Diagnosis Of Pericardial Tamponade Research Articles

Electrical storm after correction of an uncomplicated congenital atrial septal defect in an adult: a case report

BackgroundThere is a paucity of published literature describing electrical storm after the correction of uncomplicated atrial septal defect (ASD) in an adult.Case presentationWe present a 49-year-old woman with a congenital ASD combined with mild tricuspid regurgitation who denied any history of arrhythmia or other medical history. She suffered from electrical storm (≥ 3 episodes of ventricular tachycardias or ventricular fibrillations) in the early stage after ASD repair with combined tricuspid valvuloplasty. During electrical storm, her electrolytes were within normal ranges and no ischemic electrocardiographic changes were detected, which suggested that retained air embolism or acute coronary thrombosis were unlikely. Additionally, echocardiographic findings and her central venous pressure (5–8 mmHg during the interval between attacks) failed to support the diagnosis of pericardial tamponade. After a thorough discussion, the surgeons conducted an emergent re-exploration and repeated closure of the ASD with combined DeVega's annuloplasty. Eventually, the patient recovered uneventfully, without reoccurring arrhythmias during follow-up. Although we fail to determine the definite cause, we speculate that the causes probably are iatrogenic injury of the conduction system due to a rare anatomic variation, poor intraoperative protection, latent coronary distortion during tricuspid valvuloplasty, or idiopathic or secondary abnormalities of the conduction system.ConclusionsFor most surgeons, performing re-exploration without a known etiology is a difficult decision to make. This case illustrates that re-exploration could be an option when electrical storm occurs in the early stage postoperatively. Nevertheless, surgeons should assess the benefit-risk ratio when taking this unconventional measure.

Forensic relevance of post-mortem CT imaging of the haemopericardium in determining the cause of death.

The post-mortem diagnosis of pericardial tamponade is associated with several medical legal problems. Thus, we explored whether post-mortem computed tomography might provide useful and reliable information for the diagnosis of this relevant disease in combination with autopsy data. We retrospectively reviewed the post-mortem computed tomography and autopsy reports of 15 autopsy cases with haemopericardium detected at the Institute of Forensic Medicine in Berne from July 2005 to February 2010. Two computer tomography findings were examined in combination with autopsy results. The first was the "hyperdense armoured heart," which has been previously described as post-mortem evidence of heart beating for a time after the initiation of intrapericardial bleeding. The second was the "flattening of the anterior surface" of the heart which has been previously observed in vivo as a sign of the compression effect of the haemopericardium on the heart. Our retrospective analysis showed the combined presence of both of these findings in all cases of autopsy evidence of pericardial tamponade with the exception of one case. In contrast, the concomitance of both of them was never observed in cases of autopsy death due to haemorrhage in which neither the flattening of the anterior surface of the heart was detected except for one case. In conclusion, these results should be considered a first step toward the potentially using post-mortem computed tomography in combination with autopsy data in the diagnosis of pericardial tamponade especially considering the possibility to detect sign as the flattened heart signal which cannot be assessed after opening the pericardium at autopsy.

2.8. Post-mortem CT (PMCT) imaging findings of pericardial tamponade due to hemopericardium

Objectives Hemopericardium (HP) is occasionally found at autopsy, but it represents a challenge for the forensic pathologist when having to assess its pathophysiological role in causing death, particularly in those cases where ante-mortem clinical and instrumental data are not available. The aim of this study was to individuate PMCT findings indicative for the diagnosis of pericardial tamponade (PT). Materials and methods We retrospectively revised PMCT images and autopsy reports of 14 cases with fatal HP and intact pericardium. From autopsy reports, we obtained volume and cause of HP. PMCT images were reviewed to describe: appearance of HP, presence of indirect signs of increased intrapericardial pressure. A control group of 11 cases submitted to PMCT prior to autopsy was selected with the following criteria: absence of relevant pericardial effusion, venous system congestion and bleeding. Results Of the 14 PT subjects, 13 had a double concentric stratification of HP and compression of the coronary sinus and/or of the pulmonary trunk, all showed a flattening of the anterior surface of the heart; other findings indicative of venous system congestion were variably detected. In the control group none of these findings was identified, with the exception of a distended superior vena cava equalling the ascending aorta (8/11 cases). Conclusions PMCT is able to provide some findings indicative of PT. Based on this evidence, in other instances HP could be judged circumstantial rather than fatal. This study suggests the possibility to use PMCT findings to retrospectively demonstrate an in vivo dynamic condition, such as PT.

