SOB and Hypotension Following Coronary Artery Rotational Atherectomy • Xray of the Week 2016 • Week #22
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, and ordered a CT abdomen and pelvis. What is the diagnosis and treatment?
Left upper image: Axial CT showing pericardial effusion.
Left lower image: Axial CT showing no abnormality at the level of the vascular sheaths in the RLQ.
Right image: Coronal CT showing pericardial effusion.
The images demonstrate no retroperitoneal abnormality. However, the scan demonstrates a large pericardial effusion 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 as well as a moderate sized pericardial effusion. 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.
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.
Compared to angioplasty, percutaneous transluminal rotational atherectomy has four times the risk for coronary artery perforation.(1) 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. 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. Cardiac tamponade is in the differential diagnosis of pulseless electrical activity (PEA).
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. Spodick DH. Acute Cardiac Tamponade. N Engl J Med 2003; 349:684-690 August 14, 2003
Kevin M. Rice, MD is the president of Global Radiology CME
Dr. Rice serves as the Medical Director of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a Member of 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 launched Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field.
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