Informação da revista
Vol. 34. Núm. 9.
Páginas 561.e1-561.e3 (Setembro 2015)
Partilhar
Partilhar
Baixar PDF
Mais opções do artigo
Visitas
...
Vol. 34. Núm. 9.
Páginas 561.e1-561.e3 (Setembro 2015)
Case report
DOI: 10.1016/j.repc.2015.01.020
Open Access
Loculated cardiac hematoma causing hemodynamic compromise after cardiac surgery
Hematoma cardíaco loculado causando compromisso hemodinâmico após cirurgia cardíaca
Visitas
...
Andreia Fernandesa,
Autor para correspondência
andreiafvf@gmail.com

Corresponding author.
, Miryan Cassandraa, Carlos Pintob, Catarina Oliveirac, Manuel Antunesb, Lino Gonçalvesa
a Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra – Hospital Central, Coimbra, Portugal
b Serviço de Cirúrgia Cardiotorácica, Centro Hospitalar e Universitário de Coimbra – Hospital Central, Coimbra, Portugal
c Serviço de Radiologia, Centro Hospitalar e Universitário de Coimbra – Hospital Central, Coimbra, Portugal
Informação do artigo
Resume
Texto Completo
Bibliografia
Baixar PDF
Estatísticas
Figuras (2)
Abstract

The authors describe a case of a rare complication occurring after cardiac surgery. Three weeks after aortic valve replacement a young male became hemodynamically unstable. The echocardiogram showed a large loculated hematoma compressing the right atrium. The patient was reoperated and the mass was removed. Recovery was complete.

Keywords:
Aortic regurgitation
Hematoma
Aortic valve replacement
Cardiac tamponade
Resumo

Os autores descrevem um caso de uma complicação rara do pós-operatório de uma cirurgia cardíaca. Três semanas após substituição valvular aórtica, um jovem doente ficou hemodinamicamente instável. O ecocardiograma documentou um hematoma loculado de grandes dimensões a comprimir a aurícula direita. O paciente foi submetido a nova cirurgia cardíaca com remoção do hematoma. A recuperação foi completa.

Palavras-chave:
Regurgitação aórtica
Hematoma
Substituição valvular aórtica
Tamponamento cardíaco
Texto Completo
Case report

We present a case of a 37-year-old hypertensive male admitted with dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, fatigue and bilateral leg edema. The echocardiogram revealed a dilated left ventricle (diastolic diameter 79 mm, systolic diameter 70 mm) with severely depressed left ventricular function (20% by Simpson's method) and severe aortic regurgitation. He underwent aortic valve replacement and reduction of the ascending aorta. The patient's clinical condition improved significantly but discharge was delayed due to social problems. Three weeks after surgery he suddenly became hypotensive, tachycardic, sweating, pale with cool extremities, and anuric. The electrocardiogram showed sinus tachycardia with left ventricular hypertrophy, and the bedside echocardiogram revealed a medium-sized echogenic mass measuring 9cm×6cm, causing almost complete collapse of the right atrium, and mild (6 mm) circumferential pericardial effusion (Figure 1A–D). Prosthetic function was normal. The emergency computed tomography (CT) scan showed a hematoma measuring 9.4cm×8.5cm×5.9cm compressing the right atrium and an active bleeding point 2.4 cm above the aortic prosthesis in the ascending aorta (Figure 2A and B). The patient was transferred to the cardiothoracic surgery center. Surgical exploration revealed a large organized pericardial hematoma compressing the right atrium. It was removed and the aortic suture was reinforced. The recovery was uneventful. One month later he was clinically well and the echocardiogram showed no pericardial effusion, a functional biological valve and severely depressed left ventricular function.

Figure 1.

Transthoracic echocardiography showing a mass measuring 9cm×6cm and intermediate echogenicity causing almost complete collapse of the right atrium (A, B and D); mild (6mm) circumferential pericardial effusion (C).

(0,18MB).
Figure 2.

Contrast-enhanced computed tomography showing a hematoma 9.4cm×8.5cm×5.9cm compressing the right vena cava and right atrium (A, C and D); the collection was caused by an active bleeding point 2.4 cm above the aortic prosthesis (B) in the ascending aorta.

(0,19MB).
Discussion

Loculated hematomas with cardiac tamponade arising after cardiac surgery are a complication rarely reported in the literature.1 They are significantly more common after coronary artery bypass and are generally located posteriorly,2 although compression of any cardiac chamber can occur, with right atrial involvement being the most common.3 Clots are limited by adhesions causing an important mass effect1 and interfering with diastolic filling.

