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      Editorial: Invisible hematoma causing shock after open-heart surgery: Localized cardiac tamponade

      editorial
      , MD, FJCC *
      Journal of Cardiology Cases
      Japanese College of Cardiology
      Tamponade, Post-operative hematoma, Intra-pericardial hematoma, Cardiac surgery

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          Abstract

          Shock is a physiological state characterized by an inadequate tissue perfusion and cellular oxygenation associated with persistent hypotension, resulting in adverse effects on multiple organ systems. Possible causes of shock following cardiac surgery include pump failure, pulmonary embolism, hypovolemia, sepsis, and tamponade. As the prolongation of shock status can lead to irreversible organ damage or death, a prompt diagnosis of underlying cause and initiation of treatment are critical. Echocardiography is generally the first option for comprehensive assessment. However, in rare cases, unexpected cardiac tamponade can occur as a cause of shock following cardiac surgery, and this may not be detected using transthoracic echocardiography in the early period after surgery. Huang et al. [1] reported a case who had cardiac arrest on day 8 after mechanical mitral valve replacement. They found a large intra-pericardial mass compressing the right atrium (RA), a rare condition, referred to as “localized” or “isolated cardiac tamponade.” There have been several reports of a localized hematoma or hemorrhage causing systemic hypotension after cardiac surgery 2, 3, 4, 5, 6, 7, 8, 9, 10, 11. These patients exhibited progressive and persistent hypotension, tachycardia, and elevated central venous or RA pressures; these features are consistent with cardiac tamponade. However, pulmonary capillary wedge pressure and pulmonary artery pressure were normal, and pulsus paradoxus was absent. The period from surgery to the onset of shock varied considerably – from 12 h to 31 months. The cause of hypotension was not revealed using transthoracic echocardiography, but transesophageal echocardiography could provide an excellent image quality due to the alternative acoustic window. In reality, immediately after cardiac surgery, the area observable using transthoracic echocardiography is limited. In addition to surgical wounds and dressings, mechanical ventilators and intra-aortic balloon pump restrict possible changes in patient position for alternate views, and this often results in poor image quality. Moreover, when a patient is in agony, examination and diagnosis must be performed quickly to minimize patient discomfort. If a hematoma is localized in the retrosternal space, the inferior vena cava may be distended and the right ventricular free wall is not collapsed in early diastole, but the hematoma itself may be overlooked using transthoracic echocardiography. Although the specificity of transthoracic echocardiography for detecting pericardial hematoma is 83%, the sensitivity is only 33% [12]. Furthermore, Beppu et al. [7] reported that the ‘y’ descent of the RA pressure tracing was prominent, which is the characteristic of constrictive pericarditis rather than cardiac tamponade. Especially in ventilated patients under intensive care, transesophageal echocardiography may be superior to detect localized tamponade. Cardiac tamponade due to hematoma may also occur during anticoagulant therapy. A left ventricular assist device (LVAD) is often used for end-stage heart failure and requires anticoagulant therapy with a targeted international normalized ratio of 3.0–4.0 to prevent LVAD thrombosis. Therefore, localized cardiac tamponade can occur late after LVAD implantation. Hematoma compressing the right heart is a potentially life-threatening condition even under LVAD support. To begin with, in such patients, pulsus paradoxus may be masked by LVAD action. When pericardial effusion cannot be detected using transthoracic echocardiography in patients with persistent and progressive hypotension, right ventricular heart failure may be thought to manifest due to strong mechanical assistance to the left ventricle. However, if hemodynamics did not improve despite adequate catecholamine support, additional diagnostic imaging is needed to explore the cause of hypotension. In this situation, computed tomography is recommended (unless an endotracheal tube is inserted), because it is technically hard to evaluate critically ill and un-sedated patients using transesophageal echocardiography. Isolated RA tamponade is a rare and unexpected complication of cardiac surgery. In critically ill postoperative patients, it may be difficult to recognize a hematoma adjoining RA in the retrosternal space using transthoracic echocardiography. If the clinical manifestations and course are consistent with cardiac tamponade despite the lack of detectable pericardial effusion, the possibility of an invisible hematoma compressing only RA should be also considered after open-heart surgery.

