Postoperative Tamponade Research Articles

Late Postoperative Tamponade Following Coronary Artery Bypass Grafting in Patients on Antiplatelet Therapy

Myocardial revascularization was performed in 1,361 patients over a 66-month period (February, 1978 to August, 1983) without a single occurrence of late cardiac tamponade. During a subsequent 4-month-period, aspirin and dipyridamole were administered routinely to all coronary bypass patients. The incidence of late cardiac tamponade rose significantly ( p < 0.001) to 3 of 85 patients (3.5%). Routine perioperative administration of aspirin and dipyridamole to patients undergoing myocardial revascularization may be associated with an increased incidence of delayed cardiac tamponade.

Delayed Postoperative Cardiac Tamponade Mimicking Severe Tricuspid Valve Stenosis

A patient developed acute, severe hemodynamic deterioration five days after an aortic valve replacement. Cardiac catheterization revealed a markedly elevated right atrial pressure but a normal right ventricular end-diastolic pressure. Angiography revealed an extrinsic mass causing compression of the right atrium and the tricuspid anulus. A large clot overlying the right atrium and ventricle was found at emergency surgery. Postoperative cardiac tamponade may result in an atypical hemodynamic presentation when there is selective compression of one chamber or of a valve anulus.

Right Ventricular Outflow Obstruction Secondary to Right-sided Tamponade Following Myocardial Trauma

A case of isolated tamponade of the right side of the heart, seen as an abrupt change in the cardiac silhouette and as right ventricular outflow obstruction following myocardial trauma, is presented, along with a review of the English-language literature on delayed postoperative tamponade and loculated pericardial effusion. The importance of a low, fixed cardiac output and nonspecific physical findings in suggesting the clinical diagnosis is emphasized. The absence of many of the classic signs and symptoms of pericardial tamponade is noted, as is the possibility of unusual changes in the appearance or function of the heart in the presence of a loculated effusion. Finally, the differential diagnosis and the results of a variety of diagnostic techniques are discussed.

Impeded coronary flow in anatomic correction of transposition of the great arteries: Prevention, detection, and management

Six infants and a 3-year-old boy underwent primary anatomic repair (arterial switch) of their dextro-transposition of the great arteries (d-TGA). Three died: one on the operating table because of an irreducible kink in the left main coronary artery, one because of postoperative bleeding and tamponade, and one because of a postoperative management error. In the four survivors the preoperative left ventricular-to-right ventricular systolic pressure interrelationships were 35 to 115, 54 to 73, 30 to 80, and 70 to 90 mm Hg. While left ventricular inability to take over the systemic pressure did not appear to be a problem in any of our cases, reduced coronary perfusion seemed to be the rule rather than the exception in this operation. One approach to the problem of obstructed coronary flow is first to construct continuity of the "new" aorta, unclamp it, and mark the appropriate places for coronary anastomoses on the fully distended aorta. It is our conviction that further improvement in the operative technique and better understanding of the risk factors will eventually make the primary anatomic repair of d-TGA the operation of choice for most dextro-transpositions.

Late isolated left ventricular tamponade

A unique case of late postoperative left ventricular tamponade, hemodynamically indistinguishable from severe left ventricular failure, is reported in a patient 1 month after an apparently uncomplicated aortic valve replacement. An echo-free space behind the left ventricle led to surgical exploration and successful resolution of the disease process. To our knowledge, this is the first documented case of isolated left ventricular tamponade in the literature. The findings highlight the importance of postoperative echocardiography in the evaluation of the patient having cardiac surgery.

Delayed Postoperative Cardiac Tamponade: Diagnosis and Management

Symptoms and signs of decreased cardiac output associated with an elevated venous pressure should alert one to the possibility of delayed cardiac tamponade. Enlargement of the cardiothoracic ratio shown by serial roentgenograms and demonstration of significant pericardial effusion by echocardiogram or radionuclide angiocardiography support the diagnosis. Erratic response of the prothrombin time to administration of warfarin and abnormal results of liver function test are additional clues to its diagnosis. Right heart catheterization documents the presence of tamponade and excludes other diagnostic considerations. Operative decompression of the pericardial space can be accomplished by pericardicentesis, subxiphoid pericardiotomy, median sternotomy, or thoracotomy. Hemodynamic observations following the relief of tamponade assure that an adequate therapeutic procedure has been performed.

