Pseudo-Pericardial Tamponade After Cardiac Surgery

June 4, 2017 | Autor: Raquel Garcia | Categoria: Cardiac Surgery, Humans, Male, Differential Diagnosis, Middle Aged, The American
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Pseudo-Pericardial Tamponade After Cardiac Surgery Jorge Almeida, MD, Raquel Garcia, MD, Vı´tor Monteiro, MD, and Paulo Pinho, MD, Oporto, Portugal

Cardiac tamponade is a common cause of hypotension and low output after cardiac surgery. The authors present a case of false tamponade diagnosis on transesophageal echocardiography in a patient who underwent mitral valve replacement and coronary artery bypass grafting. The diagnosis was not confirmed at surgery, and the cause of the abnormal right atrial filling was a prominent Eustachian valve trapped in the suture for correction of an iatrogenic inferior vena cava laceration. Such a complication must be kept in mind when repairing inferior vena cava lacerations and should be more widely known. (J Am Soc Echocardiogr 2009;22:211.e5-e6.) Keywords: Post–cardiac surgery tamponade, Eustachian valve

CASE REPORT A 70-year-old man with hypertension and diabetes was operated on April 22, 2008, for symptomatic severe degenerative mitral valve regurgitation and coronary disease. The valve was considered unsuitable for repair, and intraoperative transesophageal echocardiography (TEE) was not scheduled. A Carpentier-Edwards 27 biologic prosthesis (Edwards Lifesciences LLC, Irvine, CA) was implanted, and double coronary artery bypass grafting was performed. A laceration at the entry of the inferior vena cava (IVC) in the right atrium occurred at the time of venous cannula removal and was sutured with a Prolene 400 discontinuous suture (Ethicon, Inc., Somerville, NJ). The patient was easily weaned from bypass, but in the intensive care unit, progressive hemodynamic deterioration refractory to the standard fluid and inotropoic therapy occurred, and intra-aortic balloon support was needed. Troponin levels increased within the expected values (from 0.89 to 12 ng/mL). TEE requested on the first postoperative day showed a normal prosthesis and quite normal function of both ventricles. Because of fluid over the left atrium and signs of right atrial (RA) compression, (Figure 1, Video 1), cardiac tamponade was suspected, and a surgical approach in the intensive care unit was decided upon. Surprisingly, no clots were found, and only a small amount of pericardial fluid was drained, but on TEE, signs of compression remained, and a mean gradient of 8.9 mm Hg between the IVC and the right atrium was measured on continuouswave Doppler. Considering that the surgical correction of IVC laceration could have created some kind of stenosis, redo was decided upon. Distension of the IVC was observed perioperatively, and at the time of suture removal, it was noticed that the obstruction was caused by the Eustachian valve, which, hooked by the suture, pulled and folded the right atrium, mimicking an external compression. After Eustachian valve release and suture reconstruction with an autologous pericardial patch, TEE disclosed a prominent and thick Eustachian valve in a nor-

From the Center of Thoracic Surgery, S. Joa˜o Hospital, Oporto, Portugal. Reprint requests: Jorge Almeida, MD, Centro de Cirurgia Tora´cica, Hospital de S. Joa˜o, 4202-451 Porto, Portugal (E-mail: [email protected]). 0894-7317/$34.00 Copyright 2009 by the American Society of Echocardiography. doi:10.1016/j.echo.2008.12.008

mal-sized right atrium (Figure 2, Video 2), and the Doppler mean gradient between the IVC and the right atrium dropped to 2.9 mm Hg. Following IVC obstruction correction, the patient’s hemodynamics improved. Intra-aortic balloon support was suspended 24 hours later, and the patient was discharged from the intensive care unit at 72 hours. However, because of right inferior limb malperfusion related to intra-aortic balloon support and diabetic vascular disease, the patient remained in the hospital for 30 days. DISCUSSION Post cardiac surgery tamponade is a common cause of hypotension and low output and frequently assumes an atypical presentation.1 This complication can occur sooner or later after surgery and should always be kept in mind as a reason for postoperative hemodynamic deterioration.2 In our patient, the observation of pericardial fluid over the left atrium in association with signs of RA compression and turbulent flow entering from the IVC led us to presume that RA cardiac tamponade was the cause of the postoperative low-output condition. Although a tighter suture of the IVC laceration could by itself justify the flow turbulence at the RA entrance, it could not explain the curved aspect of the RA free wall and the reduced size of the cavity observed on TEE. Intraoperative confirmation that the Eustachian valve was caught by the suture, pulling the RA free wall, reinforced the diagnosis of false tamponade. We believe that the patient’s hemodynamic deterioration was caused by two mechanisms related to the Eustachian valve: obstruction to RA filling at the IVC entry and traction of the RA free wall with decreased compliance because of a small-sized cavity. The Eustachian valve, a remnant of the right valve of the primitive sinus venosus, in fetal life directs oxygenated blood from the IVC into the systemic circulation through the foramen ovale. After birth, it may disappear or persist as a nonfunctional structure originating from the orifice of the IVC.3 Problems at surgery caused by enlarged Eustachian valves were described in patients operated for ostium secundum atrial defects: being mistaken for the inferior border of the septal defect, the Eustachian valve was included in the repair, shunting the IVC venous blood to the left atrium.4,5 We could not find in the medical literature any case of false cardiac tamponade caused by the reasons described here. Despite its rarity, RA flow obstruction caused by the entrapment of a Eustachian valve 211.e5

211.e6 Almeida et al

Journal of the American Society of Echocardiography February 2009

Figure 1 A small amount of pericardial fluid was observed over the left atrium (LA) (asterisk). The RA free wall was curved (arrow), as if under external compression; turbulence of the flow coming from the IVC could be seen on color Doppler. Aot, Aorta.

Figure 2 A thick and prominent Eustachian valve in a normalsized right atrium (RA) can be observed (arrow). The flow filling the right atrium from the IVC is now nearly normal on color Doppler.

in the surgical repair of an IVC laceration can occur and should be considered in a postoperative patient with hemodynamic deterioration, especially when echocardiographic findings are not classic for pericardial tamponade.

2. Kuvin JT, Harati NA, Pandian NG, Bojar RM, Khabbaz KR. Postoperative cardiac tamponade in the modern surgical era. Ann Thorac Surg 2002; 74:1148-53. 3. Otto CM. Textbook of clinical echocardiography. 2nd ed. Philadelphia: W.B. Saunders; 2000. 4. Gallaher ME, Sperling DR, Gwinn JL, Meyer BW, Fyler DC. Functional drainage of the inferior vena cava into the left atrium—three cases. Am J Cardiol 1963;12:561-6. 5. Sapin PM, Salley RK. Arterial desaturation and orthodeoxia after atrial septal defect repair: demonstration of the mechanism by transesophageal and contrast echocardiography. J Am Soc Echocardiogr 1997;10: 588-92.

REFERENCES 1. Russo AM, O’Connor WH, Waxman HL. Atypical presentations and echocardiographic findings in patients with cardiac tamponade occurring early and late after cardiac surgery. Chest 1993;104:71-8.

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