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Detection of iatrogenic cardiac tamponade by transesophageal echocardiography during vena cava filter procedure

From the Department of Anesthesiology, Veterans General Hospital-Taipei, School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC.

Address correspondence to: Dr. Shih-Tai Hsin, Department of Anesthesiology, Veterans General Hospital-Taipei, 201, sec 2, Shih-pai Road, Taipei, Taiwan, ROC. Phone: 886-2-28757549; Fax: 886-2-28751597; E-mail: sthsin{at}vghtpe.gov.tw

Purpose: To present a patient who developed cardiac tamponade during insertion of an inferior vena cava (IVC) filter. Intraoperative transesophageal echocardiography (TEE) was used as a means to diagnose the cardiac tamponade and to facilitate guiding of pericardiocentesis.

Clinical features: A 45-yr-old man with protein S deficiency complicated by repeated attacks of deep vein thrombosis and pulmonary thromboembolism was scheduled for insertion of an IVC filter. He had history of chronic renal insufficiency, heart failure, and cerebral infarction with mild left hemiparesis. Current medication included diltiazem (30 mg, 1 tab tid ), prednisolone (5 mg , 2 tabs qd ), and warfarin (2.5 mg daily).

Preoperative transthoracic echocardiography demonstrated bilateral pleural effusions, moderate mitral regurgitation and tricuspid regurgitation, left atrial appendage thrombus and severe generalized hypokinesia of left ventricle. Nuclear medicine examination by ⁹⁹Tc showed ejection fractions of left ventricle and right ventricle as 20% and 22%, respectively. Under the impression of protein S deficiency with multiple attacks of thromboembolism and failure of anticoagulant therapy, he was arranged for the procedure of vena caval filter insertion. Unfortunately, iatrogenic cardiac tamponade occurred during the course of the procedure with rapid hemodynamic deterioration. Because of the expedient of routine monitoring of cardiac condition with TEE, a prompt diagnosis was made. We successfully improved the patient's hemodynamic status after transthoracic echo-guided pericardiocentesis.

Conclusion: Intraoperative TEE is recommended to be used routinely in patients undergoing vena cava filter procedures. The availability of echocardiographic monitoring in the operation room allows the confirmation of the diagnosis and facilitation pericardiocentesis.