HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

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 Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Smart, K. Articles by Jett, G. K. Search for Related Content PubMed PubMed Citation Articles by Smart, K. Articles by Jett, G. K.

Ann Thorac Surg 1998;66:2027-2028
© 1998 The Society of Thoracic Surgeons

---

Original Articles

Late tamponade with mechanical circulatory support

^a Department of Cardiothoracic Surgery, Baylor University Medical Center, Dallas, Texas, USA

Accepted for publication June 8, 1998.

Address reprint requests to Dr Jett, Department of Cardiovascular Surgery, Providence Seattle Medical Center, 1600 E. Jefferson St, Suite 101, Seattle, WA 98122

	Abstract

Top Abstract Introduction Patients Comment References

 
Background. Circulatory support with mechanical devices often leads to bleeding and tamponade.

Methods. We report a series of three patients that required mechanical circulatory support for postcardiotomy ventricular dysfunction.

Results. Late tamponade occurred in each patient with different clinical presentations. Early postoperative bleeding occurred in 2 patients. There was no active bleeding in any of the 3 patients. Transesophageal echocardiography was not helpful in making the diagnosis.

Conclusion. Late tamponade, which may be the result of hematoma with earlier bleeding, can present as dyspnea, hypoxia, or forms of hemodynamic collapse. Exploratory media sternotomy is required to definitively make the diagnosis and to evacuate the hematoma.

	Introduction

Top Abstract Introduction Patients Comment References

 
Circulatory support with mechanical devices is occasionally needed for postcardiotomy low output syndrome. Bleeding and thrombosis are potential complications with circulatory support devices. It has previously been reported that 40% of patients who are supported with ventricular assist devices have experienced early postoperative bleeding but only 20% developed tamponade requiring reexploration [1]. We report here a series of 3 patients who experienced late tamponade while on mechanical circulatory support.

	Patients

Top Abstract Introduction Patients Comment References

 
A 57-year-old woman with idiopathic congestive cardiomyopathy underwent orthotopic cardiac transplantation and insertion of an intraortic balloon pump for postcardiotomy low output. Three days later, ABIOMED BVS 5000 biventricular assist devices (BVAD) were inserted owing to worsening of her hemodynamics. Postoperatively, she had low chest tube drainage; thus, heparin was started within 12 hours and the activated clotting times were maintained in the range of 150 to 200 seconds. On the sixth day of BVAD support pump flows diminished to 3.5 L/min and central venous pressure became markedly elevated at 35 mm Hg. A transesophageal echocardiogram was inconclusive for tamponade; however, delayed tamponade was suspected and the patient underwent exploratory median sternotomy with evacuation of a large amount of mediastinal and pleural hematoma. No active bleeding was found. Her hemodynamics markedly improved with removal of the mediastinal fluid and hematoma (flow, 4.6 L/min; central venous pressure, 17 mm Hg). After 11 days of circulatory support, the devices were removed and adequate hemodynamics were maintained.

A 63-year-old woman was admitted to the hospital for shortness of breath. On the day of admission, a transesophageal echo showed 4+ mitral regurgitation as well as left ventricular dysfunction with an ejection fraction of 30%. Cardiac catheterization showed severe mitral regurgitation, normal coronary arteries, and left ventricular dysfunction. She later was electively admitted and underwent mitral valve replacement with a porcine bioprosthesis. After her valve replacement, she had postcardiotomy low output. On her sixth postoperative day, she decompensated after an episode of ventricular tachycardia and fibrillation. She was returned to the operating room where she underwent insertion of the ABIOMED BVS 5000 BVAD. Later that evening, she experienced bleeding and underwent evacuation of mediastinal hematoma. She then had minimal chest tube output so heparin was started 24 hours after BVAD insertion and activated clotting times were maintained at 170 to 240 seconds. Over the ensuing days, she showed signs of recovery and stabilization of her hemodynamics. She was extubated on her seventh day of support. On the ninth day of support, she experienced marked dyspnea. A chest roentgenogram showed widened mediastinum and her BVAD flows were slightly decreased from 4.0 L/min to 3.6 L/min and central venous pressure increased from 12 to 18 mm Hg. She was returned to the operating room where she was found to have tamponade secondary to old hematoma. The clots were removed and no active bleeding was found. She was weaned after 14 days of support, but later died of multisystem organ failure.

