Talks
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Resident
Discipline/Specialty (Author 1)
Internal Medicine
Academic Level (Author 2)
Resident
Discipline/Specialty (Author 2)
Internal Medicine
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Resident
Discipline/Specialty (Author 3)
Internal Medicine
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Medical Student
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Community/Public Health
Abstract
Introduction: Pericardial effusion (PE) incidence can go up to 85% after cardiac procedures, however, not every pericardial effusion causes hemodynamic instability. Progression to Pericardial Tamponade (PT) occurs in 0.1 to 8.8% and may be either early (within 24 h post-cardiac surgery) or late (presenting within a week post-procedure). Both presentations may be attributed to anticoagulant use, inadequate mediastinal drainage, coagulopathy, post-pericardiotomy syndrome (recurrent pericardial effusion).
Patient presentation time might be misleading, as pericardial effusion’s clinical symptoms are varied, ranging from asymptomatic, to shortness of breath, chest pain or discomfort, hypotension, tachycardia, or other non-specific symptoms like cough, fever, and malaise. Progression to PT must be suspected with the onset of symptoms of impaired cardiac function such as dyspnea, tachycardia, jugular venous distension (JVD), pulsus paradoxus (pathognomonic), peripheral cyanosis and in the more severe cases arterial hypotension and shock. The well-known Beck triad (hypotension, JVD, decreased heart sounds) is found in less than half of the patients with PE or PT and has demonstrated low sensitivity. Hemodynamic instability is not always evident, and imaging might be needed to support diagnosis. 2-D echocardiography is the standard and fastest imaging diagnostic method for PE/PT, it can also measure hemodynamic variables. Computed tomography (CT) and MRI. Interestingly, clinical and imaging findings in patients who underwent a cardiac procedure might be atypical, as post-surgical tissue will include different characteristics such as localized adhesions and expected inflammatory cells.
We present a case of a patient who developed acute on chronic CHF and large pleural effusion after a successful CABG. Symptom persistency after thoracentesis required high clinical suspicion of the development of pericardial tamponade as late complication after CABG.
Case: A 65-year-old male with a history of DM2 with renal and circulatory manifestation, hypertension, OSA on CPAP, a nonischemic cardiomyopathy with LVEF of 25 to 30 with chronic systolic congestive heart failure, paroxysmal atrial fibrillation s/p ablation in 2021 was admitted due to non-Stemi in the setting of atrial fibrillation with troponin of 4525. Cardiac catheterization 5/23/2023 demonstrated a 60% left main stenosis and 99% proximal LAD stenosis, stabilized with an intra-aortic balloon pump and status post coronary bypass surgery x2 vessels with LIMA to the LAD and saphenous vein graft to the OM2 as well as left atrial appendage clip on 5/25/2023. His post operative course was complicated by acute on chronic CHF and large left pleural effusion. Left thoracentesis was recommended but he had received clopidogrel post operative and pulmonologist deferred thoracentesis for 5 days. The patient was discharged home on 6/3/2023 but returned on 6/4/2023 with persistent dyspnea and orthopnea. The patient underwent thoracentesis on 6/6/2023 with 900 mL removed. The patient developed cardiogenic shock after and a 2D echo on 6/7/2023 demonstrated a loculated posterior pericardial effusion with tamponade involving the RV, RA and LA. Patient underwent emergent pericardiocentesis surgically with placement of a Blake drain and evacuation of 800 mL of serous sanguineous fluid with resolution of the shock.
Conclusion: Late tamponade is a rare but serious complication that can occur after coronary artery bypass grafting surgery. Some causes of late tamponade can include infection, suture abscess, medications, such as anticoagulants or antiplatelet drugs, medical conditions, such as cancer, connective tissue disorders, and coagulation disorders. Prompt diagnosis and intervention are crucial to manage this complication effectively. Preventing late tamponade is largely about maintaining a high index of suspicion and being proactive in identifying and addressing potential risk factors and complications. Management of late tamponade is a critical and time-sensitive process, and it requires a coordinated effort by a healthcare team. The key is to relieve the pressure on the heart while addressing the underlying causes to prevent recurrence. Early recognition and intervention significantly improve the outcome for patients with late tamponade after CABG.
