Pericardial Clot Research Articles

Abstract 18104: The Unexpected Disaster: Unusual Form of Left Ventricular Rupture

Description: We present a 73-year-old female, who presented with NSTEMI. EKG showed ST depression in the inferior and anterior leads. Initial Troponin I was high (0.17 ng/mL). She received nitroglycerine with no relief of her pain, so she underwent an emergent left heart catheterization (LHC). The LHC showed two tandem 90% stenosis in the right coronary artery (RCA) and mild disease in the left anterior descending (LAD) and left circumflex (LCx) arteries. PCI to the RCA was successful. She was started on a high-intensity statin, carvedilol, dual antiplatelet therapy, and losartan. On the day after PCI, an echocardiogram showed preserved ejection fraction with no evidence of pericardial effusion. The patient was doing well until 2 days after the PCI when she was found obtunded and hypotensive. She received normal saline bolus, epinephrine, and norepinephrine, after which she improved. A bedside echocardiogram revealed evidence of pericardial effusion with tamponade physiology and a pericardial clot. The patient and her family declined further interventions and elected to proceed with comfort measures. Discussion: Mechanical complications of acute myocardial ischemia (AMI) have substantially decreased in numbers after the implication of early reperfusion therapies, but they remain fatal if not recognized early and treated. Free wall rupture (FWR) usually occurs in the first 7 days following an AMI, with an average of 2.6 days. FWR mostly happens after infarction of the LAD or LCx territories. In our case, there was no delay in reperfusion therapy and there was no evidence of infarction on the echocardiogram however the patient developed FWR as a complication and in a timeline earlier than average making this case unique.

Resuscitative transesophageal echocardiography in the diagnosis of post-CABG loculated pericardial clot causing cardiac tamponade

BackgroundPericardial effusion is a known complication of post-open cardiac surgery which can progress to life-threatening cardiac tamponade. Classical signs of tamponade such as hypotension and pulsus paradoxus are often absent. Diagnosing acute cardiac tamponade with transthoracic echocardiography (TTE) can be challenging in post-cardiac surgical patients due to distorted anatomy and limited scanning windows by the presence of surgical dressings or scar. Additionally, this patient population is more likely to have a loculated pericardial effusion, or an effusion that is isoechoic in appearance secondary to clotted blood. These findings can be challenging to visualize with traditional TTE. Missed diagnosis of cardiac tamponade due to loculated pericardial clot can result in delayed diagnosis and clinical management.Case presentationWe report a case series that illustrates the diagnostic challenge and value of resuscitative transesophageal echocardiography (TEE) in the emergency department (ED) for the diagnosis of cardiac tamponade due to posterior loculated pericardial clot in post-surgical coronary artery bypass graft (CABG) patients.ConclusionsCardiac tamponade due to loculated posterior pericardial clot post-CABG requires prompt diagnosis and appropriate management to avoid the potential for hemodynamic instability. Transesophageal echocardiography allows a rapid diagnosis, early appropriate referral and an opportunity to institute appropriate therapeutic measures.

Thoracic Trauma

More than 85% of blunt and penetrating trauma to the thorax results in injury to the lungs or ribs. Among civilians, blunt trauma is the most common mechanism, while penetrating trauma is the most common among military sectors. This review describes the assessment and stabilization, diagnosis, treatment and disposition, and outcomes of thoracic trauma. Videos shows the “lung point” sign on M-mode and two-dimensional ultrasonography, and a transthoracic echocardiogram clip of pericardial clot and tamponade due to a gunshot wound. Figures show a sonogram showing the “lung point sign”, a chest x-ray and computed tomographic scan demonstrating right-sided hemothorax in a patient with a right chest stab wound, and a three-dimensional computed tomographic scan and chest x-ray of a blunt trauma patient with displaced fractures of the left lateral sixth to ninth ribs. Tables list types of injuries, NEXUS chest decision instrument imaging criteria, level 2 evidence-based recommendations for the management of pulmonary contusion and flail chest by the Eastern Association for the Surgery of Trauma, Eastern Association for the Surgery of Trauma practice guidelines for managing issues with pulmonary contusion and flail chest, and the Vancouver simplified and University of Washington grading systems for blunt aortic injury. This review contains 2 videos, 4 highly rendered figures, 10 tables, and 94 references.

