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Enders M, Sarani N, Malik A. Isolated left ventricular cardiac tamponade diagnosed on point-of-care ultrasound in the emergency department: A case report and brief literature review. J Am Coll Emerg Physicians Open 2023; 4:e12990. [PMID: 37426555 PMCID: PMC10324463 DOI: 10.1002/emp2.12990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 05/23/2023] [Accepted: 05/23/2023] [Indexed: 07/11/2023] Open
Abstract
In this case report, we describe isolated left ventricular cardiac tamponade, a rare complication of cardiac surgery, diagnosed on point-of-care ultrasound (POCUS) in the emergency department (ED). To our knowledge, this is the first report of such a diagnosis made on ED bedside ultrasound. Our patient was a young adult female with a history of recent mitral valve replacement who presented to the ED with dyspnea and was found to have a large loculated pericardial effusion causing left ventricular diastolic collapse. Rapid diagnosis via POCUS in the ED allowed for expedited definitive treatment by cardiothoracic surgery in the operative room and emphasizes the importance of a standard 5-view cardiac POCUS examination when post-cardiac surgery patients present to the ED.
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Affiliation(s)
- Maria Enders
- Department of Emergency MedicineUniversity of Kansas Health SystemKansas CityKansasUSA
| | - Nima Sarani
- Department of Emergency MedicineUniversity of Kansas Health SystemKansas CityKansasUSA
| | - Adrienne Malik
- Department of Emergency MedicineUniversity of Kansas Health SystemKansas CityKansasUSA
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2
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Kourtinos A, Aghezzaf S, Montaigne D, Coisne A. A Misleading Left Atrial Appendage. JACC Case Rep 2023; 15:101872. [PMID: 37283826 PMCID: PMC10240283 DOI: 10.1016/j.jaccas.2023.101872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/03/2023] [Accepted: 04/13/2023] [Indexed: 06/08/2023]
Abstract
Left atrial appendage collapse is a relatively unusual echocardiographic finding. Although in post-cardiac surgery patients it may be an early sign of cardiac tamponade, and pericardiocentesis should be discussed, a conservative approach may be followed in cases secondary to viral infection without confusing it with a left atrial appendage thrombus. (Level of Difficulty: Intermediate.).
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Affiliation(s)
- Alexandros Kourtinos
- Department of Clinical Physiology and Echocardiography, France – Heart Valve Clinic, Heart and Lung Institute, CHU Lille, Lille, France
| | - Samy Aghezzaf
- Department of Clinical Physiology and Echocardiography, France – Heart Valve Clinic, Heart and Lung Institute, CHU Lille, Lille, France
- Université de Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011- EGID, Lille, France
| | - David Montaigne
- Department of Clinical Physiology and Echocardiography, France – Heart Valve Clinic, Heart and Lung Institute, CHU Lille, Lille, France
- Université de Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011- EGID, Lille, France
| | - Augustin Coisne
- Department of Clinical Physiology and Echocardiography, France – Heart Valve Clinic, Heart and Lung Institute, CHU Lille, Lille, France
- Université de Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011- EGID, Lille, France
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3
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Five-minute Test to Prevent Postcardiotomy Re-exploration. JTCVS Tech 2022; 12:121-129. [PMID: 35403041 PMCID: PMC8987325 DOI: 10.1016/j.xjtc.2021.08.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 08/16/2021] [Indexed: 11/22/2022] Open
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4
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Gonzalez J, Callan P. Invasive Haemodynamic Assessment Before and After Left Ventricular Assist Device Implantation: A Guide to Current Practice. Interv Cardiol 2021; 16:e34. [PMID: 35106070 PMCID: PMC8785090 DOI: 10.15420/icr.2021.13] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 10/10/2021] [Indexed: 11/06/2022] Open
Abstract
Mechanical circulatory support for the management of advanced heart failure is a rapidly evolving field. The number of durable long-term left ventricular assist device (LVAD) implantations increases each year, either as a bridge to heart transplantation or as a stand-alone ‘destination therapy’ to improve quantity and quality of life for people with end-stage heart failure. Advances in cardiac imaging and non-invasive assessment of cardiac function have resulted in a diminished role for right heart catheterisation (RHC) in general cardiology practice; however, it remains an essential tool in the evaluation of potential LVAD recipients, and in their long-term management. In this review, the authors discuss practical aspects of performing RHC and potential complications. They describe the haemodynamic markers associated with a poor prognosis in patients with left ventricular systolic dysfunction and evaluate the measures of right ventricular (RV) function that predict risk of RV failure following LVAD implantation. They also discuss the value of RHC in the perioperative period; when monitoring for longer term complications; and in the assessment of potential left ventricular recovery.
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Affiliation(s)
| | - Paul Callan
- Wythenshawe Cardiothoracic Transplant Unit, Manchester Foundation Trust, Wythenshawe Hospital, Wythenshawe, Manchester, UK
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5
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Ellenbroek DFJ, van Kessel L, Compagner W, Brouwer T, Bouwman RA, van Straten BAHM, Otterspoor LC, De Bie AJR. Diagnostic performance of echocardiography to predict cardiac tamponade after cardiac surgery. Eur J Cardiothorac Surg 2021; 62:6430389. [PMID: 34791128 PMCID: PMC9257667 DOI: 10.1093/ejcts/ezab468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 08/14/2021] [Accepted: 09/23/2021] [Indexed: 11/29/2022] Open
Affiliation(s)
- Dennis F J Ellenbroek
- Department of Intensive Care, Radboud University Medical Center, Nijmegen, Netherlands
| | - Luc van Kessel
- Department of Intensive Care, Catharina Hospital, Michelangelolaan 2, Eindhoven, Netherlands
| | - Wilma Compagner
- Department of Intensive Care, Catharina Hospital, Michelangelolaan 2, Eindhoven, Netherlands
| | - Tim Brouwer
- Department of Intensive Care, Catharina Hospital, Michelangelolaan 2, Eindhoven, Netherlands
| | - R Arthur Bouwman
- Department of Anesthesiology, Catharina Hospital, Eindhoven, Netherlands
| | | | - Luuk C Otterspoor
- Department of Cardiology, Catharina Hospital, Eindhoven, Netherlands
| | - Ashley J R De Bie
- Department of Intensive Care, Radboud University Medical Center, Nijmegen, Netherlands.,Department of Intensive Care, Catharina Hospital, Michelangelolaan 2, Eindhoven, Netherlands
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Adi O, Ahmad AH, Fong CP, Ranga A, Panebianco N. Resuscitative transesophageal echocardiography in the diagnosis of post-CABG loculated pericardial clot causing cardiac tamponade. Ultrasound J 2021; 13:22. [PMID: 33856577 PMCID: PMC8050179 DOI: 10.1186/s13089-021-00225-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 04/06/2021] [Indexed: 11/16/2022] Open
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. Supplementary Information The online version contains supplementary material available at 10.1186/s13089-021-00225-7.
