Left atrial compression syndrome secondary to coronary artery perforation: Pathophysiology, diagnosis, and management strategies.

Coronary perforation (CP) poses a significant risk of morbidity and mortality, particularly, in patients with a history of cardiac surgery. The occurrence of loculated pericardial effusion presents distinctive challenges in these postcardiac surgical patients. This study delves into the complexities arising from the formation of loculated pericardial effusions subsequent to CP, with a specific focus on the loculated effusion in the posterior wall leading to left atrial compression syndrome. This analysis is dedicated to elucidating pathophysiology diagnostic and treatment strategies tailored for addressing left atrium compression syndrome, providing invaluable insights into the intricacies of diagnosing, treating, and managing this entity in the postcardiac surgical patient.

Delineating phenotypes of Kawasaki disease and SARS-CoV-2-related inflammatory multisystem syndrome: a French study and literature review.

OBJECTIVE: To better define the clinical distinctions between the new severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-related paediatric inflammatory multisystem syndrome (PIMS) and Kawasaki disease (KD). METHODS: We compared three groups of patients: group 1, cases from our national historic KD database (KD-HIS), before the SARS-CoV-2 pandemic; group 2, patients with KD admitted to an intensive care unit (KD-ICU) from both our original cohort and the literature, before the SARS-CoV-2 pandemic; and group 3, patients with PIMS from the literature. RESULTS: KD-HIS included 425 patients [male:female ratio 1.3, mean age 2.8 years (s.d. 2.4)], KD-ICU 176 patients [male:female ratio 1.3, mean age 3.5 years (s.d. 3.1)] and PIMS 404 patients [male:female ratio 1.4, mean age 8.8 years (s.d. 3.7)]. As compared with KD-HIS patients, KD-ICU and PIMS patients had a higher proportion of cardiac failure, digestive and neurological signs. KD-ICU and PIMS patients also had a lower frequency of typical KD-mucocutaneous signs, lower platelet count, higher CRP and lower sodium level. As compared with KD-HIS and KD-ICU patients, PIMS patients were older and more frequently had myocarditis; they also had fewer coronary abnormalities and lower sodium levels. Unresponsiveness to IVIG was more frequent in KD-ICU than KD-HIS and PIMS patients. CONCLUSION: On clinical grounds, KD-HIS, KD-ICU and PIMS might belong to a common spectrum of non-specific pathogen-triggered hyperinflammatory states. The causes of increasing inflammation severity within the three entities and the different effects on the heart remain to be determined.

Age- and sex-based differences in patients with acute pericarditis.

BACKGROUND: Acute pericarditis has a wide spectrum of clinical presentations largely depending on underlying aetiologies. We assessed the role of age and sex in the clinical features and outcome of acute pericarditis. MATERIALS AND METHODS: A total of 240 consecutive patients hospitalized with a first episode of acute pericarditis were included. At baseline demographics, clinical features, laboratory and imaging findings and medical therapy were recorded. Patients were followed up for at least 18 months for complications. Data comparisons were performed according to sex and age (≤60 or >60 years). RESULTS: The male/female ratio was 1.42, and 56% of patients were >60 years. Younger patients depicted more often chest pain (P = .001), fever and rubs (P < .001 for both), ST elevation and PR depression (P = .032 and .009, respectively), higher CRP values (P = .009) and less often dyspnoea (P = .046) and pericardial effusion (P = .036). Moreover, they received less often glucocorticoids (P < .001) and depicted less atrial fibrillation (P = .003) and a higher rate of recurrent pericarditis (P = .013). After multivariate adjustment for confounders, age >60 years remained an independent predictor for a lower risk of recurrent pericarditis (hazard ratio 0.60, 95% CI: 0.39-0.96, P = .033). Regarding sex, females were older (P = .007), showed less often ST elevation and PR depression (P < .001 and .002, respectively) and had a higher baseline heart rate (P = .02). Sex was not associated with recurrent pericarditis risk. CONCLUSIONS: Patients with acute pericarditis have distinct presenting clinical, biochemical and prognostic features according to age and sex. Awareness of such differences is important for clinical decision-making.

Post-cardiac injury syndrome triggered by radiofrequency ablation for AVNRT.

