Br Heart J 1992;67:269-70 269 Severe rheumatic mitral stenosis with pericardial effusion causing left ventricular tamponade Br Heart J: first published as 10.1136/hrt.67.3.269 on 1 March 1992. Downloaded from

S W Davies, A Youhana, M Copp

Abstract appearance of severe mitral stenosis with an A woman of 38 was admitted for urgent enlarged left atrium and right heart. The surgery of severe mitral stenosis causing patient remained hypotensive with cold pulmonary oedema. Echocardiography extremities and a low urine output of 5 to showed a pericardial effusion with 10 ml/hour. Swan-Ganz catheterisation apparent distortion and collapse of the showed a mean right atrial pressure of left ventricle. -Urgent drainage of the 28 mmHg and a mean pulmonary artery pres- effusion before mitral valve surgery led sure of 78 mmHg; a satisfactory pulmonary to an improvement in cardiac output wedge pressure tracing could not be obtained. with no detectable change in right heart The cross sectional echocardiogram also pressures. showed a moderately sized pericardial effusion with apparent distortion and collapse of the left ventricle in some but not all cardiac cycles. Cardiac tamponade caused by pericardial While arrangements were made for urgent effusion predominantly affects the right side of mitral valve replacement it was decided to the heart, resulting in venous paradox (Kuss- drain the pericardial fluid in an attempt to maul's sign) and visible compression and dis- improve the cardiac output. After 600 ml of tortion of the right ventricle on cross sectional serous fluid was removed by subxiphoid echocardiography,.' However, in severe pul- pericardiotomy3 the systemic blood pressure monary hypertension tamponade may lead to rose to 80/50 mmHg, heart rate fell from 135 to preferential compression and distortion of the 110 beats per minute in atrial fibrillation, left heart.2 This effect is attributed the high cardiac output determined by thermodilution right heart pressures or hypertrophy, or both. (Swan-Ganz catheter) improved from 1 8 to http://heart.bmj.com/ We report a patient with severe mitral stenosis 2-6 1/min, and right heart pressures were in whom a moderately sized pericardial unchanged. effusion led to collapse of the left ventricle, One hour later mitral valve replacement was which was visualised by echocardiography, and performed via a median sternotomy. The in whom drainage of the effusion led to an native mitral valve was very thickened with improvement in haemodynamic function. rolled edges and fibrotic contraction of the papillary muscles and chordae tendineae: the area was cm2. valve orifice approximately 0-5 on September 25, 2021 by guest. Protected copyright. Case report The mitral valve was replaced with a number A 38 year old woman from Bangladesh was 27 Bjork-Shiley prosthetic valve. At the end of admitted with sudden onset of severe dyspnoea cardiopulmonary bypass the pulmonary artery and in a state ofcollapse. She was unable to give systolic pressure was 120 mmHg and the sys- a history but later it became known that she had temic arterial systolic pressure 100 mmHg. been breathless on exertion for the previous The patient required inotropic support and three years. On examination she had cold and ventilation for 48 hours but she subsequently sweaty hands and feet with a blood pressure of made an uncomplicated recovery. 70/40 mmHg, an irregular pulse rate (150 beats per minute), and a respiratory rate of 32 per minute. The chest x ray showed pulmonary Discussion oedema and an enlarged cardiac silhouette with The haemodynamic features of cardiac tam- a configuration that suggested left atrial ponade are complex and may differ between enlargement. She was urgently intubated and patients.4 Animal experiments suggest that ventilated with intermittent positive pressure right sided cardiac compression contributes ventilation. more to the haemodynamic derangement than Cardiac Department, The electrocardiogram showed atrial does left heart compression.25 Echocardiogra- The London Chest rate of phic studies in patients consistently show right Hospital, Bonner fibrillation with a ventricular approx- Road, London E2 9JX imately 160 beats per minute. Further clinical atrial diastolic collapse whereas left atrial and S W Davies examination showed a left parasternal heave, right ventricular diastolic collapse are variable A Youhana very loud first heart sound, accentuated pul- findings.67 M Copp and monary second sound, and an early but quiet Several reports suggest that the clinical Correspondence to: of cardiac Dr S W Davies, Cardiac opening snap with a long and loud diastolic echocardiographic signs tamponade Department, The London murmur at the apex. M mode and cross sec- may be atypical in patients with pulmonary Chest Hospital, Bonner and ventricular Road, London E2 9JX tional echocardiography confirmed the hypertension right hypertro- 270 Davies, Youhana, Copp

