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Ann Thorac Surg 1999;67:545-546
© 1999 The Society of Thoracic Surgeons

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Case Reports

Pericardial tamponade: an unusual complication of lobectomy for lung cancer

^a Department of Thoracic Surgery, St. Agnes Hospital, Baltimore, Maryland, USA
^b Department of Intensive Care, St. Agnes Hospital, Baltimore, Maryland, USA

Accepted for publication July 25, 1998.

Address reprint requests to Dr McLean, Dept. of Surgery, St. Agnes Hospital, 900 Caton Ave, Baltimore, MD 21229
e-mail: ronald_mclean{at}hotmail.com

	Abstract

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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.

	Introduction

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Major postoperative complications after thoracotomy for lung resection most often involve the cardiorespiratory systems [1–3]. Nagasaki and colleagues [1] found that most deaths associated with thoracotomies were respiratory complications including atelectasis, pneumonia, pulmonary emboli, empyema, and tension pneumothorax in decreasing order of occurrence. Cardiac complications occur less frequently and include atrial tachyarrhythmias, myocardial infarction, ventricular arrhythmias, and congestive heart failure [1]. Von Knorring and associates [2] noted that these complications occur most frequently during the first 2 postoperative days. Complications affecting other systems occur less frequently and might also involve bleeding [1]. Although pericardial tamponade resulting from air or other gases has been reported, pericardial tamponade as a result of bleeding is not commonly cited in the literature.

One reported case of pericardial tamponade associated with bleeding found in the recent literature occurred 13 days after a right upper lobectomy and mediastinal lymph node dissection for lung cancer [4]. Another more pertinent case was complicated by intraoperative pericardial tamponade resulting from a transected inferior pulmonary vein that had retracted into the pericardial sac where it bled freely [5]. The present case illustrates another rare cause of this uncommon complication.

A 69-year-old man presented with a right upper lobe lung nodule that had been increasing in size. His medical history included heavy cigarette smoking, chronic dyspnea, and a positive purified protein derivative test treated with isoniazid. Results of acid-fast bacilli cultures from bronchoscopy were negative. Bronchial brushings showed atypical squamous cells, but results of a computed tomogram-guided needle biopsy were inconclusive.

The patient underwent a right posterolateral thoracotomy with an upper lobectomy. Most of the vessels encountered in the dissection were suture ligated; however, very small vessels were cauterized. Dissection was difficult between the lobes and vessels because of apparent scarring; otherwise the case was uneventful, with an estimated blood loss of 400 mL.

He was stable in the intensive care unit for 4 to 5 hours postoperatively, but then his systolic blood pressure decreased suddenly to 85 mm Hg associated with sinus tachycardia of 130 bpm. Chest tube output was minimal at the time. The hypotension did not respond well to fluids, dopamine, or levophed, and arterial blood gas showed marked metabolic acidosis. Electrocardiogram and chest x-ray results were unremarkable. Urgent transthoracic echocardiogram revealed a large pericardial effusion with right ventricular collapse consistent with a pericardial tamponade (Fig 1).

View larger version (49K): [in this window] [in a new window]   Fig 1. Transthoracic echocardiogram showing compression of the right ventricle (RV) by fluid in the pericardial sac (PE). (LV = left ventricle.)

An hour later the patient’s chest tube output suddenly increased to 300 mL over 30 minutes, he was taken back to the operating room, and the pericardium was entered anteriorly through a median sternotomy incision. There was a small vessel about 1 mm in diameter coming directly off the right side of the ascending aorta within the pericardial sac itself that was actively bleeding. The vessel was suture ligated and the patient stabilized with no further bleeding. His postoperative course was further complicated by a left lower lobe pneumonia requiring prolonged intubation and a tracheostomy. He also had a myocardial infarction and was later discharged home on postoperative day 30 in good medical condition.

	Comment

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The vessel that caused the pericardial tamponade in this case probably had retracted into the pericardial sac, possibly after being cauterized, and subsequently bled. This vessel was an aberrant bronchial artery coming off the intrapericardial aorta and going to the right upper lobe of the lung. Approximately 40% of patients have one right bronchial artery coming off the third posterior intercostal artery and two left bronchial arteries coming off the thoracic aorta [6, 7]. Another 20% have two left and right bronchial arteries coming directly from the thoracic aorta. A further 20% have only one bronchial artery on either side, and 10% have two right and one left bronchial artery. Although the bronchial artery configuration can vary anatomically, these arteries usually originate directly or indirectly from the descending aorta. Rarely do they come off the aortic arch and even more rarely from the intrapericardial portion of the aorta, as in this case [6, 7].

Pericardial tamponade caused by a bleeding intrapericardial vessel after thoracotomy and lobectomy for lung cancer is rare. However, it should be considered when a patient presents with refractory hypotension after such a procedure. Diagnosis is best made by having a high index of suspicion and an urgent transthoracic echocardiogram. Treatment should be prompt and might include an urgent pericardiocentesis as a temporizing measure followed by a more definitive surgical procedure—a formal median sternotomy, which allows full inspection of the interior of the pericardium and provides adequate access for vessel ligation.

This complication can best be prevented by secure suture ligation of the vessels encountered in the dissection regardless of size, and especially if they are adjacent to the pericardial reflection [5]. This procedure prevents retraction of the vessel into the pericardial sac, where it may bleed later.

As was demonstrated by this case, aberrant vessels can produce life-threatening bleeding even though they are small. A high index of suspicion along with quick definitive diagnosis and treatment could be life saving.

	References

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1. Nagasaki F., Flehinger B.J., Martini N. Complications of surgery in the treatment of carcinoma of the lung. Chest 1982;82:25-29.[Abstract/Free Full Text]
2. Von Knorring J., Lepantalo M., Lindgren L., Lindfors O. Cardiac arrhythmias and myocardial ischemia after thoracotomy for lung cancer. Ann Thorac Surg 1992;53:642-647.[Abstract]
3. Ginsberg R.J., Hill L.D., Eagan R.T., et al. Modern thirty-day operative mortality for surgical resections in lung cancer. J Thorac Cardiovasc Surg 1983;86:654-658.[Abstract]
4. Morimoto M., Ohashi M., Nobara H., Fukaya Y., Haniuda M., Iida F. Rupture of the ascending aorta after surgical resection for lung cancer—a case report. Jpn J Surg 1991;21:476-479.[Medline]
5. Tovar E.A. Pulmonary resection complicated by abrupt pericardial tamponade. Ann Thorac Surg 1995;60:1864.[Free Full Text]
6. Chang A.B., Ditchfield M., Robinson P.J., Robertson C.F. Major hemoptysis in a child with cystic fibrosis from multiple aberrant bronchial arteries treated with tranexamic acid. Pediatr Pulmonol 1996;22:416-420.[Medline]
7. Gabella G. Cardiovascular. In: Williams P.L., ed. Gray’s anatomy—the anatomical basis of medicine and surgery, 38th ed. London: Churchill Livingstone, 1995:1451-1626.

This article has been cited by other articles:

				J. B. Pillai and S. Barnard Cardiac tamponade: a rare complication after pulmonary lobectomy Interactive CardioVascular and Thoracic Surgery, December 1, 2003; 2(4): 657 - 659. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Bahman B. Parandian Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by McLean, R. H. Articles by Nam, M. H. Search for Related Content PubMed PubMed Citation Articles by McLean, R. H. Articles by Nam, M. H.