VA-ECMO With Pericardiocentesis and Autologous Blood Transfusion - Stabilisation Strategy in Acute Cardiac Free Wall Rupture.

A 68-year old lady present with left ventricular free wall rupture and cardiac arrest post-myocardial infarction. This article illustrates a strategy combining pericardiocentesis with autologous transfusion together with VA-ECMO as a bridge to definitive surgical repair.

Direct autotransfusion following emergency pericardiocentesis in patients undergoing cardiac electrophysiology procedures.

INTRODUCTION: Acute hemopericardium during cardiac electrophysiology (EP) procedures may result in significant blood loss and is the most common cause of procedure-related death. Matched allogeneic blood is often not immediately available. The feasibility and safety of direct autotransfusion in cardiac electrophysiology patients requiring emergency pericardiocentesis is unknown. METHODS: We retrospectively analyzed records of patients undergoing EP procedures at a single, tertiary care medical center who had procedure-related acute hemopericardium requiring emergency pericardiocentesis during a 3-year period. Procedure details, transfusion volumes, and clinical outcomes of patients who received direct autotransfusion of aspirated pericardial blood via a femoral venous sheath were compared to those of patients who did not receive direct autotransfusion. RESULTS: During the study period, 10 patients received direct autotransfusion (group 1) and outcomes were compared with those of 14 control patients who did not receive direct autotransfusion (group 2). The volume of aspirated pericardial blood was similar in groups 1 and 2 (1.6 ± 0.7 L vs 1.3 ± 1.0 L, respectively; P = .52). Amongst patients with aspirated volumes <1 L, group 1 patients (n = 4) were less likely than group 2 patients (n = 8) to require allotransfusion (0% vs 75%, P = .02). Amongst patients with aspirated volume ≥1 L, group 1 patients (n = 6) required fewer units of red cell allotransfusion than group 2 patients (n = 6) (1.5 ± 0.8 units vs 4.3 ± 2.0 units, P = .01). No procedural complications related to direct autotransfusion occurred. CONCLUSIONS: Direct autotransfusion following emergency pericardiocentesis during electrophysiology procedures requiring systemic anticoagulation is feasible and safe. The utilization of direct autotransfusion may eliminate or reduce the need for allotransfusion.

Troubleshooting for epileptiform activity during percutaneous transvenous mitral commisurotomy.

Percutaneous transvenous mitral commisurotomy (PTMC) is a frequently used minimally invasive procedure for patients with symptomatic mitral stenosis. However, it is not without complications. Few complications which are distinctive to the procedure are thromboembolism, left-to-right shunts, mitral regurgitation, cardiac tamponade and complete heart block. We present the case of a 32-year-old female patient scheduled for a PTMC, who had multiple complications during the procedure. She developed cardiac tamponade for which pericardiocentesis and autotransfusion was done. Subsequently she exhibited epileptiform activity for which there was a diagnostic dilemma due to the presence of multiple confounding factors. However, she had a complete recovery without any residual sequelae at the time of discharge.

Management of acute cardiac tamponade by direct autologous blood transfusion in interventional electrophysiology.

AIMS: Acute cardiac tamponade (ACT) is the most common life-threatening complication of interventional electrophysiology. Urgent drainage by percutaneous pericardiocentesis and anticoagulation reversal are required. Immediate direct transfusion of the blood volume aspirated from the pericardial space to the patient has been rarely described. This study was designed to assess the efficacy and safety of immediate direct autologous blood transfusion (AutoBT). METHODS: A retrospective case series of direct AutoBT performed for ACT was collected. Urgent drainage by percutaneous pericardiocentesis and immediate direct AutoBT were performed to achieve hemodynamic stabilization without a cell-saver system. RESULTS: Twenty-two electrophysiology centers were contacted to participate in the case series. Fourteen centers reported not to use direct AutoBT. Three centers reported using direct AutoBT with the cell-saver system. Fourteen cases of immediate direct AutoBT without cell-saver system were included from the five remaining centers. Electrophysiological procedures were performed for ventricular tachycardia (n = 5), atrial fibrillation (n = 5), atrial tachycardia (n = 2), left accessory pathway (n = 1), and premature ventricular contraction (n = 1) with transseptal (n = 9), retroaortic (n = 4), and/or epicardial access (n = 4). Pericardial drainage was performed by percutaneous pericardiocentesis for 13 patients and via the transseptal sheath for one patient. Surgical hemostasis was required for seven patients. The mean volume of autologous blood directly transfused was 1207 ± 963 mL. Direct AutoBT permitted to resume the procedure in four patients. No major complication related to the use of AutoBT occurred. CONCLUSION: Direct AutoBT without a cell-saver system is a feasible, safe, and useful technique for salvage therapy in ACT in interventional electrophysiology.

