P009: LIFE-THREATENING PERICARDIAL EFFUSION LEADING TO CARDIAC TAMPONADE AFTER ANTERIOR AORTOPEXY
Harshvardhan Rajen, MD1; Amy Quintero, MD1; Valentina Rojas Ortiz, MD1; Katrin Post-Martens, MD2; 1HCA Florida Kendall Hospital; 2Wolfson Children's Hospital
Introduction: Our patient is a 8-year-old female with a history of tracheobronchomalacia with previous posterior aortopexy 2 years prior and anterior aortopexy recently, who presented with syncope and hypotension. She was subsequently found to have pericardial effusion with tamponade physiology. Her vital signs revealed tachycardia and hypotension. An echocardiogram revealed a large circumferential pericardial effusion with clear tamponade physiology of right atrial collapse in late diastole/early systole and diastolic right ventricular collapse. She was taken directly to the cath lab and underwent a pericardiocentesis to drain the fluid that had accumulated around her heart.
Methods: For the procedure, she was placed on a ramp of pillows to support her, as she could not tolerate laying in the supine position. She was induced with nitrous and sevoflurane via mask induction, after which an arterial line was placed in the left radial artery. She maintained spontaneous ventilation throughout the procedure. The decision was made to not place an endotracheal tube or supraglottic airway to avoid positive pressure ventilation. The patient received ketamine and midazolam in addition to the inhaled anesthetic agents. The surgeon gained access to the pericardial space and aspirated 360 ml of chylous fluid. As the fluid was removed from around the heart, there was marked improvement of the patient's blood pressure, as well as a decrease in the tachycardia that was present. A pericardial drain was left in place and the patient was taken to the CVICU.
Results: In the CVICU she was found to have a right pleural effusion and underwent pigtail chest tube placement by interventional radiology. Both pericardial and pleural drains had significant decreases in output and were removed on the 7th day of admission. Subsequent echocardiogram showed a small localized pericardial effusion located in the posterior aspect of the right atrium and right ventricle with no evidence of tamponade physiology or evidence of pleural effusion.
Discussion: Cardiac tamponade is rare in children but can happen in any age group and is important to consider as children are less capable of increasing cardiac contractility and tolerate pericardial fluid accumulation than adults. Airway compression from nearby vascular structures is one cause of secondary, or acquired, tracheobronchomalacia. Anterior aortopexy is a complex high risk surgical procedure involving suturing the anterior aspect of the aorta to the posterior sternum in order to relieve compression of the major blood vessels off of the respiratory tree. Several complications can occur, and one of the most common can be pericardial effusion. This may progress to cardiac tamponade and life threatening cardiac compromise. Recognizing the clinical signs of cardiac tamponade quickly and initiating treatment to remove the fluid around the heart is important to improve morbidity and mortality for these patients.