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Prolonged right ventricular failure after relief of cardiac tamponade

[Insuffisance ventriculaire droite prolongée après évacuation d’une tamponnade péricardique]

Arnaud Geffroy, MD^*, Hélène Beloeil, MD^*, Erik Bouvier, MD, Arnaud Chaumeil, MD, Pierre Albaladejo, MD PhD^* and Jean Marty, MD^*

^* From the Departments of Anesthesiology and Critical Care, and
Cardiology, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Université Xavier Bichat Paris 7, Clichy Cedex, France.

Address correspondence to: Dr Arnaud Geffroy, Service d’anesthésie réanimation, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Université Xavier Bichat Paris 7, 100 Bvd Général Leclerc, 92118 Clichy Cedex, France. Phone: 331 40 87 59 11; Fax: 331 40 87 44 03; E-mail: arnaud.geffroy{at}bjn.ap-hop-paris.fr

Purpose: 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.

Clinical features: 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 µg•L^–1). The patient died of refractory shock with persistent intracardiac shunt and RV akinesia on day nine.

Conclusion: 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.