Postoperative Tamponade Research Articles

Congenital Heart Surgery Nomenclature and Database Project: diseases of the pericardium

The extant nomenclature for pericardial disease is reviewed for the purpose of establishing a unified reporting system. The subject was debated and reviewed by members of the STS-Congenital Heart Surgery Database Committee and representatives from the European Association for Cardiothoracic Surgery. All efforts were made to include all relevant nomenclature categories, using synonyms where appropriate. No classification system has been reported. The groups were based on disease processes, and include: effusive pericarditis (pericardial effusion), constrictive pericarditis, cardiac tamponade, postoperative pericardial effusion, postoperative cardiac tamponade, postpericardiotomy syndrome, congenital defect, neoplastic process, benign mass, pericardial cyst, pneumopericardium, and chylopericardium. A comprehensive database set is presented that is based on a hierarchical scheme. Data are entered at various levels of complexity and detail, which can be determined by the clinician. These data can lay the foundation for comprehensive risk stratification analyses. A minimum database set is also presented that will allow for data sharing and would lend itself to basic interpretation of trends.

Spectacle-mounted prisms as an aid in face-down positioning after vitrectomy surgery

Purpose: To report a modification in the design of bed spectacles to provide an aid for patients who undergo face-down positioning after vitrectomy with gas-fluid exchange and postoperative gas tamponade. Methods: New equipment design. Bed spectacles that use prisms to move the image 90 degrees around the horizontal meridian were modified by rotating the prisms in the frame 180 degrees and adding nosepads and cable temples. The spectacles were given to 12 patients for use during postoperative face-down positioning. A questionnaire was used to evaluate the helpfulness of the spectacles during face-down positioning. Results: Patients ranked the spectacles as “helpful” to “very helpful” with a mean and SD of 8.3 ± 1.6 on a scale of 1 to 10, where 1 was “a hindrance” and 10 was “very helpful.” Patients wore the spectacles an average of 5.7 ± 4.5 hours a day (range, 1.5 to 15 hours). Conclusion: Modified bed spectacles appear to be a portable aid to patients who undergo face-down positioning while sitting, standing, or prone.

The Management of Giant Retinal Tears Using Perfluoroperhydrophenanthrene: A Multicenter Case Series

The purpose of the study was to determine the predictors of success and evaluate the use of perfluoroperhydrophenanthrene as an intraoperative and postoperative tool in the management of giant retinal tears in a multicentered collaborative study. Multicentered prospective case series. Twenty-three centers consecutively enrolled 162 eyes of 161 patients with retinal tears 90 degrees or greater in circumferential extent. Perfluoroperhydrophenanthrene was used as an intraoperative surgical adjunct in all cases and left after surgery in 16 eyes (9.9%). Retinal reattachment and visual acuity. Intraoperative reattachment was achieved in 158 eyes (97.5%); 147 eyes (90.7%) remained attached at their most recent follow-up. Seventy-nine eyes (48.8%) experienced an improvement in their visual acuity, 26 eyes (16.0%) remained unchanged, and 57 (35.2%) worsened. Recurrent retinal detachment occurred in 80 patients (49.4%). Other significant postoperative complications included cataract formation in 20 (39.2%) of 51 eyes, macular pucker in 12 (7.4%), corneal decompensation in 10 (6.2%), and hypotony (intraocular pressure equal to or less than 5 mmHg) in 9 (5.6%). A chi-square analysis of preoperative characteristics showed that hypotony (P = 0.007), macular detachment (P = 0.020), a history of cataract extraction (P = 0.003), poor visual acuity (P = 0.000), giant tear extent greater than 180 degrees (P = 0.004), and higher grade proliferative vitreoretinopathy (P = 0.000) all predicted a poor visual outcome. Vitreon (Vitrophage, Inc., Lyons, IL) was left in 16 eyes (9.9%) for an extended postoperative retinal tamponade for between 3 and 1034 days (mean, 87.2 days). The Vitreon was well tolerated, and these eyes experienced a similar outcome and rate of retinal reattachment to the rest of the group. Vitreon is a safe and useful adjunct to pars plana vitrectomy in the management of giant retinal tears and may, additionally, be the perfluorocarbon liquid that can be used most safely as a temporary postoperative tool for extended retinal tamponade, reinforcing its role as a useful adjunct in the management of these complex retinal detachments.

