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The electrocardiogram showed sinus tachycardia with left ventricular hypertrophy&#44; and the bedside echocardiogram revealed a medium-sized echogenic mass measuring 9<span class="elsevierStyleHsp" style=""></span>cm&#215;6<span class="elsevierStyleHsp" style=""></span>cm&#44; causing almost complete collapse of the right atrium&#44; and mild &#40;6 mm&#41; circumferential pericardial effusion &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>A&#8211;D&#41;&#46; Prosthetic function was normal&#46; The emergency computed tomography &#40;CT&#41; scan showed a hematoma measuring 9&#46;4<span class="elsevierStyleHsp" style=""></span>cm&#215;8&#46;5<span class="elsevierStyleHsp" style=""></span>cm&#215;5&#46;9<span class="elsevierStyleHsp" style=""></span>cm compressing the right atrium and an active bleeding point 2&#46;4 cm above the aortic prosthesis in the ascending aorta &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>A and B&#41;&#46; The patient was transferred to the cardiothoracic surgery center&#46; Surgical exploration revealed a large organized pericardial hematoma compressing the right atrium&#46; It was removed and the aortic suture was reinforced&#46; The recovery was uneventful&#46; One month later he was clinically well and the echocardiogram showed no pericardial effusion&#44; a functional biological valve and severely depressed left ventricular function&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Discussion</span><p id="par0010" class="elsevierStylePara elsevierViewall">Loculated hematomas with cardiac tamponade arising after cardiac surgery are a complication rarely reported in the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> They are significantly more common after coronary artery bypass and are generally located posteriorly&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a> although compression of any cardiac chamber can occur&#44; with right atrial involvement being the most common&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a> Clots are limited by adhesions causing an important mass effect<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> and interfering with diastolic filling&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Most cases appear in the early phase&#44; developing in the first hours or days of the postoperative period<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">4</span></a> and manifesting as atypical cardiac tamponade&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">5</span></a> Few cases have been reported in the literature as long as three weeks after surgery&#46; Delay in reaching a correct diagnosis can negatively affect prognosis&#44; since it is extremely important to treat the condition immediately&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">6</span></a> Echocardiography&#44; as an easily available and rapid imaging exam&#44; can provide detailed information including the exact location of the hematoma &#40;extracardiac&#44; intrapericardial&#44; or intracavitary&#41; and the degree of compression&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a> Nevertheless&#44; ultrasound images do not always clarify the situation<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">8</span></a> and other imaging techniques&#44; such as cardiac contrast CT or magnetic resonance imaging &#40;MRI&#41;&#44; may be needed<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a> to obtain additional information on the location and dimensions of the hematoma as well as the mechanism behind its genesis&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">9</span></a> MRI is limited in its applicability due to hemodynamic instability&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conclusions</span><p id="par0020" class="elsevierStylePara elsevierViewall">A loculated pericardial hematoma leading to localized tamponade may appear on imaging studies as a cardiac mass&#46; The differential diagnosis of this mass on imaging studies is usually challenging&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">10&#44;11</span></a> Recognition of this entity is often delayed because of the absence of the classic signs associated with cardiac tamponade&#46; A high level of clinical suspicion complemented with a rapid imaging evaluation is crucial in order to establish diagnosis and prompt treatment&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ethical disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Protection of human and animal subjects</span><p id="par0025" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Right to privacy and informed consent</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Confidentiality of data</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The authors describe a case of a rare complication occurring after cardiac surgery&#46; Three weeks after aortic valve replacement a young male became hemodynamically unstable&#46; The echocardiogram showed a large loculated hematoma compressing the right atrium&#46; The patient was reoperated and the mass was removed&#46; Recovery was complete&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Os autores descrevem um caso de uma complica&#231;&#227;o rara do p&#243;s-operat&#243;rio de uma cirurgia card&#237;aca&#46; Tr&#234;s semanas ap&#243;s substitui&#231;&#227;o valvular a&#243;rtica&#44; um jovem doente ficou hemodinamicamente inst&#225;vel&#46; O ecocardiograma documentou um hematoma loculado de grandes dimens&#245;es a comprimir a aur&#237;cula direita&#46; O paciente foi submetido a nova cirurgia card&#237;aca com remo&#231;&#227;o do hematoma&#46; A recupera&#231;&#227;o foi completa&#46;</p></span>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Transthoracic echocardiography showing a mass measuring 9<span class="elsevierStyleHsp" style=""></span>cm&#215;6<span class="elsevierStyleHsp" style=""></span>cm and intermediate echogenicity causing almost complete collapse of the right atrium &#40;A&#44; B and D&#41;&#59; mild &#40;6<span class="elsevierStyleHsp" style=""></span>mm&#41; circumferential pericardial effusion &#40;C&#41;&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Contrast-enhanced computed tomography showing a hematoma 9&#46;4<span class="elsevierStyleHsp" style=""></span>cm&#215;8&#46;5<span class="elsevierStyleHsp" style=""></span>cm&#215;5&#46;9<span class="elsevierStyleHsp" style=""></span>cm compressing the right vena cava and right atrium &#40;A&#44; C and D&#41;&#59; the collection was caused by an active bleeding point 2&#46;4 cm above the aortic prosthesis &#40;B&#41; in the ascending aorta&#46;</p>"
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Case report
Loculated cardiac hematoma causing hemodynamic compromise after cardiac surgery
Hematoma cardíaco loculado causando compromisso hemodinâmico após cirurgia cardíaca
Andreia Fernandesa,
Autor para correspondência
andreiafvf@gmail.com

Corresponding author.
