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Ann Thorac Surg 2002;74:1148-1153
© 2002 The Society of Thoracic Surgeons

Original article: cardiovascular

Postoperative cardiac tamponade in the modern surgical era

Jeffrey T. Kuvin, MDa, Nibal A. Harati, MDa, Natesa G. Pandian, MDa, Robert M. Bojar, MDb, Kamal R. Khabbaz, MD*b

a Department of Medicine, Division of Cardiology, Tufts New England Medical Center Hospitals, Tufts University School of Medicine, Boston, Massachusetts, USA
b Department of Surgery, Division of Cardiothoracic Surgery, Tufts New England Medical Center Hospitals, Tufts University School of Medicine, Boston, Massachusetts, USA

Accepted for publication May 29, 2002.

* Address reprint requests to Dr Khabbaz, Division of Cardiothoracic Surgery, Tufts New England Medical Center Hospitals, 750 Washington St, Box 276, Boston, MA 02111, USA
e-mail: kkhabbaz{at}lifespan.org


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 References
 
Background. Pericardial effusions resulting in cardiac tamponade (CT) are uncommon after open heart surgery (OHS) and are associated with significant morbidity and mortality. Characteristics and outcomes of patients who develop postoperative CT are poorly defined. Our objective was to further analyze the population at risk for developing postoperative CT, identify potential perioperative and surgical risk factors, and evaluate the impact of CT on patient outcomes.

Methods. A retrospective analysis of 4,561 consecutive patients undergoing OHS at our institution was performed. Patients with clinical suspicion of pericardial effusion following surgery were evaluated by transthoracic or transesophageal echocardiography, and clinical parameters were analyzed.

Results. Forty-eight (1%) of the 4,561 patients were found to have echocardiographic evidence of a moderate or large pericardial effusion, of whom 36 (74%) had evidence of CT. The mean age of the patients with CT was 61 years. Coronary artery bypass grafting (CABG) had been performed in 24% of these patients, valve ± CABG in 73%, and other OHS procedures in 3%. The incidence of CT following CABG alone was 0.2%, whereas it was 0.6% after valve ± CABG. Females had a higher risk for developing CT, and this occurred earlier in the postoperative period when compared with men. Aspirin, heparin, or warfarin were given to 84% of patients within 3 days of surgery. Mean time to diagnosis of CT was 10 ± 1 days after OHS. Prior to diagnosis of CT, the maximum international normalized ratio (INR) and partial thromboplastin time (PTT) were 2.7 ± 0.3 and 68 ± 5 seconds, respectively. Forty-nine percent of pericardial effusions were posterior and 46% were circumferential; one-third of the effusions were considered large by echocardiography. There was one in-hospital cardiovascular death.

Conclusions. CT after OHS is more common following valve surgery than CABG alone and may be related to the preoperative use of anticoagulants. Females appear to be at higher risk for developing early postoperative CT. When diagnosed and treated promptly, postoperative CT should not significantly increase mortality.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 References
 
Clinically insignificant pericardial effusions are common following open-heart surgery (OHS) [1, 2]. Cardiac tamponade (CT), a potentially lethal complication, occurs in a minority of patients after OHS and is associated with increased perioperative morbidity and mortality. Depending on the methodology used for its detection, pericardial effusions have been reported in 4.7% to 85%, and CT in 0% to 8.8% of patients following OHS [3, 4]. Whereas "early" CT occurs within the first 24 hours, "late" CT occurs at least 5 to 7 days after OHS and is often difficult to diagnose. Postoperative pericardial effusions are often loculated, form along the posterior left ventricular wall, and can result in hemodynamic compromise [5–7]. The site and size of pericardial effusions after OHS may be related to the type of surgery. Postoperative anticoagulation is considered to be a major contributing factor to the development of pericardial effusions and CT after OHS; however, other specific risk factors, including gender, have not been well-identified. The characteristics and outcomes of patients who develop postoperative CT are poorly defined. Therefore, we attempted to evaluate the population at risk for developing CT following OHS and assess potential risk factors for its occurrence.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 References
 
Study design
The study consisted of a retrospective analysis of 4,561 consecutive adult patients over a 6-year period (1993 to 1999) at the New England Medical Center in Boston, MA. All patients undergoing OHS at our institution were followed closely after discharge, primarily by telephone contact, for at least 30 days. If a patient required readmission to the hospital, most were sent back to our institution. Medical records for those treated elsewhere were obtained and reviewed.