BACKGROUND: Post-cardiac injury syndrome (PCIS) is an inflammatory condition following myocardial or pericardial damage. In response to catheter ablation, PCIS most frequently occurs after extensive radiofrequency (RF) ablation of large areas of atrial myocardium. Minor myocardial injury from right septal slow pathway ablation for atrioventricular nodal reentrant tachycardia (AVNRT) is not an established cause of the syndrome. CASE PRESENTATION: A 62-year-old women with a 6-year history of symptomatic narrow-complex tachycardia was referred to perform an electrophysiological study. During the procedure AVNRT was recorded and a total of two RF burns were applied to the region between the coronary sinus and the tricuspid annulus. Pericardial effusion was routinely ruled out by focused cardiac ultrasound. In the following days, the patient developed fever, elevated inflammatory and cardiac markers, new-onset pericardial effusion, characteristic ECG changes, and complained of pleuritic chest pain. An extensive workup for infectious, metabolic, rheumatologic, neoplastic, and toxic causes of pericarditis and myocarditis was unremarkable. Cardiac magnetic resonance imaging showed no signs of ischemia, infiltrative disease or structural abnormalities. The patient was diagnosed with PCIS and initiated on aspirin and low-dose colchicine. At a 1-month follow-up visit the patient was free of symptoms but still had a small pericardial effusion. After three  months of treatment the pericardial effusion had resolved completely. CONCLUSIONS: Inflammatory pericardial reactions can occur after minor myocardial damage from RF ablation without involvement of structures in close proximity to the pericardium.

Takotsubo cardiomyopathy complicated by cardiac tamponade due to non-hemorrhagic pericardial effusion: a case report.

BACKGROUND: Cardiac tamponade is a rare but serious complication of Takotsubo cardiomyopathy (TC). Two cases of cardiac tamponade subsequent to TC have been reported. The pericardial effusion in these cases was hemorrhagic and caused by ventricular rupture. Cardiac tamponade induced by an inflammatory effusion complicated with TC has not been reported. This is the first case report of TC, which developed cardiac tamponade during the recovery phase with a large volume non-hemorrhagic inflammatory effusion. CASE PRESENTATION: We describe a case of an 81-year-old woman admitted to our hospital because of severe chest pain. Her symptoms began soon after her son's hospitalization. We diagnosed her with TC based on results of an electrocardiogram, echocardiogram, and emergent coronary angiography. Her symptoms and left ventricular dysfunction improved gradually. She developed newly confirmed chest pain and dyspnea on day 9 after admission. A large pericardial effusion developed, resulting in cardiac tamponade. Her symptoms and hemodynamic status improved immediately after the pericardiocentesis. The effusion was non-hemorrhagic and exudative. No specific signs of infection, collagen disease, or malignant tumors were observed, except for TC. CONCLUSIONS: We experienced a case of circulatory collapse induced by TC-related inflammatory pericardial effusion at recovery phase. This case emphasizes the importance of careful follow-up even after improved left ventricular dysfunction in a patient with TC.

Delayed cardiac tamponade following catheter ablation of frequent premature ventricular complexes: a case report.

BACKGROUND: Cardiac tamponade is a potentially fatal complication after catheter ablation of ventricular arrhythmias. It often happens during or shortly after the procedure and needs urgent treatment. Here, we present a very incredible case about delayed cardiac tamponade after ablation of premature ventricular complexes. CASE PRESENTATION: A 66-year-old woman who underwent successful catheter ablation of right ventricular outflow tract origin premature ventricular complexes. Nineteen days after ablation, the patient experienced sudden syncope. Upon arriving at our hospital, she was "confused and shock". Transthoracic echocardiography revealed hemorrhagic cardiac tamponade, which was considered due to a delayed tiny perforation in the heart induced by the previous ablation. Following an emergent pericardiocentesis to drain a 200 mL hemorrhagic effusion, the patient's hemodynamics improved significantly. The patient was discharged after a 2-week hospitalization for investigating other probable causes with negative results. No signs of pericardial effusion recurred in a follow-up time of 12 months. CONCLUSION: This case report demonstrated, for the first time, that very late post-procedural cardiac tamponade might occur after catheter ablation of ventricular arrhythmias, even without antithrombotic treatment.

Occurrence of right ventricular dysfunction immediately after pericardiocentesis.