, Miryan Cassandraa, Carlos Pintob, Catarina Oliveirac, Manuel Antunesb, Lino Gonçalvesa
a Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra – Hospital Central, Coimbra, Portugal
b Serviço de Cirúrgia Cardiotorácica, Centro Hospitalar e Universitário de Coimbra – Hospital Central, Coimbra, Portugal
c Serviço de Radiologia, Centro Hospitalar e Universitário de Coimbra – Hospital Central, Coimbra, Portugal
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The electrocardiogram showed sinus tachycardia with left ventricular hypertrophy&#44; and the bedside echocardiogram revealed a medium-sized echogenic mass measuring 9<span class="elsevierStyleHsp" style=""></span>cm&#215;6<span class="elsevierStyleHsp" style=""></span>cm&#44; causing almost complete collapse of the right atrium&#44; and mild &#40;6 mm&#41; circumferential pericardial effusion &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>A&#8211;D&#41;&#46; Prosthetic function was normal&#46; The emergency computed tomography &#40;CT&#41; scan showed a hematoma measuring 9&#46;4<span class="elsevierStyleHsp" style=""></span>cm&#215;8&#46;5<span class="elsevierStyleHsp" style=""></span>cm&#215;5&#46;9<span class="elsevierStyleHsp" style=""></span>cm compressing the right atrium and an active bleeding point 2&#46;4 cm above the aortic prosthesis in the ascending aorta &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>A and B&#41;&#46; The patient was transferred to the cardiothoracic surgery center&#46; Surgical exploration revealed a large organized pericardial hematoma compressing the right atrium&#46; It was removed and the aortic suture was reinforced&#46; The recovery was uneventful&#46; One month later he was clinically well and the echocardiogram showed no pericardial effusion&#44; a functional biological valve and severely depressed left ventricular function&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Discussion</span><p id="par0010" class="elsevierStylePara elsevierViewall">Loculated hematomas with cardiac tamponade arising after cardiac surgery are a complication rarely reported in the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> They are significantly more common after coronary artery bypass and are generally located posteriorly&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a> although compression of any cardiac chamber can occur&#44; with right atrial involvement being the most common&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a> Clots are limited by adhesions causing an important mass effect<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> and interfering with diastolic filling&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Most cases appear in the early phase&#44; developing in the first hours or days of the postoperative period<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">4</span></a> and manifesting as atypical cardiac tamponade&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">5</span></a> Few cases have been reported in the literature as long as three weeks after surgery&#46; Delay in reaching a correct diagnosis can negatively affect prognosis&#44; since it is extremely important to treat the condition immediately&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">6</span></a> Echocardiography&#44; as an easily available and rapid imaging exam&#44; can provide detailed information including the exact location of the hematoma &#40;extracardiac&#44; intrapericardial&#44; or intracavitary&#41; and the degree of compression&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a> Nevertheless&#44; ultrasound images do not always clarify the situation<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">8</span></a> and other imaging techniques&#44; such as cardiac contrast CT or magnetic resonance imaging &#40;MRI&#41;&#44; may be needed<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a> to obtain additional information on the location and dimensions of the hematoma as well as the mechanism behind its genesis&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">9</span></a> MRI is limited in its applicability due to hemodynamic instability&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conclusions</span><p id="par0020" class="elsevierStylePara elsevierViewall">A loculated pericardial hematoma leading to localized tamponade may appear on imaging studies as a cardiac mass&#46; The differential diagnosis of this mass on imaging studies is usually challenging&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">10&#44;11</span></a> Recognition of this entity is often delayed because of the absence of the classic signs associated with cardiac tamponade&#46; A high level of clinical suspicion complemented with a rapid imaging evaluation is crucial in order to establish diagnosis and prompt treatment&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ethical disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Protection of human and animal subjects</span><p id="par0025" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Right to privacy and informed consent</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Confidentiality of data</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The authors describe a case of a rare complication occurring after cardiac surgery&#46; Three weeks after aortic valve replacement a young male became hemodynamically unstable&#46; The echocardiogram showed a large loculated hematoma compressing the right atrium&#46; The patient was reoperated and the mass was removed&#46; Recovery was complete&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Os autores descrevem um caso de uma complica&#231;&#227;o rara do p&#243;s-operat&#243;rio de uma cirurgia card&#237;aca&#46; Tr&#234;s semanas ap&#243;s substitui&#231;&#227;o valvular a&#243;rtica&#44; um jovem doente ficou hemodinamicamente inst&#225;vel&#46; O ecocardiograma documentou um hematoma loculado de grandes dimens&#245;es a comprimir a aur&#237;cula direita&#46; O paciente foi submetido a nova cirurgia card&#237;aca com remo&#231;&#227;o do hematoma&#46; A recupera&#231;&#227;o foi completa&#46;</p></span>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Contrast-enhanced computed tomography showing a hematoma 9&#46;4<span class="elsevierStyleHsp" style=""></span>cm&#215;8&#46;5<span class="elsevierStyleHsp" style=""></span>cm&#215;5&#46;9<span class="elsevierStyleHsp" style=""></span>cm compressing the right vena cava and right atrium &#40;A&#44; C and D&#41;&#59; the collection was caused by an active bleeding point 2&#46;4 cm above the aortic prosthesis &#40;B&#41; in the ascending aorta&#46;</p>"
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                          "etal" => true
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Informação do artigo
ISSN: 08702551
Idioma original: Inglês
DOI:10.1016/j.repc.2015.01.020
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