Most cases appear in the early phase, developing in the first hours or days of the postoperative period4 and manifesting as atypical cardiac tamponade.5 Few cases have been reported in the literature as long as three weeks after surgery. Delay in reaching a correct diagnosis can negatively affect prognosis, since it is extremely important to treat the condition immediately.6 Echocardiography, as an easily available and rapid imaging exam, can provide detailed information including the exact location of the hematoma (extracardiac, intrapericardial, or intracavitary) and the degree of compression.7 Nevertheless, ultrasound images do not always clarify the situation8 and other imaging techniques, such as cardiac contrast CT or magnetic resonance imaging (MRI), may be needed3 to obtain additional information on the location and dimensions of the hematoma as well as the mechanism behind its genesis.9 MRI is limited in its applicability due to hemodynamic instability.

Conclusions

A loculated pericardial hematoma leading to localized tamponade may appear on imaging studies as a cardiac mass. The differential diagnosis of this mass on imaging studies is usually challenging.10,11 Recognition of this entity is often delayed because of the absence of the classic signs associated with cardiac tamponade. A high level of clinical suspicion complemented with a rapid imaging evaluation is crucial in order to establish diagnosis and prompt treatment.

Ethical disclosuresProtection of human and animal subjects

The authors declare that no experiments were performed on humans or animals for this study.

Right to privacy and informed consent

The authors declare that no patient data appear in this article.

Confidentiality of data

The authors declare that they have followed the protocols of their work center on the publication of patient data.

Conflicts of interest

The authors have no conflicts of interest to declare.

References
[1]
J.R. Ortega, J.A.S. Román, M.J. Rollán, et al.
Atrial hematoma in cardiac postoperative patients and the diagnostic use of transesophageal echocardiography.
Rev Esp Cardiol, 55 (2002), pp. 867-871
[2]
N. Amgad, S. Matayev, D. Rosman, et al.
A case of posterior loculated tamponade masquerading as an atrial mass on transesophageal echocardiography.
J Ultrasound Med, 24 (2005), pp. 873-876
[3]
K. Ananthasubramaniam, Z. Jaffery.
Postoperative right atrial compression by extracardiac hematoma: transesophageal echocardiographic diagnosis in the critically ill patient.
Echocardiography, 24 (2007), pp. 661-663
[4]
A.M. Russo, W.H. O’Connor.
Atypical presentations and echocardiographic findings in patients with cardiac tamponade occurring early and late after cardiac surgery.
Chest, 104 (1993), pp. 71-78
[5]
G.S. Kochar, L.E. Jacobs, M.N. Kotler.
Right atrial compression in postoperative cardiac patients: detection by transesophageal echocardiography.
JACC, 16 (1990), pp. 11-16
[6]
I. Simpson, S. Munsch, E.E. Smith, et al.
Pericardial haemorrhage causing right atrial compression after cardiac surgery: role of transoesophageal echocardiography.
Br Heart J, 65 (1991), pp. 355-356
[7]
A. Jordán, M. García, F. Santos, et al.
Shock secundario a compresión extrínseca de aurícula derecha por hematoma mediastínico postoperatorio. Imagen ecocardiográfica seudotumoral en aurícula derecha.
Rev Esp Cardiol, 54 (2001), pp. 396-398
[8]
I. Kronzon, M.L. Cohen, H.E. Winer, et al.
Cardiac tamponade by loculated pericardial hematoma: limitations of M-mode echocardiography.
JACC, 19 (1983), pp. 1-235
[9]
F.E Fyke 3rd., R.G. Tancredi, C. Shub, et al.
Detection of intrapericardial hematoma after open heart surgery: the roles of echocardiography and computed tomography.
JACC, 149 (1985), pp. 6-99
[10]
S. Dunica, A. N’Guyen, S. Kural, et al.
Tamponade caused by localized compression of the superior vena cava and right atrium after aortic valve replacement under extracorporeal circulation.
Arch Mal Coeur Vaiss, 78 (1985), pp. 133-137
[11]
M. Pepi, E. Doria, C. Fiorentini.
Cardiac tamponade produced by a loculated pericardial hematoma simulating a right atrial mass.
Int J Cardiol, 29 (1990), pp. 383-386
Copyright © 2014. Sociedade Portuguesa de Cardiologia
Idiomas
Revista Portuguesa de Cardiologia

Receba a nossa Newsletter

Opções de artigo
Ferramentas
en pt

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos

Ao assinalar que é «Profissional de Saúde», declara conhecer e aceitar que a responsável pelo tratamento dos dados pessoais dos utilizadores da página de internet da Revista Portuguesa de Cardiologia (RPC), é esta entidade, com sede no Campo Grande, n.º 28, 13.º, 1700-093 Lisboa, com os telefones 217 970 685 e 217 817 630, fax 217 931 095 e com o endereço de correio eletrónico revista@spc.pt. Declaro para todos os fins, que assumo inteira responsabilidade pela veracidade e exatidão da afirmação aqui fornecida.