiogenic shock shortly after an acupuncture procedure into the sternum. Echocardiography revealed cardiac tamponade, and pericardiocentesis disclosed hemopericardium. Due to hemodynamic instability, thoracotomy was indicated. A small but actively bleeding perforation of the right ventricle was found and successfully closed. Although acupuncture represents a relatively safe therapeutic intervention, this case report should remind all acupuncturists of possible and sometimes life-threatening adverse effects. (CHEST 2000; 117:1510 –1511) Key words: acupuncture; cardiac tamponade; echocardiography; hemopericardium.
is regarded as a safe method of treatment A cupuncture for many conditions. Serious injuries resulting from
An 83-year-old emaciated female patient without any history of heart disease developed bradycardia and syncope about 20 min after acupuncture, as a needle (stainless steel, 30 mm in length) was inserted into the middle third of the sternum by an experienced acupuncturist. Resuscitation was immediately successful, and the patient was transferred to the emergency department with sinus tachycardia, low BP, jugular venous distention, and unconsciousness. Echocardiography performed in a subcostal four-chamber plane showed cardiac tamponade with collapse of the right atrium and ventricle. Acutely performed pericardiocentesis using a subxiphoid approach disclosed hemopericardium. After drainage of 300 mL of bloody effusion, the patient stabilized hemodynamically and the catheter was left in place. In the following 3 h, the drainage of sanguineous effusion persisted up to the total amount of 1,200 mL, systolic BP declined again, and transfusion of two units of blood was necessary. Echocardiography showed hemodynamically relevant, progressive pericardial effusion. As a consequence, immediate surgery was indicated. After median sternotomy, a remarkable distention of the pericardial cavity was seen and about 1,000 mL of blood and clots were evacuated. A small perforating lesion (2 to 3 mm in diameter) with ongoing oozing of blood was identified in the anterior wall of the right ventricle as the cause of hemopericardium. This lesion was oversewn with a felt-buttoned 4 – 0 Prolene suture, leading to complete termination of bleeding. The surgical procedure was successfully performed without any need of extracorporeal circulation. Thereafter, the patient was hemodynamically stable, and weaning and extubation were uneventful. The mental status of the patient was compromised for several days, but after full recovery, discharge was possible 2 weeks later.
acupuncture therapy are seldom reported. In times of increasing request for evidence-based medicine and quality control, however, a prospective investigation of the
Discussion
*From the Departments of Cardiology (Drs. Kirchgatterer, Ho¨ller, Punzengruber, and Eber) and Cardiothoracic Surgery (Drs. Schwarz and Hartl), General Hospital Wels, Austria. Manuscript received June 15, 1999; revision accepted October 21, 1999. Correspondence to: Andreas Kirchgatterer, MD, Department of Cardiology, General Hospital Wels, Grieskirchnerstr. 42, A-4600 Wels, Austria
A survey based on a MEDLINE search discovered only three reports of similar cases of acupuncture-associated cardiac tamponade in the scientific literature. The present case is remarkable in several regards. To our knowledge, this is the first case of an acupuncture-associated cardiac tamponade, which occurred immediately after the procedure and in which successful surgical intervention was
1510
Selected Reports
We report a patient with traumatic aortic rupture and preoperatively unrecognized complete disruption of the bronchus for the left lower lobe. Preoperative state was complicated by inadequate oxygenation due to total atelectasis of the unventilated collapsed left lower lobe with consequent significant shunting of the unoxygenated blood. The patient had no massive pneumothorax because the intact peribronchial tissue and pleura covered the injured place, preventing important air leakage. The suspicion of possible concomitant tracheobronchial injury and early diagnostic bronchoscopy are important in patients with aortic rupture after blunt chest trauma. (CHEST 2000; 117:1508 –1510) Key words: aortic rupture; bronchial rupture
trauma is often obscured by the presence of other A ortic serious injuries. However, if the diagnosis is made, it can overshadow the presence of other severe but rare injuries. We report a patient with traumatic aortic rupture and preoperatively unrecognized complete disruption of the bronchus to the left lower lobe, a possibly catastrophic complication.
