Ann Thorac Surg 2010;89:281-283. doi:10.1016/j.athoracsur.2009.06.049
© 2010 The Society of Thoracic Surgeons
Case Reports
Pulmonary Artery Catheter Deviation on Chest Roentgenogram After Cardiac Operation: A Sign of Tamponade
Jared L. Antevil, MDa,
Alexandros N. Karavas, MDa,
John G. Byrne, MDa,*,
Bernhard J. Riedel, MD, PhDb,
Michael R. Petracek, MDa
a Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
b Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
Accepted for publication June 9, 2009.
* Address correspondence to Dr Byrne, Vanderbilt University Medical Center, 1215 21st Ave, Medical Center East, Nashville, TN 37232-8802 (Email: john.byrne{at}vanderbilt.edu).
 |
Abstract
|
|---|
Tamponade after cardiac operations often does not manifest the classic clinical or even echocardiographic features of tamponade and may therefore be difficult to diagnose. We present 3 patients with cardiac tamponade in the early postoperative period in whom portable chest roentgenogram revealed marked leftward pulmonary artery catheter displacement at the level of the right atrium and superior vena cava due to adjacent hematoma. Awareness of this radiographic finding may allow immediate triage to a life-saving reoperation, obviating the need for further imaging or diagnostic delay.
|
Introduction
|
|---|
We report 3 patients with tamponade after cardiac surgery in whom a portable chest roentgenogram demonstrated marked leftward deviation of the Swan-Ganz catheter. Reoperation in all 3 cases revealed localized hematoma compressing the right atrium and superior vena cava. This radiographic finding may be a very useful adjunct in the diagnosis of early postoperative cardiac tamponade.
|
Case Reports
|
|---|
Patient 1
An 80-year-old woman underwent bioprosthetic aortic root replacement. She experienced significant coagulopathic bleeding postoperatively, which subsided over several hours with the transfusion of appropriate blood products. However, progressive decreases in her blood pressure and cardiac output necessitated the initiation of inotropic support. Her central venous pressure (CVP) was 18 mm Hg, with a pulmonary artery (PA) pressure of 27/17 mm Hg.
Transthoracic echocardiography demonstrated a hyperdynamic, underfilled left ventricle (LV), but was not diagnostic for significant pericardial effusion or cardiac chamber compression. Chest x-ray (CXR) films did not reveal significant pleural space opacity or appreciable mediastinal widening, but marked leftward deviation of the PA catheter was noted at the level of the superior vena cava and right atrium (Fig 1A).
View larger version (138K):
[in this window]
[in a new window]
|
Fig 1. (A) Chest roentgenogram in patient 1 demonstrates leftward pulmonary artery (PA) catheter deviation from localized hematoma. (B) Intraoperative transesophageal echocardiography confirms hematoma (arrow). (C) Postoperative roentgenogram reveals a normal PA catheter course. (D) Schematic. (RA = right atrium.)
|
|
Tamponade was suspected, and the patient was taken to the operating room for reexploration. Transesophageal echocardiography (TEE) on arrival to the operating room revealed extrinsic compression of the right atrium by a large hyperechoic mass, consistent with hematoma (Fig 1B). At exploration, a large focal hematoma anterior to the right atrium was compressing the right atrium and superior vena cava. There was no active bleeding, and very little clot elsewhere within the surgical field. After evacuation of the hematoma, the patient's hemodynamics improved immediately, and a repeat CXR film revealed a normal PA catheter course (Fig 1C). Figure 1D depicts the mechanism of leftward PA catheter displacement by hematoma.
Patient 2
A 78-year-old woman underwent bioprosthetic aortic root replacement, mitral and tricuspid valve repair, and ascending aortoplasty. On the first postoperative day, her blood pressure and cardiac output decreased significantly. Her CVP had increased from 18 to 31 mm Hg, with a PA pressure of 49/27 mmHg. CXR films revealed leftward deviation of the PA catheter at the level of the right atrium (Fig 2A). The patient was returned to the operating room, where localized clot was removed from adjacent to the right atrium (Fig 2B). A small bleeding source was oversewn, and the patient's hemodynamic variables were promptly restored.