A 69-year-old woman was admitted to the hospital with chest pain. An electrocardiogram showed an inferior wall myocardial infarction. Cardiac catheterization was performed and revealed severe triple-vessel coronary artery disease and left ventricular dysfunction. She was maintained on heparin and 3 days later underwent coronary artery bypass grafting. After surgical myocardial revascularization and chest closure, she fibrillated requiring the emergent reinstitution of cardiopulmonary bypass. Spasm of the internal mammary artery was suspected so a vein graft was placed distal to the internal mammary artery anastomosis to the left anterior descending coronary artery. After several failed attempts to separate from cardiopulmonary bypass, the ABIOMED BVS 5000 BVADs were inserted. Postoperatively, she had moderate chest tube output but maintained good pump flows of 4.5 L/min. On the morning of her first postoperative day, however, she was hypoxic despite 100% oxygen. A chest roentgenogram showed an enlarged mediastinum. Early tamponade was suspected despite stable pump flows of 4.4 L/min. The patient was explored at the bedside and immediately on evacuating the hematoma, her oxygenation markedly improved. At that time, there was no active bleeding. Postoperatively, she was stable and heparin was started 24 hours later with activated clotting times maintained between 150 and 180 seconds. During the following days, she did well and maintained pump flows of 4.5 to 5.0 L/min. On her ninth postoperative day, an echocardiogram revealed marked biventricular hypokinesis, but the ventricles would not distend with reducing or discontinuing pump flows. Tamponade was suspected. An exploratory median sternotomy revealed large amounts of old clots, which were removed. A subsequent echocardiogram showed improved biventricular function. After 13 days of pump support, the devices were removed.

	Comment

Top Abstract Introduction Patients Comment References

 
Postoperative bleeding is a frequent complication of mechanical circulatory support. This is mainly because of coagulopathy associated with prolonged time on cardiopulmonary bypass. It usually presents in the early postoperative period and requires mediastinal exploration with evacuation of the hematoma, which, if not removed, could lead to early tamponade and marked circulatory compromise. Classic tamponade occurs when the heart becomes compressed by the hematoma and impairs pump filling [2]. Typical signs of cardiac tamponade may not be present on mechanical support. Usually tamponade is diagnosed when pump flows are decreased and filling pressures are increased and not responsive to a fluid challenge. The ABIOMED BVS 5000 assist devices is preload sensitive and pump flows should increase with a fluid challenge. Patient 3, however, had early tamponade but with stable hemodynamics, marked respiratory dysfunction, and lack of oxygenation that was relieved with evacuation of the hematomas.

Late tamponade after open heart operation in patients on anticoagulants has been described [3]; however, late tamponade in patients on circulatory support is an infrequent complication that must be considered when hemodynamics begin to decline in the late postoperative period. In addition, classic signs of tamponade may not be present, as patient 2 merely experienced marked dyspnea. Active bleeding may not be found with late tamponade and may be the result of old blood clots that have begun to dissolute. In two of our patients, early postoperative bleeding occurred that did require mediastinal evacuation but thereafter bleeding ceased. A third patient did not require reexploration but the blood clot that caused her tamponade was probably the result of early postoperative bleeding that did not become clinically important until the sixth postoperative day.

Transesophageal echocardiography may not be able to diagnose tamponade [4]. Anterior mediastinal clot is difficult to visualize with transesophageal echocardiography. If ventricular dysfunction is present in a small or nondistended ventricle on reduced or partial mechanical support, then tamponade should be suspected. In addition, lack of ventricular recovery cannot be confirmed until the chest is explored.

In conclusion, BVADs are often necessary to support the failing heart and complications often occur [1]. Late tamponade, which may be the result of hematoma with earlier bleeding, can present as dyspnea, hypoxia, elevated central venous pressure, or other forms of hemodynamic collapse. Exploratory median sternotomy is required to definitely make the diagnosis and to evacuate the hematoma.

	References

Top Abstract Introduction Patients Comment References

 

1. Jett G.K. The ABIOMED BVS 5000: experience and potential advantages. Ann Thorac Surg 1996;61:301-304.[Abstract/Free Full Text]
2. Hancock W.E. Cardiac tamponade. Heart Dis Stroke 1994;3:155-158.[Medline]
3. Hill J.D., Johnson D.C., Miller G.E., Kerthy W.J., Gerbode F. Latent mediastinal tamponade after open-heart surgery. Arch Surg 1969;99:808-814.[Medline]
4. Fowler O. Cardiac tamponade: a clinical or an echocardiographic diagnosis?. Circulation 1993;85:1738-1741.

This article has been cited by other articles:

				S. Aggarwal, F. Cheema, M. C. Oz, and Y. Naka Long-Term Mechanical Circulatory Support Card. Surg. Adult, January 1, 2008; 3(2008): 1609 - 1628. [Full Text]

				S. Chumnanvej, M. J. Wood, T. E. MacGillivray, and M. F. V. Melo Perioperative Echocardiographic Examination for Ventricular Assist Device Implantation Anesth. Analg., September 1, 2007; 105(3): 583 - 601. [Abstract] [Full Text] [PDF]

				A. El-Banayosy, R. Korfer, L. Arusoglu, L. Kizner, M. Morshuis, H. Milting, G. Tenderich, O. Fey, and K. Minami Device and patient management in a bridge-to-transplant setting Ann. Thorac. Surg., March 1, 2001; 71 (2007): S98 - S102. [Abstract] [Full Text] [PDF]

				A El-Banayosy, L Arusoglu, L Kizner, O Fey, K Minami, and R Korfer Complications of circulatory assist Perfusion, July 1, 2000; 15(4): 327 - 331. [PDF]

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 Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Smart, K. Articles by Jett, G. K. Search for Related Content PubMed PubMed Citation Articles by Smart, K. Articles by Jett, G. K.