Cardiac tamponade and para-aortic hematoma post elective surgical myocardial revascularization on a beating heart – a possible complication of the Lima-stitch and sequential venous anastomosis
© Marcinkiewicz et al.; licensee BioMed Central Ltd. 2014
Received: 22 December 2013
Accepted: 24 March 2014
Published: 4 June 2014
Off-pump coronary artery bypass (OPCAB) surgery can be associated with some intrinsic, but relatively rare complications. A pericardial effusion is a common finding after cardiac surgeries, but the prevalence of a cardiac tamponade does not exceed 2% and is less frequent after myocardial revascularization.
Authors believe that in our patient an injury of a nutritional pericardial or descending aorta vessel caused by the Lima stitch resulted in oozing bleeding, which gradually leaded to cardiac tamponade. The bleeding increased after introduction of double antiplatelet therapy and caused life-threatening hemodynamic destabilization. According to our knowledge it is the first report of such a complication after OPCAB.
We present a case of a 61-year old man, who underwent elective surgical myocardial revascularization on a beating heart. On the 11th postoperative day the patient was readmitted emergently to the intensive care unit for severe chest pain, dyspnoea and hypotension. Coronary angiographic control showed a patency of the bypass grafts and significant narrowing of circumflex artery, treated with angioplasty and stenting. The symptoms and hemodynamic instability exacerbated. A suspicion of dissection of the ascending aorta and para-aortic hematoma was stated on 16-slice cardiac computed tomography. The patient was referred to the Cardiovascular Surgery Clinic. Transthoracic echocardiography revealed cardiac tamponade. On transesophageal echocardiography there were no signs of the ascending aorta dissection, but a possible lesion of the descending aorta with para-aortic hematoma was visualized. Emergent rethoracotomy and cardiac tamponade decompression were performed. 12 days after intervention the control 64-slice computed tomography showed no lesions of the ascending or descending aorta. On one-year follow-up patient is in a good condition, the left ventricular function is preserved and there is no pathology in thoracic aorta on echocardiography.
Mechanical complications of surgical myocardial revascularization on a beating heart should be considered as a cause of the clinical and hemodynamic instability relatively early in the postoperative period. Echocardiographic examination must be the first step in diagnostics process in a patient after cardiac surgery.
KeywordsLima-stitch Cardiac tamponade Aortic dissection
Avoiding extracorporeal circulation (ECC) results in a lower inflammatory response, less myocardial or kidney damage and blood–brain barrier injury. Elimination of the ECC decreased the sex-depending differences in the results of surgical revascularization . Still, there is no consensus about the long-term results of the beating heart surgery. Off-pump coronary artery bypass (OPCAB) surgery is associated with some intrinsic, but relatively rare complications: mechanical damage of the cardiac walls by suction stabilizers, coronary arteries injury by vascular loops or shunts, acute aortic dissection, lesions of the pulmonary vein, descending aorta or esophagus, gaseous embolism, as well as some exceptional adverse events as vasoplegic syndrome [2, 3]. The crucial issue during revascularization on a beating heart allowing to perform anastomoses on the posterior and lateral wall is insertion of the pericardial stitch (firstly performed by Ricardo Lima) .
We presented a case of a patient who developed cardiac tamponade on the 11th postoperative day. Authors believe that it was a result of an injury of a nutritional pericardial or descending aorta vessel caused by the Lima stitch. A double antiplatelet therapy aggravated the bleeding. Echocardiography performed on the readmission could have allowed to make a proper diagnosis. According to our knowledge it is the first report of such a complication after OPCAB.
Patient was emergently transferred to the operating theatre, where rethoracotomy was performed. Blood from the pericardial sac was evacuated and cardiac tamponade decompressed with dramatic improvement in clinical status of the patient. Para-aortic hematoma was confirmed but there was no evidence of damage to the aorta. The drainage from pericardial sac was 270 ml during the following day.
12 days after intervention the control 64-slice CT showed no lesions of the ascending or descending aorta. On one-year follow-up patient is in a good condition, the left ventricular function is preserved and there is no pathology in thoracic aorta on TEE.
