Amodeo, Antonio

Brancaccio, Gianluca

Gandolfo, Fabrizio

Secinaro, Aurelio

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Case ReportsPerigraft seromamimicking cardiac tamponade after implantation of
Berlin Heart EXCOR device in an infantFabrizio Gandolfo, MD, Gianluca Brancaccio, MD, PhD, Aurelio Secinaro, MD, and
Antonio Amodeo, MD, Rome, ItalyDevelopment of serous fluid leakage around polytetra-
fluoroethylene (PTFE) grafts used to perform systemic-
to-pulmonary arterial shunt (modified Blalock-Taussig
shunt) has been reported previously.1 Occasionally, an ex-
cessive amount of serous fluid will persistently drain
through the interstices of the fabric.
We report an unusual case of pericardial seroma in an
infant developing around the outflow cannula of a new
model of Berlin Heart left ventricular assistance device
(EXCOR; Berlin Heart GmbH, Berlin, Germany), which
includes a PTFE component. This seroma led to a initial
diagnosis of cardiac tamponade and necessitated surgical
revision.CLINICAL SUMMARY
In a 4-month-old female infant, weighing 5.5 kg and
affected by a severe form of dilative cardiomyopathy,
a 10-mL EXCOR left ventricular assistance device was im-
planted. The inflow cannula was positioned in the apex of
the left ventricle, and a newly designed outflow cannula
was placed in the ascending aorta. The aortic cannula fea-
tures a terminal part (near the aortic anastomosis) made of
PTFE graft, which is intended to allow a more physiologic
curvature around the heart and to prevent traction on the
aortic suture.
Cardiopulmonary bypass with induced ventricular fibril-
lation at 30C lasted 131 minutes. The procedure was per-
formed uneventfully.
The child was admitted to the intensive care unit
on a regimen of epinephrine (0.05 mg/[kg $ min]), mil-
rinone (1 mg/[kg $ min]), and dopamine (3 mg/[kg $
min]). No excessive bleeding was noted in the following
days.From the Department of Cardiac Surgery, Ospedale Pediatrico Bambino Gesu, Rome,
Italy.
Disclosures: Authors have nothing to disclose with regard to commercial
support.
EXCOR is a registered trademark of Berlin Heart GmbH, Berlin, Germany.
Received for publication July 2, 2012; revisions received Aug 15, 2012; accepted for
publication Sept 12, 2012; available ahead of print Oct 10, 2012.
Address for reprints: Antonio Amodeo, MD, Department of Cardiac Surgery,
Ospedale Pediatrico Bambino Gesu, Piazza S.Onofrio, 5- 00165 Rome, Italy
(E-mail: antonioamodeo@yahoo.it).
J Thorac Cardiovasc Surg 2013;145:e3-4
0022-5223/$36.00
Copyright  2013 by The American Association for Thoracic Surgery
http://dx.doi.org/10.1016/j.jtcvs.2012.09.016
The Journal of Thoracic and CEchocardiography performed during first days after
EXCOR implantation showed a normal right ventricular
function. In the ensuing postoperative course, however,
progressive right ventricular dysfunction was demon-
strated by ultrasonographic studies. Central venous pres-
sure rose to 15-20 mm Hg, with clinical evidence of
superior vena cava syndrome. Medical treatment for
right ventricular failure was started, without clinical
improvement.
Cardiac catheterization was then performed. Amean gra-
dient between the superior vena cava and the right atrium of
16 mm Hg was measured; however, neither echocardiogra-
phy nor angiography was able to reveal the etiology of the
superior vena cava obstruction.
Two weeks from implantation, a contrast computed
tomographic scan with 3-dimensional imaging was per-
formed. The 3-dimensional volumetric acquisition was in-
strumental in detailing extrinsic compression of the
superior vena cava by a high-density fluid collection around
the inflow cannula, contouring the right ventricle as well
(Figure 1). Direct compression from the arterial cannula
itself was ruled out (Figure 2).
Surgical reexploration was conducted the next day, and
a huge quantity of semisolid, yellowish material was found
around the cannula and the right ventricle. After mass
removal, central venous pressure immediately fell to
7-8 mm Hg. No signs of infection were observed.
