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

Loculated cardiac hematoma causing hemodynamic compromise after cardiac surgery

The authors describe a case of a rare complication occurring after cardiac surgery. Three weeks after aortic valve replacement a young male became hemodynamically unstable. The echocardiogram showed a large loculated hematoma compressing the right atrium. The patient was reoperated and the mass was removed. Recovery was complete.

The effects of posterior pericardiotomy on pericardial effusion, tamponade, and atrial fibrillation after coronary artery surgery

Introduction

Pericardial effusion and atrial fibrillation occur commonly after coronary artery surgery.

Aim of the study

A prospective randomized clinical trial was conducted to evaluate the effects of posterior pericardiotomy on the occurrence of pericardial effusion, tamponade, and atrial fibrillation.

Material and methods

The study group consisted of 96 patients (77 male and 19 female) at a mean age of 58.1 ± 9.8 years. The patients were randomly assigned to one of three study groups: patients undergoing posterior pericardiotomy (group I, n = 30), controls (group II, n = 33), and patients with additional posterior pericardial drainage tubes (28 mm) who did not undergo posterior pericardiotomy (group III, n = 33).

Results

Postoperative hospitalization (p = 0.03; 11.56 ± 10.64) and reoperation due to tamponade (p = 0.019; 12.1%) were significantly higher in group II. Extensive pericardial effusions were detected in one patient on the first postoperative day (group II, n = 1), in one patient on the fifth postoperative day (group III, n = 1), and in one patient on the 30^th day after the operation (group III, n = 1). Pericardial effusion exhibited regression in group I on postoperative day 30 (p = 0.028). A higher rate of postoperative atrial fibrillation was noted in group I, but no significant differences were found between the groups with regard to postoperative atrial fibrillation.

Conclusions

Patients who did not undergo posterior pericardiotomy or did not receive posterior chest tubes exhibited residual pericardial effusion, required longer hospitalization, and had to be reoperated due to tamponade. Both posterior pericardiotomy and the use of posterior tubes are effective in the early postoperative period.

Localized cardiac tamponade after open-heart surgery

PURPOSE

To describe the clinical presentation and echocardiographic findings associated with localized tamponade after open-heart surgery.

METHODS

Retrospective analysis of a case series with a surgically proven diagnosis.

RESULTS

Among 23 patients with surgically proven localized cardiac tamponade after elective open-heart surgery, 5 patients (22%) died in the ICU from multiorgan failure. At the time of diagnosis (median delay: 2 days; range: 0-8 days), shock was present in 19 patients, 8 of them being hypotensive. Transthoracic echocardiography (TTE) depicted the localized cardiac tamponade in 3 of 4 examined patients, whereas transesophageal echocardiography (TEE) was always conclusive. The right atrium was primarily involved, solely (n = 11) or with the right ventricle (n = 5), whereas the left cardiac cavities were less frequently compressed (left atrium: n = 6, left ventricle: n = 1). The free wall curvature of the involved cardiac chamber was consistently inverted, and blood flow turbulences were depicted in 12 patients. Surgical removal of the compressive hematoma improved the clinical status of 18 patients (78%) who were discharged from the hospital.

CONCLUSION

Since localized tamponade complicating open-heart surgery has various, non-specific clinical presentations and TTE is not diagnostic, indications of TEE must be liberal in this setting to prompt diagnosis and surgical reoperation.

Retrosternal compression seven years after surgical correction of partial anomalous pulmonary venous connection: Scimitar syndrome

Seven years after surgical correction of Scimitar syndrome, a 19-year-old patient complained of progressive dyspnea and tachycardia. Transthoracic echocardiography revealed a mass compressing the right ventricle. Magnetic resonance tomogram showed its exact retrosternal location and nature. A computed tomography-guided drainage decompressed the mass. Because of cystic wall persistence, a surgical extirpation of the whole cystic cavity was deemed necessary.

Transesophageal echocardiography and adult cardiac operations

Transesophageal echocardiography (TEE) now is used widely as a monitoring technique during and after cardiac operations. Widespread adoption of the technique has provided a wealth of new information. This review analyzes the influence of TEE on the routine conduct of cardiac operations and on surgical decision making in specific areas. Its use in routine hemodynamic monitoring and problem solving, both intraoperatively and postoperatively, is discussed. Transesophageal echocardiography has a particular role in valve operations, in guiding and assessing the immediate results of mitral valve repair. It also has found application in the grading and operative management of the severely atheromatous aorta, the diagnosis and management of aortic dissection, and other aspects of surgery of the thoracic aorta. In addition, management in specialized areas, such as cardiopulmonary transplantation and the insertion and monitoring of ventricular assist devices, have also been helped by the information provided by TEE.

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

OBJECTIVE

To evaluate the incidence, characteristics, and haemodynamic consequences of pericardial effusion after cardiac surgery.

DESIGN

Clinical, echocardiographic, and Doppler evaluations before and 8 days after cardiac surgery; with echocardiographic and Doppler follow up of patients with moderate or large pericardial effusion after operation.

SETTING

Patients undergoing cardiac surgery at a tertiary centre.