Autologous blood reinfusion during iatrogenic acute hemorrhagic cardiac tamponade: Safety and feasibility in a cohort of 30 patients.

BACKGROUND: Iatrogenic hemorrhagic pericardial tamponade (IHPT) represents a life-threating condition requiring emergency pericardiocentesis. In this clinical context, reinfusion of pericardial blood can stabilize the patient and sustain hemodynamic conditions. AIMS AND METHODS: We reviewed all cases of IHPT occurred at our hospital over a 10 years span. In all patient autologous blood reinfusion through a femoral vein was performed. RESULTS: In our clinical experience of 30 consecutive patients with hemorrhagic cardiac tamponade, this technique was successful to limit blood transfusions, to prevent further clinical worsening and bridge patients with intractable bleeding, to cardiac surgery. No major adverse reactions were directly related to blood autotransfusion. CONCLUSION: In the complex clinical scenario of acute tamponade occurring during catheter-based cardiac procedures, autotransfusion of pericardial blood through a femoral vein is safe and effective. It can be a useful trick up the sleeve of the interventional cardiologist.

Percutaneous Management of Left Atrial Appendage Perforation: Keep Calm and Think Fast.

Left atrial appendage (LAA) perforation is a possible complication not only after release of the closure device, but also during the diagnostic phase due to sheath positioning in the LAA. We present an 83-year-old woman with permanent atrial fibrillation and high thromboembolic and bleeding risk who was admitted for elective percutaneous LAA closure. During angiographic study, she suddenly became hypotensive. Heart perforation with leakage of contrast in the pericardial space was evident and imaging confirmed cardiac tamponade. Rapid release of the closure device and pericardial evacuation allowed the operators to successfully manage the cardiac tamponade and avoid a surgical option.

Validation of a novel CARTOSEG™ segmentation module software for contrast-enhanced computed tomography-guided radiofrequency ablation in patients with atrial fibrillation.

INTRODUCTION: Visualization of left atrial (LA) anatomy using image integration modules has been associated with decreased radiation exposure and improved procedural outcome when used for guidance of pulmonary vein isolation (PVI) in atrial fibrillation (AF) ablation. We evaluated the CARTOSEG™ CT Segmentation Module (Biosense Webster, Inc.) that offers a new CT-specific semiautomatic reconstruction of the atrial endocardium. METHODS: The CARTOSEG™ CT Segmentation Module software was assessed prospectively in 80 patients undergoing AF ablation. Using preprocedural contrast-enhanced computed tomography (CE-CT), cardiac chambers, coronary sinus (CS), and esophagus were semiautomatically segmented. Segmentation quality was assessed from 1 (poor) to 4 (excellent). The reconstructed structures were registered with the electroanatomic map (EAM). PVI was performed using the registered 3D images. RESULTS: Semiautomatic reconstruction of the heart chambers was successfully performed in all 80 patients with AF. CE-CT DICOM file import, semiautomatic segmentation of cardiac chambers, esophagus, and CS was performed in 185 ± 105, 18 ± 5, 119 ± 47, and 69 ± 19 seconds, respectively. Average segmentation quality was 3.9 ± 0.2, 3.8 ± 0.3, and 3.8 ± 0.2 for LA, esophagus, and CS, respectively. Registration accuracy between the EAM and CE-CT-derived segmentation was 4.2 ± 0.9 mm. Complications consisted of one perforation (1%) which required pericardiocentesis, one increased pericardial effusion treated conservatively (1%), and one early termination of ablation due to thrombus formation on the ablation sheath without TIA/stroke (1%). All targeted PVs (n  =  309) were successfully isolated. CONCLUSIONS: The novel CT- CARTOSEG™ CT Segmentation Module enables a rapid and reliable semiautomatic 3D reconstruction of cardiac chambers and adjacent anatomy, which facilitates successful and safe PVI.

Delayed cardiac tamponade: A rare but life-threatening complication of catheter ablation.

