Complications of Mechanical Ventricular Assistance
Wayne E. Richenbacher in Mechanical Circulatory Support, 2020
Even if LVAD flow is initially satisfactory it is important to monitor LVAD flow as the implant operation is completed and the patient moved to the intensive care unit. Pericardial closure, recommended in the patient being bridged to cardiac transplantation, can compress the heart and reposition the inlet cannula both of which can impair LVAD flow. Similarly, prolonged CPB time in the postcardiotomy cardiogenic shock patient can produce significant myocardial edema. When an edematous heart is further compressed by multiple VAD cannulae within the mediastinum sternal closure may reduce VAD filling. If either maneuver impairs VAD filling it is best to leave the pericardium open (although a pericardial membrane can be sewn anteriorly without cardiac compression) or stent the sternum open. If the sternum is stented open mediastinal drains should be placed beneath a sterile occlusive dressing. Lastly, postoperative bleeding can lead to cardiac chamber compression and inadequate VAD filling. If the patient has been in the intensive care unit with adequate VAD flow for a number of hours, when VAD flow suddenly declines an echocardiogram will often demonstrate clotted blood within the mediastinum. The hemopericardium can cause chamber compression and an inadequate flow of blood into the VAD. The patient should be returned to the operating room for sternal reexploration and mediastinal irrigation. Relief of the tamponade results in a prompt increase in VAD flow.
Thoracic trauma
Larry R. Kaiser, Sarah K. Thompson, Glyn G. Jamieson in Operative Thoracic Surgery, 2017
Adjunctive procedures such as pericardiocentesis and sub- xiphoid pericardiotomy (see “Subxiphoid pericardiotomy” subsection) were historically used mostly for the diagnosis of hemopericardium, although these procedures have been supplanted in this role by pericardial ultrasound due to the latter’s high sensitivity and noninvasiveness. Effective treatment for cardiac tamponade mandates immediate ecompression and repair of the underlying cardiac injury, which requires either a sternotomy or thoracotomy incision. Though transfer to the operating room is preferred, some patients will require immediate intervention in the trauma bay (i.e., emergency department thoracotomy [EDT]—see “ED thoracotomy” subsection). The role of pericardiocentesis as a therapeutic procedure is less clear, but most centers have abandoned therapeutic pericardiocentesis due to concerns over delays in definitive operative intervention. Occasionally, experienced surgical personnel are not immediately avail- able or ultrasound results are equivocal, and decompression of cardiac tamponade by pericardiocentesis is necessary. Furthermore, a single-center experience recently reported that performance of pericardiocentesis in the emergency department (ED) does not delay definitive therapy and that early relief of cardiac tamponade leads to improvements in patient hemodynamics.11
Aortic disease
Paul Schoenhagen, Carl J. Schultz, Sandra S. Halliburton in Cardiac CT Made Easy, 2014
Patients with aortic dissection (class I to class V) and documented involvement of the ascending aorta are typically operated on immediately (Figures 10.3 and 10.4).345 However, in certain patient populations, successful initial medical management of class II IMH of the ascending aorta has been described, but remains controversial.357c–e The identification of acute complications, in particular hemopericardium and mediastinal hematoma, is critical in the management of these patients (Figures 10.5, 10.6, and 10.7). For patients without involvement of the ascending aorta, initial treatment is typically conservative, with aggressive blood pressure control.344,345 However, distal complications including visceral branch vessel compression/ischemia, aortic rupture, intractable pain, and uncontrollable hypertension can require immediate surgical or endovascular treatment (Figures 10.7–10.9). Distal class IV and V tears may require either open or endovascular surgical intervention. In distal dissections that are subacute (2–6 weeks old), the Investigation of Stent Grafts in Patients with Type B Aortic Dissection (INSTEAD)347 study documented no benefit of prophylactic stenting. There is no proof that stenting is beneficial if the aortic dissection is chronic, i.e. more than 6 weeks old.348–350
Current practice in atrial septal defect occlusion in children and adults
Published in Expert Review of Cardiovascular Therapy, 2020
Wail Alkashkari, Saad Albugami, Ziyad M. Hijazi
With nearly 45 years after the first case of transcatheter ASD closure performed by King and Mills in New Orleans, the procedure has become an accepted first choice for majority of patients with an appropriate secundum atrial septal defect. The procedure is safe and effective. However, there is a finite risk of disastrous complications and that is device erosion with hemopericardium and on very rare occasion death. The major issue with this fearful complication is the inability to predict its timing. Some cases of erosions occurred years (after 9 years) after implantation of the device. We know that there are certain risk factors that may predispose to it, such as patients with deficient anterior/superior rim who receive an oversized device (oversizing by more than 150% of the true defect size). However, even with that, we truly cannot predict the timing of this complication, and not all patients who receive an oversized device encounter this complications. Unfortunately, our surgical colleagues claim that what we see now is only the tip of the iceburg! Of course as I mentioned with now over 20 years of experience with the most modern device (Amplatzer), the rate of erison remains extremely low at about 2–3 per 1000 cases.
Cardiac tamponade secondary to iatrogenic needle decompression in blunt force trauma
Published in Baylor University Medical Center Proceedings, 2022
Zaheer Faizi, Joseph Morales, Joseph Hlopak, Amber Batool, Asanthi Ratnasekera
Subsequently, during computed tomography (CT) scans of the head, neck, chest, abdomen, and pelvis, the patient underwent cardiac arrest with initiation of cardiopulmonary resuscitation. CT of the chest demonstrated a hemopericardium (Figure 1b). A left anterolateral resuscitative ED thoracotomy was performed. The pericardium appeared very tense. A pericardiotomy was performed with evacuation of blood clot. With intracardiac epinephrine and cardiac massage, return of spontaneous circulation was achieved after 12 minutes of resuscitation. The patient was then transferred to the operating room for further evaluation.
Nonpenetrating trauma resulting in hemopericardium presenting as syncope
Published in Baylor University Medical Center Proceedings, 2021
Nonpenetrating chest trauma resulting in hemopericardium is an uncommon cause of syncope.1 Hemopericardium may be caused by cardiac rupture or vascular damage resulting in blood accumulation in the pericardial sac.3 Usually hemopericardium will result in cardiac tamponade from blood accumulation in the pericardium. However, a few select cases will result in cardiac tamponade over a significant period of time, termed “delayed hemopericardium” due to a “small leak” that may not become clinically apparent until accumulation of blood products reaches a critical stage.2
Related Knowledge Centers
- Anticoagulant
- Cardiac Tamponade
- Myocardial Infarction
- Necrosis
- Pericardial Effusion
- Heart
- Blood
- Cardiac Muscle
- Pericardium
- Chest Injury