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Late Cardiac Tamponade Following Open-Heart Surgery: Detection by Echocardiography
CASE REPORTS
Late Cardiac Tamponade Following Open-Heart Surgery: Detection by Echocardiography Hemal A. Fernando, M.D., Howard S. Friedman, M.D., Fouad Lajam, M.D., and Hideki Sakurai, M.D. ABSTRACT Late cardiac tamponade following open-heart operation is a potentially lethal complication that is often difficult to diagnose. A case of cardiac tamponade occurring two weeks after left ventricular aneurysmectomy and coronary bypass surgery is reported. Despite opening of the anterior pericardium during operation, echocardiography revealed characteristic findings, which permitted prompt recognition of this disorder.
diac tamponade by this technique allowed for immediate decompressive therapy, which dramatically reversed cardiogenic shock and saved the patient’s life.
A 57-year-old white man who had had an abdominal aneurysmectomy with graft two years prior to admission underwent cardiac catheterization for increasing angina pectoris. An anteroapical left ventricular aneurysm with Cardiac tamponade following open-heart opera- occlusion of the proximal left anterior descendtion occurs in both the early and late postopera- ing and right coronary arteries was found. On tive periods [l,2,4,5,8,10,13,14]. This poten- May 4, 1976, he underwent open-heart operatially lethal complication often manifests itself as tion with left ventricular aneurysmectomy and a low cardiac output state masquerading as an reverse saphenous vein graft bypass of his right acute myocardial infarction or pulmonary em- coronary artery. The anterior pericardium was bolism [5]. Its occurrence in the late postopera- left open, with a wide communication to the tive period, when the patient is not closely right pleural cavity. Both the pericardial and the monitored and when the occurrence of cardiac right pleural space were drained separately with tamponade is often not anticipated, is especially chest tubes. The amount of postoperative draindangerous. The common surgical practice of age was minimal, and chest tubes were removed leaving the anterior pericardium open as a pre- after 48 hours. The early postoperative period cautionary measure does not, in fact, prevent was uneventful except for transient atrial arcardiac tamponade [lo]. Also, the classic signs of rhythmias. Five days postoperatively the paelevated venous pressure and paradoxical pulse tient started ambulating; vital signs were stable, usually found in cardiac tamponade may not be and the electrocardiogram showed a normal present. Several methods for detecting post- sinus rhythm and was unchanged from the operative cardiac tamponade have been de- preoperative tracing. Oral anticoagulant therscribed [ 10,12,17]. Although echocardiography apy with warfarin was started on the second is widely used in the detection of pericardial postoperative day and was continued with the effusion, its usefulness in the diagnosis of tam- prothrombin time in the therapeutic range. ponade following a cardiac operation has not On May 17, 13 days postoperatively, the pabeen established. Accordingly, the purpose of tient complained of dizziness and left-sided this report is to demonstrate the use of bedside chest and shoulder pain. He was found to be echocardiography in diagnosing late postopera- diaphoretic, cold, and clammy, with a systolic tive cardiac tamponade. The diagnosis of car- blood pressure of 80 mm Hg. Electrocardiogram showed a regular sinus rhythm with slight reFrom the Veterans Administration Hospital, Bronx, and the duction of QRS complex voltage over the lateral Departments of Medicine and Surgery, the Mount Sinai precordial leads. A Swan-Ganz catheter was inSchool of Medicine, New York, NY. serted, and a pulmonary capillary wedge presAccepted for publication Dec 22, 1976. sure of 18 mm Hg was obtained. A tentative Address reprint requests to Dr. Friedman, Cardiac Section, diagnosis of acute myocardial infarction with Brooklyn Hospital, 121 DeKalb Ave, Brooklyn, NY 11201. 174
175 Case Report: Fernando et al: Tamponade Detection by Echocardiography
