Extra-pericardial tamponade following Wolf Mini-Maze procedure: a case report

Abstract

BackgroundExtra-pericardial tamponade is a rare life threatening condition that has not previously been reported in association with Wolf Mini-Maze procedures. In this case, atypical presentation of cardiac tamponade caused by postoperative anticoagulation resulted in a second hospitalization, a second surgery, and delayed recovery time. The goal of this case report is to increase awareness about a life threatening complication that can occur following minimally invasive cardiac surgery.Case PresentationA 60 year old male with long standing essential hypertension, who was recently treated for atrial fibrillation utilizing the Wolf Mini-Maze procedure, experienced a postoperative international normalized ratio increase from 3.6 to 5.3 over the course of six days. Fifteen days postoperatively, the patient experienced mild exercise intolerance, his condition rapidly progressed to a constellation of symptoms including severe exercise intolerance, dyspnea, hypotension, and near syncope. A diagnosis of cardiac tamponade was made, and the patient was re-admitted to the hospital. Attempts to reverse his warfarin anticoagulation with fresh frozen plasma and vitamin K were unsuccessful after 24 h. Video-assisted thoracotomy was performed to relieve the tamponade, and during surgery he was diagnosed with extra-pericardial tamponade caused by an extensive hematoma. Complications due to anticoagulation therapy required this re-admission, additional surgery, and delayed recovery. The patient has since recovered completely with no long term morbidities and is asymptomatic three years following initial presentation.ConclusionsThis case marks the first time extra-pericardial tamponade has been reported post cardiothoracic intervention in English literature. Many surgical procedures require postoperative anticoagulation; in the past, warfarin has been the standard of care due to its purported reversibility. This case provides an example of the challenge presented when anticoagulating with warfarin, and the reversal of this anticoagulation.

Constrictive Cardiomyopathy Secondary to Calcified Pericardium

“…A maze procedure is when a cardiac surgeon creates small areas of scar tissue in a maze pattern along the atria of the heart to prevent atrial fibrillation. These procedures have been associated with pericardial inflammation and pericarditis [4,5]. In addition, due to recurrent atrial fibrillation, he underwent additional cardiac ablation one year prior to this admission, in 2021.…”

“…In the developing world, the most common cause of pericardial calcification is believed to be tuberculosis. Evidence for this is found in up to 3% of autopsied cases [5]. Most cases of pericardial calcification are asymptomatic found incidentally on CT imaging of the chest [1].…”