Case Report A 34-year-old man was transferred to our institution because of rupture of the descending thoracic aorta after a fall from the sixth floor (about 20 m height) onto the ground in an alcoholic state. He had been intubated and placed on mechanical ventilation because of head trauma and unconsciousness. Bilateral chest tubes were inserted in order to drain small hemothoraces with apical pneumothoraces, and multiple fractures of both legs were stabilized using external fixation. The other concomitant injuries were bilateral serial rib fractures and fractures of both clavicles, scapula, humerus, and pelvis. Despite these injuries, the patient *From the Deutsches Herzzentrum Berlin, Berlin, Germany. Manuscript received June 9, 1999; revision accepted October 10, 1999. Correspondence to: Miralem Pasic, MD, PhD, Deutsches Herzzentrum Berlin, Klinik fu¨r Herz-, Thorax- and Gefa¨sschirurgie, Augustenburger Platz 1, D-13353 Berlin, Germany; e-mail: [email protected] 1508
maintained stable respiratory status and an adequate blood pressure. A chest roentgenogram performed after admission at our institution revealed full expansion of the lungs without pneumothoraces. While the patient was being prepared to be transferred into the operating room, the blood gas analysis worsened abruptly, with a Po2 value of 50 mm Hg. A new chest roentgenogram showed a small left-sided apical pneumothorax, and an additional chest tube was inserted immediately, with consequent minimal air leak and full expansion of the lungs. However, ventilation became increasingly difficult and insufficient, and peripheral oxygen saturation values dropped to 70% despite administration of 100% oxygen. Repeated tracheal toilette was not followed by improvement of oxygenation. His hemodynamic state worsened progressively with tachycardia and hypotension. Because of worsening of the cardiopulmonary status, the patient was immediately transported to the operating room. Although a standard endotracheal tube was replaced with a double-lumen tube, there was no improvement in the respiratory and hemodynamic state. This situation demanded an emergency thoracotomy. When turning the patient to the right lateral decubitus position for the left thoracotomy, the peripheral pulse oximetry revealed an abrupt improvement of peripheral oxygen saturation from 70 to 100% and ventilation became increasingly normal. Immediately taken blood gas analyses showed a Po2 value of 300 mm Hg and oxygen saturation of 100% that allowed reduction of the inspired oxygen from 100 to 50%. Thereafter, the surgical procedure was straightforward. A left posterolateral thoracotomy incision was made, the left lung was deflated, and some liquid blood was evacuated from the left pleural space. Acute aortic disruption was found at the posteromedial half of the aortic circumference, distal to the origin of the left subclavian artery, with a localized mediastinal hematoma and an extravasation of blood into the periaortic area. The rupture involved all layers of the aortic wall, but the mediastinal pleura remained intact. An 18-mm Dacron gelatine-impregnated prosthesis was interposed in the proximal part of the descending thoracic aorta in a standard manner using inclusion technique and normothermic femorofemoral partial cardiopulmonary bypass. Then, the left lung was inflated and ventilation of the left lung was started and some air leak was noted. The exact site of the leakage could not be identified immediately. After visual inspection and palpation, it was noted that the bronchus to the left lower lobe was injured. There was no overt communication of the airway injury with the pleural space because intact peribronchial tissue and pleura prevented the development of a larger air leakage. Opening of the visceral pleura revealed unexpectedly a major bronchial injury with a significant loss of ventilated air. After close inspection, it was seen that the bronchus to the left lower lobe was totally transected and the lobe hung on the lobar vessels (Fig 1). End-to-end anastomosis of the disrupted bronchus was performed with absorbable polydioxanone 5-0 suture, using continuous suture for the pars membranacea and interrupted sutures for the cartilaginous part. There was no air leakage from the anastomosis, and no additional covering of the anastomosis with pleural or muscle flap was attempted. After femoral decannulation, the chest was closed in a standard way after placing two chest tubes. Intraoperative bronchoscopy showed a normal anastomotic relationship, and postoperative esophagoscopy excluded Selected Reports
Figure 1. Artistic view of the combined aortic rupture (arrowhead) and bronchial injury of the bronchus for the left lower lobe (arrow). The bronchial defect was identified by palpation and visible pleural bubbles in the interlobar fisura. The bronchial disruption encompassed complete diagonal transection of three bronchial rings.
esophageal lesions. After a prolonged postoperative course, the patient was discharged in a good general condition.