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          Most cited references12

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          Right atrial compression in postoperative cardiac patients: detection by transesophageal echocardiography.

          Four patients developed hypotension after heart surgery. Hemodynamic measurements revealed elevated right atrial pressure with normal pulmonary capillary wedge pressure. Conventional transthoracic two-dimensional echocardiography was technically suboptimal for detection of pericardial effusion. In each patient transesophageal echocardiography demonstrated significant compression of the right atrium by a localized mass. At reoperation atrial compression by an organized hematoma was found and in each instance successfully drained. Thus, transesophageal echocardiography is superior to transthoracic echocardiography in evaluating critically ill postoperative hypotensive patients and can differentiate isolated right atrial tamponade from other causes of hemodynamic deterioration such as prosthetic valve dysfunction or left ventricular systolic dysfunction, or both.
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            Pericardial clot after open heart surgery: its specific localization and haemodynamics.

            Transoesophageal echocardiography disclosed a localized pericardial blood clot compressing the right atrium (RA) and/or right ventricle (RV) in 15 patients suffering from low cardiac output failure soon after open-heart surgery. The left ventricular end-diastolic diameter was small (38.4 +/- 10.1 mm) and its fractional shortening normal (34.9 +/- 10.2%). These findings suggested cardiac tamponade as a result of pericardial clot. However, the 'y' trough of the RA pressure tracing was prominent, which is not characteristic of typical cardiac tamponade, but rather of constrictive pericarditis. This implies therefore that the pathophysiology of cardiac tamponade by pericardial clot differs from that of tamponade by fluid. Emergency open-chest removal of the pericardial clot was performed in seven patients, with good results. Pericardial clot produces low cardiac output soon after open-heart surgery, but its location is specific and its haemodynamics are not characteristic of cardiac tamponade.
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              Delayed cardiac tamponade after open heart surgery - is supplemental CT imaging reasonable?

              Background Cardiac tamponade is a severe complication after open heart surgery. Diagnostic imaging is challenging in postoperative patients, especially if tamponade develops with subacute symptoms. Hypothesizing that delayed tamponade after open heart surgery is not sufficiently detected by transthoracic echocardiography, in this study CT scans were used as standard reference and were compared with transthoracic echocardiography imaging in patients with suspected cardiac tamponade. Method Twenty-five patients after open heart surgery were enrolled in this analysis. In case of suspected cardiac tamponade patients underwent both echocardiography and CT imaging. Using CT as standard of reference sensitivity, specificity, positive and negative predictive values of ultrasound imaging in detecting pericardial effusion/hematoma were analyzed. Clinical appearance of tamponade, need for re-intervention as well as patient outcome were monitored. Results In 12 cases (44%) tamponade necessitated surgical re-intervention. Most common symptoms were deterioration of hemodynamic status and dyspnea. Sensitivity, specificity, positive and negative predictive values of echocardiography were 75%, 64%, 75%, and 64% for detecting pericardial effusion, and 33%, 83%, 50, and 71% for pericardial hematoma, respectively. In-hospital mortality of the re-intervention group was 50%. Conclusion Diagnostic accuracy of transthoracic echocardiography is limited in patients after open heart surgery. Suplemental CT imaging provides rapid diagnostic reliability in patients with delayed cardiac tamponade.
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                Author and article information

                Contributors
                Journal
                J Cardiol Cases
                J Cardiol Cases
                Journal of Cardiology Cases
                Japanese College of Cardiology
                1878-5409
                26 March 2014
                June 2014
                26 March 2014
                : 9
                : 6
                : 243-244
                Affiliations
                [0005]Department of Cardiovascular Medicine, Heart Failure Division, National Cerebral and Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka 565-8565, Japan
                Author notes
                [* ]Tel.: +81 668335012; fax: +81 68727486 kanzakih@ 123456hsp.ncvc.go.jp
                Article
                S1878-5409(14)00028-0
                10.1016/j.jccase.2014.02.002
                6278562
                af569641-cded-4c39-bdc5-81391319ada7
                © 2014 Japanese College of Cardiology. Published by Elsevier Ltd.

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

                History
                : 13 November 2013
                Categories
                Article

                tamponade,post-operative hematoma,intra-pericardial hematoma,cardiac surgery

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