CHEST Guidelines-Late-Presentation-of-Hypotension-After-Cardiac-Sur

Late-Presentation-of-Hypotension-After-Cardiac-Sur

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The article discusses a complex case of late-onset hypotension following cardiac surgery in a 52-year-old woman. The patient, who had a history of left ventricular outflow tract obstruction due to subaortic ring and hypertrophic obstructive cardiomyopathy, experienced hypotension and other symptoms 16 days after a septal myectomy and subaortic ring resection. Initial tests indicated possible sepsis and the patient was treated with antibiotics and fluids. Despite initial improvement, she developed hypotension again, prompting a point-of-care echocardiogram, which revealed a large pericardial effusion and cardiac dyskinesia, suggesting issues like cardiac tamponade or postpericardiotomy syndrome.<br /><br />Cardiothoracic surgery was deemed necessary to address the effusion and potential ventricular issues. During surgery, thick pericardial adhesions and a serosanguinous effusion were found, but no ventricular perforation or indications of bleeding were observed. The adhesions were lysed, which improved ventricular mobility. This case highlights that postoperative pericardial effusion can present significantly after surgery, and differentiating among possible causes of hemodynamic instability can be challenging.<br /><br />The article emphasizes that pericardial effusions are a common as well as a significant source of postoperative morbidity and often occur days to weeks after surgery. It underscores the importance of echocardiography in diagnosing pericardial problems and points out that a lack of echocardiographic signs of cardiac tamponade doesn’t rule out significant effusions needing intervention. The discussion also links pericardial complications to postpericardiotomy syndrome—a syndrome characterized by inflammation after cardiac surgery and other traumas. Despite the complexities involved, the therapeutic intervention involves either percutaneous drainage or surgical evacuation of the effusion. The patient in the study ultimately recovered without further complications.

Keywords

late-onset hypotension

cardiac surgery

pericardial effusion

postpericardiotomy syndrome

echocardiography

cardiac tamponade

septal myectomy

hemodynamic instability

percutaneous drainage

surgical evacuation