Download Two-dimensional echocardiography in cardiac tamponade

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JACC Vol. 5, No.5
May 1985:1250-2
Two-Dimensional Echocardiography in Cardiac Tamponade Occurring
After Cardiac Surgery
IVAN A. D'CRUZ, MD, FACC, KENNETH KENSEY, MD, CHARLES CAMPBELL, MD,
ROBERT REPLOGLE, MD, MUKESH JAIN, MD, FACC
Chicago, Illinois
Cardiac tamponade is an important comphcation after
cardiac surgery, yet little has been published on the
echocardiographic diagnosis of this situation. The twodimensional echocardiograms of 11 patients who required surgical relief of cardiac tamponade complicating
cardiac surgery were therefore reviewed. Four had nonloculated pericardial effusions surrounding both ventricles. The other seven patients had a loculated posterior
pericardial effusion; in three of these the effusion altered
left ventricular posterior wall contour so that it was
concave toward the effusion ill the long-axis view; in
two, a strikingly abnormal motion of the left ventricular
Various echocardiographic manifestations of cardiac tamponade have been described over the last decade (1-5). In
almost all of these reports, tamponade was associated with
a large nonloculated pericardial effusion that surrounded the
ventricles on all sides and usually also extended behind both
atria.
Cardiac tamponade is an important life-threatening and
not uncommon complication after open heart surgery (6-10)
and is often associated with loculated' pericardial effusions.
Yet its echocardiographic presentation has hitherto received
relatively little attention. Therefore, we studied the twodimensional echocardiograms of a series of patients who
underwent reoperation for relief of cardiac tamponade after
open heart surgery,
Methods
Patient selection. Over a 4 year period, 19 patients who
had had open heart surgery at Michael Reese Hospital underwent reoperation for relief of tamponade 3 to 42 days after
Frsrn the Division of Cardiology and Cardiac Surgery, Michael Reese
Hospital and Medical Center and University of Chicago Pritzker School
of Medicine, Chicago, Illinois. Manuscript received August 13, 1984;
revised manuscript received November 13. 1984, accepted December 5,
1984.
Address for reprints: Ivan A. D'Cruz, MD, Cardiology Division, Michael Reese Hospital and Medical Center, Lake Shore Drive at 31st Street.
Chicago, Illinois 60616.
© 1985 by the American College of Cardiology
posterior wall was noted, such that the width of the
posterior pericardial space diminished in systole and
widened abruptly in early diastole.
The quantity of pericardial contents (fluid, blood or
clot) evacuated surgically was smaller titan usually encountered' in patients with tamponade due to various
"medical" cOnditions. Thus, unlike tamponade with other
perlcardial effusions, tamponade after cardiac su~gery
is due to a pericardial effusion that is smaller in volume,
often loculated posteriorly and associated with certain
unique two-dimensional echocardiographic features.
(J Am Coli Cardiol 1985;5:1250-2)
operation. Two-dimensional echocardiography was per-'
formed in II of these patients using a wide angle mechanical
sector scanner (Advanced Technical Laboratories). This series of II patients comprised 7 men and 4 women, whose
ages ranged from 31 to 73 years (mean 59). The original
cardiac operation was coronary artery bypass grafting in
eight, mitral valve replacement in two and atrial septal defect
repair in one.
Evidence of tamponade. Echocardiography was performed after clinical signs of tamponade had developed and
usually preceded surgical relief of tamponade by less than
a few hours. In all cases, after an initial postoperative period
with stable signs, the following evidence for tamponade was
observed: 1) decrease in systemic blood pressure, with increase in jugular venous pressure, tachycardia and respiratory distress; and 2) after removal of the pericardial contents, an immediate substantial increase in blood pressure
(mean increase 45 mm Hg), with concomitant increase in
pulse pressure, decrease in venous pressure and improvement in general cardiac status. A paradoxical P41se (varying
from 15 to 40 mm Hg) was noted in six patients, including
all four patients with a nonloculated pericardial effusion,
but only two of those with a loculated posterior effusion.
Results
Relief of tamponade. The pericardial contents, removed surgically, varied from 180 to 700 ml in volume,
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lACC Vol. 5, No.5
D'CRUZ ET AL.
ECHOCARDJOGRAPHY IN POSTOPERATIVE TAMPONADE
May 1985:125G-2
and in appearance consisted of bloodstained pericardial fluid,
unclotted recently extravasated blood, "old" dark blood or
blood clots or various combinations of these.
The case of a 64 year old man is worth reporting in
detail. He had been on Coumadin therapy because of pulmonary embolism complicating the postoperative course after
coronary bypass surgery. He was readmitted 6 weeks after
his initial surgery for chest discomfort and dyspnea. Prothrombin time then was 24 seconds (control 12 seconds).
The two-dimensional echocardiogram demonstrated a large
loculated pericardial effusion (Fig. 1). A few hours later,
the patient rapidly became hypotensive. Swan-Ganz catheterization revealed pressures (mm Hg) as follows: right
atrium, mean = 15, a wave = 25, v wave = 15; right
ventricle = 42115; pulmonary artery = 42120; pulmonary
artery wedge, mean = 20, a wave = 20, v wave = 39.
Emergency surgical drainage of the loculated pericardial
effusion was promptly scheduled. In the operating room,
immediately before subcostal drainage of the pericardial
effusion, the pressures (mm Hg) were: central venous, 20;
pulmonary artery wedge, 30; mean arterial, 60. Four hundred
ml of bloody fluid were removed, and immediately thereafter pressures (mm Hg) were: central venous, 10; pulmonary artery wedge, 15; mean arterial, 95 (systolic 128, diastolic 60). These pressures remained essentially unchanged
over the next 48 hours.
