Objective: To investigate the effectiveness of X-ray and echocardiography (ECHO) as a diagnostic tool for cardiac tamponade in adult cardiac surgery patients.Methods: Thirty five coronary artery bypass and graft surgery patients who developed cardiac tamponade at Cleveland clinic foundation, were included in this study. Their diagnosis was confirmed at the time of re-exploration in the operating room. These patients were followed retrospectively for demographics, X-ray and echocardiography findings. Abnormal and enlarged cardiac silhouette which was different from first postoperative X-ray was used as radiological criteria for tamponade while echocardiographic diagnosis was left to the discretion of cardiologist.Results: Twenty four males (69%) and 11 (31%) females with an average age of 60.7 +/- 15.2 years were included in this study. Only 7 (20%) patients met our criteria for radiological diagnosis of tamponade. All 35 patients showed pericardial effusion on ECHO while cardiac tamponade was present in 30 (86%) patients. Tamponade developed on an average on 4th postoperative day.CONCLUSION: Radiological diagnosis of cardiac tamponade based on changes in cardiac silhouette provide limited information while ECHO is a reliable diagnostic tool when combined with clinical findings

Bashour, Allen C

Hamid, Mohammad

Khan, Mueen Ullah

English

eCommons@AKU

eCommons@AKUDepartment of Anaesthesia Medical College, PakistanMarch 2006Diagnostic value of chest X-ray andechocardiography for cardiac tamponade in postcardiac surgery patientsMohammad HamidAga Khan University, mohammad.hamid@aku.eduMueen Ullah KhanAllen C. BashourFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_anaesthPart of the Anesthesia and Analgesia Commons, and the Anesthesiology CommonsRecommended CitationHamid, M., Khan, M. U., Bashour, A. C. (2006). Diagnostic value of chest X-ray and echocardiography for cardiac tamponade in postcardiac surgery patients. Journal of Pakistan Medical Association, 56(3), 104-107.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_anaesth/210IntroductionCardiac tamponade is a life threatening condition,which nearly always requires urgent and precise therapeuticintervention.  Early diagnosis of cardiac tamponade isessential to prevent haemodynamic impairment.1 Cardiactamponade following heart surgery is generally due toexcessive postoperative bleeding with accumulated clotsproducing compression of one or more chambers of theheart. Incidence of tamponade varies from 1-5%2,3 and itremains a major cause of morbidity after cardiopulmonarybypass, necessitating surgical re-exploration in approxi-mately 6% of patients.4Various modalities available for tamponade diagno-sis include clinical sign5 and symptoms, chest X-ray,echocardiography (ECHO) and computed tomography scan,but all these have certain limitations.6Early diagnosis and surgical intervention is of para-mount importance to prevent haemodynamic compromiseand fatal outcome. Chest X-ray is noninvasive, cheap andeasily available diagnostic tool in most of the hospitals. Inaddition previous X-rays are easily accessible for compari-son and early diagnosis. While echocardiography is fre-quently performed for confirmation of tamponade but stillthere are concerns7 regarding its value and early availabili-ty in this surgical emergency. Delays are not uncommon ingetting echocardiography results due to non-availability ofeither machine or technician or cardiologist who can inter-pret. The aim of the present study was to retrospectivelyassess, whether the X-ray and echocardiography are usefulin the detection of cardiac tamponade and to see if X-raycan be used as a replacement diagnostic tool in postopera-tive cardiac surgery patients.Patients and MethodsWe screened all those post cardiac surgery patientswho returned to the operating room (OR) for re-explorationor pericardiocentesis for suspected tamponade during thetwo years period. Only patients coming to OR for relief oftamponade were studied as invasive lines like central andarterial