The changes in cardiac function that occur after pericardiocentesis are unclear. An understanding of the effect of pericardiocentesis on right ventricular (RV) and left ventricular (LV) function is clinically important. This study was performed to assess RV and LV function with echocardiography before and after pericardiocentesis. In total, 19 consecutive patients who underwent pericardiocentesis for more than moderate pericardial effusion were prospectively enrolled from August 2015 to October 2017. Comprehensive transthoracic echocardiography was performed before, immediately after (within 3 h), and 1 day after pericardiocentesis to investigate the changes in RV and LV function. The mean age of all patients was 72.6 ± 12.2 years. No pericardiocentesis-related complications occurred during the procedure, but one patient died of right heart failure 8 h after pericardiocentesis. After pericardiocentesis, RV inflow and outflow diameters increased (p < 0.05 versus values before pericardiocentesis), and the parameters of RV function (tricuspid annular plane systolic excursion, tricuspid lateral annular systolic velocity, fractional area change, and RV free wall longitudinal strain) significantly decreased (p < 0.001 versus values before pericardiocentesis). These abnormal values or RV dysfunction remained 1 day after pericardiocentesis (p > 0.05 versus values immediately after pericardiocentesis). Conversely, no parameters of LV function changed after pericardiocentesis. Of 19 patients, 13 patients showed RV dysfunction immediately after pericardiocentesis and 6 patients did not. RV free wall longitudinal strain before pericardiocentesis in patients with post-procedural RV dysfunction was reduced compared to those without post-procedural RV dysfunction ( - 18.9 ± 3.6 versus - 28.4 ± 6.3%; p = 0.005). The area under the curve values for prediction of post-procedural RV dysfunction was 0.910 for RV free wall longitudinal strain. The occurrence of RV dysfunction after pericardiocentesis should be given more attention, and pre-procedural RV free wall longitudinal strain may be a predictor of post-procedural RV dysfunction.

COVID-19 myopericarditis: It should be kept in mind in today's conditions.

A 78-year-old patient with acute respiratory distress was transferred to our hospital with ST segment elevation on electrocardiography. Coronary angiography revealed normal coronary arteries. Thorax computerized tomography showed ground glass opacification with consolidation in the lungs and mild pericardial effusion demonstrating myopericarditis associated with COVID-19.

Quantifying and reporting cardiac findings in imaging of COVID-19 patients.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection continues to be a public health emergency and a pandemic of international concern. As of April 31st,  the reported cases of COVID-19 are three million in 186 countries. Reported case fatality has crossed 200 thousand among which more than fifty thousand has been in the USA. Most patients present with symptoms of fever, cough, and shortness of breath following exposure to other COVID-19 patients. Respiratory manifestations predominate in patients with mild, moderate, severe illness. Imaging of patients with COVID-19 consistently reports various pulmonary parenchymal involvement. In this article we wanted to reinforce and review the various reported imaging patterns of cardiac and mediastinal involvement in COVID-19 patients. Among patients with COVID 19 who underwent various imaging of chest various cardiac findings including pericardial effusion, myocarditis, cardiomegaly has been reported. Most of these findings have been consistently reported in patients with significant acute myocardial injury, and fulminant myocarditis. Acute biventricular dysfunction has also been reported with subsequent improvement of the same following clinical improvement. Details of cardiac MRI is rather limited. In a patient with clinical presentation of acute myocarditis, biventricular myocardial interstitial edema, diffuse biventricular hypokinesia, increased ventricular wall thickness, and severe LV dysfunction has been reported. Among patients with significant clinical improvement in LV structure and function has also been documented. With increasing number of clinical cases, future imaging studies will be instrumental in identifying the various cardiac manifestations, and their relation to clinical outcome.

Fetal cardiac findings and hemodynamic changes associated with severe lower urinary tract obstruction in utero.