Echocardiographic findings. A moderate to large nonloculated pericardia I effusion was noted in four patients.
Pericardial fluid was visualized anterior and posterior to the
heart, as well as posterior to both atria. Some abnormal
pendulous cardiac motion was present, but neither extreme
ENODIASTOLE
SYSTOLE
"swinging" cardiac motion nor alternation of cardiac position was observed. Excessive inward motion (indentation)
of the right atrial wall (5) was noted in two of the four
patients. Phasic reciprocal changes with respiration in right
and left ventricular size (1,3) could be identified in all four
patients when the videotape was reviewed in slow motion
or in frame by frame sequence.
In the other seven patients. the pericardial fluid was
loculated posteriorly behind the left ventricle. No pericardial
fluid was visualized anterior to the heart, even with the
patient sitting upright. Phasic respiratory changes in ventricular dimensions were not present. In these patients, the
contour of the left ventricular and atrial posterior wall was
abnormal: convex to the left ventricular chamber, concave
toward the posterior pericardial effusion.
In two patients with a loculated pericardial effusion. a
strikingly unusual motion of the left ventricular posterior
wall and behavior of the posterior pericardial space was
observed in long-axis as well as short-axis views: the posterior pericardial space decreased in width in systole and
abruptly increased in width in diastole (Fig. I). In diastole,
the left ventricular posterior wall moved abruptly anteriorly;
concomitantly the left ventricular dimension decreased. A
decrease in left ventricular cavity width in diastole was
evident in long-axis, short-axis and apical four chamber
views. The systolic and diastolic phases of the cardiac cycle
were identified with reference to mitral valve motion and
the simultaneously recorded electrocardiogram. Such' 'paradoxical' , motion of the left ventricular posterior wall is the
reverse of what is usually noted in patients with a pericardial
effusion of moderate size. Systolic posterior motion of the
WID DIASTOLE
APICAl
1.0 GAXI S
(f!J.
v
LV
trT
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Figure 1. Two-dimensional echocardiogram of a patient with postoperative pericardial effusion (EFF) showing serial
frames from the same cardiac cycle in the
apical long-axis view (top row), the apical four chamber view (middle row) and
parasternal short-axis view (bottom row).
In each row, the left frame is at enddiastole, the center frame in systole and
the right frame in mid-diastole.The phases
of the cardiac cycle were identified with
reference to motion of the mitral valve
and to the simultaneously recorded electrocardiogram. A large loculated pericardial effusion is seen posterior and posterolateral to the heart, with virtually no
effusion anteriorly. Note that the pericardial effusion appears wider at mid-diastole (than during systole), and that this
is associated with decreased width and
altered shape of the left ventricle (LV),
which becomes more concave toward the
loculated pericardial effusion. LA = left
atrium; PER = pericardium; RV = right
ventricle.
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D'CRUZ ET AL.
ECHOCARDIOGRAPHY IN POSTOPERATIVE TAMPONADE
left ventricular wall may be noted in association with a large
pericardial effusion and "swinging" heart, but in our patients there was no cardiac swinging because the heart was
tethered anteriorly by pericardial adhesions.
In addition to the 11 patients requiring reoperation for
tamponade. I patient developed mild tamponade due to a
nonloculated pericardial effusion 3 days after coronary bypass surgery and was managed conservatively. Serial echocardiograms during the next 4 days demonstrated a gradual
decrease of the pericardial effusion and regression of clinical
signs of tamponade.
lACC Vol. 5, No.5
May 1985:1250-2
respiratory changes in ventricular dimensions (1,3), right
ventricular narrowing (2) or abnormal motion of the right
ventricular or right atrial wall (4,5). These ultrasound signs
of tamponade were present in varying degree in the four
patients in our series who had a nonloculated pericardial
effusion, with pericardial fluid freely distributed all around
both ventricles and also behind both atria.
We are indebted to Karl T. Weber, MD, Director, Cardiology Division,
Michael Reese Hospital for helpfully reviewing this manuscript.
References
Discussion
Pericardial effusion causing cardiac tamponade is not
uncommon after cardiac surgery. Although it is most frequently encountered in the immediate postoperative period,
Jones et al. (II) collected 43 instances of late postoperative
tamponade (7 days to 3 months after cardiac surgery) reported before 1979.
Loculated pericardial effusions causing tamponade.
Echocardiography has been found useful in detecting a loculated posterior pericardial effusion presenting with tamponade after surgery (9-11). Seven of our patients with
tamponade after surgery had a posterior loculated pericardial
effusion. Postoperative loculated pericardial effusions causing tamponade by selective compression of the left atrium
(12), right ventricular outflow area (13) and right atrium
(14, IS) have been described. Dunlap et al. (16) presented
echocardiographic and hemodynamic data indicating cardiac
compression in a 25 year old man who had a posttraumatic
massive organized pericardial hematoma posterior to the
heart.
Abnormal left ventricular wall motion. To our knowledge, the type of abnormal left ventricular posterior wall
motion noted in two of our patients (Fig. I) has not been
described before, although it seems present in the M-mode
echocardiograms of a patient described by Jones et al. (11)
(their Fig. 2). The posterior pericardial space appears to
expand in early diastole, and narrow during systole, the
reverse of what is usually observed in pericardial effusions.
It is likely that this finding and the concave contour of the
left ventricular and atrial posterior wall, noted in some of
our patients with a loculated posterior pericardial effusion,
is due to the high pressure in such effusions. This deformation of the left heart shape may be expected to be less
prominent during systole than in diastole; this, in fact, is
what was observed on two-dimensional echocardiography.
Tamponade complicating various "medical" causes of
pericarditis is usually caused by nonloculated pericardial
effusions, and manifests echocardiographically by phasic
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