Atypical Presentations and Echocardiographic Findings in Patients With Cardiac Tamponade Occurring Early and Late After Cardiac Surgery

doi:10.1378/chest.104.1.71

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Volume 104, Issue 1, July 1993, Pages 71-78

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Cardiac tamponade, a potentially lethal complication following cardiac surgery, may present either early or late postoperatively and may be difficult to diagnose due to atypical clinical, hemodynamic, or echocardiographic findings. To determine the frequency and clinical features of postoperative cardiac tamponade, we performed a review of 510 consecutive patients who underwent cardiac surgery. The incidence of postoperative cardiac tamponade was 2.0 percent (10/510 patients) and occurred following valvular, bypass, and aortic surgery. Nine of ten patients had either atypical clinical, hemodynamic, and/or echocardiographic findings. The diagnosis of tamponade was made 1 to 30 days (mean = 8.5 days) postoperatively. Presenting symptoms were often mild and nonspecific. Classic signs including hypotension, pulsus paradoxus greater than 12 mm Hg, and elevated jugular venous pressure were present in 7, 6, and 5 patients, respectively. Right heart hemodynamics revealed elevated and equalized diastolic pressures in three of six patients. Two-dimensional echocardiography revealed selective compression of the left ventricle (LV) (four patients), right ventricle (RV) (one patient), left atrium (LA)/ RV (one patient), LA/LV (one patient), LA/LV/RV (one patient), all four chambers (one patient), and no diastolic collapse of any chamber (one patient). There was often an absence of anterior pericardial fluid (six patients) with tethering of a portion of the RV to the chest wall anteriorly (five patients). Coagulation parameters were “supratherapeutic” in only three of eight patients who were receiving systemic anticoagulants at the time of diagnosis. The initial diagnosis was confused with congestive heart failure in one patient, pulmonary embolism in three patients, acute myocardial infarction in two patients, and sepsis in one patient. Eight of ten patients survived; all of these patients underwent surgical removal of fluid and/or hematoma in the operating room. We conclude that postoperative tamponade after cardiac surgery may have varied clinical and hemodynamic presentations, often due to selective chamber compression by loculated fluid or clot. Due to its frequently atypical features and presentation that may simulate other disorders, the diagnosis of tamponade should be considered whenever hemodynamic deterioration or signs of low output failure occur in the postcardiotomy patient.

Section snippets

Patient Population

We performed a retrospective review of 510 patients who underwent cardiac surgery between October 1989 through November 1990 at Cooper Hospital/University Medical Center in Camden, NJ. This included patients who underwent cardiac valve surgery, coronary artery bypass surgery, or other cardiothoracic surgery, including thoracic aortic aneurysm repair. Ten of 510 patients (2.0 percent) had the diagnosis of cardiac tamponade suggested by echocardiography and documented by rapid relief of symptoms

Clinical Features

Characteristics of the patient population and outcome are outlined in Table 1. Patients ranged in age from 28 to 77 years. There were seven men and three women. The mean time to diagnosis of cardiac tamponade was made 8.5±8.0 days (range, 1 to 30 days) postoperatively. Eight of ten patients (80 percent) were receiving anticoagulants at the time of diagnosis. Coagulation parameters were “supratherapeutic” in only three of these eight patients.

All patients were symptomatic. Patients complained of

Discussion

This study illustrates the frequently atypical presentation of cardiac tamponade with the presence of loeulated effusions and selective chamber compression in the majority of patients with tamponade occurring after cardiac surgery. Despite vague complaints, the diagnosis should be considered in any patient who is not progressing as expected postoperatively. Prompt diagnosis can be made by echocardiography with confirmation following drainage. Transthoracic echocardiography may be limited in

Incidence of Postoperative Cardiac Tamponade

While pericardial effusions can be identified by 2-D echocardiography in 31 to 85 percent of patients after cardiac surgery,1, 3, 14 the incidence of postoperative cardiac tamponade is only 0.5 to 5.8 percent.1, 2, 3, 4, 5, 6 Our finding of a 2.0 percent incidence of postoperative cardiac tamponade is consistent with previous studies. Some studies suggest a higher incidence up to 8 percent, but they tend to overestimate the occurrence of tamponade since they do not distinguish patients

Etiology

It has been suggested that pericardial effusions developing in the late postoperative period may have a different etiology from those developing early postoperatively. Pericardial effusions in the early postoperative period are believed to result from early postoperative bleeding.1, 21 The risk of tamponade appears to be higher in patients with increased postoperative chest tube drainage, probably related to bleeding into a relatively confined space.2, 5, 6, 12, 22, 23 Most patients requiring