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Affiliation(s)
- Osman Adi
- Resuscitation & Emergency Critical Care Unit, Department of Emergency and Trauma, Raja Permaisuri Bainun Hospital, Jalan Raja Ashman (Jalan Hospital), 30400, Ipoh, Perak, Malaysia.
| | - Azma Haryaty Ahmad
- Resuscitation & Emergency Critical Care Unit, Department of Emergency and Trauma, Raja Permaisuri Bainun Hospital, Jalan Raja Ashman (Jalan Hospital), 30400, Ipoh, Perak, Malaysia
| | - Chan Pei Fong
- Resuscitation & Emergency Critical Care Unit, Department of Emergency and Trauma, Raja Permaisuri Bainun Hospital, Jalan Raja Ashman (Jalan Hospital), 30400, Ipoh, Perak, Malaysia
| | - Asri Ranga
- Department of Cardiology, Hospital Serdang, Serdang, Selangor, Malaysia
| | - Nova Panebianco
- Division of Emergency Ultrasound, Department of Emergency Medicine, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, 19104, USA
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Hirata Y, Tayama E, Ueda T, Uchiyama H, Onzuka T, Furukawa K, Morita S. Comparison of intra-wound drainage tubes after cardiac surgery: Blake drains versus Multichannel drains. Int J Artif Organs 2020; 44:434-439. [PMID: 33183146 DOI: 10.1177/0391398820972413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Blake and Multichannel drains have been used in our department. Although both are made up of silicone, they differ in structure. We investigated the drainage effects of these two types of drains and the factors related to their occlusion. METHODS We enrolled 100 consecutive cases (50 using Blake drains and 50 using Multichannel drains) of cardiovascular surgery performed in our department from July 2017 to April 2018. The formation of thrombi in the groove and tube of the drains was evaluated in each case. The tube portion was checked for the presence of occlusion, and the groove portion was examined for the number and ratio of thrombi formed in the grooves. RESULTS The clot formation rate in the groove part was slightly higher in the Multichannel cases than in the Blake cases. In addition, analysis within the Multichannel cases revealed that the thrombus formation rate between the catheter lumen and the three grooves (without the catheter lumen) was significantly different, with the highest groove clot formation rate occurring in the catheter lumen. Out of 34 cases of occlusions, there were 26 cases (52%) of Multichannel drains, and only 8 cases (16%) of Blake drains (p < 0.01). A multiple logistic regression analysis revealed that the most important contributory factor in tube obstruction was the drain type. CONCLUSIONS The catheter lumen of the Multichannel drain was more susceptible to thrombus formation than the groove. The tube part of the Multichannel drain was more prone to occlusion than that of the Blake drain.
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Affiliation(s)
- Yuichiro Hirata
- Department of Cardiovascular Surgery, Clinical Research Institute, Kyusyu Medical Center, National Hospital Organization, Fukuoka, Japan
| | - Eiki Tayama
- Department of Cardiovascular Surgery, Clinical Research Institute, Kyusyu Medical Center, National Hospital Organization, Fukuoka, Japan
| | - Tomohiro Ueda
- Department of Cardiovascular Surgery, Clinical Research Institute, Kyusyu Medical Center, National Hospital Organization, Fukuoka, Japan
| | - Hikaru Uchiyama
- Department of Cardiovascular Surgery, Clinical Research Institute, Kyusyu Medical Center, National Hospital Organization, Fukuoka, Japan
| | - Tatsushi Onzuka
- Department of Cardiovascular Surgery, Clinical Research Institute, Kyusyu Medical Center, National Hospital Organization, Fukuoka, Japan
| | - Kojiro Furukawa
- Department of Cardiovascular Surgery, Clinical Research Institute, Kyusyu Medical Center, National Hospital Organization, Fukuoka, Japan
| | - Shigeki Morita
- Department of Cardiovascular Surgery, Clinical Research Institute, Kyusyu Medical Center, National Hospital Organization, Fukuoka, Japan
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8
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Nwafor IA, Eze JC. Management of bleeding and blood transfusion in open cardiac surgery in a developing country: five-years institutional experience. Chirurgia (Bucur) 2019. [DOI: 10.23736/s0394-9508.18.04904-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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9
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Right pericardial window opening: a method of preventing pericardial effusion. Gen Thorac Cardiovasc Surg 2019; 68:485-491. [PMID: 31559587 DOI: 10.1007/s11748-019-01213-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 09/14/2019] [Indexed: 10/25/2022]
Abstract
AIM In this study, we aimed to investigate the superiority of right pericardial window (RPW) versus posterior pericardial drain placing for the parameters of pericardial effusion and the postoperative complications at the patients who has undergone cardiac surgery. MATERIALS AND METHODS Between July and September 2018, 120 adult patients (mean age 50.30 ± 14.61) who underwent cardiac surgery without the necessity of opening the pleura were included in the study. In Group 1, the RPW was opened (n = 60), and Group 2 posterior pericardial drainage tube was placed without RPW (n = 60). Risk factors and postoperative complication were evaluated and compared between the Groups. RESULTS Cardiac tamponade occurrence was not significantly different between the Groups (Group 1, n = 0 and Group 2, n = 3, p = 0.079). Postoperative transthoracic echocardiographic controls revealed significant pericardial effusion in Group 2 (6.90 mm ± 13.02 mm) compared to Group 1 (2.30 mm ± 5.60 mm) (p = 0.013). Postoperative creatinine levels were 0.75 ± 0.26 in Group 1 and 0.88 ± 0.36 in Group 2 (p = 0.022). A significant decrease in glomerular filtration rate was observed in Group 2 (102.7 ± 24.5 and 91.2 ± 28, p = 0.019). Postoperative acute renal failure was significantly higher in Group 2 compared to Group 1 (p < 0.001). Postoperative new onset atrial fibrillation occurred in 4 patients in Group 1 and 8 in Group 2 (p = 0.224). The duration of intensive care unit stay was 36.00 ± 22.31 h in Group 1 and 53.60 ± 59.50 h in Group 2 (p = 0.034). Development of pneumothorax, pneumonia and pleural effusion were not statistically different between the Groups (p = 0.079, 0.171, 0.509). CONCLUSION RPW application is more effective on preventing postoperative complications in cardiac surgery instead of placing drains in posterior pericardium.