Histologic examination confirmed the suspicion of
serumlike material, leading to the eventual diagnosis
of seroma, probably generated by the PTFE graft. Peri-
cardial effusion has not recurred on ultrasonographic
follow-up. Drainage production was almost 20 mL se-
rum in the first 4 days, and removal was performed after
1 week.
The patient underwent transplant 1 month later. After an
uncomplicated hospital course, she was discharged in good
clinical status.DISCUSSION
Because of the lack of heart donors in the infant pop-
ulation, ventricular assist devices may remain in place
for several months, leading to multiple acute and
chronic complications. Serum leakage in the pediatric
population treated with a PTFE graft has been described
previously, particularly after systemic-to-pulmonaryardiovascular Surgery c Volume 145, Number 1 e3
FIGURE 1. The 3-dimensional volume rendering shows superior vena
cava obstruction (arrow) at the junction with the right atrium. Between
the superior vena cava and the inflow cannula (arrowhead), there is a non-
enhancing gap.
FIGURE 2. The 2-dimensional axial view reveals the presence of a fluid
collection (star) surrounding the polytetrafluoroethylene aortic cannula
(arrowhead) and right-sided chambers causing an extrinsic compression
of the superior vena cava (arrow).
Case Reportsarterial shunts.2 A perigraft seroma is defined as a sterile
collection of fluid from a nonsecretory wall surrounding
a shunt. One of the most widely accepted theories is
that handling of the PTFE graft causes leakage because
of a change from a hydrophobic state to a hydrophilic
one.
In our case, progressive elevation of central venous
pressure and mild to moderate right ventricular dysfunc-
tion, together with unclear information from echocardi-
ography, prompted us to treat the patient for right
ventricular dysfunction. Only computed tomographic
scan techniques revealed the extrinsic compression of
the superior vena cava and possibly the right ventricle.
Surgical revision became then the obvious option,3
with immediate relief of symptoms. The roles of com-
puted tomography and magnetic resonance imaging in
detecting this complication after the Blalock-Taussig
shunt have been described as well.4,5 We postulate thate4 The Journal of Thoracic and Cardiovascular Surgeserum leakage stops for a protective inner panel
formation inside the cannula a few weeks after
implantation.
In this early experience with the EXCOR device with an
aortic cannula of new design, a major complication
occurred. Its possibility must therefore be kept in mind.
We wish to stress the important role of the computed tomo-
graphic scan study in reaching the correct diagnosis.
We also suggest leaving chest drains in place for at least 2
days after none or minimal fluid production to prevent
seroma formation, which is our policy in Blalock-Taussig
shunts.References
1. van Rijn RR, Berger RM, Lequin MH, Robben SG. Development of a perigraft se-
roma around modified Blalock-Taussig shunts: imaging evaluation. AJR Am J
Roentgenol. 2002;178:629-33.
2. Sahoo M, Sahu M, Kale S, Saxena N. Serous fluid leakage following modi-
fied Blalock-Taussig operation using PTFE grafts. Indian Heart J. 2001;53:
328-31.
3. Demircin M, Dogan R, Ozkan M, Ozsoy F, Kuzgun E, G€uvener M. Perigraft
seroma complicating the modified Blalock-Taussig shunts: two consecutive
instances with review of literature. Turk J Pediatr. 2004;46:275-8.
4. Duerinckx A, Atkinson D, Klitzner TS, Perloff J, Drinkwater D, Laks H. MR
imaging of surgical complications of systemic-to-pulmonary artery shunts.
Magn Reson Imaging. 1996;14:1099-105.
5. Rudd SA, McAdams HP, Cohen AJ. Mediastinal perigraft seroma: CT and MR
imaging. J Thorac Imaging. 1994;9:120-2.ry c January 2013


Perigraft seroma mimicking cardiac tamponade after implantation of Berlin Heart EXCOR device in an infant 

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Perigraft seroma mimicking cardiac tamponade after implantation of Berlin Heart EXCOR device in an infant

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