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Severe right ventricular dysfunction following pericardiocentesis for cardiac tamponade
International Journal of Cardiology 59 (1997) 212–214
Letter to the Editor
Severe right ventricular dysfunction following pericardiocentesis for cardiac tamponade ´ Felix ´ Ignacio Anguera*, Carlos Pare, Perez-Villa ´ , Hospital Clınico ´ Servicio de Cardiologıa y Provincial de Barcelona, Villarroel 170, 08036 Barcelona, Spain Received 24 October 1996; revised 17 December 1996; accepted 17 December 1996
Abstract The accumulation of fluid in the pericardium in an amount sufficient to cause severe obstruction to blood inflow to the ventricles results in cardiac tamponade. In this condition, relief of intrapericardial pressure by pericardiocentesis usually dramatically improves cardiac output, and can be lifesaving. We report a case of a patient with malignant cardiac tamponade in which cardiogenic shock developed after pericardiocentesis due to severe right ventricular dysfunction. 1997 Elsevier Science Ireland Ltd. Keywords: Blood inflow; Obstruction; Intrapericardial pressure; Cardiogenic shock; Pericardiocentesis
1. Case report A 68-year-old woman with no past significant cardiovascular history who underwent sigmoidectomy for colorectal adenocarcinoma 2 years before had been well until 1 month earlier when she began to complain of anorexia, progressive exertional dyspnea and severe general discomfort. On admission physical examination showed severe arterial hypotension (60 / 40 mmHg), tachycardia, tachypnea and signs of peripheral hypoperfusion. She had a prominent pulsus paradoxus with distended neck veins. The chest radiograph showed an enlarged globular heart with no evidence of pulmonary edema. The ECG showed sinus tachycardia with a low QRS voltage. Cardiac enzymes were normal with no evidence of relevant abnormalities in blood tests. An echocardiogram demonstrated the presence of a massive *Corresponding author. Tel.: 134 3 2275400, ext. 2033; fax: 134 3 4210839.
pericardial effusion with prolonged diastolic right ventricular and biatrial collapse consistent with cardiac tamponade. Emergent pericardiocentesis was performed and 800 ml of serosanguineous fluid were rapidly removed (hematocrit 15%). Citologic examination of the pericardial fluid showed malignant cells consistent with metastatic adenocarcinoma. Following pericardiocentesis severe hypotension persisted in spite of treatment with fluids, dopamine and dobutamine. A second echocardiogram performed immediately after pericardiocentesis showed a marked reduction of the pericardial effusion and absence of collapse of any cardiac chamber. The RV was markedly dilated with a severe depression of its global contractility (ejection fraction 15%, measured by Simpson method in the apical four-chamber view). The interventricular septum became abnormal showing a prominent paradoxical motion (Fig. 1). The left ventricle was not dilated but the ejection fraction was slightly reduced due to the abnormal septal motion. Diastolic parameters of the RV showed a restrictive
0167-5273 / 97 / $17.00 1997 Elsevier Science Ireland Ltd. All rights reserved PII S0167-5273( 97 )02918-5
I. Anguera et al. / International Journal of Cardiology 59 (1997) 212 – 214
213
normalized but a moderate pericardial effusion persisted. The patient refused further clinical investigation aimed at discovering the primary malignancy and was discharged from hospital.
2. Discussion
Fig. 1. M-mode echocardiogram (upper panel) showing the prominent paradoxical motion of the interventricular septum characteristic of the right ventricular volume overload states. Transthoracic echocardiographic (lower panel) imaging — in short axis view — showing the dilated right ventricle and the flattened interventricular septum in diastole (RV, right ventricle; IVS, interventricular septum; LV, left ventricle; PW, posterior wall; PE, pericardial effusion; PLE, pleural effusion).