Medical records, as well as echocardiograms, of patients who developed pericardial effusions, following OHS were reviewed. Surgery was classified as either coronary artery bypass grafting (CABG), valve surgery ± CABG, or "other" which included aortic root, congenital, or transplant surgery. All patients in the analysis had undergone their first OHS; patients were excluded if they had prior OHS due to increased length of reoperative surgeries, higher postoperative morbidity, and lack of intact pericardial space.

Echocardiograms were performed on all patients after valve surgery regardless of clinical condition. Echocardiograms were performed on other patients if clinically indicated. Forty-eight patients were noted to have echocardiographic evidence of a moderate or large pericardial effusion after OHS. The 36 patients who developed postoperative CT were analyzed for various surgical parameters thought to be important for the occurrence of pericardial effusion after OHS, including timing and type of OHS, duration of cardiopulmonary bypass, and aortic cross-clamp time. Intraoperative use of antifibrinolytic agents, volume of chest-tube drainage, and time of their removal after surgery were evaluated. Other pre and postsurgical parameters, including blood samples for anticoagulation levels, renal function, and blood count, were noted.

Diagnosis of cardiac tamponade
Two-dimensional transthoracic or transesophageal echocardiographic studies with Doppler examination were performed. The diagnosis of CT was based on echocardiographic findings including right or left atrial and ventricular collapse, inferior vena cava distention, and respiratory flow variation of mitral and tricuspid inflow velocities. Echocardiography was also used to detect the site, approximate size, and volume of the pericardial effusion.

Statistical methods
To study the association between the surgical factors and the risk of developing CT, we used univariate logistic analysis. In addition, a proportional Cox hazard model was formulated. When appropriate, values were expressed as mean ± standard error of the mean. A p value of <0.05 was considered significant for all analysis and a Student’s t test was used to compare groups.


   Results
Top
 Abstract
 Introduction
 Material and methods
 Results
Comment
 References
 
Patient characteristics
Among the 48 patients with a moderate or large pericardial effusion following OHS, 36 developed postoperative CT (Table 1). On average, CT was diagnosed on the 10th postoperative day. Twenty-two percent had "early" tamponade, while 78% had "late" CT. Eleven patients were readmitted to the hospital for diagnosis and treatment of CT. The remaining 25 patients with CT were detected and treated during the initial hospitalization. The mean age of this group was 61 ± 3 years with no significant gender or ethnic predominance. Approximately half of patients (47%) received anticoagulation with warfarin or heparin prior to surgery. Twenty-four percent of patients had undergone CABG alone, 73% had valve replacement or repair ± CABG surgery, and 3% had other procedures including cardiac transplantation, congenital heart surgery, and aortic surgery. The incidence of CT was higher after combined valve ± CABG surgery (0.6%) than with CABG alone (0.2%).


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  		Table 1. Characteristics of Patients With Cardiac Tamponade After Open Heart Surgerya

 
Surgical and postoperative parameters
No patients had a history of prior sternotomy or heart surgery, and approximately one-half of the surgical procedures were considered elective and nonemergent (Table 2). The mean duration of cardiopulmonary bypass was 143 ± 9 minutes, with a mean cross-clamp time of 87 ± 6 minutes. Most patients (95%) received intraoperative antifibrinolytic agents as part of the standard operative regimen. Eighty-four percent of patients with CT had received anticoagulation with warfarin or heparin within the first 3 days following OHS. Criteria for chest tube removal included outputs of less than 100 cc in an 8-hour period. In this population, chest tubes were removed within 2 days after surgery with a mean total drainage volume of 711 ± 70 cc.


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  		Table 2. Surgical and Postoperative Parameters in Patients With Cardiac Tamponadea

 
Echocardiographic characteristics
Echocardiography was performed in all patients to confirm the diagnosis of CT (Table 3). The size of the pericardial effusions was considered moderate in 58% and large in 36% of cases. Pericardial effusions were located posteriorly in 49% and circumferentially in 46% of cases. The echocardiographic estimated volume of fluid was 570 ± 37 cc.


