Resuscitative transesophageal echocardiography in the diagnosis of post-CABG loculated pericardial clot causing cardiac tamponade

Abstract

Background Pericardial effusion is a known complication of post-open cardiac surgery which can progress to life-threatening cardiac tamponade. Classical signs of tamponade such as hypotension and pulsus paradoxus are often absent. Diagnosing acute cardiac tamponade with transthoracic echocardiography (TTE) can be challenging in post-cardiac surgical patients due to distorted anatomy and limited scanning windows by the presence of surgical dressings or scar. Additionally, this patient population is more likely to have a loculated pericardial effusion, or an effusion that is isoechoic in appearance secondary to clotted blood. These findings can be challenging to visualize with traditional TTE. Missed diagnosis of cardiac tamponade due to loculated pericardial clot can result in delayed diagnosis and clinical management. Case presentation We report a case series that illustrates the diagnostic challenge and value of resuscitative transesophageal echocardiography (TEE) in the emergency department (ED) for the diagnosis of cardiac tamponade due to posterior loculated pericardial clot in post-surgical coronary artery bypass graft (CABG) patients. Conclusions Cardiac tamponade due to loculated posterior pericardial clot post-CABG requires prompt diagnosis and appropriate management to avoid the potential for hemodynamic instability. Transesophageal echocardiography allows a rapid diagnosis, early appropriate referral and an opportunity to institute appropriate therapeutic measures.

Indications, Clinical Impact, and Complications of Critical Care Transesophageal Echocardiography: A Scoping Review

“…37 , 38 There were a number of case reports of ccTEE identifying rare causes of shock that may not have been visualized on TTE: right atrial compression from intrabdominal hematoma, 39 thoracic tamponade post lung transplant, 40 and regional pericardial tamponade in the ED after discharge home from cardiac surgery. 41 For patients who already had TTE performed, ccTEE resulted in additional changes in management in 40% of cases, and refuted TTE diagnoses in approximately 20% of cases (Table 3). 42 , 43 …”

“… 63 – 65 , 97 Regional mediastinal or pericardial hemorrhage in particular, typically occult to TTE, can be readily identified on TEE. 17 , 41 Additionally, when there are no transabdominal or transthoracic windows due to subcutaneous emphysema or body habitus, ccTEE can potentially sequence immediate priorities or disposition. The “TREE” protocol for acute trauma resuscitation TEE focuses on identifying hypovolemia, aortic injuries, pericardial disease, and pleural pathology, 98 however, prospective studies validating its use are lacking.…”

ST segment elevation for diagnosis of pericardial local blood clots after coronary artery bypass grafting: a case report

“…Pericardial effusion is a common complication after CABG), with 1-3% of them requiring timely intervention [1,2]. Encapsulated pericardial effusion, often resulting from local clots on the pericardium following CABG, can cause life-threatening cardiac tamponade [3]. Patients are usually treated with substantial sedation, ventilation, and inotropes; typical signs of tamponade are generally absent, such as hypotension and paradoxical pulse [4].…”

“…Pericardial effusion is a common complication after CABG, and 1-3% of them require timely intervention [1,2]. Encapsulated pericardial effusion is often secondary to local clots on the pericardium after CABG and can cause life-threatening cardiac tamponade [3]. It poses a signi cant challenge to the clinical and ultrasonic diagnosis of cardiac tamponade due to changes in anatomy and irregular accumulation of blood clots around the pericardium after CABG [2,5].…”