lines could be placed to observe instant changes inhaemodynamics after tamponade was relieved. Their med-ical records, X-ray reports and echocardiography reportswere reviewed. Only those patients were included in thestudy, whose sign and symptoms improved after interven-tion. Pediatric and non surgical cardiac tamponade patientswere excluded.Records were reviewed for age, sex, type of cardiacsurgery, findings on first postoperative X-ray before tam-ponade, findings on X-ray and echocardiography afterdevelopment of suspected tamponade and whether signsOriginal ArticleDiagnostic Value of Chest X-ray and Echocardiography for Cardiac Tamponade in Post Cardiac Surgery PatientsMohammad Hamid, Mueen ullah Khan, Allen C. BashourDepartment of Anaesthesia,  Aga Khan University Hospital, Karachi, Department of Anaesthesia Aga Khan University Hospital, KarachiDepartment of Cardio thoracic anaesthesia, Cleveland clinic foundation, Ohio, USA.AbstractObjective: To investigate the effectiveness of X-ray and echocardiography (ECHO) as a diagnostic tool for car-diac tamponade in adult cardiac surgery patients.Methods: Thirty five coronary artery bypass and graft surgery patients who developed cardiac tamponade atCleveland clinic foundation, were included in this study. Their diagnosis was confirmed at the time of re-explo-ration in the operating room. These patients were followed retrospectively for demographics, X-ray and echocar-diography findings. Abnormal and enlarged cardiac silhouette which was different from first postoperative X-raywas used as radiological criteria for tamponade while echocardiographic diagnosis was left to the discretion ofcardiologist.Results: Twenty four males (69%) and 11 (31%) females with an average age of 60.7 ± 15.2 years were includ-ed in this study. Only 7 (20%) patients met our criteria for radiological diagnosis of tamponade. All 35 patientsshowed pericardial effusion on ECHO while cardiac tamponade was present in 30 (86%) patients. Tamponadedeveloped on an average on 4th postoperative day.Conclusion: Radiological diagnosis of cardiac tamponade based on changes in cardiac silhouette provide lim-ited information while ECHO is a reliable diagnostic tool when combined with clinical findings (JPMA56:104;2006).Vol. 56, No. 3, March 2006 104improved after intervention.Abnormal and enlarged cardiac silhouette, whichwas different from previous postoperative X-ray, was usedas radiological criteria for tamponade. Criteria used fordiagnosis of tamponade on echocardiography included rightatrial and right ventricular collapse along with bluntedresponse of respiration on inferior vena caval plethora. Finaldiagnosis of cardiac tamponade on echocardiography wasleft to the discretion of cardiologist. Clinical diagnosis oftamponade considered on the basis of clinical signs whichwere increased CVP, hypotension, pulsus paradoxus (reduc-tion in systolic blood pressure greater than 12mmHg duringinspiration) and oliguria.8,9The statistical analysis was performed by McNemartest, to assess if the proportion of patients positive for tam-ponade on echocardiography is different from the propor-tion positive on radiography. P-value less than 0.01 wasconsidered significant. Association between cardiac tam-ponade and size of effusion diagnosed on echocardiographywas also considered for which Fisher's exact test was used.ResultsTotal 35 patients during a two years period met theinclusion criteria. The patient population comprised of 24males (69%) and 11 females (31%) with an average age of60.74±15.23 years. Surgical procedure performed on thesepatients is shown in Table 1. Eleven patients had pericardiocentesis and 24 werere-explored for tamponade. The average period for re-exploration was 4th postoperative day.Seven patients (20%) patients exhibited abnormaland enlarged cardiac silhouette on X-ray after the develop-ment of tamponade which was significantly different fromfirst postoperative X-ray (Table 2). None of these X-rayreports mentioned the possibility of tamponade.Interestingly