Presentation Type
Talk
Recommended Citation
Garcia Cruz, Jian; Kondapavuluru, Roy; Othon Martinez, Diana; and Perez Rodriguez, Julio, "Late Tamponade after Coronary Artery Bypass Grafting" (2024). Research Colloquium. 11.
https://scholarworks.utrgv.edu/colloquium/2024/talks/11
Included in
Late Tamponade after Coronary Artery Bypass Grafting
Introduction: Pericardial effusion (PE) incidence can go up to 85% after cardiac procedures, however, not every pericardial effusion causes hemodynamic instability. Progression to Pericardial Tamponade (PT) occurs in 0.1 to 8.8% and may be either early (within 24 h post-cardiac surgery) or late (presenting within a week post-procedure). Both presentations may be attributed to anticoagulant use, inadequate mediastinal drainage, coagulopathy, post-pericardiotomy syndrome (recurrent pericardial effusion).
Patient presentation time might be misleading, as pericardial effusion’s clinical symptoms are varied, ranging from asymptomatic, to shortness of breath, chest pain or discomfort, hypotension, tachycardia, or other non-specific symptoms like cough, fever, and malaise. Progression to PT must be suspected with the onset of symptoms of impaired cardiac function such as dyspnea, tachycardia, jugular venous distension (JVD), pulsus paradoxus (pathognomonic), peripheral cyanosis and in the more severe cases arterial hypotension and shock. The well-known Beck triad (hypotension, JVD, decreased heart sounds) is found in less than half of the patients with PE or PT and has demonstrated low sensitivity. Hemodynamic instability is not always evident, and imaging might be needed to support diagnosis. 2-D echocardiography is the standard and fastest imaging diagnostic method for PE/PT, it can also measure hemodynamic variables. Computed tomography (CT) and MRI. Interestingly, clinical and imaging findings in patients who underwent a cardiac procedure might be atypical, as post-surgical tissue will include different characteristics such as localized adhesions and expected inflammatory cells.
We present a case of a patient who developed acute on chronic CHF and large pleural effusion after a successful CABG. Symptom persistency after thoracentesis required high clinical suspicion of the development of pericardial tamponade as late complication after CABG.
Case: A 65-year-old male with a history of DM2 with renal and circulatory manifestation, hypertension, OSA on CPAP, a nonischemic cardiomyopathy with LVEF of 25 to 30 with chronic systolic congestive heart failure, paroxysmal atrial fibrillation s/p ablation in 2021 was admitted due to non-Stemi in the setting of atrial fibrillation with troponin of 4525. Cardiac catheterization 5/23/2023 demonstrated a 60% left main stenosis and 99% proximal LAD stenosis, stabilized with an intra-aortic balloon pump and status post coronary bypass surgery x2 vessels with LIMA to the LAD and saphenous vein graft to the OM2 as well as left atrial appendage clip on 5/25/2023. His post operative course was complicated by acute on chronic CHF and large left pleural effusion. Left thoracentesis was recommended but he had received clopidogrel post operative and pulmonologist deferred thoracentesis for 5 days. The patient was discharged home on 6/3/2023 but returned on 6/4/2023 with persistent dyspnea and orthopnea. The patient underwent thoracentesis on 6/6/2023 with 900 mL removed. The patient developed cardiogenic shock after and a 2D echo on 6/7/2023 demonstrated a loculated posterior pericardial effusion with tamponade involving the RV, RA and LA. Patient underwent emergent pericardiocentesis surgically with placement of a Blake drain and evacuation of 800 mL of serous sanguineous fluid with resolution of the shock.
Conclusion: Late tamponade is a rare but serious complication that can occur after coronary artery bypass grafting surgery. Some causes of late tamponade can include infection, suture abscess, medications, such as anticoagulants or antiplatelet drugs, medical conditions, such as cancer, connective tissue disorders, and coagulation disorders. Prompt diagnosis and intervention are crucial to manage this complication effectively. Preventing late tamponade is largely about maintaining a high index of suspicion and being proactive in identifying and addressing potential risk factors and complications. Management of late tamponade is a critical and time-sensitive process, and it requires a coordinated effort by a healthcare team. The key is to relieve the pressure on the heart while addressing the underlying causes to prevent recurrence. Early recognition and intervention significantly improve the outcome for patients with late tamponade after CABG.