Introduction
Cardiac tamponade following percutaneous transluminal coronary angioplasty (PTCA) is a rare but potentially life-threatening complication that demands prompt recognition and decisive management.1 While PTCA procedures have revolutionized the treatment of coronary artery disease, the incidence of cardiac tamponade, though low, remains a significant concern. This case report sheds light on the intricate management of a patient who developed cardiac tamponade post-PTCA, detailing the collaborative efforts spanning from the catheterization laboratory (cath lab) to the cardiothoracic operating theater (OT). In the cath lab, meticulous procedural techniques and vigilant monitoring are paramount in preventing and promptly identifying cardiac tamponade.2 Despite adherence to stringent protocols, this complication can still manifest, underscoring the unpredictable nature of interventional cardiology. Once cardiac tamponade is suspected or confirmed, swift action is imperative to stabilize the patient's hemodynamics and avert catastrophic consequences.3
Transitioning from the cath lab to the cardiothoracic OT presents a unique set of challenges. Seamless communication and coordination among the multidisciplinary team are essential to ensure a smooth transfer and continuity of care. In the OT, the focus shifts to definitive management, typically involving pericardiocentesis or emergent surgical intervention, depending on the severity and etiology of the tamponade.4 This case report aims to highlight the intricacies involved in managing post-PTCA cardiac tamponade, emphasizing the critical role of teamwork, clinical acumen, and rapid decision-making. By sharing our experience, we hope to contribute to the collective knowledge base and enhance awareness of this rare yet potentially fatal complication among healthcare providers involved in the care of cardiac patients undergoing interventional procedures.
Case Report
A female in her fifties presented to the ER with chest pain and ECG showing features of ST elevation in the chest leads. She had previous history of PCI to RCA done 3 months ago and was on oral antiplatelets She was wheeled into the cathlab for PTCA to LAD. Procedure was completed successfully and was transferred to recovery room. Post-procedure, she developed sudden bradycardia and was given Inj. atropine 0.6 mg and transferred to the ICU. On arrival at the ICU, she was hemodynamically unstable with a blood pressure of 80/30mmhg and heart rate of 130/min and the ECG showed electrical alterans with severe hypotension and tachycardia. Ionotropes (Inj.noradrenaline infusion) was started, patient was sedated with inj.fentanyl 100 mcg and paralysed with atracurium 50 mg, intubated with 7.5 size ETTube and the right Internal jugular vein central line with femoral arterial line was secured. A bedside echo was done which showed pericardial effusion with cardiac tamponade, an emergency pericardiocentesis was done and a catheter was placed, 600 ml of blood was drained through it, following a transfusion of 1 unit PRBC an urgent CT aortogram was done which showed features of suspicious of Aneurysm around the left circumflex artery, another 2 units of PRBC was transfused in the ICU. Following increased blood collection from the pericardial pigtail catheter drain and worsening hemodynamics, the decision to proceed for emergency thoracotomy was made. The patient was taken for the procedure under ASA 5E. The cardio thoracic OT was made ready with necessary blood products, emergency drugs and cardiopulmonary bypass circuit on standby. All invasive lines were connected. The patient was induced with fentanyl 200 mcg and midazolam 2mg and anaesthesia was maintained with an oxygen air mixture along with isoflurane and ionotropic supports. About 1000 ml of blood was gushing upon opening of the pericardial sac, intraoperatively 1-unit PRBC and 2 FFP were transfused. A rent in the Right ventricle was identified and tunneled Dacron grafts were used to close it and hemostasis was achieved.(Figure 1, Figure 2) Post procedure the patient was transferred to CT ICU on IPPV and ionotropes were tapered slowly. The patient improved hemodynamically and there was no evidence of further bleeding. Post operative Chest x-ray and bed side ECHO were found to be fairly normal with only post operative changes. The patient was extubated on POD 2 and is currently discharged from the hospital with weekly follow-ups and on dual anti platelet therapy.
Discussion
Cardiac tamponade following percutaneous transluminal coronary angioplasty (PTCA) is a rare but potentially life-threatening complication that requires prompt recognition and intervention. In this case, we encountered a patient who developed cardiac tamponade shortly after undergoing PTCA, highlighting the challenges associated with its management and the importance of a multidisciplinary approach. The development of cardiac tamponade post-PTCA can be attributed to various factors, including inadvertent injury to the myocardium or coronary vessels during the procedure, as well as the use of anticoagulant and antiplatelet medications. In our patient, the prompt onset of symptoms, including hypotension and tachycardia, raised suspicion for cardiac tamponade, prompting immediate evaluation and intervention.