PATIENTS

803 consecutive patients who had coronary artery bypass grafting (430), valve replacement (330), and other types of surgery (43). 23 were excluded because of early reoperation.

MAIN OUTCOME MEASURES

Size and site of pericardial effusion evaluated by cross sectional echocardiography and signs of cardiac tamponade detected by ultrasound (right atrial and ventricular diastolic collapse, left ventricular diastolic collapse, distension of the inferior vena cava), and Doppler echocardiography (inspiratory decrease of aortic and mitral flow velocities).

RESULTS

Pericardial effusion was detected in 498 (64%) of 780 patients and was more often associated with coronary artery bypass grafting than with valve replacement or other types of surgery; it was small in 68.4%, moderate in 29.8%, and large in 1.6%. Loculated effusions (57.8%) were more frequent than diffuse ones (42.2%). The size and site of effusion were related to the type of surgery. None of the small pericardial effusions increased in size; the amount of fluid decreased within a month in most patients with moderate effusion and in a few (7 patients) developed into a large effusion and cardiac tamponade. 15 individuals (1.9%) had cardiac tamponade; this event was significantly more common after valve replacement (12 patients) than after coronary artery bypass grafting (2 patients) or other types of surgery (1 patient after pulmonary embolectomy). In patients with cardiac tamponade aortic and mitral flow velocities invariably decreased during inspiration; the echocardiographic signs were less reliable.

CONCLUSIONS

Pericardial effusion after cardiac surgery is common and its size and site are related to the type of surgery. Cardiac tamponade is rare and is more common in patients receiving oral anticoagulants. Echo-Doppler imaging is useful for the evaluation of pericardial fluid accumulations after cardiac surgery. It can identify effusions that herald cardiac tamponade.

Transesophageal echocardiography in pericardial disease and tamponade

While most pericardial disorders can be imaged by transthoracic echocardiography, transesophageal echocardiography may be required in those cases where pericardial pathology is clinically suspected, but cannot be imaged adequately with transthoracic echocardiography. Transesophageal echocardiography is especially helpful in patients after heart or chest surgery, with cardiac compression by a loculated pericardial hematoma, in patients with dissection, endocarditis, or interatrial shunting associated with pericardial effusion, in patients with pericardial tumors, and in the differential diagnosis between constrictive pericarditis and restrictive cardiomyopathy.

Isolated right atrial compression as a late sequela of aortic valve replacement

Isolated right atrial compression occurred 31 months after aortic valve replacement. Aortic bleeding contained by adjacent pericardium produced a pseudoaneurysm and local atrial tamponade. Transthoracic echocardiography could not distinguish the extracardiac hematoma from an intra-atrial thrombus, temporarily misleading investigators.

Percutaneous pericardiocentesis versus subxiphoid pericardiotomy in cardiac tamponade due to postoperative pericardial effusion

In a retrospective study, 42 patients with acute cardiac tamponade due to pericardial effusion were evaluated following cardiac surgery, and the pericardial fluid was drained by one of two alternative methods: two-dimensional echocardiographic-guided pericardiocentesis (2D-echo) or subxiphoid surgical pericardiotomy. During the first period (from 1982 to 1986), one of the two methods was chosen by the treating physicians, whereas in the second period (from 1986 to 1991), 2D-echo-guided pericardiocentesis was the treatment of choice. Percutaneous pericardiocentesis was performed using local anesthesia in 29 patients. A Tuohy needle was inserted at the left xipho-costal junction and, when fluid was obtained, 6 mL of saline solution was injected during 2D-echo contrast monitoring, and a multiple-hole, 6F, 30-cm catheter was inserted by means of a guidewire and positioned into the posterior pericardium, as near as possible to the atrioventricular groove. Complete drainage of pericardial fluid by percutaneous pericardiocentesis was obtained in 26 patients (89%). This procedure also allowed the evacuation of posterior and loculated effusions. Complications included two right ventricular punctures, which were immediately recognized by 2D-echo contrast and produced no serious consequences. Sixteen patients who underwent surgical pericardiotomy had complete evacuation of pericardial fluid without major complications (two of them suffered atrial arrhythmias during the procedure). The average amount of fluid drained, as well as the localization of the effusions, were the same for both groups. 2D-echo-guided pericardiocentesis was found to be a useful, safe, and simple technique. It can be used as an alternative treatment to subxiphoid pericardiotomy for cardiac tamponade due to postoperative pericardial effusions.

Pericardial complications of cardiac surgery: emphasis on the diagnostic role of echocardiography

Pericardial effusions are common following cardiac surgery; uncommonly they are large in size and may cause tamponade, either in the early or late postoperative period. Such effusions causing tamponade may be circumcardiac, but are frequently loculated, in which case one or more cardiac chambers is selectively compressed. Fortunately, echocardiography is capable of imaging not only the presence, location, and size of the pericardial effusion, but also indicating the presence of tamponade. Constrictive pericarditis resulting from cardiac surgery is being recognized with increasing frequency and has been associated with various echocardiographic abnormalities. This review also discusses certain other pericardial complications of cardiac surgery including supraventricular arrhythmias, chylopericardium, and posttransplant problems.