The presented case requires differential diagnosis of several possible causes of the significant hemodynamic decompensation that occurred on the 11th postoperative day.
Early graft occlusion and myocardial infarction was one of the considered causes of patient’s symptoms and hemodynamic instability. Prevalence of this complication is estimated on 3-12% for venous grafts and 1–2,5% for the internal thoracic artery . Vascular loops and tourniquets passed under the coronary arteries may damage arterial walls and intraluminal shunts may cause lesions of the vascular endothelium. Although pericardial effusion is a common finding after cardiac surgeries, but the prevalence of a cardiac tamponade does not exceed 2% and is less frequent after myocardial revascularization . The effusion or hematoma is usually not massive and is more likely regional than circumferential. That is why the role of fluid accumulated in pericardium that should be considered as a cause of severe clinical condition and cardiac tamponade is neglected. The final clinical outcome depends on the appropriate time of rethoracotomy .
Dressler’s syndrome was considered but during rethoracotomy not a bloody effusion but hematoma and fresh blood filling the pericardial sac were found. It seemed apparent that bleeding was a cause of the cardiac tamponade.
Unfortunately TTE, that should be the first step of diagnostic process in this particular case and might have disclosed pericardial effusion was not performed on admission in the local hospital. At that time, mild elevation of troponin T level was not diagnostic for an acute coronary event, as blood levels of this marker may remain increased up to 2 weeks after surgical myocardial revascularization. Cardiac tamponade was another possible cause of the elevation of troponin level. In our opinion stenting of the circumflex artery was not appropriate as the marginal venous bypass graft was well functioning. Introduction of double antiplatelet therapy might have increased the oozing bleeding and caused further patient’s destabilization.
Another possible complication after beating heart surgery is an intraoperative mechanical heart wall damage with suction devices. Mandke et al.  presented a case of subepicardial hematoma, which was evacuated intraoperatively, but early after the surgery dissecting intramural hematoma with tamponade occurred.
OPCAB procedure may lead to an acute ascending aorta dissection as a result of the partial clamping of the aorta for suturing the proximal anastomoses. Hagl and Griepp  suggested that in case of poor aortic wall quality the risk of dissection is even higher for OPCAB than procedures under ECC. Some authors emphasized underestimation of this complication, which prevalence is 3-5%, especially in cases of sudden postoperative deaths with ventricular tachyarrhythmias . Iatrogenic ascending aorta dissection can occur at any time after the operation. It often presents as acute neurological deficits, rapidly arising mediastinal hematoma and finally aortic rupture. Such cases must be aggressively treated. However iatrogenic dissection can be clinically silent and found incidentally with conservative treatment as a solution . In our patient neither the clinical presentation nor the dynamics of arising effusion indicated dissection. The diagnosis of our experienced echocardiographist based on TEE excluded the presence of aortic dissection and was definitively confirmed during re-exploration of the mediastinum.
The most interesting issue in this case are the confusing results of imaging examinations. The firstly performed 16-slice CT, considered as diagnostic tool of relatively low sensitivity and specificity, revealed limited dissection of the ascending aorta at the area of the proximal bypass graft anastomosis, which was not confirmed on subsequent TEE. Thinking of the possible explanation of this diagnostic discrepancy we considered iatrogenic aortic dissection as a result of proximal bypass graft anastomosis or at the time of coronary artery bypass angiography, self-healed within following hours. Garg P et al.  described spontaneous recovery of aortic dissection in several hours.
The presented case is an example of a rare but extremely dangerous complication of beating heart revascularization. The authors believe that a lesion of a pericardial or aortic nutritional vessel caused by Lima-stitch resulted in the life-threatening complication. Echocardiographic examination remains the first step in diagnostic process in a patient after cardiac surgery.
Mechanical complications of surgical myocardial revascularization on a beating heart should be considered as a cause of the clinical and hemodynamic instability relatively early in the postoperative period.
Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.
Off-pump coronary artery bypass
Left anterior descending artery
Left internal mammary artery
Multiple organ dysfunction syndrome.
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