Left Ventricular Diastolic Collapse Research Articles

Atypical Cardiac Tamponade Manifesting as Left Ventricular Diastolic Collapse: A Case Report

Cardiac tamponade is a medical emergency, the diagnosis of which is predominantly clinical with supportive echocardiographic findings. Echocardiographic findings highly suggestive of cardiac tamponade include chamber collapse, inferior vena cava (IVC) plethora, and respiratory volume/flow variations. The right-sided cardiac chambers are a low-pressure system and are the first to show signs of collapse with high specificity for tamponade. We report the case of a 35-year-old woman who demonstrated left ventricular (LV) diastolic collapse on echocardiogram following a tricuspid valve replacement. Although left-sided chamber collapse with tamponade has been reported with localized pericardial effusions postoperatively, our patient had a large circumferential pericardial effusion. Selective chamber compression can be a presenting sign of postoperative tamponade after cardiac surgery. Our case highlights the importance of recognizing atypical forms of cardiac tamponade to help in early identification and emergent management in such patients.

A case of coagula tamponade 4 years after Bentall procedure.

A 76-year-old man was admitted to hospital because of shortness of breath, and a pericardial clot with left ventricular diastolic collapse was detected by echocardiography. Approximately 4 years earlier, the patient had undertaken the Bentall procedure with a bioprosthesis (Freestyle ) because of aortic regurgitation and dilatation of the aortic root. A transthoracic echocardiogram (TTE) obtained 1 year after the operation showed a mild pericardial effusion and no evidence of tamponade. Six months before admission, the patient noticed increased fatigue and shortness of breath. On physical examination, the patient’s blood pressure was 102/68 mmHg, heart rate 80 beats per min, respiratory rate 14 breaths per min, and his temperature was 36.7 C. The breath sounds were clear. An examination of the heart showed no significant murmurs. The arms and legs were warm, with symmetric pulses and no edema. Because the patient had a bioprosthetic valve, anticoagulant therapy was not performed, and activated partial thromboplastin time and prothrombin time were normal. The transthoracic echocardiographic study on admission showed a large localized pericardial clot mass in the postero-lateral region and the inward motion of the left ventricular posterior wall was noted during diastole (i.e., left ventricular diastolic collapse) (Figs. 1 and 2), which are findings consistent with coagula tamponade [1–3]. There were no classical echocardiographic signs of tamponade (i.e., right ventricular diastolic collapse and right atrial collapse) [4, 5]. The patient underwent elective surgery, and the pericardial clot and bloody fluid were removed. Biopsy specimens were taken from the pericardium, and the pericardial biopsy section showed a lymphocyte-rich inflammatory infiltrate. Idiopathic pericarditis was thought to be the cause of slight but continuous oozing into the pericardium, which may produce a localized clot. An echocardiogram obtained after the re-operation showed no re-accumulation of the pericardial effusion. The patient was discharged 21 days after the operation, and has remained stable at home.

The usefulness of transesophageal echocardiographic observation during chemotherapy for cardiac metastasis of non-Hodgkin lymphoma complicated with left ventricular diastolic collapse

A 53-year-old man, who had been treated for penile origin diffuse large B cell type non-Hodgkin lymphoma (NHL), suffered from right femoral pain and dyspnea. Positron emission tomography (PET) revealed abnormal accumulation in his right femur and cardiac segments. Transthoracic echocardiography revealed massive localized pericardial effusion with the collapse of both ventricles and the mass-like echo in the left atrium. We performed emergent pericardiocentesis and diagnosed this case as a recurrence of NHL with cardiac metastasis. With the use of transesophageal echocardiography (TEE), we confirmed the mass-like echo around the inter-atrial septum, which directly invaded to the aortic ring and the right atrial wall. In order to evaluate the effect of chemotherapy, we performed TEE and observed the precise changes of intra-cardiac tumor size. With the use of TEE monitoring, we could select the appropriate chemotherapeutic regimen, and the tumor became smaller and finally diminished. The femoral accumulation detected by PET also disappeared. We experienced a case of cardiac metastasis of NHL complicated with left ventricular diastolic collapse due to the massive localized pericardial effusion. TEE is a useful tool to evaluate precisely the efficacy of chemotherapy for intra-cardiac tumors.