pattern consisting of shortening of the transtricuspideal deceleration time (95 ms) and inspiratory increase of the E velocity not greater than 25%. Right heart catheterization showed a mean right atrial pressure of 21 mmHg with rapid Y descent; right ventricular end diastolic pressure was 19 mmHg and the pressure trace was of a dip and plateau type. Pulmonary artery pressure, mean pulmonary capillary wedge pressure and end-diastolic left ventricular pressure were within normal range. The cardiac index measured by thermodilution was 0.9 l / min and the stroke volume was 18 ml. Coronary angiography showed normal coronary arteries. After 72 h of treatment with high dose inotropic drugs (dopamine, dobutamine, isoproterenol) the patient slowly recovered and 10 days after admission, all hemodynamic parameters had normalized. This was parallel with the echocardiogram that showed that both ventricular dimensions, and systolic and diastolic function had completely
Dilation of the right ventricle (RV) related to pathological conditions of the pericardium has been reported after pericardiectomy [1], congenital absence of the pericardium [2] and following pericardiocentesis [3]. We have described the successful outcome of a cardiogenic shock due to a dramatic right ventricular depression in both systolic and diastolic function following pericardiocentesis. Pericardiocentesis may be a high-risk procedure [4] and may be complicated with myocardial puncture, coronary laceration etc. To our knowledge a cardiogenic shock due to severe right ventricular dilation and dysfunction following pericardiocentesis for relief of cardiac tamponade has not been previously described. Armstrong et al. [3] reported six cases of right ventricular dilation with echocardiographic signs of volume overload (paradoxical septal motion) following pericardiocentesis, and marked symptomatic relief was achieved by all of the patients after pericardiocentesis. Manyari et al. [5] reported the enlargement of the RV with radionuclide techniques, after therapeutic pericardiocentesis. Isolated and silent right ventricular infarction may mimic this entity. The echocardiographic appearance of the dilated and severe hypocontractile right ventricle, with an abnormal septal motion, is similar to that found in massive pulmonary embolism. In our case both entities could be ruled out. In agreement with Armstrong et al. [3] we hypothesise that the abrupt increase in venous return after the relief of cardiac tamponade may play a role in the development of the muscular injury, in particular, favouring the dilation of the right ventricle and the signs of volume overload. The addition of an elevated intrapericardial pressure and a lowered aortic pressure produced by the cardiac tamponade, dramatically reduces the coronary perfussion gradient, resulting in a prolonged but transient myocardial ischemia, that in addition to the abrupt increase in venous return after quick with-
214
I. Anguera et al. / International Journal of Cardiology 59 (1997) 212 – 214
drawal of pericardial fluid, may be a plausible explanation of the transient right ventricular dysfunction.
References [1] Viola AR. The influence of pericardiectomy on the hemodynamics of chronic constrictive pericarditis. Circulation 1973; 48: 1038– 1045. [2] Payvandi MN, Kerber RE. Echocardiography in congenital and acquired absence of the pericardium: an echocardiographic mimic of right ventricular volume overload. Circulation 1976; 53: 86–92.
[3] Armstrong WF, Feigenbaum H, Dillon JC. Acute right ventricular dilation and echocardiographic volume overload following pericardiocentesis for relief of cardiac tamponade. Am Heart J 1984; 107: 1266–1270. [4] Callahan JA, Seward JB, Nishimura RA, Niller FA, Reeder GS, Shub C, Callahan MJ, Schattenberg TT, Tajik J. Two-dimensional echocardiographically guided pericardiocentesis: Experience in 117 consecutive patients. Am J Cardiol 1985; 55: 476–479. [5] Manyari DE, Kostuk WJ, Purves P. Effect of pericardiocentesis on right and left vnetricular function and volumes in pericardial effusion. Am J Cardiol 1983; 52: 159–162.
Letter to the Editor
Severe right ventricular dysfunction following pericardiocentesis for cardiac tamponade ´ Felix ´ Ignacio Anguera*, Carlos Pare, Perez-Villa ´ , Hospital Clınico ´ Servicio de Cardiologıa y Provincial de Barcelona, Villarroel 170, 08036 Barcelona, Spain Received 24 October 1996; revised 17 December 1996; accepted 17 December 1996
Abstract The accumulation of fluid in the pericardium in an amount sufficient to cause severe obstruction to blood inflow to the ventricles results in cardiac tamponade. In this condition, relief of intrapericardial pressure by pericardiocentesis usually dramatically improves cardiac output, and can be lifesaving. We report a case of a patient with malignant cardiac tamponade in which cardiogenic shock developed after pericardiocentesis due to severe right ventricular dysfunction. 1997 Elsevier Science Ireland Ltd. Keywords: Blood inflow; Obstruction; Intrapericardial pressure; Cardiogenic shock; Pericardiocentesis
1. Case report A 68-year-old woman with no past significant cardiovascular history who underwent sigmoidectomy for colorectal adenocarcinoma 2 years before had been well until 1 month earlier when she began to complain of anorexia, progressive exertional dyspnea and severe general discomfort. On admission physical examination showed severe arterial hypotension (60 / 40 mmHg), tachycardia, tachypnea and signs of peripheral hypoperfusion. She had a prominent pulsus paradoxus with distended neck veins. The chest radiograph showed an enlarged globular heart with no evidence of pulmonary edema. The ECG showed sinus tachycardia with a low QRS voltage. Cardiac enzymes were normal with no evidence of relevant abnormalities in blood tests. An echocardiogram demonstrated the presence of a massive *Corresponding author. Tel.: 134 3 2275400, ext. 2033; fax: 134 3 4210839.
pericardial effusion with prolonged diastolic right ventricular and biatrial collapse consistent with cardiac tamponade. Emergent pericardiocentesis was performed and 800 ml of serosanguineous fluid were rapidly removed (hematocrit 15%). Citologic examination of the pericardial fluid showed malignant cells consistent with metastatic adenocarcinoma. Following pericardiocentesis severe hypotension persisted in spite of treatment with fluids, dopamine and dobutamine. A second echocardiogram performed immediately after pericardiocentesis showed a marked reduction of the pericardial effusion and absence of collapse of any cardiac chamber. The RV was markedly dilated with a severe depression of its global contractility (ejection fraction 15%, measured by Simpson method in the apical four-chamber view). The interventricular septum became abnormal showing a prominent paradoxical motion (Fig. 1). The left ventricle was not dilated but the ejection fraction was slightly reduced due to the abnormal septal motion. Diastolic parameters of the RV showed a restrictive
0167-5273 / 97 / $17.00 1997 Elsevier Science Ireland Ltd. All rights reserved PII S0167-5273( 97 )02918-5
I. Anguera et al. / International Journal of Cardiology 59 (1997) 212 – 214
213
normalized but a moderate pericardial effusion persisted. The patient refused further clinical investigation aimed at discovering the primary malignancy and was discharged from hospital.