Minimally Invasive Aortic Valve Surgery

Minimally Invasive Aortic Valve Surgery

Localised cardiac tamponade following cardiac surgery

We report two cases of severe cardiac tamponade following cardiac surgery. In each case a haemorrhagic collection resulted in a localised tamponade. The clinical presentation in both cases was atypical and, although the possibility of tamponade was considered, the absence of classical signs delayed diagnosis until echocardiography was performed. These cases illustrate the varied presentation of tamponade after cardiac surgery which may be localised, highlighting the need for a high level of clinical suspicion and early use of echocardiography to make a prompt diagnosis. The transoesophageal echocardiogram may have particular relevance in the detection of localised collections causing a tamponade effect. The cases indicate that post-operative cardiac tamponade occurs over a wide time-scale following surgery and that anticoagulation may be a contributing factor.

Experience with cardiac tamponade following open heart surgery.

Cardiac tamponade following open heart surgery is well described, although, fortunately, uncommon. Unlike more classical "primary" tamponade, the clinical features are not specific, and this can delay diagnosis. In practice, the threshold for investigation must be low, and echocardiography has been invaluable in the detection and localization of pericardial collections. Several factors are believed to contribute to the likelihood of postoperative tamponade, but the mechanisms are not clearly understood. Resternotomy, under general anesthesia, or subxiphoid pericardiotomy, under local or general anesthesia, are effective forms of treatment. However, recent success with the use of percutaneous pericardiocentesis under echocardiographic guidance has shown that postoperative tamponade can be treated safely and effectively by this method.

Surgical results for proliferative vitreoretinopathy.

We reviewed 88 consecutive eyes that underwent vitrectomy for retinal detachment with proliferative vitreoretinopathy (PVR) and were followed a minimum of six months. A primary goal of the surgery was the meticulous trimming of the vitreous base in hopes of decreasing the incidence of post-operative reproliferation and anterior PVR. Those eyes with anterior PVR had aggressive release of vitreous base contraction (anteroposterior and circumferential) with intraocular scissors. All posterior tractional membranes were removed. All eyes received long-acting gas for postoperative retinal tamponade. Macular reattachment was achieved in 78 (88.6%) eyes. Forty-six (52.3%) obtained at least 5/200 vision. Seventeen (19%) eyes were re-operated at least once. We compared the importance of initial lens status (pseudophakic, aphakic, phakic), need for relaxing retinotomy, presence of anterior PVR, and history of previous vitrectomy on the anatomic and visual results. No single factor was responsible for a statistically significant effect on either vision or anatomic success, except for the need for a relaxing retinotomy, which carried with it a decreased chance of an eye obtaining 5/200 vision (Fisher's exact test, p = 0.03).

Cervical Pregnancy Following In Vitro Fertilization: Evacuation After Uterine Artery Embolization with Subsequent Successful Intrauterine Pregnancy

A case is described in which a cervical pregnancy followed in vitro fertilization. Treatment was delayed at the request of the patient until the second trimester, and was successfully managed by preoperative bilateral angiographic uterine artery occlusion, surgical evacuation, and postoperative balloon tamponade. Subsequent embryo transfer of previously cryopreserved embryos resulted in a normal intrauterine pregnancy and delivery without complications. This case highlights the need for awareness of cervical pregnancy following in vitro fertilization and the success of management which preserves fertility.

