Delayed cardiac tamponade by loculated pericardial hematoma

Excerpt

Delayed cardiac tamponade is an uncommon severe complication following cardiac surgery for postoperative bleeding or post-cardiotomy syndrome [1, 2]. Early recognition and management are essential for satisfactory outcome. Early cardiac tamponade was defined as cardiac tamponade occurring earlier than 30 days after surgery. In contrast, delayed cardiac tamponade was defined as that occurring 30 days or later after surgery. Especially subacute delayed cardiac tamponade represents a challenging entity to detect with delayed evidence of clinical symptoms. A 55-year-old male presented to the emergency department 2 months after undergoing a quadruple coronary artery bypass graft operation, with a history of three episodes of near fainting. There was no history of trauma. He also had a significant pulsus paradoxus of 14 mmHg. An emergent echocardiography confirmed the presence of a large loculated pericardial effusion with collapse of the right ventricle and right atrium (Fig. 1, Supplementary material Video 1–3). Fluoroscopy-guided pericardiocentesis with echocardiographic confirmation was attempted using a Seldinger technique via the subxiphoid approach, and 750 ml of hemorrhagic effluent was drained, with immediate improvement in cardiovascular status. The diagnosis of delayed postoperative cardiac tamponade is aided by a high degree of suspicion and should be considered when hemodynamic deterioration or signs of low output failure occur in the post-cardiotomy patient. Classic symptoms, such as hypotension, tachycardia, pulsus paradoxus, increased central venous pressure, as well as low urine output, can be masked after cardiac surgery or alleviated in case of slowly increasing effusion. Transthoracic echocardiography is the first-choice modality, but is sometimes limited in patients after open heart surgery. Therefore, supplemental CT imaging may provide rapid diagnostic reliability of delayed cardiac tamponade [3].

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