Case Report

2. Case Report • 68 y/o female undergoing RFA for paroxysmal ventricular tachycarida • PMH: DM, HTN, COPD • All: erythromycin – nausea • Soc: quit smoking 20 yrs ago, no EtOH or drugs

3. Case Report • 5 hours into RFA, decreased responsiveness, hypotensive • Patient in SVT, paced out by cardiologists • Remained hypotensive, pressors started, intubated • Marked JVD noted

4. Case Report • TTE emergently preformed • 1.1-1.3cm effusion over right heart • RV collaspe • Tamponade physiology • Effusion drained under ultrasound • 35cc frank bloody fluid removed • Patient immediately stabilized • Extubated at end of case, taken to CICU • Discharged 2 days later • Continues medical management of SVT

5. A condition where fluid accumulates around the great vessels or chambers of the heart and decreases stroke volume to clinically significant levels

6. 2 layers • Parietal pericardium • Fibrous • ~2mm • Visceral pericardium • Thin mesothelial layer • Typically contains 25 – 50cc serous fluid. • Pericardial space can be considered a potential space

7. Slowly accumulating effusion • Allows for pericardial distension • May have effusion up to 1500cc before symptoms arise • Typically ‘medical’ causes’ • Uremia • Malignancy • Hypothyroidism • Rapidly accumulating effusion • Usually see in perioperative setting • As little as 200cc fluid for symptoms

9. Beck’s Triad • Hypotension • Jugular venous distension (Kussmal’s sign) • Distant heart sounds

10. Commonly sited changes: • Low voltage QRS • T wave inversions • PR depression • ST changes • Not supported by data • Combination of low voltage QRS and PR depression has weak association with effusion

11. Alteration in configuration of electrocardiographic complexes arising from the same pacemaker and independent of periodic extracardiac phenomenon • Caused by swinging of the heart in pericardial fluid • Rare phenomenon • Resolves with drainage of effusion

12. Decline in arterial pulse with negative pressure inspiration • Not a paradox, but exaggeration of normal respiratory decrease in arterial BP assoc. with effusion • Not an all-or none phenomonon

13. Systolic pressure change greater than 10 accepted as significant • Respiratory variation switched with positive pressure ventilation • Curtiss et al: • SBP change greater than 12mm HG or 9% 92% and 97% accurate respectively

14. May be found in other conditions: • Tracheal compression • Tension pneumothorax • Pleural effusion • RV infarct • PE • Hemorrhageic shock • May be absent in: • Extreme hypotension • Aortic regurgitation • Atrialseptal defect • Increased LVEDP • Cardiac adhesions

16. All CVP values elevated • Obliteration of Y descent

17. PCWP and CVP equalize • PA systolic pressure • Decreases with inspiration with mild or moderate tamponade • May increase with severe tamponade

18. Very sensitive (64-100%) • Very specific (80-100%) • Free wall diastolic inversion that persists 1/3 into systole • Affected by: • Tricuspid regurgitation • Plerual effusion • Ventricular rhythm • Pulmonary HTN • RVH

19. Not as well described • May be tethered to pulmonary veins • Found more often with loculated and smaller effusions • Seen after CT surgery • Optimal views with TEE • Decreased chamber size rather than collapse

20. Early to mid-diastolic inward motion of the right ventricle • Sensitivity 60 to 81% • Specificity 90 to 94% • Increased sensitivity and specificity with concurrent RA collapse

21. Affected by same confounding factors as RA collapse • Tethering to anterior chest wall may affect sensitivity after open heart surgery

22. Most resistant to circumferential tamponade • Most often seen with regional tamponade • May be associated with SAM • Smaller effusion for tamponade with LV dysfunction

23. Normal VTI ~10% • First inspiratory beat: • Increase in Tricuspid VTI 80% • Increase in Pulmonic VTI 90% • Decrease in Mitral VTI 35% • Decrease in Aortic VTI 30% • May identify subclinical tamponade • Useful in identifying low=pressure tamponade

24. Seen in hypovolemia • JVD, pulsus paradoxus absent • May be resistant to volume loading • Effect of transmural pressure • Low CVP and modestly elevated intrapericardial pressure result in tamponade physiology • May not have typical 2D echo findings • Doppler may be diagnostic

25. Evidence indicates rate of tamponade increasing • Tamponade associated with ~0.1 – 0.2% of interventional procedures • Minimal risk with diagnostic procedures • Analysis of 14,972 diagnostic caths showed no tamponade