phy. Arterial pulsus paradoxus may be absent, 1 Armstrong WF, Schilt BF, Helper DJ, Dillon JC, Feigen- baum H. Diastolic collapse of the right ventricle with and this has been attributed to increased cardiac tamponade: an echocardiographic study. Circula- impedance to the normal inspiratory increase tion 1982;65:1491-6. 2 Leimgruber PP, Klopfenstein HS, Wann LS, Brooks HL. in right ventricular filling.89 Echocardio- The hemodynamic derangement associated with right graphic studies show that right ventricular ventricular diastolic collapse in cardiac tamponade: an Br Heart J: first published as 10.1136/hrt.67.3.269 on 1 March 1992. Downloaded from experimental echocardiographic study. Circulation collapse may be absent if right ventricular 1983;68:612-20. hypertrophy is severe.210' Preferential left 3 Larrey DJ. New surgical procedure to open the pericardium and to determine the cause of fluid in its cavity. Clin atrial compression has been described in such a Chirurg 1829;38:393. of the left 4 Reddy PS, Curtiss EI, O'Toole JD, Shaver JA. Cardiac patient." Preferential compression tamponade: hemodynamic observations in man. Circula- heart may also occur with loculated pericardial tion 1978;58:265-72. effusions or 5 Fowler NO, Gabel M, Buncher CR. Cardiac tamponade: a haematomas."3 comparison of right versus left heart compression. J Am We are not aware of any previous reports of Coll Cardiol 1988;12:187-93. a 6 Kronzon I, Cohen ML, Winer HE. Diastolic atrial compres- compression of the left ventricle caused by sion: a sensitive echocardiographic sign of cardiac tam- generalised pericardial effusion without com- ponade. JAm Coll Cardiol 1983;2:770-5. chambers. The 7 Singh S, Wann LS, Klopfenstein HS, Hartz A, Brooks HL. pression of the other cardiac Usefulness of right ventricular diastolic collapse in diag- improvement in cardiac output after drainage nosing cardiac tamponade and comparison to pulsus paradoxus. Am J Cardiol 1986;57:652-6. of the effusion showed the haemodynamic 8 Braunwald E. Heart disease. 3rd ed. Philadelphia: WB importance of the effusion in this patient. The Saunders, 1988:1495. with 9 Frey MJ, Berko B, Palevsky H, Hirshfeld JW Jr, Herrmann haemodynamic effects of tamponade HC. Recognition of cardiac tamponade in the presence of mitral stenosis may differ from those in patients severe pulmonary hypertension. Ann Intern Med 1989; 111:615-7. with tamponade and pulmonary hypertension 10 Gaffney FA, Keller AM, Peshock RM, Lin J-C, Firth BG. owing to other causes, in whom left atrial Pathophysiologic mechanisms of cardiac tamponade and pulsus alternans shown by echocardiography. Am J Car- diastolic collapse may be important-such diol 1984;53:1662-6. collapse was not seen in our case, presumably 11 Singh S, Wann S, Schuchard GH, Klopfenstein HS, Leimgruber PP, Keelan MH Jr, et al. Right ventricular because left atrial pressure was high. and right atrial collapse in patients with cardiac tampon- ade-a combined echocardiographic and haemodynamic study. Circulation 1984;70:966-71. 12 Brodyn NE, Rose MR, Prior FP, Haft JI. Left atrial compression in a patient with a large pericardial effusion and pulmonary hypertension. Am JMed 1990;8:64N-6N. 13 Kronzon I, Cohen ML, Winer HE. Cardiac tamponade by We are grateful to Dr R Balcon and Mr P Magee for permission loculated pericardial hematoma: limitations of M-mode to report a patient under their care. echocardiography. J Am Coll Cardiol 1983;1:913-5. http://heart.bmj.com/ on September 25, 2021 by guest. Protected copyright.