OBJECTIVES: To describe fetal echocardiographic findings associated with lower urinary tract obstruction (LUTO) and to compare anatomic and hemodynamic measurements between fetuses with LUTO and gestational age (GA)-matched controls, with an emphasis on quantitative indices of diastolic function and cardiac output. METHODS: This was a retrospective cohort study of fetuses diagnosed with severe LUTO with giant bladder, which underwent at least one fetal echocardiogram at our center between January 2005 and June 2018. Fetuses with major congenital heart disease were excluded. Control fetuses did not have any structural or functional abnormalities and were GA-matched to the LUTO fetuses based on the time of the first fetal echocardiogram. Cardiac anatomy and hemodynamic measurements were compared between fetuses with LUTO and controls. In infants with LUTO, serial fetal and postnatal echocardiographic data were assessed, when available, and clinical outcomes were reviewed. RESULTS: Twenty-six fetuses with LUTO and at least one fetal echocardiogram available were identified, one of which was excluded due to hypoplastic left heart syndrome, leaving 25 LUTO fetuses in the final cohort. The mean GA at the first fetal echocardiogram was 25.4 ± 5.1 weeks in the LUTO group and 25.3 ± 5.0 weeks in the control group. Common findings in fetuses with LUTO included cardiomegaly (40%), pericardial effusion (44%), right ventricular (RV) hypertrophy (64%) and left ventricular (LV) hypertrophy (48%). Compared with GA-matched controls, LUTO fetuses had lower ascending aorta Z-score (-0.10 ± 0.94 vs -0.93 ± 1.03; P = 0.02) and aortic isthmus Z-score (-0.14 ± 0.86 vs -1.62 ± 1.11; P < 0.001), shorter mitral valve inflow time indexed to cardiac cycle length (0.46 ± 0.04 vs 0.41 ± 0.06; P = 0.002), and worse (increased) LV myocardial performance index (0.39 ± 0.03 vs 0.44 ± 0.04; P < 0.001). In addition, the ratio of RV to LV cardiac index was higher in LUTO fetuses compared with controls (1.62 ± 0.13 vs 1.33 ± 0.11; P < 0.001). Of the 25 LUTO pregnancies, two were lost to follow-up, three underwent elective termination of pregnancy and three ended in intrauterine fetal demise. Four (16%) patients had mildly hypoplastic left-heart structures, comprising two with aortic arch hypoplasia and two with mitral and aortic stenosis. CONCLUSION: In addition to presenting with cardiomegaly, pericardial effusion and ventricular hypertrophy, fetuses with LUTO demonstrate LV diastolic dysfunction and appear to redistribute cardiac output as compared to control fetuses, which may contribute to the development of left-heart hypoplasia. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Prevalencia de derrame pericárdico en enfermedades sistémicas.

INTRODUCTION: The presence of 50 mL of fluid or more in the pericardial sac is known as pericardial effusion. OBJECTIVE: To determine the prevalence of pericardial effusion in patients with systemic diseases. METHOD: Echocardiographic studies performed at the National Medical Center Siglo XXI Specialty Hospital Cardiology Department between 2006 and 2016 were reviewed. According to Weitzman's criteria, pericardial effusion was classified as mild, < 10 mm, moderate, 10 to 20 mm and severe, > 20 mm. RESULTS: In total, 10,653 studies were reviewed; the prevalence of pericardial effusion was 3.5 % (380), in 209 women (55 %, 45.9 ± 19.0 years) and 171 men (45 %, 41.9 ± 18.5 years). Etiology was uremic in 227 (59.7 %), lymphatic drainage reduction in 73 (15.8 %), autoimmune diseases in 30 (7.9 %), neoplastic in 26 (6.8 %), infectious in 19 (5 %), idiopathic in 14 (3.7 %), hypothyroidism in two (0.5 %), iatrogenic in one (0.3 %) and post-infarction in one (0.3 %). Severity was mild in 87 (22.9 %), moderate in 147 (38.7 %) and severe in 146 (38.4 %). CONCLUSIONS: The prevalence of pericardial effusion was 3.5% in patients with systemic diseases.

