Impact of Controlled Pericardial Drainage on Critical Cardiac Tamponade With Acute Type A Aortic Dissection

Abstract

Background— Cardiac tamponade is associated with fatal outcomes for patients with acute type A aortic dissection, and the presence of cardiac tamponade should prompt urgent aortic repair. However, treatment of the patient with critical cardiac tamponade who cannot survive until surgery remains unclear. We analyzed our experience of controlled pericardial drainage (CPD) managing critical cardiac tamponade. Methods and Results— Between September 2003 and May 2011, 175 patients with acute type A aortic dissection were treated surgically, including 43 (24.6%) who presented with cardiac tamponade on arrival. Eighteen patients, who did not respond to intravenous volume resuscitation, underwent CPD in the emergency department. An 8F pigtail drainage catheter was inserted percutaneously, and drainage volume was controlled by means of several cycles of intermittent drainage to maintain blood pressure at ≈90 mm Hg. After CPD, all of the patients were transferred to the operating room, and immediate aortic repair was performed. Systolic blood pressure before CPD was 64.3±8.2 mm Hg and elevated significantly in all of the cases after CPD. Systolic blood pressure after CPD was 94.8±10.5 mm Hg, and increase in systolic pressure was 30.5±11.7 mm Hg. Total volume of aspirated pericardial effusion was 40.1±30.6 mL, and 10 patients required only ≤30-mL aspiration volume. All of the patients underwent aortic repair successfully. In-hospital mortality was 16.7%; however, there was no complications or mortality related to CPD. Conclusions— Preoperative pericardial drainage with control of volume is a safe and effective procedure for acute type A aortic dissection complicated by critical cardiac tamponade. In our patient population, timely controlled pericardial drainage is warranted.

2015 ESC Guidelines for the diagnosis and management of pericardial diseases

“…W przypadku rozwarstwienia aorty, z krwawieniem do worka osierdziowego i podejrzeniem tamponady, należy w celu potwierdzenia rozpoznania wykonać pilnie echokardiografię lub CT. W takich przypadkach można próbować ostrożnie drenować worek osierdziowy, upuszczając bardzo małe ilości krwi, co ma na celu czasowe ustabilizowanie stanu pacjenta i utrzymanie ciśnienia krwi na poziomie ok. 90 mm Hg [187].…”

Pericardial Effusion in a Patient with Non-ST-Elevation Myocardial Infarction: Beware of a Hidden Malefactor

“…It has been noted that cardiac tamponade, occurring in about 10% of AAD, signals a higher risk of death as it happened in this patient [6, 8]. It is well known that in patients with aortic dissection and cardiac tamponade, routine pericardial drainage is contraindicated (must go for surgery) as it may increase the leak or rupture by restoring blood pressure, which then increases the tear and the driving pressure of the leak, thereby increasing mortality [10]. In the recent American guidelines, limited pericardiocentesis is advised to restore perfusion in patients with hemopericardium and cardiac tamponade who cannot survive until surgery or if the patient in cardiac arrest [6].…”

2015 ESC Guidelines for the Diagnosis and Management of Pericardial Diseases

“…In such a scenario, controlled pericardial drainage of very small amounts of the haemopericardium can be attempted to temporarily stabilize the patient in order to maintain blood pressure at 90 mmHg. 187 Recommendations for the management of traumatic pericardial effusion and haemopericardium in aortic dissection…”