Left Ventricular Collapse Secondary to Pericardial Effusion Treated with Pericardicentesis and Percutaneous Pericardiotomy in Severe Pulmonary Hypertension

A 61-year-old white female, a Jehovah's Witness, with severe pulmonary hypertension, presented with worsening heart failure symptoms. She had a pericardial effusion with left ventricular (LV) diastolic collapse on transthoracic echocardiography. She was not a candidate for surgical pericardial window and therefore underwent pericardiocentesis and percutaneous balloon pericardiotomy with remarkable improvement in her clinical condition and with no recurrence of the effusion. LV diastolic collapse, an atypical presentation of cardiac tamponade, is commonly seen in postoperative patients with localized pericardial effusions. However, outside the surgical setting, isolated LV diastolic collapse is rare. Our case is one of the first cases described in the literature of LV diastolic collapse in the setting of severe pulmonary hypertension treated successfully with pericardiocentesis and percutaneous balloon pericardiotomy.

Left Ventricular Diastolic Collapse and Late Regional Cardiac Tamponade Postcardiac Surgery Caused by Large Left Pleural Effusion

Cardiac tamponade is a well-recognized early complication (ie, within 15 days) of cardiac surgery usually a result of the development of a pericardial effusion postoperatively. However, left ventricular diastolic collapse as a result of the presence of a large pleural effusion, but in the absence of any pericardial effusion, is rare, particularly late (ie, after 15 days) after cardiac surgery. We present the echocardiographic findings of a man presenting with recurrent exertional breathlessness, after elective tissue aortic valve replacement, and demonstrate, by echocardiography, the mechanism of left ventricular diastolic collapse and late regional cardiac tamponade, after cardiac surgery, as a result of the effects of a large pleural effusion but in the absence of any pericardial effusion. We discuss and review the literature on this phenomenon.

Pleural effusion causing cardiac tamponade: Report of two cases and review of the literature

We report on two patients who developed large left-sided pleural effusions in association with hemodynamic compromise. In both cases transthoracic echocardiography demonstrated left ventricular diastolic collapse confirming our clinical suspicion of cardiac tamponade. Large-volume thoracentesis in the first case and thoracotomy with drainage of the pleural collection in the second case resulted in immediate hemodynamic improvement. Our report shows that large pleural effusions can result in impaired cardiac filling and a tamponade-like physiology. Thoracentesis in this setting can lead to rapid improvement of the hemodynamic profile.

Left Ventricular Apical Diastolic Collapse: An Unusual Echocardiographic Marker of Postoperative Cardiac Tamponade

A 37-year-old woman was evaluated for signs and symptoms of cardiac tamponade 11 days after mitral valve replacement and tricuspid valve repair. The transthoracic echocardiogram showed a large, compartmentalized pericardial effusion that resulted in left ventricular apical diastolic collapse. Also noted were right ventricular posterior wall diastolic collapse and hemodynamic findings consistent with cardiac tamponade. This case highlights the atypical echocardiographic findings in patients with pericardial effusions after cardiac surgery. (J Am Soc Echocardiogr 1999;12:218-20.)

Left ventricular diastolic compression in acquired immunodeficiency syndrome with large, nonloculated pericardial effusion

Left ventricular diastolic collapse is an unusual echocardiographic finding, previously reported only in patients with regional tamponade caused by large loculated pericardial effusions. 1, 2 To our knowledge, such left ventricular compression has been described only once before in patients with circumcardiac nonloculated pericardial effusions. ~ We recently encountered a patient with acquired immunodeficiency syndrome (AIDS), pulmonary hypertension, and a large nonloculated pericardial effusion, who on echocardiography exhibited left ventricular (LV) wall collapse in early diastole, but did not show any right ventricular (RV) or right atrial wall collapse. This 32-year-old white man had been diagnosed as having AIDS in 1992. In July 1993 his CD4 ÷ count was 4 cells/ ml. He developed disseminated histoplasmosis in February 1994 and was treated with amphotericin B; other complications of AIDS were peripheral neuropathy and normocytic anemia. He was admitted in July 1995 with a 3-day history of increasing dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea. His medications at this time included dapsone, acyclovir, morphine sulfate, sertraline, lorazepam, and multivitamins. On admission his temperature was 101.8 ° F/38.7 ° C, heart rate was 124 beats/min, respiratory rate was 24 breaths/rain, and blood pressure was 118/84 mm Hg. He was in mild respiratory distress. Jugular venous pressure was markedly raised. On auscultation the pulmonary second heart sound was very loud; no rubs were heard. He had diffuse rales and decreased breath sounds at both lung bases. His liver edge was palpable 3 cm below the right costal margin. Mild pretibial edema was noted. His electrocardiogram showed sinus tachycardia but was otherwise normal. His chest x-ray film showed cardiomegaly, and the cardiac silhou-

Pericardial effusion after cardiac surgery: incidence, site, size, and haemodynamic consequences.

