Cardiac tamponade complicating mitral balloon valvuloplasty

Cardiac Tamponade

Complicating

Mitral

Balloon Valvuloplasty

Manuel Pan, MD, Alfonso Medina, MD, Jose SuGrez de Lezo, MD, Enrique Hernhdez, MD, Miguel Ramero, MD, Djordje Pavlovic, MD, Francisco MelGn, MD, Jo& Segura, MD, Manuel Romh, MD, Anastasio Montero, MD, Jo& Morales, MD, Manuel France, MD, Angela Montijano, MS, and Federico VallBs, MD he efficacy of mitral balloon valvuloplasty (MBV), for the treatment of mitral stenosishas been recently demonstrated.1-5However, major complicationssuch asseveremitral insufficiency, systemic embolism, atria1 septal defect or cardiac perforation can occur during the procedure.6~7 Tamponade,although consistently reported on, has not beendescribedin detail regarding the mechanism, forms of presentation, managementand outcome.This report analyzestheseaspects in 8 patients who presentedwith acute tamponadeduring MBV. Of 300 patients with mitral stenosis treated at our institutions with percutaneous balloon valvuloplasty, 8 (2.6%) developed cardiac tamponade during the procedure. The characterization of this particular group of patients constitute the purpose of the study. The baseline data are listed in Table I. Mean age f standard deviation was 47 f 13 years. Six (75%) were in sinus rhythm, and 6 (75%) were in functional class III. All patients were clinically studied, including 2dimensional and Doppler echocardiography; the same study was repeated before discharge and at a mean period qf 10 f 7 months later.

T

From the Hospital “Reina Sofia,” University of Cbrdoba,Cordoba,and the Hospital de1Pino, University of Las Palmas, Las Palmas de Gran Canaria, Spain. Dr. Pan’s addressis: Servicio de Cardiologia, Hospital Reina Sofia, Avenida MendndezPidal 1,14004-Cordoba,Spain. Manuscript received January 21, 1991; revised manuscript received and acceptedMay 24,199 1.

After written informed consent was obtained, all patients underwent percutaneous right- and left-sided cardiac catheterization, as previously described.5,7To clarify the cardiac landmarks before transeptal puncture, we performed a pulmonary arteriography in the posteroanterior view for visualizing the left atrium in the levophase; in addition, an arterial catheter was advanced up to the aortic root and placed near the valve to mark its position. Transeptal puncture was performedfrom the right femoral vein using the standard technique; once in the left atrium, a flow-directed catheter was introduced through the Mullins sheet. Then, 1 mg/kg of heparin was administered intravenously. Mitral valvuloplasty wasperformed using the transarterial retrograde technique described by Babic et al8 in 260 patients; in the remaining 40 patients we used an Inoue balloon catheter.’ Eight patients developed cardiac tamponade during the procedure (Table I). In all of them the hemodynamic picture of cardiac tamponade (Figure 1) coincided with a still heart shadow without pulsations at fluoroscopy. Then, pericardiocentesis wasperformed. Echocardiographic confirmation of the pericardial effusion was obtained in 5 patients. Fluid was administered intravenously and heparin neutralized as soon as the balloon catheter and guidewire were removed. In all casesa large lumen-straight polyethylene catheter with spiral side holes (Mansfield pericardiocen-

TABLE I Patient Characteristics Technical Aspects and Outcome

Baseline Data Pt. Age No. (yr) Rhythm

LA Size Gorlin Area LA Pressure RA Pressure Balloon Diam. (mmHg) (mm) (cm21 (mm) (mmH@

1

52 Sinus

44

2

53 Sinus

3 4 5

49 60 60

AF Sinus AF

6 7 8

48 28 27

Sinus Sinus Sinus

AF = atrial fibrillation;

802

Perforation Site

Time

Treatment

Outcome

2 x 19

Right atrium

After BI

PD& subxiphoid window PD PD PD PD, sternotomy & CPB PD PD PD, sternotomy + CPB

Asymptomatic

1.3

16

3

48

1.3

52 42 50

0.9 0.7 0.8

24 23 40 35

4 6 7 13

2 2 2 2

19 19 19 15

Right atrium Right atrium Rrght atrium Left ventricle

After BI Before BI After BI Before BI

43 39 35

0.9 1.1 0.8

24 16 35

10 2 3

2 x 13 2 x 15 30

Left ventricle Right atrium Left atrium

Before BI After BI Before BI

BI = balloon inflation;

CPB = cardiopulmonary

x x x x

bypass: Diam. = diameter;

THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 68

LA = left atrium:

SEPTEMBER 15, 1991

PD = pericardial

drainage:

(23 mos)

Asymptomatic (12 mos) Asymptomatic (7 mos) Asymptomatic (3 mos) Died after surgery Died in laboratory Asymptomatic (12 mos) Asymptomatic (3 mos)

RA = right atrium.

tesis kit) waspercutaneously inserted into thepericar- and MBV was successfully accomplished. Three of the 5 patients with right atria1 perforation left the dium. In Spatients (62%), theperforation occurred at the laboratory in stable condition without needingfurther time of the transeptal puncture at the right atria1 treatment. Onepatient required respiratory) assistance level, as suggested by the same oxygen content in for a few hours, and the last one had a recurrent blood samples obtained simultaneously from the tamponade 4 hours after the procedure, which was right atrium and pericardial space.In I patient, tam- treated surgically with a subxiphoid pericardial winponade occurred after heparin administration and af- dow. ter transeptalpuncture; in 4 others it happened immeA left atria1 perforation (Figure 2A), identified by diately after balloon dilatation. In the first patient a angiography, occurred in 1 patient with a small left pericardial drainage was implanted before balloon atrium who had a low septal puncture: perforation insertion and, once stabilized, we decided to proceed was induced when passing the Inoue dilator and bal-

TAMPONADE FIGURE 1. simultaneous left atrial (LA), pulmonary artery (PA) and left ventricular (LV) pressure recording, before (PRE) and after (POST) valvuloplasty. Middle, hemodynamic picture of tamponade: systemic hypotension, equalization of all diastolic pressures and loss of protodiastok dip in left ventricular pressure.

’ 1j

: POST

FIGURE 2. Angiography after cardiac perforatii in order to locate the bleeding site. (A), at the left atrium (4-chamt.w view), (B), at the left ventricle (3W right anterior oblique projection). The contrast material opacifies the pericardial space (wKfe ap rows). D = pericardial drainage catheter.

BRIEF REPORTS 803

TABLE II Previously Reported Experience No. of Pts. Vahanianx Nobuyoshi4 Rochag Herrmannlo Ruiz” lnouel* Our series

2 (1)

200

106

2 3 7 14 8 8

80 74 285 527 300

*Nine traumatic pericardial ventricular perforations.

Tamponade (%I

effusions

0

(1.8) (3.7) 19.4) 14.91* (1.5) (2.6)

during

Related Mortality

transeptal

0 2 (2.7%) 2 (0.7%) 0 2 (0.7%) catheteruation

and

5

loon catheter. As in the previously described patient, we needed to insert a fast pericardial drainage that provided transient hemodynamic stability and allowed completion of MBV. This patient had high bleeding rate (>I 00 ml/min). A blood transfusion was begun; besides this, we neededto reinject all the blood drained from the pericardial space through a 9Fr sheet inserted in the left femoral vein. With this treatment a stable hemodynamic condition was maintained for about 30 minutes while the operating room was being prepared. In the mean time, we inserted two 18Fr cannulas (Bard, Inc.) percutaneously into the right femoral vein up to the right atrium and through the left femoral artery up to the aortic bifurcation. This allowed the surgical team to start extracorporeal bypass through thefemoral cannulas immediately after arrival at the operating room. On open-chest inspection, a I - to 2-cm tear wasfound at the floor of the left atrium near the inferior right pulmonary vein. The bleeding was resolved by direct suture. Then balloon commissurotomy was anatomically evaluated; we could observe a complete bicommissural opening and valve competence. No further intervention was required and the patient did well. Perforation occurred in the left ventricle in 2 patients treated with the Babic technique. In both, tamponade developed during balloon catheter manipulations when attempting to make a loop from the left ventricle to the left atrium. The first patient had sudden hypotension with extreme bradycardia requiring tracheal intubation and external cardiac massage; a pericardial drainage was immediately inserted and the hemodynamic situation stabilized. Blood transfusion and autohemoperfusion wereperformed aspreviously described. Systolic blood pressure was maintained at >80 to 90 mm Hgfor about 30 minutes and a left ventriculography was performed before transferring the patient to the operating room (Figure 2B) in order to locate the bleeding site. However, the patient’s general condition kept deteriorating while being transferred to surgery. The operation started with the patient in very poor condition. The surgical jind804

THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 68

ings revealed a 2-cm rupture at the apex of the left ventricle, which was repaired, but all recovery maneuvers were unsuccessful. In the secondpatient, tamponade was untreatable and the patient died unresponsive to all reviving maneuvers. In the 6 survivors, the mitral area changed from 0.98 f 0.2 to 2.4 f 0.8 cm2after MBV without significant mitral regurgitation. All 6 continue to be in functional class I to II 10 f 7 months later. The incidence of tamponadeduring MBV varies between 1 and 9%3,4,9-12 (Table II). Although it seemsto dependon the operator’s experience,sooneror later this complication can occur in the catheterization laboratory, and, asin other kinds of complications,l3 the valvuloplasty team must be prepared to recognize and treat it promptly. Hemopericardium can be causedby transeptal catheterization or by guidewire or balloon catheter manipulations. The rate of bleeding into the pericardial space is variable and could depend on the size of the rupture, the site of perforation, the coagulability of the blood or the abrupt pressure changes during inflation procedures. In our series,5 patients had perforation of the right atrium during the transeptal puncture; however,the clinical picture of tamponadedid not occur immediately but sometime afterwards (after heparin administration in 1 patient, and after balloon inflation in the remaining 4). Dramatic elevation of left atria1 pressureoccurs during systemicintracardiac occlusion, which is transmitted in retrograde manner to the pulmonary artery and right chambers14;this could facilitate the bleeding of a previously torn atria1wall. In thesepatients, the percutaneous insertion of a pericardial drainage and administration of protamine is generally enough to resolve the problem, and patients usually stop bleeding within a few hours. Occasionally, bleeding can recur, as it did in 1 of our patients; thus, a closemonitoring of blood pressure,fluid drainage, as well as serial echocardiograms,are recommended. Other forms of perforation, different from those induced by the transeptal catheter, can also occur. The guidewires, septal dilators or balloon catheters can produce more severelacerations of the cardiac walls, and generally bring about faster hemodynamicdeterioration. In this type of perforation, tamponadeoccursimmediately after a wrong maneuver. Pericardial drainage, fluid administration and autohemoperfusionare neededwhile waiting for an emergency surgical repair. In these patients, new advancesin percutaneouscardiac support15 may be helpful in maintaining hemodynamic condition until surgery is performed. In conclusion,tamponadecan complicate MBV, and occasionally it can be treated successfullywithout surgery. However, other patients needcontinuous drainage

SEPTEMBER 15, 1991

and autohemoperfusion to maintain systemic pressure within acceptablelevels,and most of them require emergency surgery. Results of emergency operation mainly dependon the patient’s condition on arrival at the operating room. 1. Inoue K, Owaki T, Nakamura T, Kitamura F, Miyamoto N. Clinical application of tramvenous mitral commisurotomy by a new balloon catheter. J Thorac Cardiooasc Surg 1984;87:394-402. 2. Palacios I, Block PC, Brandi S, Blanco P, Casal H, Pulido JI, Munoz S, D’Empaire G, Ortega MA, Jacobs M, Vlahakes G. Percutaneous balloon valvotomy for patients with severe mitral stenosis. Circulation 1987;75:778-784. 3. Vahanian A, Michel PL, Cormier B, Vitoux B, Michel X, Slama M, Enriquez L, Trabelsi S, Ismail MB, Acar J. Results of percutaneous mitral commissurotomy in 200 patients. Am J Cardiol 1989;63:847-852. 4. Nobuyoshi M, Hamasaki N, Kimura T, Nosaka H, Yokoi H, Yasumoto H, Horiuchi H, Nakashima H, Shindo T, Mori T, Miyamoto AT, Inoue K. Indications, complications, and short term clinical outcome of percutaneous tramvenous mitral commissurotomy. Circulation 1989;80:782-792. 5. Medina A, SuPrez de Lezo J, Hernandez E, Pan M, Romero M, Melian F, Sancho M, Bethancourt A, Vivancos R, Jimenez F, Segura J, Coello I, Drumond A. Balloon valvuloplasty for mitral restenosis after previous surgery: a comparative study. Am Heart J 1990;120:568-571. 6. Vahanian A, Michel PL, Cormier B, Vitoux B, Cazaux P, Roger V. Mitral Valvuloplasty. In Bernhard Meier, ed. Interventional Cardiology. Toronto: Hogrefe & Huber, 1990:309-325.

