International Journal of Cardiology 172 (2014) e69–e70
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Delayed cardiac tamponade following management of a massive hemothorax related to a penetrating thoracic trauma Maximilien Sochala a,1, Linda Aïssou b,⁎,1, Emmanuel Sorbets a,c,1, Natalia Pop a,1, Carla Sleiman a,1, François-Xavier Goudot a,1, Christophe Meune a,d,1 a
Department of Cardiology, Avicenne Hospital, Hopitaux Universitaires Paris-Seine-Saint-Denis, APHP, France Department of Cardiology, Avicenne Hospital, Hopitaux Universitaires Paris-Seine-Saint-Denis, Université Paris XIII, APHP, France Department of Cardiology, Bichat Hospital, Université Paris Diderot, APHP, France d Department of Cardiology, Cochin Hospital, Université Paris Descartes, APHP, France b c
a r t i c l e
i n f o
Article history: Received 18 September 2013 Accepted 21 December 2013 Available online 28 December 2013 Keywords: Cardiac tamponade Penetrating chest trauma Myocardial breach Hemothorax
A 25-year-old man, current smoker and cannabis abuser, was admitted to the emergency department for acute chest pain and dyspnea. He had no relevant past medical disease. He was admitted in the Intensive Care Unit at another institution twenty days ago for a cardiac arrest following a traumatic massive left hemothorax after a stab wound. Immediate resuscitation was successful, without no-flow and with a less than 5 min low-flow; left pleural drainage was performed. CT scan control showed multiple parenchymatic contusions and a small right pleural effusion. On day 2, cardiac monitoring showed transient diffuse ST elevation without any chest pain, and troponin I (cTn I) increased up to 16 μg/l (cut-off value of 0.15 μg/l). Transthoracic echocardiography (TTE) showed no pericardial effusion, LVEF was 57% and there was no wall motion abnormality. A cardiac MRI showed neither myocardium rupture, nor pericardial effusion. cTn I concentration decreased and the patient was discharged at day 6 after a second normal echocardiography. At presentation to our institution, heart rate was 115 bpm, blood pressure was 110/75 mm Hg, and blood temperature was 37.9 °C. He had no signs of heart failure or any abnormal cardiac murmur. Chest ⁎ Corresponding author at: Cardiology Department, Avicenne Hospital, 125 Bd de Stalingrad, 93000 Bobigny, France. Tel.: +33 148955320. E-mail address: [email protected] (L. Aïssou). 1 This author takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.
0167-5273/$ – see front matter © 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2013.12.049
X-ray showed widened cardiac silhouette evocative of pericardial effusion that was confirmed by immediate TTE. A CT scan ruled out type A aortic dissection and showed non-proximal right pulmonary embolism, basal left lung contusion and large pericardial effusion (Fig. 1). While he received no anticoagulant or antiplatelet therapy, signs of cardiac tamponade occurred (Fig. 2); a pericardiocentesis by subxiphoid approach was performed under ultrasound guidance and 800 cm3 of active hemorrhagic fluid was collected within 10 min. Immediate sternotomy was performed after general anesthesia and showed 1) hemorrhagic pericardial effusion, 2) multiple pericardial adherences, and 3) a pericardial and myocardial breaches localized at the apex of the left ventricle. After surgical correction of the myocardium breach, drains were placed in left pleural cavity, in retro-sternal area and in pericardial cavity. Twelve hours after surgery, a collapse occurred. Immediate treatment included fluid expansion, norepinephrine, antibiotherapy and heparin therapy for possible massive pulmonary embolism and/or septic shock. TTE showed localized pericardial effusion that involved the left ventricle, with markedly reduced cardiac output. Surgery confirmed localized pericardial effusion that was responsible of left ventricle collapse. After pericardial surgical drainage, he progressively recovered and was discharged two weeks later. Penetrating chest trauma is a very severe and complex condition. Delayed cardiac tamponade after a penetrating chest trauma has been previously reported although it is assumed to be a very rare condition [1–3]. However, post pericardiotomy syndrome and sepsis are the most common cause of delayed pericardial effusion. Our observation is very original as 1) we assume that delayed cardiac tamponade occurred as a consequence of initial penetrating chest trauma. This is suggested by the collection of hemorrhagic fluid and the findings of a myocardial breach at the time of surgery. 2) While ST elevation occurred and cTn-I increased 48 h after the stab wound, myocardial breach remains unnoticed despite repeated echocardiography, MRI examination [4] and CT scan[5]. Overall, our case report emphasizes the need of comprehensive evaluation, possibly including surgical examination, in a large number of patients with acute chest trauma [6,7]. In our observation, we had no evidence of active infection; however, a possible benefit of antibiotic prophylactic treatment has been suggested [8,9].