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10
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Khan J, Khan N, Mennander A. Lower incidence of late tamponade after cardiac surgery by extended chest tube drainage. SCAND CARDIOVASC J 2019; 53:104-109. [DOI: 10.1080/14017431.2019.1590630] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Jahangir Khan
- Department of Cardio-Thoracic Surgery, Tampere University Heart Hospital, Tampere, Finland
| | - Niina Khan
- Division of Vascular Surgery, Department of Surgery, Tampere University Hospital, Tampere, Finland
| | - Ari Mennander
- Department of Cardio-Thoracic Surgery, Tampere University Heart Hospital, Tampere, Finland
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11
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Yu PSY, Ng VWK, Lau RWH, Ng CSH. Massive pericardial effusion after Nuss procedure: to drain or not to drain? J Thorac Dis 2018; 10:E27-E30. [PMID: 29600099 DOI: 10.21037/jtd.2017.11.131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
A 11-year-old boy presented with refractory fever and dyspnoea after Nuss procedure. Massive pericardial effusion was detected on computer tomography scan performed under corticosteroid cover for his asthmatic history. With rapid clinical improvement following corticosteroids, a clinical diagnosis of post-pericardiotomy syndrome (PPS) was made. Following a course of oral prednisolone, serial blood test and echocardiogram showed gradual resolution of inflammation and pericardial effusion. This rarely-reported case serves as a poignant reminder to PPS after Nuss procedure as a cause of febrile massive pericardial effusion. Early therapeutic trial of corticosteroids may prevent clinical deterioration, and have invasive pericardial drainage avoided.
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Affiliation(s)
- Peter S Y Yu
- Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - Vikki W K Ng
- Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - Rainbow W H Lau
- Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - Calvin S H Ng
- Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
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12
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Khan NK, Järvelä KM, Loisa EL, Sutinen JA, Laurikka JO, Khan JA. Incidence, presentation and risk factors of late postoperative pericardial effusions requiring invasive treatment after cardiac surgery. Interact Cardiovasc Thorac Surg 2017; 24:835-840. [PMID: 28329077 DOI: 10.1093/icvts/ivx011] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 01/03/2017] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Occurrence and risk factors of late postoperative pericardial effusions requiring invasive treatment, i.e. pretamponade and tamponade, following cardiac surgery are incompletely described in current literature. The purpose of this study was to define the incidence and presentation of late pretamponade and tamponade as well as to outline significant predisposing factors. METHODS A cohort of 1356 consecutive cardiac surgery patients treated in a tertiary academic centre between January 2013 and December 2014 was followed up for 6 months after surgery. Pericardial effusion was considered late when presenting after the 7th postoperative day. The incidence, timing and risk factors, as well as symptoms and clinical findings associated with late pretamponade and tamponade in patients surviving at least 7 days was analysed. RESULTS Of 1308 patients included in the analysis, 81 (6.2%) underwent invasive treatment for late postoperative pericardial effusion, 27 (2.1%) for pretamponade and 54 (4.1%) for tamponade, respectively, with a median delay of 11 (range 8-87) days after the primary operation. Haemodynamic instability was present in 34.6%, signs of cardiac chamber compression in 54.3% and subjective symptoms, mostly dyspnoea, in 56.8% of patients, respectively. Treated patients were younger, had lower EuroSCORE-II rating, less coronary disease, better cardiac function, higher preoperative haemoglobin values and had mostly undergone elective surgery involving cardiac valves. In multivariable analysis, independent risk factors were single valve surgery and high preoperative haemoglobin level, whereas age 60-69 years was associated with lower risk. CONCLUSIONS Younger, generally healthier patients undergoing valve surgery are at greatest risk for developing late tamponade or pretamponade.
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Affiliation(s)
- Niina K Khan
- Department of Vascular Surgery, Tampere University Hospital, Tampere, Finland
| | - Kati M Järvelä
- Department of Cardio-Thoracic Surgery, Heart Hospital, Tampere University Hospital, Tampere, Finland
| | - Eetu L Loisa
- School of Medicine, University of Tampere, Tampere, Finland
| | | | - Jari O Laurikka
- Department of Cardio-Thoracic Surgery, Heart Hospital, Tampere University Hospital, Tampere, Finland
| | - Jahangir A Khan
- Department of Cardio-Thoracic Surgery, Heart Hospital, Tampere University Hospital, Tampere, Finland
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Abstract
The pericardium serves many important functions but is not essential for life. Pericardial heart disease comprises only pericarditis and its complications, tamponade and constriction, and congenital lesions. However, the pericardium is affected by virtually every category of disease. Thus the critical care physician is likely to encounter the patient with pericardial disease in a variety of settings, either as an isolated phenomenon or as a complication of a variety of systemic disorders, trauma, or certain drugs. Despite exhaustive etiological lists, the cause of pericardial heart disease is often never identified. This article reviews the diagnosis and management of acute and chronic pericarditis with an emphasis on those areas of greatest interest to the intensivist.