INTRODUCCIÓN: La presencia de 50 mL o más de líquido dentro del saco pericárdico se denomina derrame pericárdico. OBJETIVO: Determinar la prevalencia de derrame pericárdico en pacientes con enfermedades sistémicas. MÉTODO: Se revisaron los estudios ecocardiográficos efectuados en el Servicio de Cardiología del Hospital de Especialidades del Centro Médico Nacional Siglo XXI, entre 2006 y 2016. Conforme los criterios de Weitzman, el derrame pericárdico se clasificó en ligero, < 10 mm, moderado de 10 a 20 mm y severo, > 20 mm. RESULTADOS: Se revisaron 10 653 estudios; la prevalencia del derrame pericárdico fue de 3.5 % (380), 209 mujeres (55 %, 45.9 ± 19.0 años) y 171 hombres (45 %, 41.9 ± 18.5 años). La etiología fue urémica en 227 (59.7 %), reducción del drenaje linfático en 73 (15.8 %), enfermedades autoinmunes en 30 (7.9 %), neoplásicas en 26 (6.8 %), infecciosas en 19 (5 %), idiopáticas en 14 (3.7 %), hipotiroidismo en dos (0.5 %), iatrogénica en uno (0.3 %) y posinfarto en uno (0.3 %). La severidad fue ligera en 87 (22.9 %), moderada en 147 (38.7 %) y severa en 146 (38.4 %). CONCLUSIONES: La prevalencia de derrame pericárdico fue de 3.5 % en pacientes con enfermedades sistémicas.

Incidence of pericardial effusion after left atrial appendage closure: The impact of underlying heart rhythm-Data from the EWOLUTION study.

INTRODUCTION: Pericardial effusion/tamponade (PE/PT) is a rare but serious complication following left atrial appendage closure (LAAC). It may be speculated that LAA contraction during sinus rhythm (SR) exerts mechanical force on the device that eventually leads to PE. We sought to determine the incidence and predictors of PE following LAAC using Watchman with special emphasis on the underlying heart rhythm during implant. METHODS AND RESULTS: From 47 centers in 13 European countries 1,020 patients underwent LAAC and data on baseline rhythm were available from 1,010 patients (mean age 73 ± 9 years, 60% male, median CHA2DS2-VASc = 4). Data were collected via electronic case report forms. A Cox proportional hazard model was calculated adjusting for multiple variables: age, gender, number of recaptures, and device oversizing. During implant, 41% and 59% of patients were in SR and atrial fibrillation (AF), respectively. PE/PT rate was significantly lower in patients implanted during AF at day 30 postimplant (n = 1; 0.2% vs. n = 6; 1.5%; P = 0.02). No PE requiring intervention occurred in the AF group compared to 5 events (1.2%) in the SR group (P = 0.01). While univariate analysis identified SR and gender as predictors for PE/tamponade, multivariate analysis only showed a statistical trend for both variables. CONCLUSION: The overall incidence of PE/PT was very low after LAAC using Watchman. Although SR was not identified as an independent predictor of PE/PT, all events requiring intervention occurred in patients with SR. It may be advisable to perform an extended echocardiographic follow-up in that patient population.

MitraClip-induced systolic anterior motion complicated by pericardial effusion: A case report.

Systolic anterior motion (SAM) of the anterior mitral leaflet is a well reported complication of surgical mitral valve repair (MVR). In the current report, we present a case of SAM with left ventricular outflow tract obstruction (LVOTO) which occurred after transcatheter mitral valve repair (TMVR) using the MitraClip device. LVOTO was caused by the combination of protrusion of the MitraClip device into the LVOT and underfilling of the left ventricle due to pericardial effusion and atrial fibrillation. Rapid clinical resolution and marked decline in LVOT pressure gradient occurred following surgical drainage and windowing of the pericardium. We conclude that SAM and LVOTO could occur after TMVR. Seeking and addressing reversible aggravators of LVOTO including pericardial effusion is essential and could potentially make the difference between a successful procedure and a failed one. © 2016 Wiley Periodicals, Inc.

Non-surgical management in hemodynamically unstable blunt traumatic pericardial effusion: A feasible option for treatment.

INTRODUCTION: Little is known about the outcomes of deliberate non-surgical management for hemodynamically unstable patients with blunt traumatic pericardial effusion. We evaluated the efficacy of management with pericardiocentesis or subxiphoid pericardial window in hemodynamically unstable patients who reach the hospital alive with blunt traumatic pericardial effusion. METHODS: We conducted a review of a consecutive series of patients with pericardial effusion following blunt trauma who arrived at Fukui Prefectural Hospital between January 1, 2009 and December 31, 2017. All patients with traumatic pericardial effusion were included, irrespective of the type of blunt trauma. RESULTS: Eleven patients were identified arrived to the Emergency Department with a pericardial effusion after blunt trauma. Of the eleven patients, five patients had cardiopulmonary arrest on arrival and none survived. Of the other six patients who reached the hospital alive, five were hemodynamically unstable and clinically diagnosed with cardiac tamponade. One patient was hemodynamically stable and managed conservatively without pericardiocentesis or pericardial window. Otherwise, two patients were managed with pericardiocentesis alone. One patient was managed with pericardial window alone. One was managed with both pericardiocentesis and pericardial window. The remaining patient underwent median sternotomy because of unsuccessful pericardial drainage tube insertion. All six patients who reached the hospital alive survived. Five patients did not require surgical repair. CONCLUSION: The results of the present study suggested that non-surgical management of hemodynamically unstable patients who reach hospital alive with blunt pericardial effusion may be a feasible option for treatment.