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M. Sochala et al. / International Journal of Cardiology 172 (2014) e69–e70
Fig. 1. Large pericardial effusion and non-proximal right pulmonary embolism at CT scan.
Fig. 2. Cardiac tamponade at TTE.
References [1] Harris DG, Janson JT, Van Wyk J, Pretorius J, Rossouw GJ. Delayed pericardial effusion following stab wounds to the chest. Eur J Cardiothorac Surg 2003;23(4):473–6. [2] Hermens JA, Wajon EM, Grandjean JG, Haalebos MM, von Birgelen C. Delayed cardiac tamponade in a patient with previous minor blunt chest trauma. Int J Cardiol 2009;131(3):e124–6. [3] Rendon F, Gomez Danes LH, Castro M. Delayed cardiac tamponade after penetrating thoracic trauma. Asian Cardiovasc Thorac Ann 2004;12(2):139–42. [4] Restrepo CS, Gutierrez FR, Marmol-Velez JA, Ocazionez D, Martinez-Jimenez S. Imaging patients with cardiac trauma. Radiographics 2012;32(3):633–49.
[5] Co SJ, Yong-Hing CJ, Galea-Soler S. Role of imaging in penetrating and blunt traumatic injury to the heart. Radiographics 2011;31(4):E101–15. [6] Broderick SR. Hemothorax: etiology, diagnosis, and management. Thorac Surg Clin 2013;23(1):89–96 [vi-vii]. [7] Goodman M, Lewis J, Guitron J, Reed M, Pritts T, Starnes S. Video-assisted thoracoscopic surgery for acute thoracic trauma. J Emerg Trauma Shock 2013;6(2):106–9. [8] Bosman A, de Jong MB, Debeij J, van den Broek PJ, Schipper IB. Systematic review and meta-analysis of antibiotic prophylaxis to prevent infections from chest drains in blunt and penetrating thoracic injuries. Br J Surg 2012;99(4): 506–13. [9] Petersen K, Waterman P. Prophylaxis and treatment of infections associated with penetrating traumatic injury. Expert Rev Anti Infect Ther 2011;9(1):81–96.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Delayed cardiac tamponade following management of a massive hemothorax related to a penetrating thoracic trauma Maximilien Sochala a,1, Linda Aïssou b,⁎,1, Emmanuel Sorbets a,c,1, Natalia Pop a,1, Carla Sleiman a,1, François-Xavier Goudot a,1, Christophe Meune a,d,1 a
Department of Cardiology, Avicenne Hospital, Hopitaux Universitaires Paris-Seine-Saint-Denis, APHP, France Department of Cardiology, Avicenne Hospital, Hopitaux Universitaires Paris-Seine-Saint-Denis, Université Paris XIII, APHP, France Department of Cardiology, Bichat Hospital, Université Paris Diderot, APHP, France d Department of Cardiology, Cochin Hospital, Université Paris Descartes, APHP, France b c
a r t i c l e
i n f o
Article history: Received 18 September 2013 Accepted 21 December 2013 Available online 28 December 2013 Keywords: Cardiac tamponade Penetrating chest trauma Myocardial breach Hemothorax
A 25-year-old man, current smoker and cannabis abuser, was admitted to the emergency department for acute chest pain and dyspnea. He had no relevant past medical disease. He was admitted in the Intensive Care Unit at another institution twenty days ago for a cardiac arrest following a traumatic massive left hemothorax after a stab wound. Immediate resuscitation was successful, without no-flow and with a less than 5 min low-flow; left pleural drainage was performed. CT scan control showed multiple parenchymatic contusions and a small right pleural effusion. On day 2, cardiac monitoring showed transient diffuse ST elevation without any chest pain, and troponin I (cTn I) increased up to 16 μg/l (cut-off value of 0.15 μg/l). Transthoracic echocardiography (TTE) showed no pericardial effusion, LVEF was 57% and there was no wall motion abnormality. A cardiac MRI showed neither myocardium rupture, nor pericardial effusion. cTn I concentration decreased and the patient was discharged at day 6 after a second normal echocardiography. At presentation to our institution, heart rate was 115 bpm, blood pressure was 110/75 mm Hg, and blood temperature was 37.9 °C. He had no signs of heart failure or any abnormal cardiac murmur. Chest ⁎ Corresponding author at: Cardiology Department, Avicenne Hospital, 125 Bd de Stalingrad, 93000 Bobigny, France. Tel.: +33 148955320. E-mail address: [email protected] (L. Aïssou). 1 This author takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.