Effects of Abstinence

on Alcoholic

7. Sancho M, Medina A, Sudrez de Lezo J, Hernandez E, Pan M, Coello 1, Romero M, Melidn F, Segura J, Jim&z F, Vivancos R, Laraudogoitia E, Vall& F. Factors influencing progression of mitral regurgitation after transarterial balloon valvuloplasty for mitral stenosis. Am J Cardiol 1990;66:737-740. 6. Babic UU, Pejcic P, Djurisic Z, Vucinic M, Grujicic M. Percutaneous transarterial balloon valvuloplasty for mitral valve stenosis. Am I Cardiol 1986; 57:1101-l 104. 9. Rocha P, Berland J, Mechmeche R, Gamra H, Boussadia H, Gerber L, Grigera F, Letac B. Percutaneous mitral valvuloplasty using balloon catheterization. Immediate results in 80 cases. Arq Bras Cardiol 1989;52:253-258. 10. Hermann HC, Kleaveland P, Hill JA, Cowley MJ, Margolis JR, Nocero MA, Zalewski A, Pepine CJ, for the M-Heart Group. The M-Heart Percutaneous Balloon Mitral Valvuloplasty Registry: initial results and early follow-up. J Am CON Cardiol 1990;15:1221-1226, 11. Ruiz CE, Allen JW, Lao FYK. Percutaneous Double Balloon Valvotomy for severe rheumatic mitral stenosis. Am J Cardiol 1990;65:473-477, 12. Inoue K, Hung JS. Percutaneous mitral commissurotomy: the Far East experience. In Topol EJ, ed. Textbook of Interventional Cardiology. Philadelphia: WB Saunders, 1990:887-899. 13. Romero M, Melien F, Suirez de Lezo J, Medina A, Pan M, Hernandez E, Segura J, Jimenez F, Sancho M, Bethencourt A. Transarterial mitral valvuloplasty in conditions of acute pulmonary edema. Am Heart J 1990;119:1416-1419. 14. Suarez de Lezo J, Mantilla P, Pan M, Romero M, Sancho M, Ruiz de Castroviejo J, Tejero I, Arizon J, Carrasco JL. Abrupt homeostatic responses to transient intracardiac occlusion during balloon valvuloplasty. Am J Cardiol 1989;64:491-497. 15. Shawl FA, Domanski MJ, Wish M, Davis M. Percutaneous cardiopulmonary bypass support in the catheterization laboratory: technique and complications. Am Heart J 1990;120:195-203.

Heart Muscle Disease

Ashok J. Jacob, MRCP, Kathryn M. McLaren, MRC Path, and Nicholas A. Boon, MD bout 1% of chronic alcoholics develop cardiac failure, l a condition best referred to as “alcoholic heart muscle disease,”and there is anecdotal evidence that this can be reversed with abstinence.2-4 Unfortunately, most attempts to demonstratethis have been flawed by the failure to establish conclusively that alcohol ingestion is the solecauseof ventricular dysfunction. Our aim therefore in this prospectivestudy was to

A

establish the diagnosisof alcoholic heart muscle disease in a group of patients, having attempted to exclude ischemit heart diseaseand myocarditis using coronary angiography and right ventricular endomyocardial biopsy, respectively,and then document its natural history after abstinencefrom alcohol.

Six patients with a background of chronic alcohol abuse and concomitant heart failure were studiedprospectively (Table I). A full history and examination From the Department of Cardiology, Royal Infirmary, 1 Lauriston were performed together with electrocardiography Place, Edinburgh EH3 9YW, and the Department of Pathology, Uni- and chest x-ray. Blood was drawn for analysis oj versity of Edinburgh Medical School, Edinburgh, Scotland, United renal and hepatic function as well as haematologic Kingdom. Dr. Jacob is supported by the British Heart Foundation, Manuscript receivedMarch 14, 1991;revisedmanuscript receivedand indexes. A Hewlett Packard Sonos 1000 ultrasound machine with a 2..5-MHz probe was employed for the acceptedMay 15, 1991. TABLE I Patient Characteristics

------1 CTR

Ejection Fraction

Pt.

Age (yr)

Alcohol Intake W/week)*

-&T (U/liter)

MCV (fl)

Before

After

Before (%)

After (%)

Abstain

1 2 3 4 5 6

40 55 33 41 37 52

110 60 56 40 40 84

74 132 25 31 32 22

98 92 105 96 98 92

0.55 0.55 0.61 0.49 0.53 0.56

0.43 0.48 0.43 0.47 0.57 0.53

16 17 17 43 25 22

48 41 49 44 23 25

Yes Yes Yes No No No

*l unit = 0.5 pmt of beer or 1 measure of spirits. CTR = catdiothoracic ratio; rGT = gamma glutamyl transferase; MCV = mean corpuscular volume.

I

BRIEF REPORTS 805