Presenting Signs and Symptoms

Postoperative cardiac tamponade may present with typical findings in some patients.8, 10, 27 Only one of our patients (patient 7) presented with typical signs and symptoms with a circumferential pericardial effusion, but this did not occur until 30 days postoperatively. The diagnosis may be missed in a patient who develops symptoms weeks or months after hospital discharge, particularly when the patient presents with relatively nonspecific complaints, sometimes attributed to the

Selective Chamber Tamponade

Typical signs of tamponade may be absent due to the presence of loculated effusion or clot with selective chamber compression. Pericardial adhesions with localized fluid collections may occur around specific chambers, particularly the posterior heart, even when the anterior pericardium is left open. The RA and RV are often spared, probably secondary to adhesions or tethering of the RV to the chest wall anteriorly. Isolated LV tamponade has been reported35, 38 and occurred in four of our

Treatment of Postoperative Tamponade

Treatment options include pericardiocentesis,2, 5, 10, 11, 12, 23, 27 creation of a pericardial window,⁹ or pericardial stripping.¹⁰ Some investigators recommend pericardiocentesis as an initial therapeutic measure because repeated median sternotomy may increase the risk of mediastinitis.¹² While some patients have been treated successfully by needle aspiration alone,¹¹ others may require up to five subsequent pericardiocenteses for recurrent tamponade.10, 12 Surgical evacuation may be safer or

Conclusion

Postoperative tamponade can occur early or late after cardiac surgery and may have varied clinical and hemodynamic presentations, often due to localized compression of the heart by loculated fluid or clot. This study illustrates the need to consider the diagnosis of cardiac tamponade whenever hemodynamic deterioration or signs of low output failure occur in the postcardiotomy patient. Due to its frequently atypical presentation, the possibility of late tamponade developing weeks to months after

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To evaluate the effectiveness of the 5-minute test (FMT), developed to record the amount of pericardial bleeding in patients undergoing general cardiac surgery, and determine the relationship between this test and postcardiotomy bleeding.
The medical records of 573 patients who underwent adult cardiac surgery between January 2016 and December 2019 were reviewed retrospectively. Patients were divided into 2 groups: the FMT group included patients who underwent general cardiac surgery between January 2018 and December 2019 (n = 278), and the control group included patients who underwent general cardiac surgery between January 2016 and December 2017 (n = 295). The postcardiotomy reexploration rate due to intrapericardial bleeding or cardiac tamponade within 1 week after surgery and the amount of bleeding until 2 days after surgery were compared. The FMT procedure involved counting the amount of bleeding by packing 4 to 6 surgical gauze sheets for 5 minutes. Sternal closure was performed when the amount of blood measured by the FMT was <100 g.
Compared with the control group, the FMT group had a significantly lower incidence of postcardiotomy reexploration (1.5% vs 5.7%; P = .007) and a reduced amount of bleeding after cardiac surgery (median, 1165 mL [interquartile range (IQR), 756.2-1743.8 mL] versus 1440 mL [IQR, 825.0-2130.0 mL]; P = .005). There was a significant positive correlation between the FMT gauze sheet weight and postcardiotomy bleeding (r = 0.322; P < .001).
The FMT is an objective and effective tool for estimating postoperative bleeding during cardiac surgery that can prevent postcardiotomy reexploration and reduce the amount of postcardiotomy bleeding.
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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.
Os autores descrevem um caso de uma complicação rara do pós-operatório de uma cirurgia cardíaca. Três semanas após substituição valvular aórtica, um jovem doente ficou hemodinamicamente instável. O ecocardiograma documentou um hematoma loculado de grandes dimensões a comprimir a aurícula direita. O paciente foi submetido a nova cirurgia cardíaca com remoção do hematoma. A recuperação foi completa.
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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.>
Perioperative complications of cardiac surgery and postoperative care
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: Manuscript received September 4; revision accepted December 8.

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Clinical InvestigationsAtypical Presentations and Echocardiographic Findings in Patients With Cardiac Tamponade Occurring Early and Late After Cardiac Surgery

Section snippets

Patient Population

Clinical Features

Discussion

Incidence of Postoperative Cardiac Tamponade

Etiology

Presenting Signs and Symptoms

Selective Chamber Tamponade

Treatment of Postoperative Tamponade

Conclusion

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Clinical Investigations
Atypical Presentations and Echocardiographic Findings in Patients With Cardiac Tamponade Occurring Early and Late After Cardiac Surgery