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Case Reports

Acute Pulmonary Edema After Pericardial Drainage for Cardiac Tamponade

Division of Cardiothoracic Surgery, University of Tennessee Health Science Center, Memphis, Tennessee

Accepted for publication February 2, 2009.

^_* Address correspondence to Dr Weiman, Division of Cardiothoracic Surgery, University of Tennessee Health Science Center, 910 Madison Avenue, 2nd Floor, Memphis, TN 38163 (Email: dweiman{at}utmem.edu).

	Abstract

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Pericardial effusions with tamponade may present a clinical challenge in management for the cardiothoracic surgeon. We report a case of acute pulmonary edema secondary to the rapid release of a chronic traumatic pericardial effusion that resulted in the death of the patient.

	Introduction

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Pericardiocentesis for the treatment of pericardial tamponade may lead to a variety of complications. More commonly, these include lacerations of the right ventricle or coronary arteries, arrhythmias, hypotension, and pneumothorax. Acute pulmonary edema has rarely been reported [1–4]. We describe a patient with a chronic traumatic pericardial effusion in whom severe pulmonary edema developed after pericardial drainage that resulted in hemodynamic collapse and death. Various mechanisms for this physiologic derangement are discussed.

A 19-year-old woman was involved in a motor vehicle accident. Her injuries included cerebral contusion, bilateral rib fractures with pulmonary contusions, and a grade II to III liver laceration. She required bilateral tube thoracostomies and prolonged endotracheal intubation necessitating a tracheostomy. She eventually improved, recovered from her injuries, and was discharged home.

The patient presented to the emergency department 8 weeks after her initial injury with increasing fatigue and shortness of breath. On admission, her initial vital signs showed a heart rate of 110 beats/minute, blood pressure 120/80 mm Hg, with no pulsus paradoxus noted. She had mild jugular venous distention, normal heart sounds, and clear breath sounds bilaterally. Computed tomography imaging revealed a large pericardial effusion and an enlarged inferior vena cava. Her systolic blood pressure dropped rather suddenly to 90 mm Hg, and she became increasingly tachycardic.

She was taken to the operating room for an emergency pericardial decompression. Attempts to intubate her failed due to a subglottic stenosis at the previous tracheostomy site. A subxiphoid pericardial window was performed while she was being ventilated by mask. A total of 1600 mL of pericardial fluid was drained, resulting in immediate improvement of her hemodynamics. Arterial blood gases and oxygen saturations remained normal throughout the procedure.

While the patient was being transferred from the operating room to the intensive care unit, her peripheral oxygen saturations suddenly dropped to 70% and her respirations became increasingly labored. Attempted endotracheal intubation again failed, and an emergent redo-tracheostomy was performed. The patient continued to have difficulties with oxygenation and ventilation because of copious secretions of frothy pulmonary edema fluid that had to be continuously cleared from the tracheostomy tube and ventilatory circuit. The patient subsequently became progressively bradycardic and sustained a circulatory collapse. Bilateral tube thoracostomies were performed with minimal improvement. Further resuscitative attempts failed and she died.

	Comment

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Acute pulmonary edema after pericardiocentesis for cardiac tamponade is an unusual complication [1–5]. It was first described in 1983 by Vandyke and colleagues [6], who hypothesized that left ventricular dysfunction after pericardiocentesis for chronic tamponade may be related to acute hemodynamic changes from interventricular volume mismatch in the setting of elevated systemic vascular resistance and tachycardia. The initial left ventricular response is characterized by optimization of the Frank-Starling mechanism. Release of the tamponade may allow a sudden increase in pulmonary venous return thereby overloading the left ventricle while systemic vascular resistance remains high. Further increments in preload into the left ventricle can cause increasing wall stress, a reduction in stroke volume, and pulmonary edema. This response may be related to the magnitude and the velocity at which the load develops and to the extent of peripheral vascular resistance.

Other proposed mechanisms include stunning of myocardium from primary alterations in intramyocardial blood distribution, myocardial ischemia, and subendothelial hemorrhage during tamponade persisting after relief of the tamponade. Whether pericardiocentesis provides a milieu for the development of myocardial stunning or a variant of reperfusion injury remains unknown.

The tracheal stenosis in this patient might have created large fluctuations in her intrathoracic pressures that might have increased her transpulmonary pressures. The transpulmonary pressures are thought to have a role in reexpansion pulmonary edema after drainage of large pleural effusions, and it is possible that these pressures increased the risk that pulmonary edema would develop after this pericardial effusion was drained [7].

Although the exact pathophysiologic mechanism for left ventricular dysfunction after pericardiocentesis remains speculative, the abrupt disproportionate increase in left ventricular wall stress, coupled with the chronicity of tamponade and compensation by increased peripheral vascular resistance, may be critical determining factors. Myocardial stunning may have a contributory affect, considering the almost complete and uniform recovery of function seen in previously reported surviving patients.

In patients with chronic effusion and tamponade, it appears prudent to initially decompress the pericardium gradually until the pathophysiology of tamponade is resolved. As proposed by Vandyke and colleagues [1], subsequent fluid should be drained gradually through an indwelling catheter while the patient's hemodynamic variables are monitored. Although it is sometimes necessary to remove large amounts of fluid rapidly to restore normal blood pressure, it might be better to remove enough fluid to bring the central venous pressure and systemic blood pressure to normal, and then to use a catheter for slowly removing the remaining effusion. This may permit adaptive changes in coronary flow, myocardial mechanics, and wall stress by minimizing abrupt fluctuations in loading conditions otherwise associated with a more rapid decompression of the pericardial space.

	References

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1. Shenoy M, Dhar S, Gittin R, Sinha A, Sabado M. Pulmonary edema following pericardiotomy for cardiac tamponade Chest 1984;86:647-648.[Abstract/Free Full Text]
2. Glasser F, Fein A, Feinsilver S, Cotton E, Niederman M. Non-cardiogenic pulmonary edema after pericardial drainage for cardiac tamponade Chest 1988;94:869-870.[Abstract/Free Full Text]
3. Naunheim K, Wood L, Little A. Pulmonary edema as a complication of pericardial drainage Surg Gynecol Obst 1987;65:165-166.
4. Bernal J, Pradhan J, Tchokonte R, Afonso L. Acute pulmonary edema following pericardiocentesis for cardiac tamponade Can J Cardiol 2007;23:1155-1156.[Medline]
5. Ditchey R, Engler R, LeWinter M. The role of the right heart in acute cardiac tamponade in dogs Circ Res 1981;48:701-710.[Free Full Text]
6. Vandyke Jr WH, Cure J, Chakko CS, Gheorghiade M. Pulmonary edema after pericardiocentesis for cardiac tamponade N Engl J Med 1983;309:595-596.[Medline]
7. Barbetakis N, Samanidis G, Paliouras D, Tsilikas C. Re-expansion pulmonary edema following video-assisted thoracic surgery for recurrent malignant pleural effusion Interact Cardio Vasc Thorac Surg 2008;7:532-534.

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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): John M. Karamichalis Andrei Gursky Ganpat Valaulikar James W. Pate Darryl S. Weiman Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Karamichalis, J. M. Articles by Weiman, D. S. Search for Related Content PubMed PubMed Citation Articles by Karamichalis, J. M. Articles by Weiman, D. S. Related Collections Lung - other Pericardium