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Affiliation(s)
- Brian D. Hoit
- From the Division of Cardiology, University of Cincinnati, Cincinnati, OH
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14
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Davidovich I, Vance J, Picton P. Pleural Effusion Causing Cardiac Tamponade Following the Transition From Negative- to Positive-Pressure Ventilation During Aortic Aneurysm Repair. J Cardiothorac Vasc Anesth 2016; 30:736-40. [PMID: 26724914 DOI: 10.1053/j.jvca.2015.08.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Indexed: 11/11/2022]
Affiliation(s)
| | | | - Paul Picton
- University of Michigan Medical School, Ann Arbor, MI..
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15
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Boyle EM, Gillinov AM, Cohn WE, Ley SJ, Fischlein T, Perrault LP. Retained Blood Syndrome after Cardiac Surgery: A New Look at an Old Problem. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2015. [DOI: 10.1177/155698451501000502] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Edward M. Boyle
- Department of Thoracic Surgery, St. Charles Medical Center, Bend, OR USA
| | - A. Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH USA
| | - William E. Cohn
- Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX USA
| | - S. Jill Ley
- Department of Nursing, California Pacific Medical Center, San Francisco, CA USA
| | - Theodor Fischlein
- Department of Cardiac Surgery, Paracelsus Medical University, Nuremberg, Germany
| | - Louis P. Perrault
- Department of Surgery, Montreal Heart Institute, Montreal, QC Canada
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16
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Loculated cardiac hematoma causing hemodynamic compromise after cardiac surgery. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2015. [DOI: 10.1016/j.repce.2015.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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17
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Retained Blood Syndrome after Cardiac Surgery: A New Look at an Old Problem. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2015; 10:296-303. [DOI: 10.1097/imi.0000000000000200] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Retained blood occurs when drainage systems fail to adequately evacuate blood during recovery from cardiothoracic surgery. As a result, a spectrum of mechanical and inflammatory complications can ensue in the acute, subacute, and chronic setting. The objectives of this review were to define the clinical syndrome associated with retained blood over the spectrum of recovery and to review existing literature regarding how this may lead to complications and contributes to poor outcomes. To better understand and prevent this constellation of clinical complications, a literature review was conducted, which led us to create a new label that better defines the clinical entity we have titled retained blood syndrome. Analysis of published reports revealed that 13.8% to 22.7% of cardiac surgical patients develop one or more components of retained blood syndrome. This can present in the acute, subacute, or chronic setting, with different pathophysiologic mechanisms active at different times. The development of retained blood syndrome has been linked to other clinical outcomes, including the development of postoperative atrial fibrillation and infection and the need for hospital readmission. Grouping multiple objectively measurable and potentially preventable postoperative complications that share a common etiology of retained blood over the continuum of recovery demonstrates a high prevalence of retained blood syndrome. This suggests the need to develop, implement, and test clinical strategies to enhance surgical drainage and reduce postoperative complications in patients undergoing cardiothoracic surgery.
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18
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Fernandes A, Cassandra M, Pinto C, Oliveira C, Antunes M, Gonçalves L. Loculated cardiac hematoma causing hemodynamic compromise after cardiac surgery. Rev Port Cardiol 2015; 34:561.e1-3. [PMID: 26300161 DOI: 10.1016/j.repc.2015.01.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 01/02/2015] [Indexed: 10/23/2022] Open
Abstract
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.
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Affiliation(s)
- Andreia Fernandes
- Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra - Hospital Central, Coimbra, Portugal.
| | - Miryan Cassandra
- Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra - Hospital Central, Coimbra, Portugal
| | - Carlos Pinto
- Serviço de Cirúrgia Cardiotorácica, Centro Hospitalar e Universitário de Coimbra - Hospital Central, Coimbra, Portugal
| | - Catarina Oliveira
- Serviço de Radiologia, Centro Hospitalar e Universitário de Coimbra - Hospital Central, Coimbra, Portugal
| | - Manuel Antunes
- Serviço de Cirúrgia Cardiotorácica, Centro Hospitalar e Universitário de Coimbra - Hospital Central, Coimbra, Portugal
| | - Lino Gonçalves
- Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra - Hospital Central, Coimbra, Portugal
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19
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A case of right ventricular diastolic dysfunction due to a large hematoma posterior to the left ventricle. J Cardiol Cases 2015; 12:8-11. [PMID: 30534268 DOI: 10.1016/j.jccase.2015.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Revised: 02/09/2015] [Accepted: 02/22/2015] [Indexed: 11/22/2022] Open
Abstract
We report a case of right ventricular (RV) diastolic dysfunction due to a large hematoma posterior to the left ventricle (LV) after cardiac surgery. An 80-year-old woman underwent cardiac surgery. After surgery, her physical findings revealed right heart failure. Localized hematoma posterior to the pericardial space and the RV compression to the sternum were shown by computed tomography. Transthoracic Doppler echocardiography demonstrated restrictive physiology of the RV although there was no evidence of constrictive pericarditis. These findings suggest that RV diastolic dysfunction could have occurred due to the hematoma posterior to the LV. Since pleural effusion had persisted despite medical therapy, the hematoma was removed surgically. Soon after surgery, dyspnea and pretibial edema were diminished; bilateral pleural effusion dramatically disappeared. RV diastolic dysfunction estimated by echocardiography was improved and RV compression disappeared. We speculate that there are two physiological mechanisms for the RV compression: (1) the localized hematoma elevated the intrapericardial pressure and (2) the hematoma shifted the entire heart to the sternum. In conclusion, this is the first case report of RV diastolic dysfunction due to large hematoma posterior to the LV. <Learning objective: Localized hematoma posterior to the left ventricle can be a cause of right ventricular compression that leads to onset of severe right ventricular diastolic dysfunction.>.