all seven patients were operated for eithervalve surgery or ascending aorta surgery while no coronaryartery and bypass patients showed X-ray changes. Out ofthese seven patients, six had their ascending aorta openedup for a procedure and one patient had mitral valve surgery.All thirty five patients showed pericardial effusionon ECHO, while tamponade was seen in 86% (n=30) ofthese patients. Five patients did not have tamponade onechocardiography, despite the presence of clinical signs andimprovement after intervention. All these five patients hadvalvular surgery. Large pericardial effusion was present in65% (n=22) and all these patients had tamponade as well onECHO (Table 3). Moderate pericardial effusion was presentType of surgery No. ofpatientsTamponadeon ECHOChange incardiac sil-houetteCoronary artery bypass and grafting (CABG)Ascending aorta or arch repairAortic valve surgeryMitral valve surgeryCombine aortic valve  & CABGAortic and Mitral valveAscending aorta and aortic valveThoracotomy and pericardial windowMitral valve and CABGMitral valve +CABG +aortic valveASD repairMaze procedure0802080603010101020101010802070403000102010101000103010001010000000000Total 35 30Table 1. Type of surgery, ECHO and X-ray findings.X-ray findings No. of patientsn= (%)Abnormal cardiac silhouette on first postoperative X-rayAbnormal cardiac silhouette after tamponadeChange in cardiac silhouette after tamponadePericardial effusion25 (71%)32 (91%)7 (20%7 (20%)Table 2. Radiological findings.Small Medium LargeTotalFrequencyPercentageRow %Column %FrequencyPercentageRow %Column %39107513202551517564118044226373100000030871005141004 9 22 35PresentAbsentTotalCardiac Tamponade onEchocardiographyEffusion on EchocardiographyTable 3. Association between Cardiac tamponade andsize of pericardial effusion**p-value 0.0026 highly significant105 J Pak Med AssocECHO (Table 3). Moderate pericardial effusion was presentin 24% (n=9) while 11% (n=4) had a small size effusion. Comparison between X-ray and echocardiographyclearly demonstrated that the proportion of patients positiveon X-ray were significantly different from the proportionpositive on echocardiography (p-value=0.000).DiscussionPericardial effusion is present in nearly all patientspost cardiac surgery. The effusion is frequently asymmetri-cal or loculated. Cardiac tamponade is an infrequent occur-rence post cardiac surgery but requires urgent intervention.Radiological examination is commonly sought for the diag-nosis of tamponade but the value of chest X-ray is doubtfulin post cardiac surgery patients as pericardium is left openand blood collection is usually regional, further impairingits diagnostic reliability. Majority of patients in our studydid not show any change in cardiac silhouette although clin-ical signs of tamponade were present along with positiveECHO findings. Reasons may be due to loculated nature ofpost surgical bleeding causing haemodynamic compromise.CABG surgery can make cardiac silhouette abnormal with-in hours after surgery which not only decreases the sensitiv-ity but also delays the diagnosis by X-ray. This may be thereason that we were unable to find any change in the X-rayin CABG patients. All study patients had their pericardiumleft open after surgery, which made cardiac silhouetteabnormal on X-ray and the diagnosis became very difficult.X-rays taken soon after cardiac surgery showed the pres-ence of abnormal cardiac silhouette in twenty five patientseven before these patients developed tamponade. In suchsituations serial X-rays may be helpful to see any change inabnormal cardiac silhouette along with other clinical evi-dence.There are several problems with radiological diagno-sis of tamponade. It often shows an enlarged cardiac silhou-ette when compared with previous films if mediastinalbleeding is present. This is not a sensitive marker however,because presence of mediastinal bleeding does not meantamponade. Abnormal enlarged cardiac silhouette may sug-gest the presence of a large effusion but supplies no infor-mation about