operation [4, 51. It can occur early in the postoperative period, when it is related to hemorrhage, or late postoperatively, after removal of temporary atrial pacing wires [ l l , after dislodgment of a left atrial catheter [31, or as a complication of either the postcardiotomy syndrome [5, 143 or anticoagulant therapy [2, 4, 81. Our patient developed tamponade while on anticoagulants, despite a prothrombin time within the therapeutic range. Almost all reported patients having late cardiac tamponade following open-heart operation had received anticoagulants [41. Many patients, like ours, had prothrombin times that were not excessive. Diagnosis of cardiac tamponade is often delayed because of the difficulty in differentiating cardiac tamponade from other causes of a low cardiac output state [lo]. Moreover, accumulation of blood and fluid in the mediastinum may compress only the left heart, a consequence of the heart’s adherence to the pericardium anteriorly [15]. Such findings may produce left-sided cardiac tamponade, which may appear clinically as a low cardiac output state but with minimal elevation of venous pressure and absence of paradoxical pulse [15,18]. Fall in the hematocrit [5] and an enlarging cardiac silhouette roentgenogram [4] may be the only helpful signs. However, there is considerable uncertainty in interpreting changes in cardiac silhouette on bedside roentgenograms, and falling hematocrit may suggest another diagnosis. In view of the difficulty in diagnosing postoperative cardiac tamponade, other techniques have been suggested. Use of the Swan-Ganz catheter to demonstrate a diastolic pressure plateau of pulmonary capillary, pulmonary artery, right ventricular, and right atrial pressures has been reported [17]. Separation of juxtaposed epicardial-pericardial clips inserted at operation may also assist in diagnosing cardiac tamponade [12]. On the other hand, echocardiography is a relatively simple noninvasive technique that can be performed at bedside. Demonstration of an echo-free space behind the left ventricle that disappears on recording over the left atrium is a cardinal feature of fluid in the pericardial cavity [6,11,16]. However, failure to Comment perform an adequate study may result in either Cardiac tamponade has been reported to occur false-negative or false-positive echocardioin 3 to 6% of patients undergoing open-heart graphic diagnoses of pericardial fluid [6, 111.In cardiogenic shock was made and, .despite volume expansion, an intravenous dopamine drip was required to maintain arterial pressure. Over the next 36 hours there was further deterioration in the patient’s clinical condition: he remained hypotensive and diaphoretic, with cold extremities and scanty urine output. The jugular venous pressure was elevated to the angle of the mandible. The cardiac apex was not palpable, and bilateral rales were heard over the lung bases. A chest roentgenogram showed an increase in the cardiac silouette. At this time bedside echocardiography was performed in the standard manner [7] to determine whether a pericardial effusion was present. With the patient in the supine position, the transducer was placed in the fourth intercostal space and angled to identify echoes from the mitral valve. With appropriate adjustments both mitral leaflets, the interventricular septum, the left ventricular endocardium, and the epicardium were recorded. The transducer was then angled medially and superiorly to record over the aortic root and left atrium. The recording was made in one continuous sweep from the left ventricular apex to the aortic root. Part A of the Figure shows the echocardiogram obtained at the time of cardiac tamponade. An echo-free space posterior to the left ventricular epicardium, which is highly suggestive of fluid behind the heart, is shown. Also, enlargement of the left atrium, anterior motion of the mitral leaflets in systole, and a reduction of the D to E slope are present. Because of the patient’s extremely poor condition, a drainage procedure using the subxiphoid approach was carried out at bedside, with the patient under local anesthesia. About 800 ml of blood-stained fluid poured out of the incision. Blood pressure rose dramatically from 60/40 to 130/80 mm Hg, and concomitantly the patient showed marked clinical improvement. Repeat echocardiography (Figure, B) shows disappearance of the echo-free space, reduction of left atrial dimensions, and normalization of mitral leaflet motion. Subsequently, the patient made an uneventful recovery and was discharged from the hospital.
176 The Annals of Thoracic Surgery Vol 24 No 2 August 1977
I Icm
Echocardiograms with corresponding diagnostic illustrations during ( A )and after ( B ) tamponade, showing echo-free space (EFS)during tamponade (A)and its disappearancefollowing removal of fluid (B).(AAR = anterior aortic root; PAR = posterior aorticroot; AL = aortic leaflets; AML = anterior mitral leaflet; EN = endocardium; EP = epicardium; M = myocardium; LA = left atrium; IVS = interventricular septum.)