26. Risk factors include • Elderly • Female sex • Multi-vessel disease • Complex coronary lesions

27. Immediate presentation • Associated with direct coronary perforation • Hypotension, chest pain, shortness of breath • 94% patients require ventilatory support • 82% of patients require CPR • Delayed presentation • 45-60% of all cases • Usually 2 to 36 hours • Mortality • Unclear but may be up to 42% • Probably related to site of perforation and rate of fluid accumulation

28. Increasing frequency as rate of implanted devices increases • Several methods of extraction • Manual • Constant tension • Excitimer laser • Wires may fibrose over time • ICD wires more likely to tenaciously fibrose

29. 1.4% experience cardiac tamponade • Associated with 20% mortality • Tamponade most common major problem • Risk Factors • Female • ICD • Multiple leads • Leads greater than 8 years old

30. North American Society of Pacing and Electrophyiology Policy Statement • Large bore peripheral IV • Arterial Line • “Adequate” anesthesia • MHMC • Endotracheal intubation/GA • Large bore IV • Arterial line • No longer have OR and surgeon ready

31. ASA Closed Claims Database Analysis 2004 • 16 cases of cardiac tamponade in 6449 claims • Significantly (p<0.05) higher association with mortality compared to other complications • 78-95% rate of mortality • Right atrium most common site of perforation, right ventricle second

32. Presentation may be from minutes to days • Many reports of finding previously healthy patients expired at bedside • Several reports of pericardiocentesis removing TPN

33. Increased incidence of tamponade with left internal jugular placement • Tip position important • Vessel wall erosion plays a major role in delayed presentations • More vessel wall contact increases change of erosion • Right atrial placement increases risk of perforation

34. Don’t be the ‘I’ in iatrogenic • NOT necessary to ‘bury’ guidewire or elicit dysrhythmia • Check line with CXR • Don’t place lines too deep • Consider contrast injection • Observe PA catheter waveforms after transport to the ICU

35. Two main categories: • Penetrating Trauma • Blunt Trauma

36. Tamponade in 80-90% of all penetrating wounds • Wounds of axilla, neck, back, mediastinum, epigastrium, and upper abdomen • Typically caused by knives and guns. • Reports of embolized bullets, nails, knitting needles, lawn mower projectiles , and ice picks permeate literature

37. Review of 1802 penetrating cardiac injuries found • Right ventricle 43% • Left ventricle 33% • Right atrium 14% • Left atrium 5% • Intrapericardial vessels 5% • Associated with area each structure occupies in the anterior chest

38. Left ventricle often spontaneously seals due to thick myocardium • Right ventricle unlikely to spontaneously seal • Atria may seal due to low pressure and tethering to pericardium but thin walls make this unlikely • *Remember myocardial wall stress inversely related to thickness

39. Smaller wounds (>2.5cm) are associated more commonly with tamponade • Larger wounds are associated with exsangiunation into chest • Larger wounds less likely to spontaneously seal

40. Only 20% present with tamponade • Remainder result in exsanguination into chest • Higher velocity associated with exsanguination • Lower velocity associated with tamponade • Knife wounds more likely to result in tamponade because pericardium will spontaneously close • Stab and gunshot wounds usually affect more than one cardiac structure

41. Penetrating injury usually declares itself immediately • Can have delayed presentation up to four weeks • Re-bleed usually in non-surgically repaired wounds • Pericardial effusion seen in 22% of all penetrating injuries but rarely a problem

42. 10% of all blunt chest trauma sustain cardiac or aortic injuries • Very few patients require operative treatment • Most patients expire before they reach the hospital

43. Chirillo et al TEE study of 83 patients with chest trauma • 40 with pericardial effusion • One with pericardial tamponade • History of airbag deployment associated with tamponade • 1st and 2nd rib fractures often associated with tamponade

44. COPD patients at risk of pneumopericardium

45. Effusion found in 50 to 85% of patients • Tamponade estimated at 0.75 to 0.8% from two recent large reviews (range Zero to 8.8%) • Higher rate in valve replacement vs CABG • More common in females

46. Early tamponade • Active re-bleed • Signs/symptoms of low CO • Acute decrease in chest tube output • Late tamponade • Post-pericardotomy syndrome • Presents 15-20 days post-op • Very inconsistent presentation

47. Anterior effusion more common with CABG

48. Typical TEE findings • Loculated effusion • Posterior location • Small volume • Left atrial collapse common • Paradoxical LV motion possible • effusions with valves

49. Treatment Recognize Condition

50. Treatment • Medical management • “Tight” - increase SVR, minimize chamber collapse • “Tachy”– fixed CO, increase HR • “Tank full” –volume load