its haemodynamic significance. Presence of effusion can also give a clue as tampon-ade is almost always associated with effusion. But it can notbe taken as a sensitive indicator because of high incidenceof pericardial effusion in post cardiac surgery patients,which is usually reversible and not always associated withtamponade. Another problem is that an abnormal enlargedcardiac silhouette may make it difficult to differentiate oneffusion from cardiac dilatation in association with cardiacfailure.10 The absence of pericardial effusion on ECHOalmost always excludes the diagnosis of tamponade but wecan not say the same about X-ray. Thirty five study patientshad effusion confirmed by ECHO, out of which only sevenpatients had radiological findings of effusion which showsdiminished predictive value of X-ray in diagnosing effusionand tamponade.There are no X-ray features11 diagnostic of tampon-ade, but the presence of abnormal enlarged cardiac silhou-ette, which is different from previous postoperative X-ray,may give a clue to the diagnosis in the patients suspected ofcardiac tamponade. Another clue to the diagnosis of tam-ponade on plain chest X-ray film would be distortion of thepath of a swan ganz catheter12 due to ventricular compres-sion, which we were unable to find in our patients.Echocardiography is a reliable noninvasive13method for detection of pericardial effusion. As small as 20-50ml of pericardial fluid can be diagnosed by ultrasound.14Absence of pericardial effusion usually excludes the diag-nosis of tamponade. There is a good correlation betweenabsence of collapse on echocardiography and absence oftamponade.7Studies have shown a high prevalence of atrial col-lapse in patients with large and moderate effusion, whichwas also seen in this study when all large pericardial effu-sion patients showed tamponade on echocardiography,while 50% patients with moderate effusion showed tampon-ade. Patients who had CABG alone or in combination withvalve surgery exhibited tamponade on ECHO, while nochange was observed in cardiac silhouette on X-ray. Thisshows the positive diagnostic value of ECHO and unrelia-bility of X-ray in CABG surgery.Echogenecity of haemorrhagic effusion especiallywhen clots have been formed may sometimes make delin-eation of the borders of the pericardium and ventricle walldifficult, compromising the sensitivity of this technique.15Two patients in whom tamponade was missed on echocar-diography had presence of clots after re-exploration.Sometimes imaging is difficult because of mechanical ven-tilation in early postoperative period. Those patients inwhom diagnosis of tamponade was missed by ECHO hadmoderate (n=4) and small effusion (n=1) and also thesepatients developed tamponade in the early period.In evaluating a patient for tamponde, it is essential toremember that tamponade is a clinical and haemodynamicdiagnosis. In a patient with convincing clinical evidence fortamponade, the presence of moderate to large pericardialeffusion16 on echocardiography can help in the diagnosis.But it should also be kept in mind that pericardial effusionafter surgery is quite common17 and it does not always leadVol. 56, No. 3, March 2006 106to tamponade. Effusion is usually reversible and not lifethreatening but sometime it may evolve towards tamponade.On the other hand absence of effusion on ECHO does notalways exclude the diagnosis of tamponade as even smallamount of clots can produce clinical signs and symptomsand echocardiographic evidence of tamponade. Furtherstudies may need to be done to include all suspected tam-ponade patients who underwent Pericardiocentesis outsidethe operating room to make the findings representative.There is enough evidence to suggest that radiologi-cal examination is unreliable for the diagnosis of tamponadedue to changes, which appear on X-ray soon after cardiacsurgery. Although change in cardiac silhouette or presenceof pericardial effusion on X-ray does indicate possibility oftamponade but as shown in this study that radiological diag-nosis is