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Anticoagulant-Induced Hemopericardium with Tamponade: a Case Report and Review of the Literature

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Anticoagulant-Induced Hemopericardium with Tamponade: a Case Report and Review of the Literature JCEI / Ertaş et al. Hemopericardium with tamponade 2013; 4 (2): 229-233229 Journal of Clinical and Experimental Investigations doi: 10.5799/ahinjs.01.2013.02.0273 CASE REPORT Anticoagulant-induced hemopericardium with tamponade: A case report and review of the literature Antikoagülasyonun indüklediği hemoperikardiyumlu tamponad: Olgu sunumu ve literatür incelemesi Faruk Ertaş, Nihat Polat, Abdulkadir Yıldız, Mustafa Oylumlu, Mehmet Sıddık Ülgen ABSTRACT ÖZET Acute cardiac tamponade requires urgent diagnosis and Akut kardiyak tamponad acil tanı ve tedavi gerektirir. Biz treatment. We report a case of a 43-year-old man who 43 yaşında, erkek ve mitral valv replasmanı sonrası sekiz was receiving warfarin treatment for 8 months following aydır warfarin tedavisi alan bir olguyu aldık. Hastanın bir- mitral valve replacement. The patient had complaint of kaç gündir başlayan nefes darlığı ve halsizlik şikayetikleri dyspnea and fatigue for a few days. Cardiac tamponade mevcuttu. Kardiyak tamponad tanısı konuldu ve 1400 ml was diagnosed, and the INR at that time was 10.4. Urgent mai perikardiyosentezle acil olarak drene edildi. Tanı sı- pericardiocentesis were undertaken and 1400 ml of peri- rasında İNR değeri çok yüksek olan hastaya Vitamin K cardial blood was drained. Following surgery the patient’s antagonistleri ve taze donmuş plazma verilerek yuksek recovery was uneventful. An intravenous vitamin K injec- koagülasyon durumu geriye döndürüldü. Patolojik incele- tion and fresh frozen plasma transfusion were adminis- me sonucunda enfeksiyon ve malingnensi saptanmadı. tered to reverse the patient’s over-anticoagulated state. Hastada kronik inflamasyon düşünüldü. Sonuç olarak The final pathology revealed chronic inflammation and warfarin overdoz acil bir durum olup hemoperikardiyumla there was no malignancy, and no bacteria or mycobacte- tamponada yol açabilmektedir. Bunun için warfarin teda- rium were seen. Emergency physicians should remember visi başlanılan hastalarda warfarin dozu ve hedef İNR de- that over-anticoagulation with warfarin may contribute to ğerleri sıkı kontrol edilmelidir. certain complications, including hemopericardium, and Anahtar kelimeler: Warfarin, hemoperikardiyum, tampo- that strict control of target INR should be the goal for pa- nad, İNR tients who require continuous warfarin treatment. J Clin Exp Invest 2013; 4 (2): 229-233 Key words: Hemopericardium, tamponade, oral antico- agulation, warfarin, echocardiography INTRODUCTION Here, we are presenting a case of cardiac tampon- ade as a result of warfarin intoxication and a review Cardiac tamponade is a life-threatening emergency of the literature. condition as a result of fluid accumulation in pericar- dium which primarily disrupts right atrial and ven- tricular filling [1]. Several conditions such as peri- CASE carditis, malignancy, acute myocardial infarction, A 43-year-old man applied to the emergency room end-stage renal disease, congestive heart failure, with a complaint of dyspnea and fatigue for a few collagen vascular diseases, viral and bacterial in- days. His blood pressure was 80/50 and heart rate fections can cause pericardial effusion resulting in was 132/min. immediately, after admission the pa- tamponade [2]. Hemopericardium may develop af- tient developed syncope. With IV fluid therapy the ter trauma, aortic dissection, myocardial infarction, patient got conscious. The patient was on 5 mg/day malignancy and invasive procedures. Presenta- warfarin therapy because of prosthetic mitral valve tion with hemopericardium and cardiac tamponade for 8 months. Twelve-lead electrocardiogram [ECG] due to warfarin intoxication is a very rare condition. revealed sinus rhythm and low voltage in chest and Dicle University Faculty of Medicine Department of Cardiology Diyarbakır, Turkey Correspondence: Faruk Ertaş, Dicle University Faculty of Medicine, Department of Cardiology, Diyarbakır, Turkey Email: [email protected] Received: 21.03.2013, Accepted: 22.04.2013 J Clin Exp InvestCopyright © JCEI / Journal of Clinical www.jceionline.organd Experimental Investigations 2013, All rightsVol reserved 4, No 2, June 2013 230 Ertaş et al. Hemopericardium with tamponade extremity leads [Figure 1]. On chest radiogram car- evacuated. After P/S blood pressure was 120/70 diomegaly and blunt costophrenic sinuses were and heart rate was 92/dk. INR was normalized after detected [Figure 2]. International normalized ratio 4 units of fresh frozen plasma and 5 mg intrave- (INR) was 10.4. Bedside echocardiography detect- nous vitamin K. We didn’t find any detectable cause ed pleural effusion and a severe pericardial effusion in the examination of