Discordant phenotypes in monozygotic twins with 16p11.2 microdeletions including the SH2B1 gene.

A 200∼240 kb SH2B1-containing deletion region on 16p11.2 is associated with early-onset obesity and developmental delay. Here, we describe monozygotic twin brothers with discordant clinical presentations. Intrauterine fetal growth restriction was present in both twins. Additionally, twin A exhibited coarctation of aorta, left ventricular noncompaction, atrial septal defect, pericardial effusion, left hydronephrosis, and moderate developmental delay, whereas twin B exhibited single umbilical artery. Chromosome microarray analysis was performed on both twins and their parents. An identical 244 kb microdeletion on 16p11.2 including 9 Refseq genes, including SH2B1, was identified in the twins. The novel findings in monozygotic twins may expand the phenotypic spectrum of 16p11.2 microdeletion. Further studies are needed to strengthen the correlation between genotypes and abnormal clinical features.

Team-based approach to identify cardiac toxicity in critically ill hematopoietic stem cell transplant recipients.

INTRODUCTION: We observed pulmonary hypertension (PH), pericardial effusions, and left ventricular systolic dysfunction (LVSD) in multiple critically ill hematopoietic stem cell transplant (HSCT) recipients. We implemented routine structured echocardiography screening for HSCT recipients admitted to the pediatric intensive care unit (PICU) using a standardized multidisciplinary process. METHODS: HSCT recipients admitted to the PICU with respiratory distress, hypoxia, shock, and complications related to transplant-associated thrombotic microangiopathy were screened on admission and every 1-2 weeks thereafter. Echocardiography findings requiring intervention and/or further screening included elevated right ventricular pressure, LVSD, and moderate to large pericardial effusions. All echocardiograms were compared to the patient's routine pretransplant echocardiogram. RESULTS: Seventy HSCT recipients required echocardiography screening over a 3-year period. Echo abnormalities requiring intervention and/or further screening were found in 35 (50%) patients. Twenty-four (34%) patients were noted to have elevated right ventricular pressure; 14 (20%) were at risk for PH, while 10 (14%) had PH. All patients with PH were treated with pulmonary vasodilators. LVSD was noted in 22 (31%) patients; 15/22 (68%) received inotropic support. Moderate to large pericardial effusions were present in nine (13%) patients, with six needing pericardial drain placement. DISCUSSION: Echocardiographic abnormalities are common in critically ill HSCT recipients. Utilization of echocardiogram screening may allow for early detection and timely intervention for cardiac complications in this high-risk cohort.

Upper gastrointestinal tract symptoms are predictors of postoperative large pericardial effusion in cardiac surgery.

In this prospective observational study we evaluated the clinical symptoms in patients who presented with early or late significant pericardial effusion after cardiac surgery and underwent its open drainage in our institution. It was a series of 35 patients where the clinical symptoms and lab investigations were recorded. There were 21 male and 14 female (3:2). Majority of patients presented with postoperative large pericardial effusion within 2 -3 weeks of cardiac surgery. Eighteen (51.4%) patients presented with predominantly nonspecific upper gastrointestinal tract (GIT) symptoms like nausea, vomiting, loss of appetite and epigastric discomfort, 29 (82.85%) patients with postoperative large pericardial effusion had undergone mechanical valve replacement surgery. Majority of patients were on anticoagulation therapy and had prolonged INR. This study showed that non- specific upper gastrointestinal tract (GIT) symptoms like nausea, vomiting, loss of appetite are very frequent in patients with post-operative pericardial effusion. If a patient presents with these non-specific GI symptoms along with raised INR and low haemoglobin in postoperative follow up, significant pericardial effusion should be excluded.