HEMOPERICARDIUM WITH CARDIAC TAMPONADE IN THE LONG-TERM PERIOD AFTER CONCOMITANT INJURY Batekha V.I., Podkamennyy V.A., Novak D.G., Grigoryev E.G.
Irkutsk State Medical University,
Irkutsk State Medical Academy for Postgraduate Education,
Irkutsk Scientific Center of Surgery and Traumatology, Irkutsk, Russia
Cardiac tamponade is a rare complication of severe chest injury (0.3-1.1 % of cases) [1, 2] with mortality of 74-89.2 % [1, 3].
For cardiac tamponade in long term period after non-penetrating injury, identification of cause-and-effect relationship between a traumatic event and hemopericardium is intricate. This publication offers a detailed description of circumstances of occurrence of a rare complication of closed chest injury.
Objective − to discuss the features of surgical tactics in patients with hemopericardium and cardiac tamponade in the long-term period after a blunt trauma of the chest.
CLINICAL FOLLOW-UP
The study was conducted in compliance with ethical standards of Helsinki Declare − Ethical Principles for Medical Research with Human Subjects, 2013, and the Order by the Health Ministry of RF, April 1, 2016, No. 200n "About confirmation of the rules for clinical practice". The patient gave the informed consent for publication of the clinical case.
A man, age of 37, addressed to the admission unit at Irkutsk State Clinical Hospital on November 22, 2019, with complaints of hindered breathing, especially in lying position, pain in the left scapular region, general weakness, edema in lower extremities, and heaviness in epigastrium.
A day before, ultrasonic examination of the abdomen was carried out outpatiently. Intense hepatomegalia was identified (oblique-vertical size of the right lobe − 17 cm). Considering the clinical signs of cardiac insufficiency, the heart was examined with sub-xyphoid approach: high amount of fluid was found in the pericardium (700-800 ml), cardiac contractions of low amplitude. Urgent admission was recommended.
10 weeks before, the patient received a severe concomitant injury in a road traffic accident. He received multiple bilateral fractures of ribs and the sternum (Fig. 1), left-sided hemopneumothorax, lung, heart and brain contusion, subarachnoidal bleeding, a closed fragmented fracture of the left femoral bone. Pleural cavity draining to the left and closed extrafocal fixation were carried out. After correction of intramedullary shock, intramedullary locked fixation was performed (Fig. 2). Artificial lung ventilation lasted for 10 days. The patient was discharged in satisfactory condition on 33rd day.
Figure 1
VRT reconstruction of the chest MSCT after thoracic trauma (14.09.2019). Left-side multiple fragmentary fractures of the ribs (arrows).
Figure 2
Closed comminuted fracture of the left femur at the boundary of upper and middle thirds with dislocation of fragments (a) and the result of blocking intramedullary osteosynthesis (b).
On October, 2019 (8 weeks after trauma), the patient started to perform strength exercises. During push-ups, sharp pain appeared in the chest to the left. 2 days later, labored breathing appeared. During 3 weeks, the signs of cardiac insufficiency were progressing gradually.
At the moment of admission: orthopnea position, labored breathing in rest, pale skin, acrocyanosis, leg edema, increased pulsation of jugular veins, hypotonia (100/60 mm Hg), tachycardia (100 beats per minute). Auscultation showed impalpable cardiac tones, vesicular breathing in lungs, which was weak in lower parts. There was hepatomegalia. The liver was 4 cm below the costal arch.
Plain chest X-ray imaging showed an increase in sizes of cardiac shadow, and evident intensification of lung pattern (Fig. 3). Echocardiography showed high amount of non-homogenous fluid with fibrin deposits, inferior vena cava fullness, paradoxic movement of interventricular septum, right ventricle collapse. The blood analysis: Hb 107 g/l, Ht 34 %, absence of cardiac muscle injury markers (Troponin-I 0,25 ng/ml).
Figure 3
Plan radiography of the chest. Transversal expansion of the heart borders, smoothed contours. Cardiothoracicindex – 85%.
In urgent order, under ultrasonic control, pericardium draining according to Larrey with silicone catheter 18 Fr was carried out. 300 ml of saturated hemorrhagic fluid (Ht 30 %) was drained. Labored breathing decreased. Bulau draining was performed. After 8 hours, the volume of drained fluid was 1,200 ml. Blood clots appeared.