0167-5273/$ – see front matter © 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2013.12.049
X-ray showed widened cardiac silhouette evocative of pericardial effusion that was confirmed by immediate TTE. A CT scan ruled out type A aortic dissection and showed non-proximal right pulmonary embolism, basal left lung contusion and large pericardial effusion (Fig. 1). While he received no anticoagulant or antiplatelet therapy, signs of cardiac tamponade occurred (Fig. 2); a pericardiocentesis by subxiphoid approach was performed under ultrasound guidance and 800 cm3 of active hemorrhagic fluid was collected within 10 min. Immediate sternotomy was performed after general anesthesia and showed 1) hemorrhagic pericardial effusion, 2) multiple pericardial adherences, and 3) a pericardial and myocardial breaches localized at the apex of the left ventricle. After surgical correction of the myocardium breach, drains were placed in left pleural cavity, in retro-sternal area and in pericardial cavity. Twelve hours after surgery, a collapse occurred. Immediate treatment included fluid expansion, norepinephrine, antibiotherapy and heparin therapy for possible massive pulmonary embolism and/or septic shock. TTE showed localized pericardial effusion that involved the left ventricle, with markedly reduced cardiac output. Surgery confirmed localized pericardial effusion that was responsible of left ventricle collapse. After pericardial surgical drainage, he progressively recovered and was discharged two weeks later. Penetrating chest trauma is a very severe and complex condition. Delayed cardiac tamponade after a penetrating chest trauma has been previously reported although it is assumed to be a very rare condition [1–3]. However, post pericardiotomy syndrome and sepsis are the most common cause of delayed pericardial effusion. Our observation is very original as 1) we assume that delayed cardiac tamponade occurred as a consequence of initial penetrating chest trauma. This is suggested by the collection of hemorrhagic fluid and the findings of a myocardial breach at the time of surgery. 2) While ST elevation occurred and cTn-I increased 48 h after the stab wound, myocardial breach remains unnoticed despite repeated echocardiography, MRI examination [4] and CT scan[5]. Overall, our case report emphasizes the need of comprehensive evaluation, possibly including surgical examination, in a large number of patients with acute chest trauma [6,7]. In our observation, we had no evidence of active infection; however, a possible benefit of antibiotic prophylactic treatment has been suggested [8,9].
e70
M. Sochala et al. / International Journal of Cardiology 172 (2014) e69–e70
Fig. 1. Large pericardial effusion and non-proximal right pulmonary embolism at CT scan.
Fig. 2. Cardiac tamponade at TTE.
References [1] Harris DG, Janson JT, Van Wyk J, Pretorius J, Rossouw GJ. Delayed pericardial effusion following stab wounds to the chest. Eur J Cardiothorac Surg 2003;23(4):473–6. [2] Hermens JA, Wajon EM, Grandjean JG, Haalebos MM, von Birgelen C. Delayed cardiac tamponade in a patient with previous minor blunt chest trauma. Int J Cardiol 2009;131(3):e124–6. [3] Rendon F, Gomez Danes LH, Castro M. Delayed cardiac tamponade after penetrating thoracic trauma. Asian Cardiovasc Thorac Ann 2004;12(2):139–42. [4] Restrepo CS, Gutierrez FR, Marmol-Velez JA, Ocazionez D, Martinez-Jimenez S. Imaging patients with cardiac trauma. Radiographics 2012;32(3):633–49.
[5] Co SJ, Yong-Hing CJ, Galea-Soler S. Role of imaging in penetrating and blunt traumatic injury to the heart. Radiographics 2011;31(4):E101–15. [6] Broderick SR. Hemothorax: etiology, diagnosis, and management. Thorac Surg Clin 2013;23(1):89–96 [vi-vii]. [7] Goodman M, Lewis J, Guitron J, Reed M, Pritts T, Starnes S. Video-assisted thoracoscopic surgery for acute thoracic trauma. J Emerg Trauma Shock 2013;6(2):106–9. [8] Bosman A, de Jong MB, Debeij J, van den Broek PJ, Schipper IB. Systematic review and meta-analysis of antibiotic prophylaxis to prevent infections from chest drains in blunt and penetrating thoracic injuries. Br J Surg 2012;99(4): 506–13. [9] Petersen K, Waterman P. Prophylaxis and treatment of infections associated with penetrating traumatic injury. Expert Rev Anti Infect Ther 2011;9(1):81–96.