Management of Giant Retinal Tears Using Perfluorodecalin as a Postoperative Short-Term Vitreoretinal Tamponade: A Long-Term Follow-Up Study

To avoid postoperative "compartmentalization" of the vitreous cavity, which may accelerate the recurrence of proliferative vitreoretinopathy (PVR), and to provide a tamponading effect lasting long enough to allow the formation of a firm chorioretinal adhesion by retinopexy, we managed 11 eyes with giant retinal tears and grade-B PVR with lensectomy, vitrectomy, 5-day internal tamponade with perfluorodecalin (PFD), and postoperative supine positioning until the PFD was removed. Baseline characteristics included myopia (10 eyes; range, 5.00 to 15.00 diopters) and perforating trauma (one eye). All patients underwent PFD/fluid exchange 5 days after surgery. Anatomic attachment of the retina was achieved with two operations (the second one being the removal of the PFD) in 9 (82%) of the 11 eyes (median follow up, 18 months). In eight eyes (73%), there was no evidence of reproliferation; in one (successfully reattached after PFD/fluid exchange), a macular pucker developed. The intraocular PFD used as an internal tamponade appeared to be well tolerated for up to 5 days, as judged by static threshold perimetry in the two patients tested, and by the functional outcomes (64% of the reattached eyes had a final visual acuity of 20/40 or better).

Pars Plana Vitrectomy for Treatment of Stage 2 Macular Holes

To assess the anatomic outcome and visual acuities at follow-up after pars plana vitrectomy in the management of stage 2 macular holes. Retrospective. Retina Consultants, Ltd, St Louis, Mo. Thirty-three patients, aged 43 to 75 years, with stage 2 macular holes. Total pars plana vitrectomy with separation of the posterior hyaloid membrane and injection of intraocular gas followed by postoperative face-down positioning. Visual acuity and anatomic appearance of the macular hole. Postoperatively, 20 (61%) of 33 eyes attained a visual acuity of 20/50 or greater. Twenty (61%) of 33 eyes showed an improvement in visual acuity, while nine (27%) of 33 were stable. Four (12%) of 33 eyes showed a decline in postoperative visual acuity with progression to a stage 3 macular hole. Twenty-five (76%) of 33 eyes showed stabilization or improvement in the appearance of the macular hole. Pars plana vitrectomy in conjunction with postoperative intraocular gas tamponade may result in visual and anatomic stabilization or improvement in eyes with stage 2 macular holes. However, because of limited natural history data, it is unknown whether these results are any better than those that might occur without surgery.

Atypical Presentations and Echocardiographic Findings in Patients With Cardiac Tamponade Occurring Early and Late After Cardiac Surgery

Cardiac tamponade, a potentially lethal complication following cardiac surgery, may present either early or late postoperatively and may be difficult to diagnose due to atypical clinical, hemodynamic, or echocardiographic findings. To determine the frequency and clinical features of postoperative cardiac tamponade, we performed a review of 510 consecutive patients who underwent cardiac surgery. The incidence of postoperative cardiac tamponade was 2.0 percent (10/510 patients) and occurred following valvular, bypass, and aortic surgery. Nine of ten patients had either atypical clinical, hemodynamic, and/or echocardiographic findings. The diagnosis of tamponade was made 1 to 30 days (mean = 8.5 days) postoperatively. Presenting symptoms were often mild and nonspecific. Classic signs including hypotension, pulsus paradoxus greater than 12 mm Hg, and elevated jugular venous pressure were present in 7, 6, and 5 patients, respectively. Right heart hemodynamics revealed elevated and equalized diastolic pressures in three of six patients. Two-dimensional echocardiography revealed selective compression of the left ventricle (LV) (four patients), right ventricle (RV) (one patient), left atrium (LA)/RV (one patient), LA/LV (one patient), LA/LV/RV (one patient), all four chambers (one patient), and no diastolic collapse of any chamber (one patient). There was often an absence of anterior pericardial fluid (six patients) with tethering of a portion of the RV to the chest wall anteriorly (five patients). Coagulation parameters were "supratherapeutic" in only three of eight patients who were receiving systemic anticoagulants at the time of diagnosis. The initial diagnosis was confused with congestive heart failure in one patient, pulmonary embolism in three patients, acute myocardial infarction in two patients, and sepsis in one patient. Eight of ten patients survived; all of these patients underwent surgical removal of fluid and/or hematoma in the operating room. We conclude that postoperative tamponade after cardiac surgery may have varied clinical and hemodynamic presentations, often due to selective chamber compression by loculated fluid or clot. Due to its frequently atypical features and presentation that may simulate other disorders, the diagnosis of tamponade should be considered whenever hemodynamic deterioration or signs of low output failure occur in the postcardiotomy patient.