The importance of simulation education for the management of traumatic cardiac injuries: a case series

BackgroundThe management of cardiac trauma requires rapid intervention in the emergency room, facilitated by a surgeon with prior experience to have good outcomes. Many surgeons have little experience in the requisite procedures. We report here 4 patients who suffered cardiac trauma, and all 4 patients survived with good neurologic outcomes.Case presentationsPatient 1 suffered blunt cardiac trauma from a motor vehicle accident and presented in shock. Cardiac tamponade was diagnosed and a cardiac rupture repaired with staples through a median sternotomy after rapid transport to the operating room. Patient 2 suffered blunt cardiac trauma and presented in shock with cardiac tamponade. Operating room median sternotomy allowed extraction of pericardial clot with recovery of physiologic stability. Patient 3 presented with self-inflicted stab wounds to the chest and was unstable. She was brought to the operating room and thoracotomy allowed identification of a left ventricle wound which was repaired with a suture. Patient 4 presented in cardiac arrest with multiple self-inflicted stab wounds to the chest. Emergency room thoracotomy allowed repair of a right ventricle laceration with recovery of vital signs.ConclusionsThe management of all 4 patients was according to the principles taught in the ATOM course. Three of the 4 surgeons had no prior experience with management of cardiac trauma and credited the good outcomes to taking the ATOM course. These are uncommon injuries and formal training in their management is beneficial to patients.

Bedside Ultrasonography in the Management of Penetrating Cardiac Injury Caused by a Nail Gun

BackgroundInjuries from nail guns are a unique type of penetrating trauma seen in emergency departments (EDs), rising in prevalence in the United States. These devices can lead to life-threatening injuries that require rapid diagnosis to help guide management. Case ReportAn elderly man was brought to the ED having sustained a nail gun injury to the chest. After loss of pulses, brief closed chest compressions and rapid blood product administration led to a return of spontaneous circulation. Using bedside ultrasound, a metallic foreign body was identified tracking through the right ventricle with associated pericardial fluid and pericardial clot. This rapid diagnosis with bedside ultrasound helped facilitate timely transport to the operating room for median sternotomy, foreign body removal, and pledgeted cardiac repair. Why Should an Emergency Physician Be Aware of This?With continued developments in image quality and acquisition, and improvements of physician operator performance, ultrasonography has continued to make significant impacts in traumatically injured patients in new ways. We present this case report to highlight precordial nail gun injuries and to emphasize the diagnostic capabilities of bedside ultrasound for these patients.

Unilateral pulmonary venous occlusion caused by a localized pericardial clot.

Unilateral pulmonary venous occlusion caused by a localized pericardial clot.

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.

Hematoma pericárdico dos años después de cirugía coronaria

Cardiac tamponade is a life-threatening complication after cardiac surgery which may develop in the early or late postoperative period. The latest have been defined arbitrarily as the ones occurring after the 7th postoperative day. They are less common than the early ones and most of the cases have been reported up to six months after the operation. They usually determine diagnostic difficulties that can negatively influence the prognosis. Because of its atypical late appearance, a case of a 65 year old man is presented who developed a postpericardiotomy syndrome and subsequently a pericardial clot nearly two years after aortocoronary bypass grafting.

Pericardial clot after open heart surgery: its specific localization and haemodynamics.

Transoesophageal echocardiography disclosed a localized pericardial blood clot compressing the right atrium (RA) and/or right ventricle (RV) in 15 patients suffering from low cardiac output failure soon after open-heart surgery. The left ventricular end-diastolic diameter was small (38.4 +/- 10.1 mm) and its fractional shortening normal (34.9 +/- 10.2%). These findings suggested cardiac tamponade as a result of pericardial clot. However, the 'y' trough of the RA pressure tracing was prominent, which is not characteristic of typical cardiac tamponade, but rather of constrictive pericarditis. This implies therefore that the pathophysiology of cardiac tamponade by pericardial clot differs from that of tamponade by fluid. Emergency open-chest removal of the pericardial clot was performed in seven patients, with good results. Pericardial clot produces low cardiac output soon after open-heart surgery, but its location is specific and its haemodynamics are not characteristic of cardiac tamponade.

ROENTGENOGRAM OF THE MONTH

Injuries from nail guns are a unique type of penetrating trauma seen in emergency departments (EDs), rising in prevalence in the United States. These devices can lead to life-threatening injuries that require rapid diagnosis to help guide management.An elderly man was brought to the ED having sustained a nail gun injury to the chest. After loss of pulses, brief closed chest compressions and rapid blood product administration led to a return of spontaneous circulation. Using bedside ultrasound, a metallic foreign body was identified tracking through the right ventricle with associated pericardial fluid and pericardial clot. This rapid diagnosis with bedside ultrasound helped facilitate timely transport to the operating room for median sternotomy, foreign body removal, and pledgeted cardiac repair.With continued developments in image quality and acquisition, and improvements of physician operator performance, ultrasonography has continued to make significant impacts in traumatically injured patients in new ways. We present this case report to highlight precordial nail gun injuries and to emphasize the diagnostic capabilities of bedside ultrasound for these patients.