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Abstract
Focused cardiac echocardiography has become a critical diagnostic tool for the emergency physician and critical care physician caring for patients in shock and following trauma to the chest, and those presenting with chest pain and shortness of breath,. Cardiac echocardiography allows for immediate diagnosis of pericardial effusions and cardiac tamponade, evaluation of cardiac contractility and volume status, and detection of right ventricular strain possibly seen with a significant pulmonary embolus. This article addresses how to perform cardiac echocardiography using the standard windows, how to interpret a focused goal-directed examination, and how to apply this information clinically at the bedside.
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Affiliation(s)
- Phillips Perera
- Division of Emergency Medicine, Department of Surgery, Stanford University Medical Center, 300 Pasteur Drive, Alway Building M121, Stanford, CA 94305, USA.
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Christiansen LK, Frederiksen CA, Juhl-Olsen P, Jakobsen CJ, Sloth E. Point-of-care ultrasonography changes patient management following open heart surgery. SCAND CARDIOVASC J 2014; 47:335-43. [PMID: 24295290 DOI: 10.3109/14017431.2013.859294] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Although pericardial effusions (PE) and pleural effusions (PLE) may lead to life-threatening respiratory and circulatory deterioration following open heart surgery the postoperative frequency is not fully recognized. The diagnosis is typically based on ultrasonography, X-ray or computer tomography and often disclosed when circulatory collapse is evident. Point-of-care (POC) ultrasonography protocols constitute a noninvasive evaluation of the cardiopulmonary status. We hypothesized that POC ultrasonography could diagnose unknown PE and PLE. DESIGN Patients scheduled for open heart surgery were eligible for inclusion. Baseline evaluation including POC examination and dyspnea score was performed one day prior to surgery and repeated on the 4th and 30th postoperative day. RESULTS Eighty patients were included and complete follow-up was 80%. Thirteen patients (19%) had PE on the 4th day postsurgery and 19 patients (30%) had PE on the 30th day. Ultrasonography facilitated change in management in one patient with PE requiring drainage. Forty-nine patients (70%) had PLE on the 4th day following surgery and 19 patients (30%) had PLE on the 30th postoperative day. Ultrasonography facilitated a change in management in seven patients with PLE requiring drainage. CONCLUSION POC ultrasonography detected pathology, otherwise undisclosed, and was responsible for a change in management in a considerable number of cases.
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Nearman H, Klick JC, Eisenberg P, Pesa N. Perioperative Complications of Cardiac Surgery and Postoperative Care. Crit Care Clin 2014; 30:527-55. [DOI: 10.1016/j.ccc.2014.03.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Song Y, Sim J, Seo SJ, Choi SA, Shim JK. Isolated central venous pressure elevation caused by hematoma formation compressing the superior vena cava following a Bentall operation: a case report. Korean J Anesthesiol 2014; 66:71-4. [PMID: 24567818 PMCID: PMC3927006 DOI: 10.4097/kjae.2014.66.1.71] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Revised: 12/28/2012] [Accepted: 12/28/2012] [Indexed: 11/25/2022] Open
Abstract
We present a case of a patient exhibiting isolated elevation of the central venous pressure with minimal hemodynamic deterioration in an immediate postoperative period after Bentall operation requiring re-exploration. Isolated elevation of the central venous pressure usually alerts physicians of a volume overload or right ventricular dysfunction. However, even in the absence of significant hemodynamic deterioration, the development of loculated hematoma that compresses the superior vena cava should be ruled out, as it can be life-threatening through the formation of cerebral and laryngeal edema, similar to superior vena cava syndrome. This case emphasizes the importance of a prompt differential diagnosis of the isolated central venous pressure elevation after cardiac surgery with transesophageal echocardiography for the administration of appropriate treatment.
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Affiliation(s)
- Young Song
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jeesuk Sim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Sai Ju Seo
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Seong Ah Choi
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jae-Kwang Shim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
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Rahman IA, Hussain A, Davies A, Bryan AJ. NICE thromboprophylaxis guidelines are not associated with increased pericardial effusion after surgery of the proximal thoracic aorta. Ann R Coll Surg Engl 2013; 95:433-6. [PMID: 24025294 DOI: 10.1308/003588413x13629960048154] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION In 2010 the National Institute for Health and Clinical Excellence (NICE) released guidelines on venous thromboembolism. Strategy focused on risk assessment, antiembolic stockings, sequential compression devices, subcutaneous high dose enoxaparin (40 mg), early mobilisation and hydration. The 40 mg enoxaparin dose over the previous 20 mg regimen was worrisome, and its effect on pericardial effusion rates and mortality in proximal aortic surgery was investigated. METHODS Proximal aortic reconstructions performed between December 2008 and April 2011 were identified from prospectively collected data in a tertiary centre database. Retrospective analysis of patient notes was performed. Proximal aortic surgery patients were categorised as low dose (20 mg) enoxaparin and high dose (40 mg) enoxaparin, and compared for confounding variables. In-hospital, early and one-year readmission rates for pericardial effusion were ascertained from echocardiography reports. The primary outcome was total pericardial effusion rate. Secondary outcomes consisted of 30-day and 1-year mortality. RESULTS A total of 198 patients underwent proximal thoracic aortic surgery. Nine patients were excluded due to early postoperative death (n=5) and missing patient records (n=4). This left 189 cases for analysis. There were 93 patients in the low dose group and 96 in the high dose group. Groups were comparable for age, cardiopulmonary bypass time, aortic cross-clamp time, postoperative warfarin and antiplatelet agents. Pericardial effusion rates up to one year were comparable (low dose 19% vs high dose 21%). Thirty-day mortality was lower in the low dose group (0 vs 3 deaths). There were four deaths up to one year but these were not attributable to increased enoxaparin. CONCLUSIONS Increased perioperative thromboprophylaxis dosage does not increase pericardial effusion rates or mortality in proximal aortic surgery.
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Affiliation(s)
- I A Rahman
- University Hospitals Bristol NHS Foundation Trust, Bristol Heart Institute, Bristol Royal Infirmary, Upper Maudlin Street, Bristol BS2 8HW, UK.