177 Case Report: Fernando et al: Tamponade Detection by Echocardiography
some instances, technical conditions such as the presence of bandages and chest tubes may obviate diagnostic echocardiograms in the postoperative period. Our patient showed a typical posterior echo-free space but did not show fluid anteriorly, which may have been due to postoperative adhesions formed between the anterior mediastinum and the heart. Other echocardiographic features noted in our patient were an increased left atrial diameter that was reversed following removal of fluid, a reduced D to E slope, and abnormal motion of the mitral leaflet in systole. A reduced D to E slope of the anterior mitral leaflet has been correlated with markedly elevated left ventricular diastolic pressure [7], which is characteristically found in cardiac tamponade [9]. It is also possible that the decline of the D to E slope may have reflected a reduction in the rate of decline of left ventricular pressure during isovolumetric relaxation, which has been found to be one of the earliest abnormalities in experimental cardiac tamponade [91. Thus echocardiography is a useful noninvasive technique for detecting mediastinal fluid and for diagnosing cardiac tamponade, even following open-heart operation when the anterior pericardium has been opened.
References Baldwin BJ, Dorney ER: Acute cardiac tamponade following the removal of temporary epicardial pacemaker wires after open heart surgery. Am J Med Sci 261:241, 1971 Berger RL, Loveless G, Warner 0: Delayed and latent postcardiotomy tamponade: recognition and nonoperative treatment. Ann Thorac Surg 12:22, 1971 Bricker DL, Dalton ML: Cardiac tamponade following dislodgment of a left atrial catheter after coronary artery bypass. J Thorac Cardiovasc Surg 66:636, 1973 Ellison LH, Kirsh MM: Delayed mediastinal tam-
ponade after open heart surgery. Chest 65:64, 1974 5. Engelman RM, Spencer FC, Reed GE, et al: Cardiac tamponade following open-heart surgery. Circulation 41-42:Suppl 2:165, 1970 6. Feigenbaum H: Echocardiographic diagnosis of pericardial effusion. Am J Cardiol 26:475, 1970 7. Feigenbaum H: Echocardiography. Philadelphia, Lea & Febiger, 1973, p 162 8. Fraser DG, Ullyot DJ: Mediastinal tamponade after open-heart surgery. J Thorac Cardiovasc Surg 66:629, 1973 9. Friedman HS, Lajam F, Zaman Q, et al: The effect of autonomic blockade on the hemodynamic findings in acute cardiac tamponade. Am J Physiol 232:H5-Hll, 1977 10. Hill JD, Johnson DC, Miller GE, et al: Latent mediastinal tamponade after open-heart surgery. Arch Surg 99:808, 1969 11. Horowitz MS, Schultz CS, Stinson EB, et al: Sensitivity and specificity of echocardiographic diagnosis of pericardial effusion. Circulation 50:239, 1974 12. Meckstroth CV, Cattaneo SM: Juxtaposed epicardial-pericardial clips: an adjunct to the differential diagnosis of hemopericardium, pericardial tamponade, and primary low cardiac output syndrome after open heart surgery. J Thorac Cardiovasc Surg 68:447, 1974 13. Nelson RM, Jenson CB, Smoot WM: Pericardial tamponade following open-heart surgery. J Thorac Cardiovasc Surg 58:510, 1969 14. Prewitt TA, Rackley CE, Wilcox BR, et al: Cardiac tamponade as a late complication of open heart surgery. Am Heart J 76:139, 1968 15. Simpkin P, Brown AH, Ersoz A, et al: Chronic left heart tamponade. J Thorac Cardiovasc Surg 65:531, 1973 16. Vignola PA, Pohost GM, Curfman GD, et al: Correlation of echocardiographic and clinical findings in patients with pericardial effusion. Am J Cardiol 37:701, 1976 17. Weeks KR, Chatterjee K, Block S, et al: Bedside hemodynamic monitoring: its value in the diagnosis of tamponade complicating cardiac surgery. J Thorac Cardiovasc Surg 71:250, 1976 18. Yacoub MH, Cleland WP, Deal CW: Left atrial tamponade. Thorax 21:305, 1966
Late Cardiac Tamponade Following Open-Heart Surgery: Detection by Echocardiography Hemal A. Fernando, M.D., Howard S. Friedman, M.D., Fouad Lajam, M.D., and Hideki Sakurai, M.D. ABSTRACT Late cardiac tamponade following open-heart operation is a potentially lethal complication that is often difficult to diagnose. A case of cardiac tamponade occurring two weeks after left ventricular aneurysmectomy and coronary bypass surgery is reported. Despite opening of the anterior pericardium during operation, echocardiography revealed characteristic findings, which permitted prompt recognition of this disorder.
