Subxiphoid Pericardial Window in Patients with Suspected Traumatic Pericardial Tamponade

The technique, indications, and results of subxiphoid pericardial window in penetrating chest wounds with suspected traumatic pericardial tamponade are reported.The classic signs of pericardial tamponade (elevated central venous pressure, muffled heart sounds, and paradoxical pulse) are unreliable in an emergency situation. Chest roentgenograms and electrocardiograms are of little diagnostic value. Pericar-dicentesis was either falsely positive or negative in 50% of our patients. Therefore, unexplainedhigh central venous pressure and hypotension were considered to be pericardial tamponade until disproved by the results of a subxiphoid pericardial window.There were 4 negative and 46 positive findings of tamponade in 50 consecutive patients with suspected traumatic pericardial tamponade who underwent creation of a subxiphoid pericardial window. There were no deaths or complications from the procedure. The early use of subxiphoid pericardial window has been a major factor in reducing our mortality rate from penetrating heart wounds to 12% overall, and 8% in the past three years.     

Chylopericardial tamponade

Pericardial tamponade is a life-threatening emergency. Chyle is a rare cause of pericardial effusion and can lead to cardiac tamponade. This case illustrates the presentation, work-up and operative video of a patient in pericardial tamponade secondary to chylopericardium.     

Unusual Delayed Manifestation of a Penetrating Chest Trauma

Abstract Pericardial tamponade remains a diagnostic challenge to the clinician especially when the patient is well compensated hemodynamically. We report an unusual case who sought medical help 1 month after having been stabbed in his chest. An investigation revealed a perforation of the myocardium and a pericardial tamponade. The patient survived thanks to a large organized clot that plugged the perforation. The patient was exposed to increased risk due to delayed onset, recognition, and therapy of the tamponade. Most reports on this subject deal with acute pericardial tamponade. Only few cases of delayed pericardial tamponade have been reported. A review of the relevant literature and the therapeutic approaches are discussed.     

Pericardial tamponade: an unusual complication of lobectomy for lung cancer.

A rare case of pericardial tamponade developed in a 69-year-old man after a right upper lobectomy for lung cancer. This unusual complication presented in the early postoperative period and was associated with what we believed to be an aberrant right bronchial artery coming off the intrapericardial portion of the aorta. This vessel retracted into the pericardial sac where it bled causing a pericardial tamponade.     

Laparoscopic pericardio-peritoneal window: an alternative approach in the treatment of recurrent pericardial effusion, in-hospital evolution and survival

BACKGROUND: Although cardiac tamponade due to pericardial effusion is not frequently seen it may, in many cases require surgical drainage. The aim of this study is to show our experience with a laparoscopic approach to perform the pericardio-peritoneal window in the management of recurrent pericardial effusion. METHODS: We included 16 patients with recurrent pericardial effusion and echocardiographic global tamponade. A pneumoperitoneum was made and 3 trocars were placed; an avascular area of the diaphragm was chosen and a pericardial window was made (4 cm diameter). RESULTS: Pericardial-peritoneal window was carried out successfully (mean operative time 40 min). All patients presented relief of symptoms. The mean follow-up was 729 days. No patient experienced recurrence on repeated ecocardiographic examinations. There were no fatal events related to the procedure. CONCLUSIONS: Laparoscopic pericardial window is a simple, safe, and effective alternative for the treatment of recurrent pericardial effusion with global cardiac tamponade.     

Hemodynamics of cardiac tamponade: early recognition from jugular venous flow velocity.

An experimental study was undertaken to determine the effect of cardiac tamponade on peak jugular venous flow velocity (JVFV). Tamponade was produced in seven dogs by incremental infusion of saline into the pericardial cavity while right atrial pressure, right ventricular pressure, pericardial pressure, aortic pressure, electrocardiogram cardiac output, respiration and directional jugular venous flow velocity was monitored. The development of tamponade was associated with an increase in venous and pericardial pressure. Aortic pressure and cardiac output declined progressively. The control JVFV averaged 14 cm/sec and declined markedly during tamponade before other hemodynamic parameters had changed significantly. A 10% decline in mean aortic pressure was associated with a decrease in JVFV to 53% of control. Jugular venous flow velocity had decreased markedly before pericardial pressure or venous pressure had risen into a range suggestive of tamponade. This study documents the marked reduction in JVFV early in the course of cardiac tamponade which can be easily monitored with a directional Doppler velocity detector.     