Discussion The reported case emphasizes the importance of a suspicion of concomitant tracheobronchial injury in patients with aortic rupture after blunt chest trauma. Early recognition of tracheobronchial disruption is essential because if overlooked, it may have severe, life-threatening consequences.1 The clinical presentations of a bronchial injury may be overt or subtle, and usually present when they are least expected and are a challenge to manage.2 In a patient with massive air leak, the use of double-lumen endobronchial tube or selective endobronchial intubation
may be needed to achieve adequate pulmonary ventilation.3 Our patient had no massive pneumothorax because the intact peribronchial tissue and pleura covered the injured place, preventing important air leakage. Thus, the cause of inadequate oxygenation in this patient was total atelectasis of the unventilated collapsed left lower lobe with consequent significant shunting of the unoxygenated blood. The suspicion of possible concomitant tracheobronchial injury and early diagnostic bronchoscopy are important in patients with aortic rupture after blunt chest trauma. The possible causes of bronchial disruption after blunt injury are presumably similar to that of aortic rupture. Traumatic aortic rupture results most commonly from sudden high-speed deceleration or less frequently from chest compression. The typical point of injury is located in the most proximal descending thoracic aorta, at the site of insertion of the ligamentum arteriosum, just distal to the origin of the left subclavian artery, where a highly mobile region of the aorta is placed between two fixed aortic segments. The aortic arch is anchored with the neck vessels including the left subclavian artery, and the descending thoracic aorta is fixed to the thorax by the ligamentum arteriosum and by the intercostal arteries. The mobile part of the aorta—the distal part of the aortic arch and the most proximal part of the descending thoracic aorta—is only loosely fixed to the chest wall by the parietal pleura. With the abrupt deceleration of the thorax, as in our patients when the body crashed against the ground, the fixed portions decelerate with the chest but the loosely fixed part of the aorta continues to move forward until they finally decelerate. Aortic rupture occurs at the interface between these two parts. The similar principle can be applied for the transection of the bronchus, in which complete rupture occurs at the transition region between the fixed and nonfixed part of the tracheobronchial tree. The trachea and the proximal part of the bronchi are fixed, and sudden deceleration results in movement of the left lower bronchus around its fixed points of attachment. This movement may lead to shearing forces that may cause disruption. We report on an exceedingly rare4,5 combination of injuries with traumatic aortic disruption and concomitant left lower bronchial transection. The complete disruption of the bronchus—a possibly catastrophic complication— was not recognized preoperatively. Therefore, in a patient with traumatic aortic injury and similar clinical presentation of abrupt deterioration of pulmonary function without a clinicaly identifiable cause, we recommend emergency bronchoscopy to exclude a concomitant injury of the tracheobronchial tree. After blunt chest trauma, early diagnosis of possibly associated vascular, tracheobronchial, and esophageal injuries should be performed, because all these lesions may be caused by the same mechanism. Therefore, we suggest that patients with traumatic aortic injury should routinely undergo screening to exclude concomitant lesions of the tracheobronchial tree and esophagus regardless of the presence or absence of pulmonary symptomatology or signs of esophageal trauma. CHEST / 117 / 5 / MAY, 2000
1509
Bronchoscopy and esophagoscopy may be performed in the operating room prior to chest closure in these patients. Awareness of the possibility of these rare concurrent injuries could contribute to timely diagnosis and treatment.