Delayed cardiac tamponade (DCT) is a rare and life-threatening complication of catheter ablation performed as a treatment of atrial fibrillation, with few cases described in the medical literature. We present the case of a 57year-old man presenting with DCT 61days following a catheter ablation procedure. To the best of our knowledge, this is the most delayed case of cardiac tamponade (CT) following catheter ablation described in the literature. We also discuss the importance of point of care ultrasound (POCUS) in the diagnosis and treatment of CT. Emergency physicians must maintain a high index of suspicion in making the diagnosis of CT as patients may present with vague symptoms such as neck or back pain, shortness of breath, fatigue, dizziness, or altered mental status, often without chest pain. Common risk factors for CT include cancer, renal failure, pericarditis, cardiac surgery, myocardial rupture, trauma, and retrograde aortic dissection. In addition, although rare, both catheter ablation and use of anticoagulation carry risks of developing CT. A worldwide survey of medical centers performing catheter ablation found CT as a complication in less than 2% of cases [1]. Some proposed mechanisms of DCT include small pericardial hemorrhages following post-procedural anticoagulation or rupture of the sealed ablation-induced left atrial wall [2]. Clinical examination and electrocardiography may be helpful. However, the criterion standard for diagnosing CT is echocardiography [3].

Pulmonary Vein Isolation for Paroxysmal Atrial Fibrillation Using a Circular Multipolar Ablation Catheter: Safety and Efficacy Using Low-Power Settings.

INTRODUCTION: The circular irrigated decapolar nMARQ ablation catheter designed for treating atrial fibrillation (AF) has recently been recalled following two deaths due to esoatrial fistula. Injury to the esophagus has been previously reported in up to 50% of patients using 20-25 W unipolar radiofrequency (RF) energy. Low power of 15 W has been proposed to prevent this complication, but the efficacy of this strategy to avoid AF recurrence is unknown. METHODS AND RESULTS: Consecutive patients with drug-refractory, symptomatic AF were included. Under electroanatomical navigation, the nMARQ catheter was used to isolate all PVs by applying 15 W of unipolar RF simultaneously from up to 10 poles during 40 seconds. Multiple applications were used for each vein, until isolation was achieved. Follow-up was performed after a 2-month blanking period. A total of 50 patients (37 males, age 58 ± 10 years) were included. All PVs were acutely isolated without requiring touch-up by conventional ablation catheters. Pericardial effusion occurred in two patients, of whom one required periocardiocentesis. Right phrenic nerve palsy occurred in another patient, which partially resolved. There were no cases of esophageal fistula or stroke. After a follow-up of 15 ± 4 months, AF recurred in 27/50 (54%) patients. CONCLUSION: The recurrence rate of AF with 15 W unipolar applications is high. Despite use of low power, complications such as pericardial effusion and phrenic nerve palsy may occur.

Post-infarction myocardial rupture: a case of pericardial tamponade salvaged by auto-blood transfusion.

Left ventricular free-wall rupture (LVFWR) is a serious and lethal complication of acute myocardial infarction. Although this complication is not common, the fatality rate is high due to haemodynamic collapse in the setting of cardiac tamponade. We report a case of LVFWR in a patient with a rare blood group, who survived because of an innovative technique for pericardiocentesis and simultaneous transfusion of the aspirated blood into the femoral sheath. A video of the patient's ventriculography is provided.

Pericardial breast cancer metastasis 25 years after mastectomy.

Pericardial effusion in a patient with a history of cancer should always prompt a hypothesis of malignant involvement. We report the case of a 66-year-old white woman presenting with pericardial effusion 25 years after a mastectomy for ductal breast carcinoma. This is one of the cases with the latest recurrence ever reported.

Staphylococcus aureus Pericardial Abscess Presenting as Severe Sepsis and Septic Shock After Acupuncture Therapy

Pericardial abscess is an extremely rare complication of Staphylococcus aureus bacteremia. We report a case of a 72-year-old woman with multiple acupuncture scars on both knees who presented with shortness of breath and general weakness. Transthoracic echocardiography and pericardiocentesis confirmed the presence of pericardial fluid collection. Staphylococcus aureus grew in both pericardial fluid and blood. Although an aggressive medical treatment including intravenous antibiotics and percutaneous drainage, the patient died 2 days after admission.

Hemopericardium following acupuncture.

Acupuncture-related hemopericardium is a rare but potentially fatal complication. We describe a hemopericardium that occurred shortly after acupuncture in a 55-year-old woman. A chest CT scan and echocardiography revealed a hemopericardium, and pericardiocentesis was then immediately and successfully performed. Subsequently, her clinical course improved. This case increases the attention of emergency physicians for acupuncture-related complications, especially hemopericardium, and the necessity of rapid diagnosis and management.