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Affiliation(s)
- Sandra Laidler
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Freeman Hospital, High Heaton, Newcastle upon Tyne
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Pagel PS, Khotimsky I, Almassi GH. A heart with six chambers: a remarkable anomaly or a late complication after cardiac surgery? J Cardiothorac Vasc Anesth 2013; 28:435-7. [PMID: 24035450 DOI: 10.1053/j.jvca.2013.03.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Indexed: 11/11/2022]
Affiliation(s)
- Paul S Pagel
- Anesthesia, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI.
| | - Ilya Khotimsky
- Anesthesia, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI
| | - G Hossein Almassi
- Cardiothoracic Surgery (GAH) Services, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI
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Floerchinger B, Camboni D, Schopka S, Kolat P, Hilker M, Schmid C. Delayed cardiac tamponade after open heart surgery - is supplemental CT imaging reasonable? J Cardiothorac Surg 2013; 8:158. [PMID: 23800191 PMCID: PMC3698060 DOI: 10.1186/1749-8090-8-158] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Accepted: 06/20/2013] [Indexed: 01/06/2023] Open
Abstract
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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Affiliation(s)
- Bernhard Floerchinger
- Department Cardiothoracic Surgery, University Medical Center Regensburg 93053, Regensburg, Germany.
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Affiliation(s)
| | - Mark H. Yazer
- The Institute for Transfusion Medicine; The Department of Pathology; University of Pittsburgh; Pittsburgh; PA
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Diagnosis in a Heart Beat, or Focused Echocardiography: How Should it be Used in the Emergency Room? CURRENT CARDIOVASCULAR IMAGING REPORTS 2012. [DOI: 10.1007/s12410-012-9161-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Grumann A, Baretto L, Dugard A, Morera P, Cornu E, Amiel JB, Vignon PP. Localized cardiac tamponade after open-heart surgery. Ann Thorac Cardiovasc Surg 2012; 18:524-9. [PMID: 22785553 DOI: 10.5761/atcs.oa.11.01855] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Anna Grumann
- Medical-Surgical ICU, Dupuytren Teaching Hospital, Limoges, France
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Dixon B, Santamaria JD, Reid D, Collins M, Rechnitzer T, Newcomb AE, Nixon I, Yii M, Rosalion A, Campbell DJ. The association of blood transfusion with mortality after cardiac surgery: cause or confounding? (CME). Transfusion 2012; 53:19-27. [DOI: 10.1111/j.1537-2995.2012.03697.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Pérez Vela J, Martín Benítez J, Carrasco González M, De la Cal López M, Hinojosa Pérez R, Sagredo Meneses V, del Nogal Saez F. Guías de práctica clínica para el manejo del síndrome de bajo gasto cardíaco en el postoperatorio de cirugía cardíaca. Med Intensiva 2012; 36:e1-44. [DOI: 10.1016/j.medin.2012.02.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Accepted: 01/07/2012] [Indexed: 01/04/2023]
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Perera P, Mailhot T, Riley D, Mandavia D. The RUSH Exam 2012: Rapid Ultrasound in Shock in the Evaluation of the Critically Ill Patient. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/j.cult.2011.12.010] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Jaussaud N, Boignard A, Durand M, Bach V, Porcu P, Hacini R, Blin D, Chavanon O. Percutaneous drainage of postoperative pericardial effusion in cardiac surgery. J Interv Cardiol 2011; 25:95-101. [PMID: 21981588 DOI: 10.1111/j.1540-8183.2011.00680.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND AND AIM OF THE STUDY Postoperative pericardial effusion is frequent and can be complicated by cardiac tamponade. Although the different drainage techniques are well described in the setting of medical effusion, there is not a standard postoperative effusion treatment. The aim of this work was to assess the feasibility and effectiveness of the percutaneous pericardial drainage. METHODS This a retrospective study involving 197 patients from 1990 to 2008. Drainage was performed by subxiphoid puncture (91.9%) or left parasternal puncture (8.1%) between 3 and 690 days following a cardiac procedure via median sternotomy. Effusion thickness was at least 10 mm in the subcostal echocardiography view. RESULTS No deaths directly related to the procedure were observed. Complete and enduring drainage was achieved in 158 patients (80.2%). The procedure failed for 22 patients (11.2%) because no fluid was drained in 14 cases (7.1%) and a right ventricular puncture in 8 cases (4.1%). Recurrence of the effusion, which occurred for 17 patients (8.6%), was more frequent if an effusion of more than 5 mm persisted after the first drainage (P = 0.024) and if the drainage was performed outside the operating room because of emergency (P = 0.046). Risk factors for mortality were recurrence of the effusion (P = 0.04) and drainage performed outside the operating room (P = 0.007). CONCLUSIONS Percutaneous pericardial drainage is effective to treat postoperative pericardial effusion. When the effusion is thicker than 10 mm and accessible, it can be the initial strategy and surgical drainage can serve as an alternate strategy in case of failure and complications of this procedure.
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Affiliation(s)
- Nicolas Jaussaud
- Department of Cardiac Surgery, Grenoble University Hospital, Grenoble, France
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Carmona P, Mateo E, Casanovas I, Peña JJ, Llagunes J, Aguar F, De Andrés J, Errando C. Management of cardiac tamponade after cardiac surgery. J Cardiothorac Vasc Anesth 2011; 26:302-11. [PMID: 21868250 DOI: 10.1053/j.jvca.2011.06.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2010] [Indexed: 01/27/2023]
Affiliation(s)
- Paula Carmona
- Anaesthesia, Critical Care and Pain Medicine Department, Consorcio Hospital General of Valencia, Valencia, Spain.