difficult and not all these findings are associatedwith cardiac tamponade.Echocardiography is a more reliable method thanchest X-ray but caution is required in drawing conclusionssolely on the basis of echocardiography, as shown by thehigh number of false negative results in the present study.ECHO does not have 100% predictive value and each find-ing needs to be considered in conjunction with clinicaldata.18References1. Kuvin JT, Harati N A, Pandian N G, Bojar RM, Khabbaz KR. Postoperativecardiac tamponade in the modern surgical era. Ann Thorac Surg2002;74:1148-53.2. Pepi M, Muratori M, Barbier P, Doria E, Arena V, Besti M, et al. Pericardialeffusion and cardiac surgery: incidence, site, size, and haemodynamic conse-quences. Br Heart J 1994;72:327-31.3. Onofrio Patafio. Postoperative haemorrhage with cardiac tamponade. In: Fun-Sun F.Yao, MD, eds. Anesthesiology: Problem-Oriented Patient Management.4th ed. Lippincott Williams & Wilkins Philadelphia.1998, pp.334-51.4. Kenneth J.Tuman. Emergency Situations. In: Fawzy G.Estafanous, MD, PaulG. Barash, MD, J.G.Reves, MD, eds. Cardiac Anesthesia: Principles andClinical Practice. 1st ed. J.B. Lippincott Philadelphia, 1994, pp.658-9.5. Barkat MJ, Morgan JA. Haemopericardium causing cardiac tamponade: a latecomplication of pectus excavatum repair. Heart 2004;90:22.6. Larose E, Discharge A, Mercer L A, Pelletier G, Hard F, Tardif J. Prolongeddistress and clinical deterioration before pericardial damage in patients withcardiac tamponade. Can. J Cardiol. 2000;16:331-6.7. Merce J, Sagrista-Sauleda J, Permanyer-Miralda G, Evangelista A, Soler-soler J. Correlation between clinical and Doppler echocardiographic findingsin patients with moderate and large pericardial effusion: Implications for thediagnosis of cardiac tamponade. Am Heart J 1999;138:759-64.8. Sagrista-Sauleda J, Merce J, Permanyer-Miralda G, Soler-soler J. Clinicalclues to the Causes of Large Pericardial Effusion. Am J Med 2000;109:95-101.9. Vignola PA, Pohos GM, Curfman GD, Myers GS. Correlation ofEchocardiographic and clinical findings in patients with pericardial effusion.Am J Cardiol 1976;37:701-7.10. Winney RJ, Wright N, Sumerling MD, Lambie AT. Echocardiography inuraemic pericarditis with effusion. Nephron 1977;18:201-7.11. Antman EM. Medical management of the patients undergoing cardiac surgery.In: Eugene Braunwald MD, eds. Heart disease, A text book of cardiovascularmedicine. 4th ed. W.B. Saunders Company. Philadelphia PA. 1992; pp.1681.12. Jones BV, Vu D. Diagnosis of post traumatic pericardial tamponade by plainfilm and computed tomography and control of bleeding by embolotherapy ofthe left inferior phrenic artery. Cardiovascular-Intervent-Radiol 1993;16:183-5.13. Chan D. Echocardiography in thoracic trauma. Emergency medicine Clinicsof North Am 1998;16:191-207.14. Spodick DH. Pathophysiology of cardiac tamponade. Chest 1998;113:1372-8.15. Oliver WC, De Castro MA. Strickland RA. Uncommon diseases and cardiacanaesthesia. In: Joel A. Kaplan, MD, eds. Cardiac Anaesthesia. 3rd ed. W.B.Saunders Company. Philadelphia PA.pp.848.16. Eisenberg MJ, Oken K, Guerrero S, Saniei MA, Schiller NB. Prognostic valueof Echocardiography in hospitalized patients with pericardial effusion. Am JCardiol 1992;70:934-9.17. Weitzman LB, Tinker WP, Kronzon I, Cohen ML, Glassman E, Spencer FC.The incidence and natural history of pericardial effusion after cardiac surgery- an echocardiographic study. Circulation 1984; 69:506-11.18. Otto and Pearlman. Pericardial disease: Two dimensional echocardiographicand doppler findings. In: Catherine M. Otto, Alan S. Pearlman, eds. Textbookof Clinical Echocardiography. 1st ed. W.B Saunders Philadelphia, 1995,pp.193-208.107 J Pak Med Assoc

Diagnostic value of chest X-ray and echocardiography for cardiac tamponade in post cardiac surgery patients

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Diagnostic value of chest X-ray and echocardiography for cardiac tamponade in post cardiac surgery patients

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