Cardiac tamponade and para-aortic hematoma post elective surgical myocardial revascularization on a beating heart – a possible complication of the Lima-stitch and sequential venous anastomosis

Abstract

BackgroundOff-pump coronary artery bypass (OPCAB) surgery can be associated with some intrinsic, but relatively rare complications. A pericardial effusion is a common finding after cardiac surgeries, but the prevalence of a cardiac tamponade does not exceed 2% and is less frequent after myocardial revascularization.Authors believe that in our patient an injury of a nutritional pericardial or descending aorta vessel caused by the Lima stitch resulted in oozing bleeding, which gradually leaded to cardiac tamponade. The bleeding increased after introduction of double antiplatelet therapy and caused life-threatening hemodynamic destabilization. According to our knowledge it is the first report of such a complication after OPCAB.Case presentationWe present a case of a 61-year old man, who underwent elective surgical myocardial revascularization on a beating heart. On the 11th postoperative day the patient was readmitted emergently to the intensive care unit for severe chest pain, dyspnoea and hypotension. Coronary angiographic control showed a patency of the bypass grafts and significant narrowing of circumflex artery, treated with angioplasty and stenting. The symptoms and hemodynamic instability exacerbated. A suspicion of dissection of the ascending aorta and para-aortic hematoma was stated on 16-slice cardiac computed tomography. The patient was referred to the Cardiovascular Surgery Clinic. Transthoracic echocardiography revealed cardiac tamponade. On transesophageal echocardiography there were no signs of the ascending aorta dissection, but a possible lesion of the descending aorta with para-aortic hematoma was visualized. Emergent rethoracotomy and cardiac tamponade decompression were performed. 12 days after intervention the control 64-slice computed tomography showed no lesions of the ascending or descending aorta. On one-year follow-up patient is in a good condition, the left ventricular function is preserved and there is no pathology in thoracic aorta on echocardiography.ConclusionsMechanical complications of surgical myocardial revascularization on a beating heart should be considered as a cause of the clinical and hemodynamic instability relatively early in the postoperative period. Echocardiographic examination must be the first step in diagnostics process in a patient after cardiac surgery.

Intrathoracic hemorrhage by deep pericardial sutures as detected by transesophageal echocardiography: report of two cases

“…The area surrounding the LLPV immediately behind the pericardium in case 1 and the wide area along with the diaphragm in case 2 are notable examples for the localization of the injury site. The previous reports identified the aorta, pulmonary veins, esophagus, and lung as organs susceptible to injuries by DPS [3][4][5][6]. Our case 2 suggested that the diaphragm also requires attention during DPS stitching.…”

“…Left lower pulmonary vein flow is depicted using the color Doppler imaging mode. LLPV, left lower pulmonary vein low molecular weight heparin, and the postoperative administration of double antiplatelet agents presumably increased the bleeding [4][5][6]. In contrast, in our two cases, no agents relating to coagulation cascade or platelet function, except a low dose of aspirin or preoperative heparin infusion, were administered.…”

“…During DPS stitching, great caution should be taken to avoid serious bleeding. Although this complication seems rare because, to our best knowledge, only four case reports have been published [3][4][5][6], DPS may cause life-threatening bleeding. In one out of the four published cases, the patient died because of aortic injury [3].…”

“…TEE was a useful tool for detecting bleeding complications in the thorax, pericardium, and para-aortic space [4][5][6]. Intrathoracic fluid or blood accumulation is often encountered during cardiac surgery and is easily visualized using TEE with the counterclockwise rotation of the probe from the mid-esophageal four-chamber view, considering the left-sided accumulation in a patient in a supine position.…”

“…The use of deep pericardial suture (DPS) is a common technique to lift the heart and expose the targeted vessels during OPCAB [1]. This procedure holds the advantage of not requiring special devices and incurring extra costs [2], whereas there have been several reports on complications of bleeding due to DPS [3][4][5][6].…”