sum of two units patients with large pericardial thrombi following cardiac surgery not awayed as having right cardiac tamponade.

sum of two units patients with large pericardial thrombi following cardiac surgery not awayed as having right cardiac tamponade. Transesophageal echocardiography (TEE) identified a large pericardial hematoma compressing the right atrium and was well tolerated by dint of these critically ill patients. These case reports demonstrate the diagnostic value of TEE in the identification of this unrelenting complication in the late postoperative period.

In sum of two units patients with severe hemodynamic deterioration following cardiac surgery a large pericardial hematoma, which was missed on transthoracic echocardiography, was diagnosed with transesophageal echocardiography. This report stresse the importance of transesophageal echocardiography in the evaluation of complications following cardiac surgery

Case Reports

Case 1

A 55-year-old white man was referr to the coronary care unit 3 weeks after autograft aortic valve replacement. The patient readyed with chest pain, dyspnea, and hypotension. A two-dimensional transthoracic echocardiographic examination, performed a not many hours before hospital admission, revealed a mass in the right atrium. At the time of admission, the legumes rate was 90 beats/min and BP was 100/70 mm Hg The jugular veins were moderately distended. Inspiratory crackles were heard above the lower third of the left lung Auscultation of the heart revealed no abnormalities.

The electrocardiogram showed right pack branch block. A chest radiograph showed an enlarged cardiac silhouette. Transthoracic two-dimensional echocardiography was repeated and demonstrated a moderate pericardial effusion and an echodense formation that obliterated most of the right atrial cavity. A transesophageal echocardiogram was performed and showed the vicinity of a large pericardial thrombus compressing the right atrium.

The patient underwent pressing surgical reintervention that confirmed the carriage of an organized thrombus that was remov from the pericardial space. No site of active bleeding was fix and the postoperative course was uneventful

Case 2

A 75-year-old white woman had undergone implantation of an Ionescu-Shiley valve prosthesis in aortic, mitral, and tricuspid position in 1985 Because of bitter aortic and mitral regurgitation, a Bjork-Shiley valve replacement was performed in July 1991 The postoperative course was complicated by way of total atrioventricular block, requiring the implantation of a pacemaker. The pacemaker lead was inserted via the right subclavian vein after wound This procedure was complicated on a right-sided hemothorax. Transthoracic drainage was performed.

Twenty days after pacemaker implantation, the patient at handed to the emergency department with abrupt attack of thoracic pain, accompanied according to nausea, sweating, and dyspnea. Immediately afterwards, cardiogenic assault developed. The jugular venous press was markedly increased. Inspiratory crackles were heard through the lower third of as well-as; not only-but also; not only-but; not alone-but lungs. Auscultation of the heart revealed normal opening and closing goods of the artificial valves. An electrocardiogram, obtained during chest pain, showed 2-mm ST-segment elevation in leads 2 3 and aVF and 25-mm ST-segment depression in leads [Vsub3] between the sides of [V.sub.6]. The creatine kinase flat was 315 U/L, with a 18 percent MB-fraction.

Transthoracic two-dimensional echocardiography revealed simply a moderate pericardial effusion, whereas transesophageal echocardiography demonstrated a pericardial hematoma that bind tightlyed the right atrium and a portion of the right ventricle. imperative surgical exploration confirmed the nearness of a large pericardial thrombus, compressing the right atrium, the upper part of the right ventricle, and the right coronary artery. An active bleeding site was not set up Rapid hemodynamic improvement was noted after evacuation of the hematoma. The patient had an monotonous postoperative course.

Discussion

Isolated atrial tamponade caused by way of a localized pericardial hematoma is an extraordinary but well-known complication after cardiac deeds A localized pericardial effusion or thrombus can flash on the mind as a result of pericardial adhesions.[1] Although localized compression from a hematoma can cause life-threatening hemodynamic deterioration, it may easily be superviseed by transthoracic echocardiography. The compression of an atrium may not affect the normal function of the remaining chambers.[2] Moreover, transthoracic two-dimensional echocardiography is frequently technically suboptimal in the postoperative period.[3] These sum of two units cases illustrate the diagnostic potential of transesophageal echocardiography in detecting localized pericardial thrombus.[4]

In the first patient, the clinical picture and the transthoracic two-dimensional echocardiogram were not typical for tamponade. An echodense arrangement of parts at the level of the right atrium was visualized, if it were not that the precise localization (intracardial or pericardial) could not be defined.

In the next to the first patient, the initial clinical findings adviseed an acute ischemic event. The clectrocardiographic findings and the moderate rise of creatine kinase flushs were indeed suggestive of acute inferior infarction. Transthoracic two-dimensional echocardiography demonstrated the mien of a moderate pericardial effusion.

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