Usefulness of right ventricular indices in early diagnosis of cardiac tamponade

Early diagnosis of postoperative cardiac tamponade is impeded by its clinical similarity to left ventricular failure. Moreover, the hemodynamic changes necessary to diagnose cardiac tamponade are detected by conventional monitoring technique only after clinical compromise. Early signs of cardiac tamponade and left ventricular failure were studied with emphasis on right ventricular function in anesthetized dogs. One group (n = 20) had cardiac tamponade produced by incrementally increasing pericardial pressure (2 to 20 mm Hg), and another group (n = 20) had acute left ventricular failure produced by successive ligation of the anterior descending coronary artery at the lower, middle, and upper thirds. Besides standard hemodynamic measurements, right ventricular function was examined with a rapid-response thermodilution catheter. During cardiac tamponade, cardiac output, right ventricular ejection fraction, right ventricular stroke volume, and right ventricular end-diastolic volume were significantly decreased from baseline values after a pericardial pressure of 8 mm Hg or more ( p < 0.05). Right atrial and pulmonary arterial pressures were not significantly elevated until 14 and 20 mm Hg of pericardial pressure, respectively. Although cardiac function in the left ventricular failure group was reduced after each ligation, right ventricular ejection fraction remained unchanged. This study suggests that right ventricular indices may facilitate earlier diagnosis of cardiac tamponade with greater accuracy.

Left Atrial Tamponade: Diagnosis by Transesophageal Echocardiography

A 60-year-old white man became hypotensive and dyspneic 3 days after right pneumonectomy for bronchogenic carcinoma. Transthoracic echocardiography was nondiagnostic because of technical difficulty. Transesophageal echocardiography demonstrated a loculated posterior pericardial effusion with isolated diastolic left atrial collapse. The hemodynamic disturbance resolved after drainage of the effusion. Transesophageal echocardiography plays a valuable role in the diagnosis of postoperative cardiac tamponade.

Linsenveränderungen nach intraokulärer Tamponade bei Vitrektomie - Lineardensitometrische Bildanalyse von Scheimpflug-Photographien 6 Monate nach der Operation

A complication arising from vitrectomy is the formation of cataract. As a result of an intra- and postoperative tamponade chosen (BSS, air, SF6-gas, silicon oil) the size and frequency of the cataract varies accordingly. 6 months after vitrectomy Scheimpflug photography and microdensitometric evaluation of the negatives were performed on 30 pairs of phacic eyes showing changes in the transparency of the lens. Following silicon oil tamponade a significant deterioration of transparency (t-test) was observed in the lens nucleus of the operated eye; in the area of the lens in front of the nucleus a marked but not significant deterioration of transparency was discovered following both silicon oil and SF6-gas tamponade. In the case of the area in front of the nucleus following SF6-gas tamponade as well as the whole of the lens following BSS or air tamponade a small but not at all significant difference in lens transparency was apparent after comparison of the operated to the non-operated eyes.

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.

Primary Anastomosis for Acute Ascending Aortic Dissection

Intimal tear resection and primary anastomosis of the aorta were used for the treatment of eight patients with DeBakey I and II type acute aortic dissection. Five patients were of DeBakey I type, and three patients were of the II type. Moderate or severe aortic regurgitation (AR) was observed in six of eight patients. The site of the intimal tear was diagnosed by intraoperative echocardiography, and the adventitia corresponding to the intimal tear was transversely opened under total cardiopulmonary bypass. While resuspension of the aortic valve was performed on only one of six patients, AR disappeared in four, postoperatively. Two of eight patients died early postoperatively. The cause of death was postoperative cardiac tamponade in one patient and cerebral herniation in the remaining one. The other six patients have been observed for a mean period of 27 months. There is no late death, and they show no dilatation of the aortic root and deterioration of AR. We believe that this operative method is a simple and safe emergency procedure for DeBakey I and II type acute aortic dissection.