Transesophageal Echocardiography in the Diagnosis of Acute Pericardial Tamponade During Hiatal Hernia Repair

q i c h t d t t r m WHEN MEDICAL TREATMENT of hiatal hernia is unsuccessful (eg, worsened symptoms of gastroesophageal reflux) or when there is progressive enlargement of the hernia defect, surgical repair is indicated.1 Among several surgical techniques described for hiatal hernia repair, the Nissen fundoplication has been superior, with symptomatic improvement occurring in 85%-90% of patients.2,3 This procedure entails rapping the gastric fundus around the distal esophagus and astroesophageal junction to reinforce them.2 Laparoscopic erformance of Nissen fundoplication shortens hospital stay ompared with performing the surgery with an open laparotmy.4 A relatively recent selective addition to the procedure is mplantation of a mesh graft to decrease the diaphragmatic efect. This provides an additional mechanical barrier and, herefore, is thought to decrease recurrence.3 In general, Nissen fundoplication is a safe procedure. However, life-threatening complications have been described and include injury to the stomach and spleen, bleeding complications, and injury to neighboring organs.5-7 This report describes the case of a patient who developed pulseless bradycardia during a modified Nissen fundoplication with mesh graft implantation. The cause of the electromechanical dissociation was an acute pericardial tamponade. This evolved from an accidental perforation of the right ventricle by a spiral tack used to affix the mesh graft to the diaphragm to close the hernia defect more securely. The diagnosis of pericardial tamponade was made by transesophageal echocardiography (TEE).

Paradoxical Hypertension With Cardiac Tamponade

Subacute (medical) tamponade develops over a period of days or even weeks. Previous studies have shown that subacute tamponade is uncommonly associated with hypotension. On the contrary, many of those patients are indeed hypertensive at initial presentation. We sought to determine the prevalence and predictors of hypertensive cardiac tamponade and hemodynamic response to pericardial effusion drainage. We conducted a retrospective study of patients who underwent pericardial effusion drainage for subacute pericardial tamponade. Diagnosis of pericardial tamponade was established by the treating physician based on clinical data and supportive echocardiographic findings. Patients were defined as hypertensive if initial systolic blood pressure (BP) was ≥140 mm Hg. Thirty patients with subacute tamponade who underwent pericardial effusion drainage were included in the analysis. Eight patients (27%) were hypertensive with a mean systolic BP of 167 compared to 116 mm Hg in 22 nonhypertensive patients. Hypertensive patients with tamponade were more likely to have advanced renal disease (63% vs 14%, p <0.05) and pre-existing hypertension (88% vs 46, p <0.05) and less likely to have systemic malignancy (0 vs 41%, p <0.05). Systolic BP decreased significantly in patients with hypertensive tamponade after pericardial effusion drainage. Those results are consistent with previous studies with an estimated prevalence of hypertensive tamponade from 27% to 43%. In conclusion, a hypertensive response was observed in approximately 1/3 of patients with subacute pericardial tamponade. Relief of cardiac tamponade commonly resulted in a decrease in BP.

Focused emergency echocardiography: lifesaving tool for a 14-year-old girl suffering out-of-hospital pulseless electrical activity arrest because of cardiac tamponade

Cardiac arrest presenting as pulseless electrical activity (PEA) is associated with poor outcome. Its major underlying causes (e.g. cardiac tamponade, pulmonary embolism, tension pneumothorax or hypovolaemia) are difficult to detect reliably in an out-of-hospital setting. We here present a case of a 14-year-old girl suffering from PEA because of cardiac tamponade 4 weeks after surgical closure of a ventricular septal defect. Immediate focused echocardiography on scene by an emergency physician showed a large pericardial effusion that had led to cardiac tamponade and finally to a PEA cardiac arrest. Immediate pericardiocentesis was carried out. The girl progressed to complete neurological recovery. This case report demonstrates that focused emergency echocardiography may be useful for the diagnosis of pericardial tamponade leading to cardiac arrest and this diagnosis can be made out-of-hospital by an appropriately trained physician.