Pericardial Decompression

Pericardial tamponade and chronic pericardial effusion were treated in 32 patients by creating a subxiphoid pericardial window under local anesthesia in preference to pericardiocentesis or pericardiectomy. Chest roentgenograms, fluoroscopy, and cardiac catheterization as standard clinical methods of diagnosis have been largely replaced by echocardiography as the most sensitive method for detecting pericardial effusion. Eleven patients had pericarditis of viral, uremic, or purulent origin. Two had intrapericardial hemorrhage following catheter perforation of the heart. Four had pericardial effusion associated with cardiomyopathy and rheumatoid arthritis. In the remaining 15 patients malignancy was the cause of tamponade. In 10 patients we attempted to control the effusion initially with pericardiocentesis. Five of these (50%) required an additional procedure. In 22 patients subxiphoid pericardial decompression was the primary method of treatment; there were no fatalities during or immediately following operation. None of these patients has had any recurrence of tamponade or effusion for up to three years.     

Intrapericardial urokinase irrigation and systemic corticosteroids: an alternative to pericardectomy for persistent fibrino-purulent pericarditis

A 39-year-old man was admitted for upper abdominal pain and shortness of breath. The chest roentgenogram demonstrated cardiomegaly and left lower lobe atelectasis. Echocardiography showed circumferential pericardial effusion with signs of cardiac tamponade. Pericardial biopsy and fluid analysis were consistent with fibrino-purulent pericarditis. Despite broad-spectrum antibiotics, percutaneous and subsequently surgical drainage, pericardial effusion and tamponade recurred. We report successful treatment of a non-resolving fibrino-purulent pericardial effusion by combined intrapericardial irrigation of fibrinolytics and systemic corticosteroids administration as an alternative to pericardectomy.     

Percutaneous Tube Pericardiostomy

Abstract The classic subxiphoid pericardial window technique and the newer, minimally invasive percutaneous fluoroscopy-controlled method of surgical treatment of pericardial effusions and/or tamponade are reviewed and compared based on 12 years of surgical experience. Since 1988, 114 patients underwent surgery for treatment of pericardial effusion and/or tamponade. The classic subxiphoid approach was used on 66 patients, and since 1993, the percutaneous tube pericardiostomy method was employed on 48 patients. In choosing a method for pericardial decompression, disease etiology and patient characteristics must be considered as well as the experience of the surgeon.     

Myocardial effects of pericardial tamponade

Through a previously implanted catheter, normothermic normal saline solution was infused into the pericardial sacs of dogs. Sufficient pericardial tamponade was induced to lower the arterial pressure from an average control of 160/112 mm. Hg to an average of 97/69. Tamponade was maintained for 6 hours during constant monitoring of arterial, central venous, and pericardial pressures. During the 72 hours following tamponade, serial determinations of serum creatine phosphokinase, serum glutamic oxaloacetic transaminase, and lactic dehydrogenase were made. At 72 hours the animals were sacrificed and their hearts studied for gross and microscopical myocardial pathology. All experimental animals showed striking enzyme elevations, and 6 of 10 had visible myocardial necrosis. Correlation between elevations of serum CPK and central venous and pericardial pressures with the degree of myocardial necrosis was significant at the p < 0.005, < 0.009, and < 0.013 levels, respectively. Prolonged pericardial tamponade may result in significant myocardial necrosis, which suggests coronary artery insufficiency and myocardial hypoxia as a cause.     

Repair of intrapericardial rupture of left sinus of Valsalva aneurysm

A 62-year-old man with no history of preexisting heart disease was seen in cardiogenic shock. Prompt cardiac catheterization and aortography revealed pericardial tamponade and aneurysms of the right and left sinuses of Valsalva. Immediate sternotomy relieved the tamponade, which was secondary to an aneurysm of the left sinus of Valsalva rupturing into the transverse pericardial sinus. Endoaneurysmorrhaphy was performed successfully.     

Pericardio-peritoneal drainage using a subcostal approach.

A 56-year-old man admitted to our hospital for cardiac tamponade due to dilated cardiomyopathy did not respond to treatment by usual medical means or surgery. Pericardio-peritoneal drainage was conducted using a subcostal approach. Seven months later, the patient remains well and free of signs of pericardial tamponade. This method has proved to be safe and effective in patients with persistent massive pericardial effusion.     