2. Discussion
Fig. 1. M-mode echocardiogram (upper panel) showing the prominent paradoxical motion of the interventricular septum characteristic of the right ventricular volume overload states. Transthoracic echocardiographic (lower panel) imaging — in short axis view — showing the dilated right ventricle and the flattened interventricular septum in diastole (RV, right ventricle; IVS, interventricular septum; LV, left ventricle; PW, posterior wall; PE, pericardial effusion; PLE, pleural effusion).
pattern consisting of shortening of the transtricuspideal deceleration time (95 ms) and inspiratory increase of the E velocity not greater than 25%. Right heart catheterization showed a mean right atrial pressure of 21 mmHg with rapid Y descent; right ventricular end diastolic pressure was 19 mmHg and the pressure trace was of a dip and plateau type. Pulmonary artery pressure, mean pulmonary capillary wedge pressure and end-diastolic left ventricular pressure were within normal range. The cardiac index measured by thermodilution was 0.9 l / min and the stroke volume was 18 ml. Coronary angiography showed normal coronary arteries. After 72 h of treatment with high dose inotropic drugs (dopamine, dobutamine, isoproterenol) the patient slowly recovered and 10 days after admission, all hemodynamic parameters had normalized. This was parallel with the echocardiogram that showed that both ventricular dimensions, and systolic and diastolic function had completely
Dilation of the right ventricle (RV) related to pathological conditions of the pericardium has been reported after pericardiectomy [1], congenital absence of the pericardium [2] and following pericardiocentesis [3]. We have described the successful outcome of a cardiogenic shock due to a dramatic right ventricular depression in both systolic and diastolic function following pericardiocentesis. Pericardiocentesis may be a high-risk procedure [4] and may be complicated with myocardial puncture, coronary laceration etc. To our knowledge a cardiogenic shock due to severe right ventricular dilation and dysfunction following pericardiocentesis for relief of cardiac tamponade has not been previously described. Armstrong et al. [3] reported six cases of right ventricular dilation with echocardiographic signs of volume overload (paradoxical septal motion) following pericardiocentesis, and marked symptomatic relief was achieved by all of the patients after pericardiocentesis. Manyari et al. [5] reported the enlargement of the RV with radionuclide techniques, after therapeutic pericardiocentesis. Isolated and silent right ventricular infarction may mimic this entity. The echocardiographic appearance of the dilated and severe hypocontractile right ventricle, with an abnormal septal motion, is similar to that found in massive pulmonary embolism. In our case both entities could be ruled out. In agreement with Armstrong et al. [3] we hypothesise that the abrupt increase in venous return after the relief of cardiac tamponade may play a role in the development of the muscular injury, in particular, favouring the dilation of the right ventricle and the signs of volume overload. The addition of an elevated intrapericardial pressure and a lowered aortic pressure produced by the cardiac tamponade, dramatically reduces the coronary perfussion gradient, resulting in a prolonged but transient myocardial ischemia, that in addition to the abrupt increase in venous return after quick with-
214
I. Anguera et al. / International Journal of Cardiology 59 (1997) 212 – 214
drawal of pericardial fluid, may be a plausible explanation of the transient right ventricular dysfunction.
References [1] Viola AR. The influence of pericardiectomy on the hemodynamics of chronic constrictive pericarditis. Circulation 1973; 48: 1038– 1045. [2] Payvandi MN, Kerber RE. Echocardiography in congenital and acquired absence of the pericardium: an echocardiographic mimic of right ventricular volume overload. Circulation 1976; 53: 86–92.
[3] Armstrong WF, Feigenbaum H, Dillon JC. Acute right ventricular dilation and echocardiographic volume overload following pericardiocentesis for relief of cardiac tamponade. Am Heart J 1984; 107: 1266–1270. [4] Callahan JA, Seward JB, Nishimura RA, Niller FA, Reeder GS, Shub C, Callahan MJ, Schattenberg TT, Tajik J. Two-dimensional echocardiographically guided pericardiocentesis: Experience in 117 consecutive patients. Am J Cardiol 1985; 55: 476–479. [5] Manyari DE, Kostuk WJ, Purves P. Effect of pericardiocentesis on right and left vnetricular function and volumes in pericardial effusion. Am J Cardiol 1983; 52: 159–162.