To evaluate the incidence, characteristics, and haemodynamic consequences of pericardial effusion after cardiac surgery. Clinical, echocardiographic, and Doppler evaluations before and 8 days after cardiac surgery; with echocardiographic and Doppler follow up of patients with moderate or large pericardial effusion after operation. Patients undergoing cardiac surgery at a tertiary centre. 803 consecutive patients who had coronary artery bypass grafting (430), valve replacement (330), and other types of surgery (43). 23 were excluded because of early reoperation. Size and site of pericardial effusion evaluated by cross sectional echocardiography and signs of cardiac tamponade detected by ultrasound (right atrial and ventricular diastolic collapse, left ventricular diastolic collapse, distension of the inferior vena cava), and Doppler echocardiography (inspiratory decrease of aortic and mitral flow velocities). Pericardial effusion was detected in 498 (64%) of 780 patients and was more often associated with coronary artery bypass grafting than with valve replacement or other types of surgery; it was small in 68.4%, moderate in 29.8%, and large in 1.6%. Loculated effusions (57.8%) were more frequent than diffuse ones (42.2%). The size and site of effusion were related to the type of surgery. None of the small pericardial effusions increased in size; the amount of fluid decreased within a month in most patients with moderate effusion and in a few (7 patients) developed into a large effusion and cardiac tamponade. 15 individuals (1.9%) had cardiac tamponade; this event was significantly more common after valve replacement (12 patients) than after coronary artery bypass grafting (2 patients) or other types of surgery (1 patient after pulmonary embolectomy). In patients with cardiac tamponade aortic and mitral flow velocities invariably decreased during inspiration; the echocardiographic signs were less reliable. Pericardial effusion after cardiac surgery is common and its size and site are related to the type of surgery. Cardiac tamponade is rare and is more common in patients receiving oral anticoagulants. Echo-Doppler imaging is useful for the evaluation of pericardial fluid accumulations after cardiac surgery. It can identify effusions that herald cardiac tamponade.

Diagnosis of cardiac tamponade after cardiac surgery: Relative value of clinical, echocardiographic, and hemodynamic signs

Early detection and treatment of cardiac tamponade is crucial in management of patients after cardiac surgery. Because of the atypical features of this condition and paucity of data on relative frequency of different signs, we evaluated the sensitivity of various clinical, echocardiographic, and hemodynamic signs. We retrospectively evaluated the relative frequency of clinical, echocardiographic, and hemodynamic signs in 29 patients with cardiac tamponade after cardiac surgery. In our study 66% had a localized, posterior pericardial effusion, and the other 34% had circumferential pericardial effusion. In the whole group 24% of patients had hypotension, and pulsus paradoxus was noted in 48%, right atrial collapse in 34%, right ventricular diastolic collapse in 27%, left ventricular diastolic collapse in 65%, and left atrial collapse in 13%. Elevation with equalization of pressures was noted in 81% patients. In the patient group with circumferential pericardial effusion and cardiac tamponade 40% patients were hypotensive and 50% patients had pulsus paradoxus. RA collapse was present in 70%, RV diastolic collapse in 70%, and LV diastolic collapse in 20%. Elevated diastolic pressures with equalization of these pressures was present in 71%. In the group with regional pericardial effusion and cardiac tamponade hypotension was present in 16% and pulsus paradoxus in 47%. RA collapse was present in 16%, RV diastolic collapse in 5%, LV diastolic collapse in 89%, and LA collapse in 21% of the patients with regional tamponade. Elevated diastolic pressures with equalization of these pressures was noted in 86% of the patients. Our observations indicate that among patients who have undergone cardiac surgery the presentation of cardiac tamponade is usually atypical. If tamponade is suspected, clinical, echocardiographic, and hemodynamic indicators, as individual sets of diagnostic criteria, are unreliable, and the diagnosis of cardiac tamponade should not be excluded without additional echocardiographic, and if necessary, hemodynamic evaluation.