diac tamponade by this technique allowed for immediate decompressive therapy, which dramatically reversed cardiogenic shock and saved the patient’s life.
A 57-year-old white man who had had an abdominal aneurysmectomy with graft two years prior to admission underwent cardiac catheterization for increasing angina pectoris. An anteroapical left ventricular aneurysm with Cardiac tamponade following open-heart opera- occlusion of the proximal left anterior descendtion occurs in both the early and late postopera- ing and right coronary arteries was found. On tive periods [l,2,4,5,8,10,13,14]. This poten- May 4, 1976, he underwent open-heart operatially lethal complication often manifests itself as tion with left ventricular aneurysmectomy and a low cardiac output state masquerading as an reverse saphenous vein graft bypass of his right acute myocardial infarction or pulmonary em- coronary artery. The anterior pericardium was bolism [5]. Its occurrence in the late postopera- left open, with a wide communication to the tive period, when the patient is not closely right pleural cavity. Both the pericardial and the monitored and when the occurrence of cardiac right pleural space were drained separately with tamponade is often not anticipated, is especially chest tubes. The amount of postoperative draindangerous. The common surgical practice of age was minimal, and chest tubes were removed leaving the anterior pericardium open as a pre- after 48 hours. The early postoperative period cautionary measure does not, in fact, prevent was uneventful except for transient atrial arcardiac tamponade [lo]. Also, the classic signs of rhythmias. Five days postoperatively the paelevated venous pressure and paradoxical pulse tient started ambulating; vital signs were stable, usually found in cardiac tamponade may not be and the electrocardiogram showed a normal present. Several methods for detecting post- sinus rhythm and was unchanged from the operative cardiac tamponade have been de- preoperative tracing. Oral anticoagulant therscribed [ 10,12,17]. Although echocardiography apy with warfarin was started on the second is widely used in the detection of pericardial postoperative day and was continued with the effusion, its usefulness in the diagnosis of tam- prothrombin time in the therapeutic range. ponade following a cardiac operation has not On May 17, 13 days postoperatively, the pabeen established. Accordingly, the purpose of tient complained of dizziness and left-sided this report is to demonstrate the use of bedside chest and shoulder pain. He was found to be echocardiography in diagnosing late postopera- diaphoretic, cold, and clammy, with a systolic tive cardiac tamponade. The diagnosis of car- blood pressure of 80 mm Hg. Electrocardiogram showed a regular sinus rhythm with slight reFrom the Veterans Administration Hospital, Bronx, and the duction of QRS complex voltage over the lateral Departments of Medicine and Surgery, the Mount Sinai precordial leads. A Swan-Ganz catheter was inSchool of Medicine, New York, NY. serted, and a pulmonary capillary wedge presAccepted for publication Dec 22, 1976. sure of 18 mm Hg was obtained. A tentative Address reprint requests to Dr. Friedman, Cardiac Section, diagnosis of acute myocardial infarction with Brooklyn Hospital, 121 DeKalb Ave, Brooklyn, NY 11201. 174
175 Case Report: Fernando et al: Tamponade Detection by Echocardiography
operation [4, 51. It can occur early in the postoperative period, when it is related to hemorrhage, or late postoperatively, after removal of temporary atrial pacing wires [ l l , after dislodgment of a left atrial catheter [31, or as a complication of either the postcardiotomy syndrome [5, 143 or anticoagulant therapy [2, 4, 81. Our patient developed tamponade while on anticoagulants, despite a prothrombin time within the therapeutic range. Almost all reported patients having late cardiac tamponade following open-heart operation had received anticoagulants [41. Many patients, like ours, had prothrombin times that were not excessive. Diagnosis of cardiac tamponade is often delayed because of the difficulty in differentiating cardiac tamponade from other causes of a low cardiac output state [lo]. Moreover, accumulation