Cardiopulmonary bypass in infants under four months of age

Thirty infants under 4 months of age who had cardiac surgery with standard cardiopulmonary bypass were reviewed in order to assess the results and applicability of cardiopulmonary bypass in these very young infants. Their major diagnoses were as follows (deaths in parentheses): transposition of the great vessels (TGA), 9 cases (5); aortic stenosis, 5 cases (2); double-outlet right ventricle, 3 cases (3); total anomalous pulmonary venous drainage, 3 cases (one); ventricular septal defect (VSD), 3 cases (0); tetralogy of Fallot, 2 cases (one); pulmonary stenosis, 2 cases (one); atrial septal defect (ASD) with primary pulmonary hypertension, one case (one), VSD and ASD, one case (0); and dextrocardia and common atrioventricular canal, one case (0). The over-all hospital mortality rate was 46.6 per cent (14 deaths). Two deaths in the transposition group resulted from attempts to explore or close a patent ductus arteriosus (PDA). These cases might have been better managed by surface cooling and limited cardiopulmonary bypass. One case of postoperative hemorrhage and cardiac tamponade might have been partially related to the use of cardiopulmonary bypass. Four deaths were due to uncorrectable lesions, two each were related to technical errors and improper choice of operations, and one each was related to irreversible preoperative deterioration, advanced primary pulmonary hypertension, and intractable arrhythmia. Thus the deaths directly related to the use of cardiopulmonary bypass are infrequent. Standard cardiopulmonary bypass, in conjunction with mild-to-moderate hypothermia, is applicable even in small infants and gives satisfactory exposure in most routine operations. No imposition of a significant time limit is advantageous on a surgical teaching service. The so-called Kyoto technique may afford better exposure in repairs of TGA and total anomalous pulmonary venous drainage and may also facilitate concomitant repair of associated extracardiac shunts.

Closure of pericardium after open heart surgery. A way to prevent postoperative cardiac tamponade.

Between July 1968 and December 1975, 821 patients underwent open heart operations. In 596 cases the pericardium was left open and in 225 the pericardium was closed. Forty-one patients in the open pericardium group required reoperation and 23 of these had tamponade. Four patients in the closed pericardium group had reoperation but there was not a single case of tamponade. In most cases that required reoperation the bleeding was from extrapericardial sources. Absence of tamponade in the closed pericardium group can be explained by the fact that blood from extrapericardial sources of bleeding cannot collect round the heart because the pericardium is closed. Thus closure of pericardium helps to prevent tamponade. Reoperations some months or years after the original operation are technically easier and less hazardous if the pericardium has been closed because the closed pericardium prevents the heart from becoming adherent to the back of sternum and also because there are fewer adhesions in the pericardial cavity.

Doppler jugular flow velocity to differentiate cardiac tamponade from failure.

Jugular venous flow velocity (JVFV) was analyzed by the directional Doppler velocity detector in an experimental model to distinguish postoperative acute cardiac tamponade from myocardial failure in eight dogs. Cardiac tamponade was produced by infusion of saline solution into the pericardial cavity; acute myocardial failure was created by temporary occlusion of the left anterior descending artery and circumflex coronary artery. A decrease in mean arterial pressure of only 10% was associated with a decrease in JVFV of 30% +/- 6% (mean +/- SE) in the tamponade group compared to 10% +/- 2% in the myocardial failure group. The difference was statistically significant (P less than .005) and persisted to severe levels of hypotension. An increase in venous pressure to 8 mm Hg resulted in a decrease in JVFV of 41% +/- 11% in the tamponade group. Thus, there is an early notable decrease in JVFV in tamponade, which allows differentiation from myocardial failure.

Latent mediastinal tamponade after open-heart surgery.

Postoperative cardiac tamponade due to mediastinal blood clot or fluid under tension may remain latent for some days after open heart surgery. The initial clinical state frequently masquerades as a state of refractory congestive cardiac failure or a mild low cardiac output syndrome producing mental disorientation. When severe tamponade eventuates there is an extreme surgical emergency, but as one to two weeks may have elapsed since surgery the significance is often missed. The classical picture of tamponade due to pericardial fluid as described by Stewart et al1may occur, but usually there is mediastinal tamponade similar to the acute traumatic mediastinal hematomata described by Endress2and Al-Naaman,3or an encysted collection of clot about the heart producing local compression of one or more cardiac chambers.4 This paper describes seven cases of latent tamponade at Pacific Medical Center which have been instructive in avoiding errors in diagnosis

Postoperative cardiac tamponade produced by thymic hematoma.

Cardiac tamponade may be encountered during the early postoperative period following open heart operations, and is a surgical emergency necessitating immediate reoperation. In such patients, there is usually an excessive amount of postoperative bleeding, accompanied by widening of the mediastinal shadow on chest roentgenogram, progressive elevation of the central venous pressure, and systemic hypotension becoming progressively more severe and less responsive to treatment. This sequence may ensue even though a large communication between the pericardial and pleural spaces was created at the time of operation, and is usually the result of an accumulation of blood and clot restricting cardiac filling. We have recently observed a child, however, in whom the clinical features of cardiac tamponade occurred following correction of the pentalogy of Fallot, and resulted from hemorrhage into the thymus gland. This cause for postoperative cardiac tamponade has apparently not been previously described. Report of a Case An 8-year-old girl

Pericardial drainage at cardiac operations

At the conclusion of cardiac operations, drainage and closure of the pericardium seems preferable to leaving it open. Satisfactory drainage can be obtained by transverse openings at the anterolateral parts of the pericardium directly above the diaphragm. It is here that there is a space in the pericardium adjacent to the ventricles. A drainage tube with side holes can be safely placed in one opening and out the other. We have not had cases of postoperative pericardial tamponade since we began draining the pericardium in this manner.