pleural and pericardial fluids. with right ventricular collapse [Figure 3]. The patient Although mild pericardial effusion was detected on was taken to the intensive care unit and emergent the follow-up echocardiograms, warfarin therapy pericardiocentesis [P/S] was performed via subcos- was initiated and the patient was discharged after tal route. A total of 1400 cc hemorrhagic fluid was reaching the target INR value. Figure 1. Sinus rhythm and low voltage in chest and extremity leads Figure 3. Echocardiography show that a severe pericar- dial effusion with right ventricular collapse Figure 2. Chest radiogram shows cardiomegaly and blunt costophrenic sinuses DISCUSSION cardial injury syndromes [postmyocardial infarction The most common causes of pericardial effusion effusions, postpericardiotomy syndromes, posttrau- are infections (viral, bacterial, especially tubercu- matic pericarditis], metabolic diseases [especially losis), cancer, connective tissue disorders, peri- hypothyroidism, anorexia nervosa], myopericardial J Clin Exp Invest www.jceionline.org Vol 4, No 2, June 2013 Ertaş et al. Hemopericardium with tamponade 231 Table 1. Cases of warfarin induced pericardial tamponade in the literature Indication of Warfarin Symptom of Diagnostic Reference Sex/age Treatment Outcome warfarin dose/INR the patient tool Pain shoulders, dyspnea, Pericardiocentesis Granot 5 M/48 DVT ?/PT 42 s TTE Survive abdominal 2500 discomfort FFP Symptoms of Wong 6 F/59 MVR ?/9 TTE Pericardiocentesis Survive tamponade 900 cc Malaise, FFP Wong 6 M/63 AVR ?/5.4 worsening TTE Pericardiocentesis Survive dyspnoea 800 cc Vertebral- Weight gain, K vit, FFP basilar Abdominal Lee7 M/67 PT 30s TTE Pericardiocentesis Survive arterial distension, 2000 cc insufficiency dyspnea Survive malaise, RV laceration Thoracotomy Jadoon8 F/75 AF ?/>8 diaphoresis, TTE secondary 300cc chest pain to PM wire perforation K vit, FFP, 5mg/ Chest pain, CT Katis9 F/67 PE pericardiocentesis Survive 3,51 dyspnea TTE 600cc Cough, K vit, FFP DVT 10mg/ Hillyard4 M/? fatigue, TTE Pericardiocentesis Survive prophylaxis 3.5 and malaise 1100 cc K vit, FFP Yu-Cheng 5mg/ Dyspnea and F/70 MVR TTE pericardiocentesis Survive Hong10 7,52 orthopnoea 1300cc Embolic Griffiths11 M/? ?/>15 Collapsed, Autopsy 950cc Exitus stroke Pericardial Dyspnea, With non-small window Braiteh12 F/74 PE ?/PT 17.6 s Chest TTE cell lung procedure, tightness carcinoma 750cc Syncop, chest pain, K vit, FFP Levis13 M/54 AF ?/6 shortness TTE pericardiocentesis Survive of breath, 1100cc palpitations Chest and K vit, FFP 5mg/d Abdomen CT Gumrukcuoglu14 F/27 DVT Pericardiocentesis Exitus 13.8 pain, TTE 1100 cc syncop Syncopal episode, Pericardiocentesis Gumrukcuoglu14 M/32 MVR ?/15.5 shortness TTE Exitus 600 cc of breath and palpitations PE, factor Dyspnea, CT Pericardiocentesis DH Hsi15 M/49 V Leiden 15 mg/? Survive orthopnea TTE 1300cc abnormality K vit, Protrombin Epigastric CT consante, Al-Jundi 16 F/65 DVT, PE, AF ?/16,9 Survive pain, fullnes TTE pericardiocentesis 750 cc Shortness of CT Pericardiocentesis Reed17 M/53 PE ?/6 breath and Survive TTE 2000 cc chest pain Fatigue, shortness of Pericardiocentesis Our case M/43 MVR 7.5/10.4 TTE Survive breath, 1400 cc syncope AF: Atrial fibrillation, AVR: Aortic valve replacement, CT: Computed tomography, DVT: Deep vein thrombosis, F: Fe- male, FFP: Fresh frozen plasma, M: Male, MVR: Mitral valve replacement, PT: Prothrombin time, TTE: Transthoracic echocardiography J Clin Exp Invest www.jceionline.org Vol 4, No 2, June 2013 232 Ertaş et al. Hemopericardium with tamponade diseases [especially pericarditis, but also myocar- formation with respect to the morphologic and func- ditis, heart failure] and aortic diseases [3]. In this tional features of the diseased pericardium [18]. case we present a rare cause of pericardial effu- In this series, more than half of the cases were sion, significant INR elevation, resulting in pericar- diagnosed by echocardiography. In cases diag- dial tamponade. The risk of non-traumatic bleeding nosed by CT, echocardiography was performed to in patients taking warfarin is less than 10%, the risk evaluate whether the pericardial effusion was caus- of bleeding into pericardial space is less than 1% ing a tamponade or not, and clarification of the P/S [12]. We suppose that pericardial tamponade is indication. This shows us the importance of echo- much lesser. In our case, 8 months after MVR op- cardiography in the diagnosis and treatment of peri- eration, the patient developed cardiac tamponade cardial effusion and tamponade. due to warfarin intoxication with an INR 10.4. There was no history of trauma or drug ingestion that can Main treatment of the pericardial tamponade is interact with warfarin. P/S. In a study of 1127 patients echocardiography- guided pericardiocentesis has been demonstrated We have detected elevated transaminase lev- to be a safe and effective
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