The Importance of Transesophageal Echocardiography in Diagnosis of Pericardial Tamponade After Cardiac Surgery

Despite the fact that there is a simple and effective treatment for pericardial tamponade (PCT), delayed diagnosis can cause serious morbidities or even mortality. In this study, we discuss the management and the diagnostic procedures of PCT. Sixty-two patients with suspected PCT were initially evaluated with transthoracic echocardiography (TTE) and then with transesophageal echocardiography (TEE). Forty-nine (79%) patients were chosen for surgery after TEE displayed a suspected PCT diagnosis. Patients with suspected PCT were divided into two groups: Early-phase PCT (symptoms developed within 72 hours) and late-phase PCT (symptoms developed after 72 hours). Thirty-five (56%) patients were in the early phase and 27 (44%) patients were in the late phase. In 13 out of 22 (59%) cases, from both early and late phases, TTE findings showed no PCT, but TEE findings showed a positive PCT diagnosis. All 13 of the cases where TEE was positive after a negative TTE were confirmed by surgery. Overall, the PCT diagnoses in 48 out of 49 patients were confirmed during surgery. The role of echocardiography in PCT diagnosis is shown to be extremely important in some clinical cases, such as in patients during the postoperative period after cardiac surgery. Furthermore, particularly when TTE does not provide complete imaging of the pericardial sac, TEE should be mandatory. We recommend that even patients with a negative diagnosis of PCT from TTE should undergo further evaluation with TEE.

Dual Thrombosis of the Pulmonary Arterial and Venous Anastomotic Sites After Single Lung Transplantation: Role of Transesophageal Echocardiography in Diagnosis and Management

We present the case of a patient who developed severe respiratory and hemodynamic compromise shortly after single right lung transplantation. Transesophageal echocardiography showed a large intraluminal thrombus at the right pulmonary artery anastomosis resulting in severe obstruction to flow together with thrombosis of the right pulmonary veins extending into the left atrium. After thrombectomy and surgical revision of the vascular anastomoses, the patient made an uneventful recovery. This case illustrates the usefulness of transesophageal echocardiography in the diagnosis and treatment of patients who are hemodynamically unstable after lung transplantation.

Hemopericardium leading to cardiac tamponade in the traumatized pediatric patient: Discovery by CT

Cardiac rupture is a condition uncommonly sustained in blunt chest trauma. Survival is rare. Patients with extensive pericardial as well as cardiac laceration almost inevitably exsanguinate unless the pericardial leak is occluded by massive hematoma. Those with pericardium intact, however, develop cardiac tamponade, and may survive this highly lethal insult if the correct diagnosis is made. Unfortunately, the physician may be reluctant to consider tamponade, assuming that the patient would not have reached the facility alive had cardiac rupture occured. Series show that the diagnosis of pericardial tamponade is rarely suspected even in patients with classic presentation (1). To compound this difficult diagnosis, the patient may arrive at the facility before the pattern of tamponade is fully developed-symptoms may further be masked by rapid intravenous (IV) administration of fluid and use of vasopressors to maintain systemic blood pressure (2). Echocardiography, the traditional diagnostic test, is slow and cumbersome to perform under the hectic conditions of acute critical care (3). A physician who is not highly suspicious of tamponade is unlikely to order this time-consuming test. However, many trauma patients have computed tomography (CT] scans performed to evaluate suspected thoracic or abdominal injury. It is critical then, to recognize the CT appearance of this lethal, but highly treatable condition. We present this case as an example of a pediat-

Pericardial tamponade due to penetrating fragment wounds of the heart

Ten cases of pericardial tamponade due to penetrating fragment wounds of the heart seen at a surgical hospital in Vietnam are presented. Two of the three deaths in this series were due to associated injuries. The diagnosis of pericardial tamponade must be suspected in any penetrating wound of the thorax or upper part of the abdomen, especially if the response to adequate blood and fluid replacement is suboptimal. The classical signs of pericardial tamponade, such as elevated central venous pressure, poor peripheral perfusion, and distant heart sounds, may be altered or nonspecific in the hypovolemic patient. Some cases of pericardial tamponade can be handled conservatively with initial pericardiocentesis. However, the advantages of early surgical decompression once the diagnosis is established seem so great that conservative treatment is rarely indicated.

Pericardial tamponade; diagnosis and treatment.

ACUTE pericardial tamponade is not encountered frequently in a general medical practice, nor is it likely to become commonplace even in the more specialized experience of the cardiologist. Nevertheless, it is an important mechanical disorder, because failure to recognize it, or delay in initiating treatment, may mean death for the patient or progression of an underlying treatable disease. During the past few years we have had the valuable experience of seeing and treating a number of patients with pericardial tamponade in a large hospital. As the cases in this series accumulated, three facts became apparent: 1. The diagnosis of pericardial tamponade is frequently missed. 2. There is need to stress the dangers of the acute tamponade. 3. Surgical approach is of great value in selected cases. DESCRIPTION Pericardial tamponade results when accumulation of fluid within the pericardial sac or constriction of the pericardium by scar or tumor tissue seriously interferes