Abstract
Cardiac tamponade is defined as compression of the heart due to accumulation of fluid in the pericardial sac, leading to raised pericardial pressures with haemodynamic compromise. We describe the case of a 76-year old female patient who underwent a routine off-pump coronary artery bypass graft operation and within 48 h developed classic signs of cardiac tamponade. The perioperative echocardiogram and operative findings at re-exploration revealed no clots or fluid collection. A giant hiatus hernia was found to be responsible for the tamponade through extrinsic compression. After insertion of a nasogastric tube and decompression of the stomach, there was a rapid improvement of the clinical picture. The remaining postoperative course was uneventful and the patient was discharged 5 days later, with referral to the general surgeon for further management. We conclude that, in cases of tamponade post-cardiac surgery, extrapericardial pathologies should be considered.
CASE REPORT
Chest X-ray (immediate postoperative).
The following day the patient became haemodynamically unstable with increasing inotropic requirements and a low urine output. An electrocardiogram showed no new ischaemic changes, and a repeated chest radiograph demonstrated clear lung fields, no evident effusions or enlarged pericardial shadow, but did reveal an increase in the size of the hiatus hernia. A bedside transthoracic echocardiogram was then performed and was suggestive of poor venous return and filling of all chambers, with mildly impaired ventricular function and extrinsic cardiac compression.
Owing to the patient’s clinical picture of cardiac tamponade and ongoing deterioration, she was returned to the theatre for urgent re-exploration.
Intraoperative transoesophageal echocardiogram. RA: right atrium; LA: left atrium; LV: left ventricle; AO: aorta; RV: right ventricle.
The patient was extubated the following day and proceeded to an uneventful recovery with discharge on the fifth postoperative day.
DISCUSSION
Cardiac tamponade is a life-threatening condition usually caused by active haemorrhage or clots and is thus frequently encountered postoperatively in cardiothoracic surgery. Gastric dilatation is also a common observation in the early postoperative period following cardiac surgery, but has rarely been reported to cause cardiac tamponade. Hiatus herniation is defined as the prolapsing of abdominal contents through the oesophageal hiatus. Its prevalence is higher in western countries and in men, and it has been associated with obesity and increasing age [1]. Most hiatal hernias are considered to be asymptomatic and are discovered incidentally. However, they can present most typically with symptoms of gastro-oesophageal reflux disease as well as peptic ulceration and are associated with oesophageal adenocarcinoma and idiopathic pulmonary fibrosis. Hiatal hernias can lead to fatal outcomes, such as gastric volvulus and incarceration. In a retrospective Finnish study of patients admitted due to symptomatic hiatal hernias and treated conservatively, the mortality rate related to the condition was 16.4% [2].
There are cases of extrapericardial tamponade due to acute hiatal hernia recurrence post-repair reported in the literature. To the best of our knowledge, this is only the second case describing tamponade through extrinsic compression by a hiatus hernia after coronary artery bypass surgery [3], although a similar case was also described post-type A aortic dissection repair [4].
Routine placement of a nasogastric tube in cardiac surgery continues to remain debatable, although it was deemed superfluous in a randomized controlled trial by Russell et al. [5]. However, patients with hiatal hernias might benefit from a nasogastric tube in order to avoid an increased risk of gastric stasis, vomiting and aspiration pneumonia and, in the worst cases, haemodynamic compromise, increasing requirements for ionotropic support and the added insult of consequent re-exploration.
CONCLUSION
Hiatus hernia should be identified preoperatively and considered as a cause of cardiac tamponade, if present. Routine insertion of nasogastric tubes in patients with known hiatal hernias should be common practice as a pre-emptive measure to increase patient safety.
Conflict of interest: none declared.
