Left ventricular tamponade- pathophysiology determines the therapeutic approach: a case series

Abstract

Background Left ventricular (LV) tamponade is rare. LV tamponade can occur in cases of a loculated pericardial effusion overlying the LV and in cases of circumferential pericardial effusions in patients with severe pulmonary arterial hypertension (PAH). Both causes of LV tamponade share the common feature of not presenting with the classical features of cardiac tamponade. However, the therapeutic approach of the two is different. Case summary Here, we report two cases of LV tamponade. The first patient was a case of post-mitral valve replacement who presented with loculated posterior pericardial effusion with LV tamponade. Due to the loculated and posterior nature of the effusion, his pericardial fluid was drained from the axilla by echocardiographic and fluoroscopic guidance. The second patient presented with features of severe PAH with a circumferential pericardial effusion and LV tamponade. Due to the circumferential nature of the effusion, the pericardiocentesis was performed from the subxiphoid route. Discussion The pathophysiology of LV tamponade must be determined accurately before performing pericardiocentesis. Left ventricular tamponade in patients with severe PAH and non-loculated circumferential effusion can be drained from the subxiphoid route, while LV tamponade due to loculated effusion overlying LV must be drained by echocardiographic and fluoroscopic guidance from the axilla.

Isolated left ventricular cardiac tamponade diagnosed on point‐of‐care ultrasound in the emergency department: A case report and brief literature review

“…5 even in the absence of RA or RV collapse. [7][8][9] In patients with loculated effusions or other localized compressive effects such as with esophageal stents or massive pleural effusions, as seen in other case reports, 10,11 the intrapericardial pressure exerted by the effusion only affects the adjacent chambers, which can potentially cause isolated left heart tamponade.…”

“…Risk factors include patients with circumferential effusions with concomitant underlying severe pulmonary hypertension as well as patients with loculated effusions surrounding the LA or LV, typically seen after cardiac surgery. 7 In patients with pulmonary hypertension, when right heart pressures are severely elevated, the intrapericardial pressure exerted by the circumferential effusion can overcome the diastolic pressure in the LV, causing LA or LV diastolic collapse even in the absence of RA or RV collapse. 7 , 8 , 9 In patients with loculated effusions or other localized compressive effects such as with esophageal stents or massive pleural effusions, as seen in other case reports, 10 , 11 the intrapericardial pressure exerted by the effusion only affects the adjacent chambers, which can potentially cause isolated left heart tamponade.…”

“…In rare cases, tamponade of the left atrium and/or left ventricle can occur. Risk factors include patients with circumferential effusions with concomitant underlying severe pulmonary hypertension as well as patients with loculated effusions surrounding the LA or LV, typically seen after cardiac surgery 7. In patients with pulmonary hypertension,when right heart pressures are severely elevated, the intrapericardial pressure exerted by the circumferential effusion can overcome the diastolic pressure in the LV, causing LA or LV diastolic collapse F I G U R E 2 Apical 4-chamber view centered on left ventricular cavity (asterisk) with focal left-sided pericardial effusion (arrowheads) causing diastolic left ventricular free wall collapse (arrow).…”

Cardiac Tamponade Causing Predominant Left Atrial and Ventricular Compression After Left Ventricular Assist Device Placement

“…Patients undergoing left ventricular assist device (LVAD) placement are at particularly high risk of pericardial bleeding and cardiac tamponade because of the need for postoperative anticoagulation agents [ 3 ]. Cardiac tamponade typically affects right-sided cardiac chambers because of the lower pressures of the right atrium and right ventricle [ 4 ]. Cardiac tamponade of the left-sided cardiac chambers is rare and typically only seen in situations such as those in patients with severe pulmonary arterial hypertension (PAH) or loculated posterior pericardial effusion [ 4 ].…”

“…Cardiac tamponade typically affects right-sided cardiac chambers because of the lower pressures of the right atrium and right ventricle [ 4 ]. Cardiac tamponade of the left-sided cardiac chambers is rare and typically only seen in situations such as those in patients with severe pulmonary arterial hypertension (PAH) or loculated posterior pericardial effusion [ 4 ]. This case report describes a patient who developed left-sided cardiac tamponade after LVAD placement and his subsequent hospital course.…”