A Case of Delayed Postoperative Cardiac Tamponade with Unusual Echocardiographic Findings

Postoperative cardiac tamponade due to localized compression of the atria occurred in a 64-year-old man after aortic valve replacement and repair of an ascending aortic dissection. The clinical findings were subtle and the echocardiographic findings were unusual. Color Doppler flow imaging assisted in making the diagnosis of localized atrial compression.

鼻閉時の呼吸様式に関する研究

The change of the mode of respiration by two kinds of artificial nasal occlusion was investigated. For the short term occlusion (less than 2 hours), 6 normal adults with the nasal packing were used as subjects, and for the long term occlusion (24 hours) 30 patients who underwent intranasal small surgery with postoperative nasal tamponade were used. The parameters investigated were: respiration time, tidal volume, closing volume, ventilation equivalent, respiratory exchange ratio, and some others.The results were as follows. 1. After the short term occlusion, the inspiration time and the tidal volume increased, and the ventilation equivalent decreased, showing the temporary amelioration of respiratory efficiency. 2. After the long term occlusion, on the other hand, the inspiration time, the tidal volume, and the respiratory exchange ratio decreased, while the ventilation equivalent increased. Therefore, the long term nasal occlusion results in decrease of respiratory efficiency. 3. The increase of the closing volume was observed one hour after the nasal occlusion and continued even after the long term nasal occlusion. This suggests the existence of peripheral air way stenosis.Generally speaking, continuous inspiration of dry air due to the loss of humidifying function of the nose results in the stenosis of peripheral airways by desiccated mucous. Also, the expansion of alveoli becomes insufficient due to the decreased surfactant function.In the condition of this study, the respiration was inhibited after the short term nasal occlusion, because the nasopulmonary reflex caused by the nasal packing overcame the influence of the loss of humidifying effect.On the other hand, after the long term occlusion, as the nasopulmonary reflex was already decreased, the respiration was accelerated although the respiratory function was aggravated.

Late postoperative cardiac tamponade presenting as dysphagia

A case of late cardiac tamponade seen with progressive dysphagia 15 days after aortic valve replacement is reported. The diagnosis was confirmed echocardiographically and successful pericardiocentesis was followed by immediate alleviation of the dysphagia.

Extended retinal tamponade in the treatment of retinal detachment with proliferative vitreoretinopathy.

We have used intraocular sulphur hexafluoride or liquid silicone as an adjunct to vitreous surgery in the treatment of a non-randomised sequential series of 19 eyes with retinal detachment complicated by proliferative vitreoretinopathy. We have studied the surgical results and complications of these two tamponades and drawn preliminary conclusions on their use in retinal reattachment surgery. After a seven-month minimum follow-up 13 (68%) of the eyes have reattached retinas. Six (60%) of 10 eyes treated only with silicone have reattached retinas, and four (67%) of six eyes treated only with sulphur hexafluoride gas tamponade have reattached retinas. An additional three eyes treated initially with silicone oil subsequently developed retinal detachments; all were successfully reattached with sulphur hexafluoride tamponade after silicone oil removal. Intraoperative pneumatic retinal reattachment to assess relief of retinal traction combined with the production of widespread chorioretinal adhesions to wall off persistent anterior traction and detachment, as well as extended postoperative gas tamponade of the retina, appears to enhance the surgical results in retinal detachment complicated by proliferative vitreoretinopathy. Silicone oil tamponade of the retina appears to be useful in cases where retinal traction cannot be entirely relieved and in patients who are unable to tolerate the head positioning required for effective gas tamponade of the retina. A controlled clinical study recently begun will be required to define further the precise role of these methods of retinal tamponade.