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ten Tusscher BL, Groeneveld JAB, Kamp O, Jansen EK, Beishuizen A, Girbes ARJ. Predicting outcome of rethoracotomy for suspected pericardial tamponade following cardio-thoracic surgery in the intensive care unit. J Cardiothorac Surg 2011; 6:79. [PMID: 21624108 PMCID: PMC3118337 DOI: 10.1186/1749-8090-6-79] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2010] [Accepted: 05/30/2011] [Indexed: 11/10/2022] Open
Abstract
Objectives Pericardial tamponade after cardiac surgery is difficult to diagnose, thereby rendering timing of rethoracotomy hard. We aimed at identifying factors predicting the outcome of surgery for suspected tamponade after cardio-thoracic surgery, in the intensive care unit (ICU). Methods Twenty-one consecutive patients undergoing rethoracotomy for suspected pericardial tamponade in the ICU, admitted after primary cardio-thoracic surgery, were identified for this retrospective study. We compared patients with or without a decrease in severe haemodynamic compromise after rethoracotomy, according to the cardiovascular component of the sequential organ failure assessment (SOFA) score. Results A favourable haemodynamic response to rethoracotomy was observed in 11 (52%) of patients and characterized by an increase in cardiac output, and less fluid and norepinephrine requirements. Prior to surgery, the absence of treatment by heparin, a minimum cardiac index < 1.0 L/min/m2 and a positive fluid balance (> 4,683 mL) were predictive of a beneficial haemodynamic response. During surgery, the evacuation of clots and > 500 mL of pericardial fluid was associated with a beneficial haemodynamic response. Echocardiographic parameters were of limited help in predicting the postoperative course, even though 9 of 13 pericardial clots found at surgery were detected preoperatively. Conclusion Clots and fluids in the pericardial space causing regional tamponade and responding to surgical evacuation after primary cardio-thoracic surgery, are difficult to diagnose preoperatively, by clinical, haemodynamic and even echocardiographic evaluation in the ICU. Only absence of heparin treatment, a large positive fluid balance and low cardiac index predicted a favourable haemodynamic response to rethoracotomy. These data might help in deciding and timing of reinterventions after primary cardio-thoracic surgery.
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Affiliation(s)
- Birkitt L ten Tusscher
- Department of Intensive Care, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
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Ueno M, Higashi A, Sakata R. Rare Bleeding Complication of the Radial Artery Conduit after Coronary Artery Bypass Grafting with Endoscopic Harvesting. Ann Thorac Cardiovasc Surg 2011; 17:201-3. [DOI: 10.5761/atcs.cr.09.01512] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2009] [Accepted: 02/02/2010] [Indexed: 11/16/2022] Open
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Ariyama J, Imanishi H, Nakagawa H, Kitamura A, Hayashida M. Epicardial hematoma and myocardial ischemia following application of Starfish stabilizer: an uncommon complication of the device. J Anesth 2010; 24:801-2. [PMID: 20640451 DOI: 10.1007/s00540-010-0989-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2010] [Accepted: 06/25/2010] [Indexed: 11/30/2022]
Abstract
The Starfish heart positioning device allows excellent cardiac positioning and hemodynamic stability during off-pump coronary artery bypass graft surgery. Herein, we present a patient in whom the use of this device caused epicardial hematoma as the result of an injured epicardial vein, an uncommon complication of this device. In this patient, regional left ventricular wall motion abnormality on transesophageal echocardiography and a ST-T change on electrocardiogram occurred secondary to the development of the epicardial hematoma. These signs completely disappeared upon removal of the hematoma. These findings suggested that the hematoma resulted in reversible myocardial ischemia.
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Affiliation(s)
- Jun Ariyama
- Department of Anesthesiology, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama, Japan.
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Elmer J, Noble VE. An Evidence-Based Approach for Integrating Bedside Ultrasound Into Routine Practice in the Assessment of Undifferentiated Shock. ACTA ACUST UNITED AC 2010. [DOI: 10.1177/1944451610369150] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Undifferentiated hypotension remains a central diagnostic and therapeutic challenge in emergency and critical care medicine. Increasingly, bedside ultrasound conducted by intensivists and emergency medicine providers is assuming a central role in diagnosis and resuscitation of hypotension. This review discusses sample algorithms for the bedside ultrasonographic assessment of undifferentiated shock and outlines an evidence-based framework for the intensivist seeking to incorporate bedside ultrasound into daily clinical practice. The literature regarding specific applications including cardiac, thoracic, pulmonary, and vascular assessment is briefly reviewed, as is the evidence pertaining to effective implementation, training, credentialing, and ongoing quality assurance.
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Affiliation(s)
- Jonathan Elmer
- Harvard Affiliated Emergency Medicine Residence, Massachusetts General Hospital and Brigham and Women’s Hospital, Boston, Massachusetts
| | - Vicki E. Noble
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
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Murugesan C, Murugesan S, Gupta R, Muralidhar K. Pulmonary embolism masqueraded as severe bronchospasm following coronary artery bypass surgery. Indian J Thorac Cardiovasc Surg 2010. [DOI: 10.1007/s12055-009-0024-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Perera P, Mailhot T, Riley D, Mandavia D. The RUSH exam: Rapid Ultrasound in SHock in the evaluation of the critically lll. Emerg Med Clin North Am 2010; 28:29-56, vii. [PMID: 19945597 DOI: 10.1016/j.emc.2009.09.010] [Citation(s) in RCA: 361] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The RUSH exam (Rapid Ultrasound in SHock examination), presented in this article, represents a comprehensive algorithm for the integration of bedside ultrasound into the care of the patient in shock. By focusing on a stepwise evaluation of the shock patient defined here as "Pump, Tank, and Pipes," clinicians will gain crucial anatomic and physiologic data to better care for these patients.
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Affiliation(s)
- Phillips Perera
- New York Presbyterian Hospital, Columbia University Medical Center, Division of Emergency Medicine, 622 West 168th Street, New York, NY 10032, USA.
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Abstract
There are multiple imaging modalities currently available to noninvasively evaluate the heart and coronary arteries. Choosing the most appropriate modality depends on the pertinent clinical question and the underlying patient characteristics. This article provides an overview of the fields of echocardiography, myocardial perfusion imaging, cardiac computed tomography, and cardiac magnetic resonance imaging, with particular attention to specific clinical applications for cardiac surgery patients.
