Prolonged right ventricular failure after relief of cardiac tamponade.
OBJECTIVE
To report a case of severe and fatal cardiac complication following pericardiotomy to relieve a malignant tamponade. Right ventricular (RV) failure was responsible for major hypoxemia and for a persistent shunt through a patent foramen ovale. In the absence of pulmonary embolism and coronary occlusion, possible pathophysiologic mechanisms are discussed.


METHODS
This 53-yr-old patient presented with oropharyngeal carcinoma previously treated by chemotherapy. One month later, he showed clinical and echocardiographic signs of cardiac tamponade. He had a circumferential pericardial effusion with complete end-diastolic collapse of the right cavities. After an emergent pericardiotomy, he rapidly presented severe hypoxemia. Transesophageal echocardiography showed an akinetic and dilated right ventricle, paradoxical septal wall motion and a normal left ventricular function. A contrast study revealed a right-to-left shunt. No residual pericardial effusion was detectable. Pulmonary angiography excluded a pulmonary embolism and the coronary angiogram was normal. Troponin Ic was elevated postoperatively and peaked on day two (3.78 micro g x L(-1)). The patient died of refractory shock with persistent intracardiac shunt and RV akinesia on day nine.


CONCLUSIONS
Although pulmonary embolism or thrombus of a coronary vessel are the most common causes of prolonged RV failure after pericardiotomy, other mechanisms may be invoked. The possibility is raised that a rapid increase in RV tension may induce the development of muscular injury and impair coronary blood flow, despite a normal coronary angiogram. These could result in a stunned myocardium and opening of a patent foramen ovale. We hypothesize that gradual decompression of a chronic pericardial effusion might be beneficial in patients at risk.
Geffroy
Arnaud
A
Department of Anesthesiology and Critical Care, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Université Xavier Bichat Paris 7, Clichy Cedex, France. arnaud.geffroy@bjn.ap-hop-paris.fr
Beloeil
Hélène
H
Bouvier
Erik
E
Chaumeil
Arnaud
A
Albaladejo
Pierre
P
Marty
Jean
J
D002305:Cardiac Tamponade / Q000150:complications* / Q000503:physiopathology; D017548:Echocardiography, Transesophageal; D004562:Electrocardiography; D017809:Fatal Outcome; D006344:Heart Septal Defects, Atrial / Q000209:etiology / Q000503:physiopathology; D006801:Humans; D000860:Hypoxia / Q000209:etiology; D008297:Male; D008875:Middle Aged; D009959:Oropharyngeal Neoplasms / Q000601:surgery; D010492:Pericardiectomy; D012121:Respiration, Artificial; D012772:Shock, Septic / Q000139:chemically induced; D018497:Ventricular Dysfunction, Right / Q000209:etiology* / Q000503:physiopathology