References 1 Rossbach MM, Johnson SB, Gomez MA, et al. Management of major tracheobronchial injuries: a 28-year experience. Ann Thorac Surg 1998; 65:182–186 2 Devitt JH, Boulanger BR. Lower airway injuries and anaesthesia. Can J Anaesth 1996; 43:148 –159 3 Bishop MJ, Benson MS, Pierson DJ. Carbon dioxide excretion via bronchopleural fistulas in adult respiratory distress syndrome. Chest 1987; 91:400 – 402 4 Sadow SH, Murray CA III, Wilson RF, et al. Traumatic rupture of ascending aorta and left main bronchus. Ann Thorac Surg; 1988; 45:682– 683 5 Marzelle J, Nottin R, Dartevelle Ph, et al. Combined ascending aortic rupture and left main bronchus disruption from blunt chest trauma. Ann Thorac Surg 1989; 47:769 –771
incidence and variety of acupuncture-related adverse effects is not available up to now. Recently, a literature survey of acupuncture-related adverse effects was published, concluding that substantial evidence for the high degree of safety of this technique exists.1 However, a study from Norway that analyzed data of 135 randomly selected physicians and 197 acupuncturists revealed various adverse effects, among them pneumothorax as a major adverse event.2 Even fatal acupuncture-induced pneumothorax has previously been reported.3 Cardiac tamponade resulting from penetrating trauma represents a life-threatening emergency, for elevated intrapericardial pressure compromises diastolic filling and systolic stroke volume, leading to profound circulatory collapse and shock.4 Acupuncture-associated cardiac tamponade represents an extremely rare but serious event. Only three case reports of cardiac tamponade due to acupuncture were found in the literature.5–7
Case Report
Cardiac Tamponade Following Acupuncture* Andreas Kirchgatterer, MD; Christian D. Schwarz, MD; Eva Ho¨ller, MD; Christian Punzengruber, MD; Peter Hartl, MD; and Bernd Eber, MD
We present a rare complication of acupuncture in a 83-year-old woman who developed syncope and cardiogenic shock shortly after an acupuncture procedure into the sternum. Echocardiography revealed cardiac tamponade, and pericardiocentesis disclosed hemopericardium. Due to hemodynamic instability, thoracotomy was indicated. A small but actively bleeding perforation of the right ventricle was found and successfully closed. Although acupuncture represents a relatively safe therapeutic intervention, this case report should remind all acupuncturists of possible and sometimes life-threatening adverse effects. (CHEST 2000; 117:1510 –1511) Key words: acupuncture; cardiac tamponade; echocardiography; hemopericardium.
is regarded as a safe method of treatment A cupuncture for many conditions. Serious injuries resulting from
An 83-year-old emaciated female patient without any history of heart disease developed bradycardia and syncope about 20 min after acupuncture, as a needle (stainless steel, 30 mm in length) was inserted into the middle third of the sternum by an experienced acupuncturist. Resuscitation was immediately successful, and the patient was transferred to the emergency department with sinus tachycardia, low BP, jugular venous distention, and unconsciousness. Echocardiography performed in a subcostal four-chamber plane showed cardiac tamponade with collapse of the right atrium and ventricle. Acutely performed pericardiocentesis using a subxiphoid approach disclosed hemopericardium. After drainage of 300 mL of bloody effusion, the patient stabilized hemodynamically and the catheter was left in place. In the following 3 h, the drainage of sanguineous effusion persisted up to the total amount of 1,200 mL, systolic BP declined again, and transfusion of two units of blood was necessary. Echocardiography showed hemodynamically relevant, progressive pericardial effusion. As a consequence, immediate surgery was indicated. After median sternotomy, a remarkable distention of the pericardial cavity was seen and about 1,000 mL of blood and clots were evacuated. A small perforating lesion (2 to 3 mm in diameter) with ongoing oozing of blood was identified in the anterior wall of the right ventricle as the cause of hemopericardium. This lesion was oversewn with a felt-buttoned 4 – 0 Prolene suture, leading to complete termination of bleeding. The surgical procedure was successfully performed without any need of extracorporeal circulation. Thereafter, the patient was hemodynamically stable, and weaning and extubation were uneventful. The mental status of the patient was compromised for several days, but after full recovery, discharge was possible 2 weeks later.
acupuncture therapy are seldom reported. In times of increasing request for evidence-based medicine and quality control, however, a prospective investigation of the
Discussion
*From the Departments of Cardiology (Drs. Kirchgatterer, Ho¨ller, Punzengruber, and Eber) and Cardiothoracic Surgery (Drs. Schwarz and Hartl), General Hospital Wels, Austria. Manuscript received June 15, 1999; revision accepted October 21, 1999. Correspondence to: Andreas Kirchgatterer, MD, Department of Cardiology, General Hospital Wels, Grieskirchnerstr. 42, A-4600 Wels, Austria
A survey based on a MEDLINE search discovered only three reports of similar cases of acupuncture-associated cardiac tamponade in the scientific literature. The present case is remarkable in several regards. To our knowledge, this is the first case of an acupuncture-associated cardiac tamponade, which occurred immediately after the procedure and in which successful surgical intervention was
1510
Selected Reports