Cardiac Tamponade Caused by Epigastric Acupuncture: A Case Report / 대한구급학회지

Acupuncture is considered a relatively safe procedure. However, there are serious adverse effects; neurological damage, pneumothorax, cardiac tamponade, serum hepatitis, bacterial and viral infections may occur. Cardiac tamponade is considered to be a rare adverse effect of acupuncture. In the following case, cardiac tamponade was caused by epigastric acupuncture. A 78-year-old male was admitted with a chief complaint of drowsy mentality and hypotension, suggesting a status of shock. He had received acupuncture therapy over epigastric area for gastric dyspepsia at a local oriental medical clinic. An abdominal CT scan and chest x-ray showed a hemopericardium. After receiving pericardiocentesis, his clinical condition improved immediately. He was short in stature and slender for his age. Chest x-ray and computed tomography showed cardiomegaly and pectus excavatum. A proper use of acupuncture by a skilled medical provider is essential to avoid serious complications.

Hemopericardium Following Acupuncture

Acupuncture-related hemopericardium is a rare but potentially fatal complication. We describe a hemopericardium that occurred shortly after acupuncture in a 55-year-old woman. A chest CT scan and echocardiography revealed a hemopericardium, and pericardiocentesis was then immediately and successfully performed. Subsequently, her clinical course improved. This case increases the attention of emergency physicians for acupuncture-related complications, especially hemopericardium, and the necessity of rapid diagnosis and management.

Hemopericardium Following Acupuncture

Acupuncture-related hemopericardium is a rare but potentially fatal complication. We describe a hemopericardium that occurred shortly after acupuncture in a 55-year-old woman. A chest CT scan and echocardiography revealed a hemopericardium, and pericardiocentesis was then immediately and successfully performed. Subsequently, her clinical course improved. This case increases the attention of emergency physicians for acupuncture-related complications, especially hemopericardium, and the necessity of rapid diagnosis and management.

Management and clinical outcomes of acute cardiac tamponade complicating electrophysiologic procedures: a single-center case series.

BACKGROUND: Cardiac perforation with tamponade is an infrequent occurrence during an electrophysiologic procedure. The customary approach to management includes volume resuscitation followed by pericardiocentesis. Such a procedure, however, is not without its own risk, especially when performed emergently. We hypothesized that some patients experiencing this type of complication can be managed successfully in a conservative fashion, without the need for an additional invasive procedure. METHODS: We retrospectively analyzed the clinical outcomes and echocardiographic features of 33 consecutive patients who experienced this complication during cardiac electrophysiology (EP) procedures performed at our institution from 1988 to 2007. Nineteen patients (58%) were managed conservatively with intravenous fluids and vasopressors (Group A). Fourteen patients (42%) were managed invasively with pericardiocentesis (Group B). RESULTS: The mean systolic blood pressure at diagnosis did not differ between the two groups (64 vs 71 mmHg, P = 0.134). The mean lengths of hospitalization (4.7 vs 4.9 days, P = 0.75) and survival to hospital discharge (100% in both groups) were also similar. A large pericardial effusion (>or=2 cm) was seen predominantly among Group B patients. There was a statistically significant temporal trend toward managing this type of complication invasively (P = 0.038). CONCLUSION: Among patients who experience cardiac perforation as an acute complication of EP procedure, there appears to be a role for conservative management in a subset of patients who do not have echocardiographic evidence of a large effusion and who respond well to initial stabilizing measures consisting of fluids and vasopressors.

Use of an autologous blood recovery system during emergency pericardiocentesis in the electrophysiology laboratory.

INTRODUCTION: Emergency pericardiocentesis during electrophysiology procedures is often associated with significant aspiration of pericardial blood, requiring transfusion. We sought to assess the feasibility of urgent use of an autologous blood recovery system in the electrophysiology laboratory to autotransfuse blood aspirated from the pericardium. METHODS AND RESULTS: We retrospectively analyzed Mayo Clinic electrophysiology records for patients who had ablation procedure-related pericardial effusions requiring emergency pericardial drainage during an 8-month period. An autologous blood recovery system was used during pericardiocentesis to separate and clean packed red blood cells from the pericardial aspirate. These cells were returned acutely to the patient intravenously. The procedural safety, aspirated and autotransfused volumes, and efficacy of this approach were evaluated. During the study period, nine patients underwent pericardial drainage with autotransfusion using a cell-salvage instrument during electrophysiology procedures. The mean aspirated volume was 1,078 mL, with a mean autotransfused volume of 390 mL. For four patients, all with aspirated volumes of 1,100 mL or less, autotransfusion alone was sufficient to maintain hemodynamic stability and avoid allogeneic transfusion. One patient required surgical intervention because of ongoing pericardial bleeding. The ablation procedure was completed after aspiration in two patients. No procedural complications related to the use of the cell-salvage system occurred. CONCLUSION: Autologous blood recovery during pericardiocentesis is safe, convenient, and feasible. With early use it may decrease or eliminate the need for allogeneic blood transfusion and, in selected cases, may permit completion of the ablation procedure.