of blood and fluid in the mediastinum may compress only the left heart, a consequence of the heart’s adherence to the pericardium anteriorly [15]. Such findings may produce left-sided cardiac tamponade, which may appear clinically as a low cardiac output state but with minimal elevation of venous pressure and absence of paradoxical pulse [15,18]. Fall in the hematocrit [5] and an enlarging cardiac silhouette roentgenogram [4] may be the only helpful signs. However, there is considerable uncertainty in interpreting changes in cardiac silhouette on bedside roentgenograms, and falling hematocrit may suggest another diagnosis. In view of the difficulty in diagnosing postoperative cardiac tamponade, other techniques have been suggested. Use of the Swan-Ganz catheter to demonstrate a diastolic pressure plateau of pulmonary capillary, pulmonary artery, right ventricular, and right atrial pressures has been reported [17]. Separation of juxtaposed epicardial-pericardial clips inserted at operation may also assist in diagnosing cardiac tamponade [12]. On the other hand, echocardiography is a relatively simple noninvasive technique that can be performed at bedside. Demonstration of an echo-free space behind the left ventricle that disappears on recording over the left atrium is a cardinal feature of fluid in the pericardial cavity [6,11,16]. However, failure to Comment perform an adequate study may result in either Cardiac tamponade has been reported to occur false-negative or false-positive echocardioin 3 to 6% of patients undergoing open-heart graphic diagnoses of pericardial fluid [6, 111.In cardiogenic shock was made and, .despite volume expansion, an intravenous dopamine drip was required to maintain arterial pressure. Over the next 36 hours there was further deterioration in the patient’s clinical condition: he remained hypotensive and diaphoretic, with cold extremities and scanty urine output. The jugular venous pressure was elevated to the angle of the mandible. The cardiac apex was not palpable, and bilateral rales were heard over the lung bases. A chest roentgenogram showed an increase in the cardiac silouette. At this time bedside echocardiography was performed in the standard manner [7] to determine whether a pericardial effusion was present. With the patient in the supine position, the transducer was placed in the fourth intercostal space and angled to identify echoes from the mitral valve. With appropriate adjustments both mitral leaflets, the interventricular septum, the left ventricular endocardium, and the epicardium were recorded. The transducer was then angled medially and superiorly to record over the aortic root and left atrium. The recording was made in one continuous sweep from the left ventricular apex to the aortic root. Part A of the Figure shows the echocardiogram obtained at the time of cardiac tamponade. An echo-free space posterior to the left ventricular epicardium, which is highly suggestive of fluid behind the heart, is shown. Also, enlargement of the left atrium, anterior motion of the mitral leaflets in systole, and a reduction of the D to E slope are present. Because of the patient’s extremely poor condition, a drainage procedure using the subxiphoid approach was carried out at bedside, with the patient under local anesthesia. About 800 ml of blood-stained fluid poured out of the incision. Blood pressure rose dramatically from 60/40 to 130/80 mm Hg, and concomitantly the patient showed marked clinical improvement. Repeat echocardiography (Figure, B) shows disappearance of the echo-free space, reduction of left atrial dimensions, and normalization of mitral leaflet motion. Subsequently, the patient made an uneventful recovery and was discharged from the hospital.
176 The Annals of Thoracic Surgery Vol 24 No 2 August 1977
I Icm
Echocardiograms with corresponding diagnostic illustrations during ( A )and after ( B ) tamponade, showing echo-free space (EFS)during tamponade (A)and its disappearancefollowing removal of fluid (B).(AAR = anterior aortic root; PAR = posterior aorticroot; AL = aortic leaflets; AML = anterior mitral leaflet; EN = endocardium; EP = epicardium; M = myocardium; LA = left atrium; IVS = interventricular septum.)