The initial management of cardiac tamponade in the catheterization laboratory focused on stabilizing the patient's hemodynamics while preparing for definitive treatment. Bedside echocardiography and POCUS (point of care ultrasound) played a crucial role in confirming the diagnosis and guiding pericardiocentesis, allowing for the rapid removal of the accumulated pericardial fluid. However, it is important to note that pericardiocentesis may be challenging in the setting of acute coronary artery perforation, necessitating surgical exploration and repair. Transitioning from the catheterization laboratory to the cardiothoracic operating theater required seamless communication and collaboration among the interventional cardiology and cardiothoracic surgery teams. Once in the operating theater, the patient underwent emergent surgical intervention, which included exploration of the pericardial space, repair of the right ventricular rent, and evacuation of any remaining hematoma or effusion. This underscores the importance of a coordinated approach and the availability of resources to manage this critical complication effectively.
The successful outcome in this case can be attributed to several factors, including the prompt recognition of cardiac tamponade, the rapid initiation of appropriate interventions, and the expertise of the multidisciplinary team involved in the patient's care.
When compared to other studies, Mixon et al. described a case involving anterior myocardial infarction treated with thrombolytics, leading to postinfarction pericarditis.5 Bottner et al. highlighted a novel complication of stent implantation with adjuvant platelet IIb/IIIa receptor inhibitors, resulting in cardiac tamponade treated by pericardiocentesis and platelet transfusion.6 Kim et al. presented a case of ST-elevation myocardial infarction managed with PCI and intravenous glycoprotein IIB/IIIa inhibitor, resulting in cardiac tamponade and subsequent subacute stent thrombosis.7
Hashidomi et al. encountered a case where septal collateral artery dilation led to cardiac tamponade, managed by pericardiocentesis and coil embolization.8 Chen KM et al. reported a case of cardiac tamponade which developed post right internal jugular vein central line placement during trauma resuscitation, managed with emergency median sternotomy, evacuation and internal jugular vein repair.9 Desikan reported a case of anaesthetic management of cardiac tamponade in peri arrest stage in cath lab, by giving procedural sedation for pig tail catheterisation and needle aspiration following which the patient improved hemodynamically.10
Yoshida et al. reported a case of cardiac tamponade developed post operatively after aortic arch replacement which was managed with emergency left thoracotomy.11 Heo et al. describes the management of cardiac tamponade by proceeding to emergency left anterior thoracotomy with one lung ventilation with double lumen tube and induction with remimezolam but they had reported significant hemodynamic variations noted with remimezolam.12 Wharton et al. have successfully diagnosed and managed a case of cardiac tamponade with the help of point of care ultrasound and pericardiocentensis guided by pocus in the ICU.13 Doniger SJ et al have presented 2 pediatric cases of pericardial effusion identified through point of care ultrasound and one patient was managed with pocus guided pericardiocentensis and the other patient had an additional mediastinal mass which was surgically explored. Pocus played a major role in identifying such life threatening conditions.14
Cameron E et al. have described the role of POCUS in diagnosing life threatening cardiac tamponade in a patient with JAK2 mutation myeloproliferative syndrome. Following which pericardiocentensis with removal of serosanguinous fluid was done.15 The management of post-PTCA cardiac tamponade requires a coordinated and multidisciplinary approach, with timely recognition, prompt intervention, and close monitoring being paramount for optimal patient outcomes. This case explains the importance of vigilance, knowledge of POCUS and preparedness in managing rare but potentially life-threatening complications associated with interventional cardiology procedures.
Conclusion
This case report emphasizes the most dangerous but rare complication of PTCA and the importance of early identification of cardiac tamponade through POCUS and its surgical intervention in improving patient outcomes. It highlights the importance of a proactive approach by anaesthesiologists in identifying and managing complications associated with PTCA. Continued vigilance, prompt recognition, and a coordinated multidisciplinary effort are essential for ensuring optimal outcomes in patients undergoing interventional cardiology procedures. This case also highlights the importance of the knowledge of POCUS for anaesthesiologists as they play the dual role of perioperative physicians as well as intensivists, and therefore their paramount role in diagnosing critical events and making life saving decisions. This case contributes to the growing body of evidence aimed at improving the safety and efficacy of PTCA and underscores the need for ongoing research and education in this field.