View larger version (85K):
[in this window]
[in a new window]
|
Fig 2. (A) Leftward pulmonary artery catheter deviation from localized hematoma in patient 2. (B) Chest roentgenogram after evacuation of hematoma.
|
|
Patient 3
A 69-year-old man underwent urgent 3-vessel coronary artery bypass grafting with mitral valve repair and closure of a patent foramen ovale. His early postoperative course was complicated by coagulopathic bleeding and the need for high-dose inotropic and vasopressor support. Although the patient's bleeding subsided by the morning of postoperative day 1, he manifested a persistent low cardiac output syndrome and required placement of a femoral intraaortic balloon pump. The patient's CVP was 15 mm Hg, with a PA pressure of 24/18 mm Hg.
A CXR film revealed marked leftward deviation of the PA catheter (Fig 3A). Subsequent TEE demonstrated a large clot posterior to the right atrium associated with atrial compression and tamponade physiology. This finding was confirmed at the time of reoperation, where a small leak in the left atrial suture line was repaired. A CXR film after hematoma evacuation showed a normal PA catheter course (Fig 3B).
View larger version (66K):
[in this window]
[in a new window]
|
Fig 3. (A) Leftward pulmonary artery (PA) catheter displacement by hematoma (arrow) in patient 3. (B) Chest radiography after hematoma evacuation reveals a normal PA catheter course.
|
|
|
Comment
|
|---|
Tamponade after cardiac operations typically manifests as hypotension and a low output state, most commonly the result of cardiac chamber compression and associated LV underfilling. However, the presentation of tamponade shares clinical features with postcardiopulmonary bypass LV dysfunction, inflammatory response, prosthetic valve dysfunction, and inappropriate volume loading, making the diagnosis difficult at times [1].
Unlike medical causes of tamponade, most postoperative cases result from loculated hematoma or fluid collections, which may be associated with localized compression of any cardiac chamber [2]. Localized hematomas most commonly affect the right atrium [3–5]. The clinical manifestations of postoperative tamponade are highly variable and nonspecific [2], particularly in the setting of single-chamber compression [3, 4]. Pulsus paradoxicum and equalization of right and left heart pressures are seen in a minority of cases [3]. CVP elevation is similarly a variable finding in postoperative tamponade [1], and hemodynamic signs are inconsistent [2].
Because compression of a single cardiac chamber may not affect normal function of the remaining chambers, the typical echocardiographic features of medical tamponade are not reliably present in patients after cardiac operations [2]. Transthoracic echocardiography may be diagnostic in some patients, but is often technically unsatisfactory in the early postoperative period due to air in the pericardium, limitations in positioning, or interference from dressings and monitoring devices [4]. Although TEE is a reliable diagnostic modality for clinically suspected tamponade caused by local chamber compression [1, 3, 4], it requires specialized equipment and an expert sonographer. These resources may not be immediately available in the intensive care setting, particularly in the evenings or on weekends. The 3 patients described demonstrate that simple imaging from a portable x-ray machine may suggest the presence of a localized hematoma adjacent to the right atrium and superior vena cava by demonstrating associated leftward PA catheter deviation.
In conclusion, we describe 3 patients with early tamponade after cardiac operations due to localized right atrial compression where portable CXR imaging revealed marked leftward PA catheter deviation at the level of the right atrium and superior vena cava. Although its absence is of little utility, leftward PA catheter displacement in the clinical setting of suspected postoperative tamponade is highly suggestive of right atrial compression from an adjacent hematoma. This rapid, simple, and universally available diagnostic test may thereby allow immediate triage to a life-saving reoperation, obviating the need for further imaging or diagnostic delay.
|
References
|
|---|
- Simpson IA, Munsch C, Smith EE, Parker DJ. Pericardial haemorrhage causing right atrial compression after cardiac surgery: role of transoesophageal echocardiography Br Heart J 1991;65:355-356.[Abstract/Free Full Text]
- Chuttani K, Tischler, MD, Pandian NG, Lee RT, Mohanty PK. Diagnosis of cardiac tamponade after cardiac surgery: Relative value of clinical, echocardiographic, and hemodynamic signs Am Heart J 1994;127:913-918.[Medline]
- Cujec B, Johnson D, Bharadwaj B. Cardiac tamponade by loculated pericardial hematoma following open heart surgery: diagnosis by transesophageal echocardiography Can J Cardiol 1991;7:37-40.[Medline]
- Kochar GS, Jacobs LE, Kotler MN. Right atrial compression in postoperative cardiac patients: detection by transesophageal echocardiography J Am Coll Cardiol 1990;16:511-516.[Abstract]
- Kronzon I, Cohen ML, Winer HE. Cardiac tamponade by loculated pericardial hematoma: limitations of M-mode echocardiography J Am Coll Cardiol 1983;1:913-915.[Abstract]
Top
Abstract
Introduction