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García-Vicente E, Campos-Nogué A, Gobernado Serrano MM. [Echocardiography in the Intensive Care Unit]. Med Intensiva 2009; 32:236-47. [PMID: 18570834 DOI: 10.1016/s0210-5691(08)70946-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The echocardiography can provide important and relevant information and the critically ill patient presents a challenge for the echocardiographer: from limitations in image acquisition to interpretation in the context of rapid physiological and intervention changes. The most frequent reason for requesting an echocardiogram in the ICU is probably to assess left ventricular function. In any case, information of direct relevance for clinical management can in relationship to abnormalities of structure and function can be obtained and used to estimate pulmonary arterial and venous pressures. It can help to investigate the consequences of myocardial ischemia, valvular dysfunction and pericardial disease and detect changes characteristic of specific conditions (e.g. sepsis, pulmonary thromboembolism), although this must be interpreted in the context of each individual patient. The echocardiography also can be used to monitor the therapeutic interventions. The applications of echocardiography in the critical care setting are reviewed, with special emphasis on the assessment of cardiac physiology.
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Affiliation(s)
- E García-Vicente
- Unidad de Cuidados Intensivos, Hospital Santa Bárbara, Soria, España.
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Almeida J, Garcia R, Monteiro V, Pinho P. Pseudo-pericardial tamponade after cardiac surgery. J Am Soc Echocardiogr 2009; 22:211.e5-6. [PMID: 19117724 DOI: 10.1016/j.echo.2008.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2008] [Indexed: 10/21/2022]
Abstract
Cardiac tamponade is a common cause of hypotension and low output after cardiac surgery. The authors present a case of false tamponade diagnosis on transesophageal echocardiography in a patient who underwent mitral valve replacement and coronary artery bypass grafting. The diagnosis was not confirmed at surgery, and the cause of the abnormal right atrial filling was a prominent Eustachian valve trapped in the suture for correction of an iatrogenic inferior vena cava laceration. Such a complication must be kept in mind when repairing inferior vena cava lacerations and should be more widely known.
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Affiliation(s)
- Jorge Almeida
- Center of Thoracic Surgery, S. João Hospital, Oporto, Portugal.
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Vohra HA, Khout H, Bapu D, Abid Q. Localised pericardial tamponade diagnosed by computed tomography: a case presentation. J Med Case Rep 2007; 1:162. [PMID: 18053151 PMCID: PMC2222672 DOI: 10.1186/1752-1947-1-162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2007] [Accepted: 12/01/2007] [Indexed: 11/12/2022] Open
Affiliation(s)
- Hunaid A Vohra
- Department of Cardiothoracic Surgery, University Hospital of North Staffordshire NHS Trust, Stoke-on-Trent, UK.
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Abstract
The pericardium serves many important functions, but it is not essential for life. Pericardial heart disease comprises only pericarditis and its complications, tamponade and constriction, and congenital lesions. However, the pericardium is affected by virtually every category of disease. The critical care physician is thus likely to encounter the patient with pericardial disease in a variety of settings, either as an isolated phenomenon or as a complication of a variety of systemic disorders, trauma, or certain drugs. Echocardiography is the primary tool for diagnosing and quantifying pericardial effusions, and in the context of the clinical presentation, a thorough understanding of M-mode, two-dimensional, and Doppler findings can help not only to identify patients with impending tamponade, but also to suggest a diagnosis of constrictive pericarditis. This article reviews the pathogenesis and diagnosis of pericardial heart disease, focusing on the diagnostic utility of echocardiography, with an emphasis on those areas of greatest interest to the intensivist.
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Affiliation(s)
- Brian D Hoit
- Department of Medicine, University Hospitals of Cleveland and Case Western Reserve University, Cleveland, OH, USA.
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Yamano T, Nakatani S, Nakamura T, Sawada T, Azuma A, Yaku H, Matsubara H. Left atrial appendage collapse as a sole feature of cardiac tamponade after cardiac surgery: a case report. J Am Soc Echocardiogr 2007; 20:1415.e1-2. [PMID: 17624731 DOI: 10.1016/j.echo.2007.04.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2007] [Indexed: 11/22/2022]
Abstract
We report on a postoperative patient with cardiac tamponade caused by posteriorly localized pericardial effusion. In this case, transthoracic echocardiography only suggested mild left atrial compression. However, transesophageal echocardiography demonstrated significant collapse of the left atrial appendage that completely disappeared after pericardial drainage. The left atrial appendage collapse should be a valuable diagnostic sign in this setting. Transesophageal echocardiography would surely be valuable in diagnosing postoperative cardiac tamponade as a result of localized effusion when clinical symptoms and transthoracic echocardiographic findings are atypical.
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Affiliation(s)
- Tetsuhiro Yamano
- Department of Cardiology, National Cardiovascular Center, Suita, Osaka, Japan
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Abstract
Advances in ultrasound technology continue to enhance its diagnostic applications in daily medical practice. Bedside echocardiographic examination has become useful to properly trained cardiologists, anesthesiologists, intensivists, surgeons, and emergency room physicians. Cardiac ultrasound can permit rapid, accurate, and noninvasive diagnosis of a broad range of acute cardiovascular pathologies. Although transesophageal echocardiography was once the principal diagnostic approach using ultrasound to evaluate intensive care unit patients, advances in ultrasound imaging, including harmonic imaging, digital acquisition, and contrast for endocardial enhancement, has improved the diagnostic yield of transthoracic echocardiography. Ultrasound devices continue to become more portable, and hand-carried devices are now readily available for bedside applications. This article discusses the application of bedside echocardiography in the intensive care unit. The emphasis is on echocardiography and cardiovascular diagnostics, specifically on goal-directed bedside cardiac ultrasonography.
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Affiliation(s)
- Yanick Beaulieu
- Hôpital Sacré-Coeur de Montréal, Université de Montréal, Montréal, Québec, Canada.
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