Owing to ongoing bleeding, longitudinal mid-line sternotomy and pericardiotomy were performed. 300 ml of blood with clots were drained (total volume of hemopericardium − 1,800 ml). The heart was covered with fibrin. The anterior wall of the left ventricle and the apex were fixed to pericardium. Cardiolysis with maximally possible removal of dense fibrin, and pericardium sanitation were performed. During examination of magistral veins and the heart, after its dislocation to the surgical wound, no injuries were found.
Pericardium revision was performed. A round defect (1 × 1 cm) with thickened edges of cartilaginous density with insignificant ongoing venous bleeding was found to the left in the plane of 4th rib along anterior axillary line (Fig. 4). A sharp bone fragment in the defect depth was removed with Luer's forceps. Revision showed that the pericardium was not connected with pleural cavity. Hemostasis of the pericardium defect with electrocoagulation, and suturing with continuous twisted two-row suture were performed. The second defect (0.5 × 1 cm) was found along posterior axillary line in the plane of 5th rib. The bottom of the defect included smooth callus without sharp fragments. The edges of the pericardium were dissected, and the defect was sutured. The wound was sutured in layer-by-layer manner.
Figure 4.
VRT reconstruction (03.12.2019): a) the defect along the anterior axillary line in the pericardium with persisting bleeding (arrow); b) the provisional cause of pericardial perforation with unconsolidated splinters of the 4th rib along the middle clavicular line and of the 5th rib along the posterior axillary line (arrow).
The postsurgical period was without complications. The patient was discharged from the hospital on the 8th day. His condition was satisfactory.
The examination was performed after 8 months. No edema was found. No labored breathing was found at rest and during physical load. A trend to increase in systolic arterial pressure (140-150 mm Hg) was found. Hypotensive therapy was initiated. Echocardiography did not show any fluid in the pericardium. The liver size was common. According to MSCT from 17.08.2020, union of multiple fractures occurred (Fig. 5). Physical loads were not contraindicated.
Figure 5
MSCT of the chest. Consolidated multiple fragmentary rib fractures on the left (arrows).
DISCUSSION
Location of pericardial defects and density of pericardium edges supposed that the injury had occurred at the moment of damage to the chest by costal fragments. The absence of contents in the pericardium according to echoCG and MSCT at discharge from the hospital on the day 33 after the concomitant injury testified the delayed occurrence of hemopericardium as result of extension of the movement conditions. After strength exercises, one could observe intense pain in the left side of the chest and gradual progression of cardiac insufficiency signs that was probably related to displacement of non-united fragmented of ribs with pericardial vascular injuries or injuries near pericardial tissue.
Despite of high volume of hemopericardium, the patient had not any signs of hemodynamic instability for a long time. It was determined by slow fluid accumulation in the pericardium and by increasing volume of circulating blood. Therefore, central venous pressure was higher than pericardial pressure for a long time.
For low development of hemopericardium, diuretic therapy, which decreases central venous pressure to the point below pericardial one, can contort the clinical picture and cause late diagnosis of causes of cardiac insufficiency and lethal outcome [4].
Knowledge of these features in patients with previous chest trauma and cardiac insufficiency in the late period allows including delayed heart tamponade into the diagnostic tools.
In the presented case, the history of the concomitant injury, data of ultrasonic examination of the abdomen and late EchoCG explained the cause of labored breathing, hepatomegalia and edema. Pericardium draining and fluid removal improved the patient's condition, but ongoing bleeding determined the indication for heart revision.
Selection of the approach was determined by suspected myocardial injury with possible penetration into heart cavity. In contrast to lateral thoracotomy and video-assisted pericardioscopy, mid-line sternotomy provides sufficient exposure, simplifies direct heart massage and creates favorable conditions for activation of artificial circulation device.
CONCLUSION
For patients with signs of cardiac insufficiency after blunt chest trauma, one should consider the possibility of hemopericardium with heart tamponade in long term period. One should remember that pericardium draining is not always the final method of surgical management. If a heart injury is suspected, the preferable surgical approach is mid-line sternotomy. Final hemostasis can be achieved without use of axillary methods of blood circulation.
Information on financing and conflict of interests
The study was conducted without sponsorship. The authors declare the absence of any clear or potential conflicts of interests relating to publication of this article.