Importance of haemodynamic monitoring in cardiac tamponade

Abstract

A55-year-old man presented to the emergency room (ER) with complaints of anorexia, feelings of being unwell and anuria from the previous day. He denied any chest pain, palpitations, dyspnoea on exertion or fever. He was recovering from a recent throat infection and had a past medical history of diabetes mellitus, hypertension and hypercholesterolaemia. He was pale-looking and his physical examination revealed hypotension (90/60 mmHg) and tachycardia. He appeared in mild respiratory distress. Examination of neck veins showed raised jugular venous pressure of 6 cm above the sternal angle. His chest was clear on auscultation and the intensity of heart sounds were diminished with no added sounds. He had a measured pulsus-paradoxus of 20 mmHg. His electrocardiogram showed diffuse low-voltage complexes with no evidence of electrical alternans. There were ST segment elevations in lateral leads with tall T-waves in anterior precordial leads suggestive of posterolateral myocardial infarction (Figure 1). Posterior changes were confirmed on a posterior electrocardiogram (Figure 2). Right-sided electrocardiogram failed to reveal any ST-T abnormalities suggestive of right ventricular infarction. The initial set of laboratory tests done in ER revealed high blood urea nitrogen (9.64 mmol/litre) and serum creatinine (150.28 μmol/litre). The first set of cardiac enzymes revealed high troponin I (23.05 μg/litre) with normal myoglobin and creatine kinase. An arterial line was placed that revealed pulsus-paradoxus of 20 mmHg. A Swan–Ganz catheter was placed and showed: right ventricle of 53/33 mmHg; right atrium of 28 mmHg; pulmonary artery of 50/32 mmHg; pulmonary capillary wedge pressure of 30 mmHg. The central venous pressure tracing showed complete obliteration of ‘y’ descent. Dopplerechocardiography was done. It showed mild-to-moderate pericardial effusion with possible thrombus overlying the right ventricular wall. Posterior and lateral walls were found to be hypokinetic. The patient underwent coronary angiography before emergency pericardiocentesis. Angiography revealed complete occlusion of the first obtuse marginal. Aortic-pulse tracing is shown in Figure 3. These pressure tracings were consistent with cardiac tamponade with a demonstrable pulsus-paradoxus of about 20 mmHg. Ventriculography was not performed because of a suspected subacute rupture of the myocardial wall. A cautious pericardiocentesis was performed. Examination of the pericardial cavity revealed 300 cm3 of blood clots. In the absence of an ongoing leak, a pericardial window was created and a drain was left in situ. The patient was dialysed once after the procedure. His haemodynamics improved significantly after surgery. He remained stable through the course of his stay in the hospital and was discharged 3 days after pericardiocentesis.