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Atypical presentations in the cardiac surgery post-operative period.

  • Variations of blood volume may influence sensitivity and specificity of the right atrial collapse (occurs earlier in hypovolemia)
  • Absence of right atrial / right ventricular collapse (false negative signs) in the presence of an acute or chronic increase in the pressures of the right heart chambers
  • Absence of pulsus paradoxus secondary to LV systolic dysfunction, loculated (regional) effusion, positive end-expiratory pressure ventilation (PEEP)
  • In the presence of of left heart compression in loculated (regional) tamponade, the tamponade occurs in the presence of normal right atrial and venous systemic pressures.
Figure 58. Publications by Pepi et al, Br Heart J 1994
Figure 58. Pepi et al., Br Heart J 1994;72:327
  • 803 consecutive patients
  • Occurrence of  pericardial effusion= 64%
    Mild= 68% / Moderate= 30% / Severe= 2%
  • Type of effusion
    Loculated= 58% / Diffuse= 42%
  • Tamponade= 1.9%
    (12 valvular prosthesis and 3 CABG)
Figure 58. 2D parasternal short axis
Figure 59. 2D apical 4-chamber
Figure 60. 2D subcostal 4-chamber
Figure 61. Pulsed Doppler 5-chamber, LVOT. Pericardial tamponade in patient with localized severe effusion
Figure 61. Pulsed Doppler 5-chamber, LVOT
Figure 62. M-mode subcostal, LV lateral wall. Pericardial tamponade in patient with localized severe effusion
Figure 62. M-mode subcostal, LV lateral wall

Figures 58-62. Severe loculated effusion lateral to the LV (Figures 58-60) with signs of local tamponade (Figure 61): diastolic collapse of the LV wall (Figure 62, white arrow). Figure 61 shows 20% inspiratory reduction of LV stroke volume (LVOT peak flow velocity, white dots). Asterisk: pericardial effusion.

Figure 63. TE exam, lower esophagus 4-chamber. Progression of pericardial hematoma lateral to the left atrium
Figure 63. TE exam, lower esophagus 4-chamber

Figure 63. Post-open heart surgery TE exam (lower esophagus, 4-chamber) showing LA loculated effusion (1, white arrow), with progression towards hematoma formation (2 and 3, white arrow), with compression of the LA wall and almost complete obliteration of the LA cavity and cardiac tamponade. In 4, after surgical drainage.

Figure 64. TE lower 2D esophagus, 4-chamber
Figure 65. TE color Doppler low esophagus, 4-chamber
Figure 66. TE color Doppler upper esophagus
Figure 67. TE 2D upper esophagus
Figure 68. TE 2D transgastric short axis LV, right rotation

Figures 64-68. Loculated left atrial pericardial effusion with progression towards hematoma, complete LA compression, and tamponade. Fig 64: LA hematoma compressing the LA lateral wall. Fig 65: obstructed (aliasing) flow in the LA. Fig 66: Scan from the descending thoracic aorta (on the right) and the LA (visualized unimpeded flow in left pulmonary veins). Fig 67: the large LA hematoma. Fig 68: from left to right: LV, pericardial effusion, pleural effusion.

Figure 69. Severe pericardial effusion. 2D parasternal long axis and M-mode
Figure 69.
Figure 70. Severe pericardial effusion posterior to the left ventricle
Figure 70.

Figure 69-70. Severe pericardial effusion (8 days after CABG) inferior and posterior to the LV. Collapse of the LA wall (Fig. 69, left panel, white arrow). Diastolic collapse of the LV posterior wall (Fig. 69, right panel, M-mode, white arrow). Early diastolic collapse of the LV inferior wall (Fig.70, right panel, double white arrow).