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  		Table 3. Echocardiographic Characteristics of Pericardial Effusions in Patients With Postoperative Cardiac Tamponadea

 
Coagulation parameters
Coagulation profiles differed significantly before and after surgery due to the institution of pharmacologic therapy (Table 4). The preoperative international normalized ratio (INR) of 1.2 ± 0.05 and partial thromboplastin time (PTT) of 43.9 ± 4.08 seconds increased significantly during the first 7 days following OHS to 2.7 ± 0.3 and 68.1 ± 4.8 seconds, respectively (p < 0.001 for each). Postoperative hematocrit (HCT) levels decreased significantly compared to preoperative values (35.6 ± 1.4 to 30.1 ± 0.9%; p < 0.001). Renal function remained unchanged in the postoperative state.


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  		Table 4. Preoperative and Postoperative Laboratory Data in Patients With Postoperative Cardiac Tamponadea

 
Risks factors for developing cardiac tamponade
Univariate Cox analysis was performed comparing demographic, clinical, and surgical factors between patients with and without CT (Table 5). Preoperative PTT was significant in predicting CT. For every 10 units increase of preoperative PTT, the hazard ratio for developing CT was 1.34. Preoperative INR was marginally predictive of CT. For every 10 units increase in preoperative HCT, the hazard ratio was 0.4. Preoperative PTT and HCT were also predictors for determining time to CT, and those with a higher preoperative HCT and lower PTT had a lower hazard rate for developing CT. Postoperative chest tube output was marginally statistically significant for predicting CT.


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  		Table 5. Univariate Cox Analysis Comparing Patients With and Without Cardiac Tamponade

 
Gender was an additional factor found to contribute to the development of CT. A proportional Cox hazard model was developed. Female patients had a higher risk of developing CT than males with a hazard ratio of 2.08. The median number of days to CT for men was 13 while it was 8 days for women (Fig 1). The difference in the two survival curves for men versus women yielded a p value = 0.03 for both log-rank and Wilcoxon test. None of the other surgical factors showed significance in predicting CT.



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  		Fig 1. Time to developing postoperative cardiac tamponade (CT) in male and female patients. The difference in the two survival curves for men vs women yielded a p-value of 0.03 for both log-rank and Wilcoxon test.

 
Treatment and outcomes
Fifty-three percent of patients with CT underwent surgical drainage of the pericardial effusion either by resternotomy or by subxiphoid incision (Table 6). Most other pericardial effusions were drained by percutaneous drainage (39%). One in-hospital cardiovascular death occurred, but was not related to CT; otherwise, patients were discharged either home or to rehabilitation.


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  		Table 6. Management and Outcome of Patients With Postoperative Cardiac Tamponade

 

   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
References
 
Pericardial effusions are common following OHS with an incidence as high as 85% [8, 9]. Few pericardial effusions, however, progress to become hemodynamically significant and result in CT. In fact, the reported incidence of CT following OHS is quite low, ranging from 0.1% to 6% [10–13]. In our study, among 4,561 patients who underwent OHS over a 6-year period, just over 1% were found to have moderate or large pericardial effusions with three-fourths of these developing CT. Female patients had a higher risk of developing CT than males, and CT occurred earlier in the postoperative period in women.

Though the incidence of pericardial effusions and CT have been reported to be higher in the early postoperative period in other studies [14], 28 of the 36 patients in our series developed "late" CT. "Early" CT is usually related to surgical bleeding or coagulopathy due to the heart-lung machine, whereas "late" CT seems to be multifactorial in origin. Late CT may develop without clear-cut clinical signs, may be easily missed, and, without early diagnosis and treatment, can be life threatening [15, 16]. Previous studies have related "late" postoperative CT to various surgical factors including excessive postoperative mediastinal drainage and postpericardiotomy syndrome [17, 18]. Interestingly, 11 of the patients in this study had been previously discharged from the hospital following surgery and required readmission.