Left ventricular diastolic collapse in regional left heart cardiac tamponade: An experimental echocardiographic and hemodynamic study

Objectives. This study was designed to describe the hemodynamic abnormalities associated with the appearance of left ventricular diastolic collapse in the setting of regional left heart cardiac tamponade.Background. Cardiac tamponade after heart surgery is frequently associated with localized pericardial effusion. Although right ventricular diastolic collapse and right atrial collapse are reliable echocardiographic findings in patients with circumferential pericardial effusion and tamponade, they are often not present in postoperative patients with localized pericardial effusion and regional left heart tamponade. Left ventricular diastolic collapse has been described in such patients, but the degree of hemodynamic alteration that exists with this finding is not known.Methods. Acute regional left heart tamponade was produced 14 times in seven spontaneously breathing anesthetized dogs by infusing fluid into an isolated compartment created in the pericardial space adjacent to the left ventricular free wall. Continuous echocardiographic imaging and hemodynamic monitoring of left ventricular, systemic arterial, right atrial, pulmonary capillary wedge and pericardial pressures were performed. Measurements at baseline were compared with those made at the onset of left ventricular diastolic collapse and at decompensated tamponade.Results. Left ventricular diastolic collapse was noted in all 14 episodes of regional tamponade. It occurred when pressure in the left pericardial compartment exceeded left ventricular diastolic pressure by 3.0 ± 1.9 mm Hg. At the onset of left ventricular diastolic collapse, cardiac output and mean arterial pressure were significantly reduced from the control value (p < 0.05). Systolic hypotension was noted only twice at this stage, respiratory variation in systolic pressure > 10 mm Hg only once. The appearance of this sign was also associated with elevated left heart filling pressures.Conclusions. Left ventricular diastolic collapse is a reliable sign of regional left ventricular tamponade and is associated with a reduction in cardiac output. This echocardiographic finding usually occurs before the development of arterial hypotension and pulsus paradoxus. Thus, left ventricular diastolic collapse is potentially more reliable than hypotension or pulsus paradoxus in the diagnosis of regional left ventricular tamponade.

Left Ventricular Diastolic Collapse in the Absence of Cardiac Tamponade

Left ventricular diastolic collapse has been presented in the literature as a sign of cardiac tamponade in the setting of pulmonary hypertension. We report the case of a patient with human immunodeficiency virus (HIV) disease, and associated pulmonary hypertension and pericardial effusion. Left ventricular diastolic collapse was present, but tamponade was not, as judged by failure of pericardio‐centesis to improve cardiac index or symptoms. We suggest that left ventricular diastolic collapse occurred because left ventricular filling was impaired by the hemodynamic consequences of pulmonary hypertension, not by extrinsic compression. Left ventricular diastolic collapse is not pathognomonic for cardiac tamponade in the setting of pulmonary hypertension.

Two-dimensional echocardiographic demonstration of left ventricular diastolic collapse due to compression by pleural effusion

Two-dimensional echocardiographic demonstration of left ventricular diastolic collapse due to compression by pleural effusion

Left ventricular diastolic collapse. An echocardiographic sign of regional cardiac tamponade.

Cardiac tamponade after cardiac surgical procedures is often associated with hemodynamically significant localized pericardial effusions. The localized collection of pericardial effusion in the postoperative period and the atypical presentation of cardiac tamponade limit the use of conventional clinical and echocardiographic signs usually seen with a circumferential pericardial effusion. Observation of left ventricular diastolic collapse in the echocardiogram of a patient with postoperative regional cardiac tamponade prompted us to explore the frequency of this sign in regional cardiac tamponade. We retrospectively analyzed the echocardiograms of 18 patients with postoperative cardiac tamponade for the following echocardiographic findings: right atrial collapse, right ventricular diastolic collapse, left atrial collapse, and left ventricular diastolic collapse. Three of the 18 patients had circumferential pericardial effusion, and 15 had loculated pericardial effusion; in 10, the effusion was predominantly posterior, and in the other five, it extended laterally or inferiorly. The conventional echocardiographic signs of cardiac tamponade such as right atrial collapse, right ventricular diastolic collapse, and left atrial collapse were present in only 3, 1, and 3 of these 15 patients, respectively, but all exhibited left ventricular diastolic collapse. Increasing pressure within the compartment of a loculated pericardial effusion reaching the limit of pericardial distensibility and consequent transient reversal of transmural left ventricular pressure during diastole are most likely the basis for diastolic collapse of the thick-walled ventricle in a setting of regional cardiac tamponade. We conclude that left ventricular diastolic collapse is a frequent sign of regional cardiac tamponade and could be a useful marker of tamponade in postoperative patients.