Pericardial haemorrhage causing right atrial compression after cardiac surgery: role of transoesophageal echocardiography.

Abstract

After cardiac surgery transoesophageal echocardiography showed a large thrombus compressing the right atrium in 'three hypotensive patients. No satisfactory images were obtained by transthoracic imaging, which is often difficult in ventilated patients after cardiac surgery. Transoesophageal echocardiography, however, provided rapid diagnostic information and permitted prompt surgical intervention.In patients who become hypotensive after major cardiac surgery it is often not easy to make the differential diagnosis between left ventricular dysfunction, prosthetic valve dysfunction, sepsis, cardiac tamponade, and intrathoracic bleeding. Echocardiography can provide additional information about the contractile state of the left ventricle and the function of prosthetic valves but transthoracic imaging in a ventilated patient after cardiac surgery is difficult. Transoesophageal echocardiography provides rapid, real time high resolution imaging of the heart and surrounding structures that is valuable in the management of these patients.We describe three patients in whom compression of the right atrium by localised haematoma formation presented as either an early or late postoperative complication of valve surgery and in whom transoesophageal echocardiography was of primary diagnostic importance. 1). Colour Doppler flow mapping showed that the right atrial cavity was less than 1 cm in diameter. The right ventricle and the left heart were underfilled and the mitral valve prosthesis seemed to be functioning normally. At reoperation the transoesophageal echocardiographic findings were confirmed and direct left atrial puncture showed a left atrial pressure of 5 mm Hg. The large haematoma was removed and haemostasis secured. The patient subsequently made an uneventful postoperative recovery. CASE 2A 66 year old man who had had a CarpentierEdwards aortic valve replacement for aortic regurgitation and dilatation of the ascending aorta 10 years previously had the prosthetic valve replaced by a number 12 Starr-Edwards valve. The operative procedure was uncomplicated and the patient had an uneventful postoperative course. He was discharged seven days after operation. He was readmitted three days later with a history of increasing shortness of breath, a heart rate of 120 beats/ min, and a systolic blood pressure of 70-80 mm Hg. There were no clinical signs of valve dysfunction or chest infection. The electrocardiogram showed atrial fibrillation with a rapid ventricular response and the chest x ray showed some cardiomegaly but clear lung fields. Echocardiography showed a large haematoma surrounding and compressing the right atrium, like that in patient 1. At reoperation there was a large clot compressing the right atrium contained by a partially obliterated pericardium. The source

Pericardial effusion after cardiac surgery: incidence, site, size, and haemodynamic consequences.

“…In patients presenting with moderate or large pericardial effusions or echocardiographic signs of cardiac tamponade, echocardiography was performed daily (postoperative day [9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25]. The decision to perform percutaneous or surgical pericardiocentesis was based on clinical evidence of raised venous pressure, hypotension and pulsus paradoxus.…”

Localized Cardiac Tamponade after Open-Heart Surgery

“…This presumably accounts for the substantial delay of diagnosis. 1) As previously reported, [6][7][8][9][10][11][12] TTE failed to identify the compressed cardiac cavity in 1/4 of our patients, whereas TEE was always conclusive. During the first week following open-heart surgery, Flynn et al 13) showed that TTE provides adequate visualization of cardiac ventricles in only 58% of patients, since numerous factors are known to interfere with image quality in ventilated ICU patients.…”

“…8) Accordingly, none of our patient exhibited a circumferential pericardial effusion and typical echocardiographic findings associated with cardiac tamponade were not observed, as previously reported. 1,7,9) It has long been known that the hemodynamic effects of tamponade mainly result from atrial rather than ventricle compression. 17) Interestingly, an atrial compression was observed in 90% of our patients.…”

Pericardial Complications of Cardiac Surgery: Emphasis on the Diagnostic Role of Echocardiography

“…The first report of chylous pericardial effusion following cardiac surgery came from the Mayo Clinic in 1971P4 Since then, several additional case reports have appeared, documenting its occurrence following a variety of cardiac surgical procedure^.^^-^^ Incision and manipulation of the pericardium by the surgeon was involved in all of these; however, chylopericardium has also been reported in an instance of Blalock-Taussig anastomosis in which the pericardium was not opened. 34 There are at least three reports of chylopericardium complicating a Waterston ~h u n t .~~-~' The interval from the heart operation to diagnosis of chylopericardium has varied from 1 day to several months. The chylous nature of the pericardial effusion is suspected by the milky appearance of fluid draining from the pericardium in the early postoperative phase, or obtained by paracentesis at a later stage; tamponade can occur.…”