The development of pericardial effusions following cardiac surgery appears to be directly related to coagulation abnormalities [19–20]. Use of preoperative antiplatelet agents such as aspirin, anticoagulation with warfarin or heparin, or thrombolysis following myocardial infarction can cause increased bleeding at surgery and may all contribute to postoperative pericardial effusions. It is unclear why preoperative use of heparin was related to CT, but possibilities include heparin rebound or intrinsic clotting abnormalities. In our series, nearly one-half of the patients were taking aspirin and were receiving heparin or warfarin therapy prior to surgery. Most patients received aspirin within the first 24 hours after surgery, while heparin or warfarin were usually given within 3 days after surgery. Anticoagulant therapy has therefore been considered a major contributing factor in the development of intrapericardial bleeding and CT. However, despite elevated INR and PTT levels in our series, the levels were therapeutic for their indications. Thus, even when initiated after early bleeding has stopped and the chest tubes have been removed, well-controlled anticoagulation still plays a role in the development of postoperative pericardial effusions.

The adverse effects of cardiopulmonary bypass on coagulation parameters are well known and likely have a role in the pathogenesis of postoperative pericardial effusions [21]. In our series, patients had a mean duration of 143 ± 9 minutes on the cardiopulmonary bypass machine and a mean cross-clamp time of 87 ± 6 minutes. An increased time of those two parameters, as noted in our series, is more likely to be associated with increased risk of bleeding and probability of developing pericardial effusions and CT following surgery.

Echocardiography is useful for the detection of pericardial effusions following OHS and allows for rapid, safe, and accurate localization of the effusion and estimation of its size [22]. It should be noted that the size of postoperative pericardial effusion does not necessarily reflect the likelihood of developing CT. Although the pericardium may be left open following surgery, acute accumulation of only a moderate amount of blood can readily cause cardiac tamponade in a postoperative patient [23]. Right ventricular diastolic collapse is a useful echocardiograhic sign of tamponade in the presence of circumferential effusion [24]. However, when the effusion is loculated or in the presence of elevated right-sided pressures, this sign may be absent.

Because CT can be potentially fatal, early decompression is required as soon as its presence is confirmed. CT occurring within 24 hours is almost always treated surgically, since it is essential to identify the source of bleeding. "Late" CT has been traditionally drained surgically by a subxiphoid incision or a full resternotomy. However, CT has been successfully treated by percutaneous pericardiocentesis under echocardiographic and fluoroscopic guidance, and may allow for shorter hospital stay and decreased morbidity. This technique has been shown to be effective in the treatment of anterior and circumferential perfusions, but surgery is usually required for loculated posterior effusions. One in-hospital death occurred in our series but was unrelated to CT. All other patients were discharged either home or to rehabilitation. Finally, it remains unclear why women appear to have a higher risk of developing CT than men following OHS. Over one-half of the population studied were women and CT occurred earlier in the postoperative course.

Limitations
There are several limitations to this study. This was a retrospective analysis of patients who developed CT after OHS and the findings were not compared with a control group. In addition, not all patients underwent an echocardiogram after OHS; therefore, the incidence of pericardial effusions or CT after OHS may be underestimated. While all postoperative patients are followed closely by our nursing staff after hospital discharge, it is possible that some cases of CT were missed and were not used for this analysis. In addition, each patient examined in this study underwent full cardiopulmonary bypass and did not involve patients undergoing "off-pump" heart surgery. Furthermore, this study was conducted before newer antiplatelet agents were commonly used. Thus, with the recent advances in cardiology and OHS, it is unclear how these findings will play a role in present-day cardiac surgery.

Conclusion
CT following OHS is a serious and potentially fatal condition that can be clinically challenging from diagnostic and therapeutic perspectives. In our study, we found that CT after OHS was more common following valve surgery ± CABG than CABG alone. Preoperative use of anticoagulants, low hematocrit, and high chest-tube output are related to the development of CT. In addition, women appear to have a higher risk for developing postoperative CT than men. To our knowledge, no prior study has addressed gender differences in postoperative CT and this area deserves further investigation. In this era of new and innovative operating techniques in cardiac surgery, further prospective studies on evaluating risk factors for postoperative CT are needed.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 References
 

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