177 Case Report: Fernando et al: Tamponade Detection by Echocardiography
some instances, technical conditions such as the presence of bandages and chest tubes may obviate diagnostic echocardiograms in the postoperative period. Our patient showed a typical posterior echo-free space but did not show fluid anteriorly, which may have been due to postoperative adhesions formed between the anterior mediastinum and the heart. Other echocardiographic features noted in our patient were an increased left atrial diameter that was reversed following removal of fluid, a reduced D to E slope, and abnormal motion of the mitral leaflet in systole. A reduced D to E slope of the anterior mitral leaflet has been correlated with markedly elevated left ventricular diastolic pressure [7], which is characteristically found in cardiac tamponade [9]. It is also possible that the decline of the D to E slope may have reflected a reduction in the rate of decline of left ventricular pressure during isovolumetric relaxation, which has been found to be one of the earliest abnormalities in experimental cardiac tamponade [91. Thus echocardiography is a useful noninvasive technique for detecting mediastinal fluid and for diagnosing cardiac tamponade, even following open-heart operation when the anterior pericardium has been opened.
References Baldwin BJ, Dorney ER: Acute cardiac tamponade following the removal of temporary epicardial pacemaker wires after open heart surgery. Am J Med Sci 261:241, 1971 Berger RL, Loveless G, Warner 0: Delayed and latent postcardiotomy tamponade: recognition and nonoperative treatment. Ann Thorac Surg 12:22, 1971 Bricker DL, Dalton ML: Cardiac tamponade following dislodgment of a left atrial catheter after coronary artery bypass. J Thorac Cardiovasc Surg 66:636, 1973 Ellison LH, Kirsh MM: Delayed mediastinal tam-
ponade after open heart surgery. Chest 65:64, 1974 5. Engelman RM, Spencer FC, Reed GE, et al: Cardiac tamponade following open-heart surgery. Circulation 41-42:Suppl 2:165, 1970 6. Feigenbaum H: Echocardiographic diagnosis of pericardial effusion. Am J Cardiol 26:475, 1970 7. Feigenbaum H: Echocardiography. Philadelphia, Lea & Febiger, 1973, p 162 8. Fraser DG, Ullyot DJ: Mediastinal tamponade after open-heart surgery. J Thorac Cardiovasc Surg 66:629, 1973 9. Friedman HS, Lajam F, Zaman Q, et al: The effect of autonomic blockade on the hemodynamic findings in acute cardiac tamponade. Am J Physiol 232:H5-Hll, 1977 10. Hill JD, Johnson DC, Miller GE, et al: Latent mediastinal tamponade after open-heart surgery. Arch Surg 99:808, 1969 11. Horowitz MS, Schultz CS, Stinson EB, et al: Sensitivity and specificity of echocardiographic diagnosis of pericardial effusion. Circulation 50:239, 1974 12. Meckstroth CV, Cattaneo SM: Juxtaposed epicardial-pericardial clips: an adjunct to the differential diagnosis of hemopericardium, pericardial tamponade, and primary low cardiac output syndrome after open heart surgery. J Thorac Cardiovasc Surg 68:447, 1974 13. Nelson RM, Jenson CB, Smoot WM: Pericardial tamponade following open-heart surgery. J Thorac Cardiovasc Surg 58:510, 1969 14. Prewitt TA, Rackley CE, Wilcox BR, et al: Cardiac tamponade as a late complication of open heart surgery. Am Heart J 76:139, 1968 15. Simpkin P, Brown AH, Ersoz A, et al: Chronic left heart tamponade. J Thorac Cardiovasc Surg 65:531, 1973 16. Vignola PA, Pohost GM, Curfman GD, et al: Correlation of echocardiographic and clinical findings in patients with pericardial effusion. Am J Cardiol 37:701, 1976 17. Weeks KR, Chatterjee K, Block S, et al: Bedside hemodynamic monitoring: its value in the diagnosis of tamponade complicating cardiac surgery. J Thorac Cardiovasc Surg 71:250, 1976 18. Yacoub MH, Cleland WP, Deal CW: Left atrial tamponade. Thorax 21:305, 1966