Ketamine anesthesia for pericardial window in a patient with pericardial tamponade and severe COPD

PURPOSE: To describe the use and concerns of ketamine anesthesia for pericardial window in a patient with pericardial tamponade and severe chronic obstructive pulmonary disease (COPD) with CO(2) retention. CLINICAL FEATURES: A 73-yr-old woman with long-standing COPD and cor pulmonale admitted with pericardial effusion and tamponade had surgery for a pericardial window receiving a total of ketamine 450 mg iv. Arterial pCO(2) increased from 71.8 mmHg preoperatively to 96 mmHg intraoperatively postdrainage of 1000 mL of effusion. Hemodynamic stability and SpO(2) >93% were maintained. Intubation was avoided and concerns of increased pulmonary vascular resistance and potential for right ventricular failure in an already compromised right ventricle were not observed clinically. CONCLUSION: In this patient with pericardial tamponade, COPD and CO(2) retention, the advantages of ketamine included maintaining spontaneous ventilation, avoiding institution and weaning of mechanical ventilation, bronchodilation and relative preservation of the CO(2) response curve. Deleterious effects on right ventricular afterload were not observed.     

Pericardial fluid gas analysis in hemorrhagic pericardial tamponade.

Nine patients with hemorrhagic pericardial tamponade were studied to determine the localizing value of gas analysis of pericardial fluid in therapeutic pericardiocentesis. The aspirate and the central venous blood was analyzed simultaneously for partial pressure of oxygen (PO2), partial pressure of carbon dioxide (PCO2), and hematocrit at the time of pericardiocentesis. In all 9 patients the difference in hematocrit between the pericardial fluid and the central venous blood was not significant. The PCO2 of pericardial fluid was significantly higher than that of central venous blood (p less than 0.025). The PO2 of pericardial fluid was consistently and significantly lower than that of central venous blood (p less than 0.005). We conclude that in patients with hemorrhagic pericardial tamponade, the simultaneous measurement of PO2 and PCO2 of central venous blood and pericardial fluid is a useful rapid bedside method to confirm the site of aspiration during pericardiocentesis. The PO2 determination is statistically the best discriminator between the two fluids in this setting.     

Emergent surgical treatment for purulent pericarditis associated with cardiac tamponade; report of a case

We describe a case of purulent pericarditis presented with cardiac tamponade. A 65-year-old man was admitted to our hospital with shock by cardiac tamponade and high grade fever. Transthoracic echocardiography revealed a large amount of pericardial effusion. Surgical drainage via median sternotomy was carried out in an emergent manner. Because culture of pericardial effusion showed positive for methicillin sensitive Staphylococcus aureus and thick white purulence covering over all pericardium, purulent pericarditis was diagnosed. Postoperative course was uneventful and discharged in a good condition. Special care should be taken of purulent pericaditis in differential diagnosis of cardiac tamponade.     

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 less than 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.     

Pericardial tamponade secondary to perforation by central venous catheters in orthopaedic patients.

Pericardial tamponade from an indwelling central venous catheter developed in four orthopaedic patients. Two of these patients died acutely, and the other two sustained severe anoxic brain injury. The early signs of tamponade include tachycardia, hypotension, and increased central venous pressure. The outcome most often is fatal. When a central venous catheter has been placed incorrectly or has migrated, it can perforate the heart and produce pericardial tamponade. To avoid this complication, the tip of the catheter must be placed within the superior vena cava rather than the right atrium, and the position of the catheter must be ascertained with a radiograph of the chest. Prompt recognition and treatment of pericardial tamponade are imperative if a disastrous outcome is to be prevented.     

Acute Stanford type B dissection and cardiac tamponade: rupture from around ductus arteriosus

Pericardial tamponade is rarely associated with acute Stanford type B aortic dissection. We encountered this unusual combination in a 59-year-old patient. He underwent an emergency drainage procedure through a midline sternotomy. Operative findings strongly suggested that the dissected aorta ruptured into the pericardial cavity from around the ductus arteriosus. Clinicians should be aware that Stanford type B aortic dissection can cause pericardial tamponade.     

Cardiac herniation mimics cardiac tamponade in blunt trauma. Must early resuscitative thoracotomy be done?

Blunt rupture of the pericardium is a rare injury. Strangulated cardiac hernia following blunt trauma is one cause of reversible cardiac arrest. Traumatic pericardial tears usually have delayed diagnoses and carry high mortality rates (64%). Clinical signs mimic cardiac tamponade during the primary survey. We report here two cases of blunt trauma. Both patients arrived alive in the emergency room and presented signs of cardiac tamponade caused by pericardial rupture.