Cardiac Tamponade Following Coronary Artery Rotational Atherectomy

SOB and Hypotension Following Coronary Artery Rotational Atherectomy • Xray of the Week

This 85 year old female became short of breath, hypotensive, and lethargic shortly after rotational atherectomy of the right coronary artery. The cardiologist was concerned that there may be a retroperitoneal hemorrhage related to the femoral artery puncture, and ordered a CT abdomen and pelvis. What is the diagnosis and treatment?

Figure 1A: Axial CT of lower chest.

Figure 1B: Axial CT at the level of the vascular sheaths in the RLQ.

Figure 1C: Coronal CT abdomen and pelvis.

Figure 2A: Axial CT showing pericardial effusion (white arrows).

Figure 2B: Axial CT showing no abnormality at the level of the vascular sheaths in the RLQ (white arrow).

Figure 2C: Coronal CT showing pericardial effusion (white arrows).

The images demonstrate no retroperitoneal abnormality. However, the CT scan demonstrates a large pericardial effusion (Figs. 1A, 1C, 2A, 2C) and, based on the clinical findings cardiac tamponade is suspected. An echocardiogram was performed which demonstrates right ventricular collapse in early diastole and right atrial inversion in late diastole in addition to the moderate sized pericardial effusion. (Fig. 3) A dilated inferior vena cava without respiratory variation was also seen, all signs of cardiac tamponade. Emergent pericardiocentesis and pericardial drainage catheter placement was performed resulting in rapid improvement in the patient's condition, no longer requiring pressors.

Figure 3: Apical 4 chamber view showing right ventricular collapse in early diastole and right atrial inversion in late diastole. There is also a moderate sized pericardial effusion.

Discussion

Rotational atherectomy is increasingly being used for percutaneous coronary intervention due to the of the expansion of indications to more complex lesions (1,2,3). However, the compared to angioplasty, percutaneous transluminal rotational atherectomy has four times the risk for coronary artery perforation (1,3). The incidence of important procedure-related complications from rotational atherectomy is 1.3%, and the incidence of tamponade is 0.64% (4). Beck's triad consisting of jugular venous distension, distant heart sounds, and hypotension is the classic presentation of cardiac tamponade. Other symptoms of tamponade include severe respiratory distress, tachycardia, and agitation. Pulsus paradoxus, low voltage QRS complex on EKG, and a chest x-ray with enlarged cardiac silhouette may also be seen with tamponade (5). Even a small amount of pericardial fluid may cause tamponade in the acute setting, whereas a large amount of fluid accumulated over a long period of time may not cause tamponade. Treatment is pericardiocentesis and placement of a pericardial drain preferably with ultrasound guidance. Rapid treatment is often life-saving, resulting in prompt improvement in the patient's condition. Thoracotomy may be required in severe trauma. (6) Cardiac tamponade is in the differential diagnosis of pulseless electrical activity (PEA).

References:

1. Wasiak J, Law J, Watson P, Spinks A. Percutaneous transluminal rotational atherectomy for coronary artery disease. Cochrane Database Syst Rev. 2012 Dec 12

2. Lee MS. Rotational Atherectomy: An Invaluable Tool for Complex Lesions. Cath Lab Digest Issue Number: Volume 19 - Issue 6 - June 2011

3. Gunning, MG, et al. Coronary artery perforation during percutaneous intervention: incidence and outcome. Heart. 2002 Nov; 88(5): 495–498.

4. Sakakura K, Inohara T, Kohsaka S, et al. Incidence and Determinants of Complications in Rotational Atherectomy. Circulation: Cardiovascular Interventions. 2016;9:e004278

5. Spodick DH. Acute Cardiac Tamponade. N Engl J Med 2003; 349:684-690 August 14, 2003

6. Shekar PS, Leacche M ,Farnam KA, et al. Surgical Management of Complications of Percutaneous Coronary Rotational Atherectomy Interventions. Ann Thorac Surg 2004;78:e81–2

Kevin M. Rice, MD is the president of Global Radiology CME

Dr. Rice has served in many leadership positions; he has been the Chair of the Radiology Department and Chief of Staff of Valley Presbyterian Hospital in Los Angeles, California and is a Radiologist with Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator.

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