Acute Marginal Artery Laceration as a Complication of Pericardiocentesis.

The safety of pericardiocentesis as a therapy for cardiac tamponade has improved since the advent of echocardiography-guided pericardiocentesis. The most life-threatening, albeit rare, complication is injury to the coronary vessels or ventricular wall resulting in recurrent tamponade. We present a rare case of acute marginal artery laceration resulting from pericardiocentesis. (Level of Difficulty: Beginner.).

A Rare Case of an Ectopic Liver Presenting as Right Atrial Mass.

Ectopic liver tissue is commonly observed in the abdominal cavity in adjacent organs. Extension of hepatic tissue into the intrathoracic cavity is rarely reported. We present the case of a 46-year-old woman with a 2.1 × 1.8 cm mass confirmed by transesophageal echocardiogram to be at the right atrial and inferior vena cava junction that was initially thought to be a myxoma which prompted surgical excision but subsequently identified as ectopic liver by histology.

A rare case of simultaneous pulmonary and paradoxical emboli with a thrombus straddling a patent foramen ovale.

BACKGROUND: Paradoxical embolism is a rare event and the exact contribution of patent foramen ovale in stroke is unclear. Intracardiac thrombi or 'embolus-in-transit' are associated with high mortality. Acutely elevated pulmonary arterial pressure due to pulmonary embolism or Valsalva maneuver make foramen ovale patent and promote right to left migration of intraatrial clot. A large thrombus trapped during its passage produces impending paradoxical embolism, which though proposed, is documented very rarely in live patients. This is a high-risk situation. Surgical embolectomy, like our case, has shown to have better outcomes in overall patient survival. CASE: A 66-year-old female with acute left main cerebral artery infarct and acute bilateral pulmonary embolism. In initial assessment, lower extremities venous Doppler study revealed left leg deep venous thrombosis and transthoracic echocardiogram showed a long biatrial clot straddling through patent foramen ovale and a right-to-left interatrial shunt. After heparinization and inferior vena caval filter placement, she underwent successful surgical embolectomy along with closure of patent foramen ovale with subsequent uneventful recovery. CONCLUSION: 'Embolus in transit' is a high-risk situation and should be actively searched for in patients of pulmonary embolism and stroke. We recommend surgical embolectomy over other treatment modalities in such situations.

Postoperative cardiac tamponade in the modern surgical era.

BACKGROUND: Pericardial effusions resulting in cardiac tamponade (CT) are uncommon after open heart surgery (OHS) and are associated with significant morbidity and mortality. Characteristics and outcomes of patients who develop postoperative CT are poorly defined. Our objective was to further analyze the population at risk for developing postoperative CT, identify potential perioperative and surgical risk factors, and evaluate the impact of CT on patient outcomes. METHODS: A retrospective analysis of 4,561 consecutive patients undergoing OHS at our institution was performed. Patients with clinical suspicion of pericardial effusion following surgery were evaluated by transthoracic or transesophageal echocardiography, and clinical parameters were analyzed. RESULTS: Forty-eight (1%) of the 4,561 patients were found to have echocardiographic evidence of a moderate or large pericardial effusion, of whom 36 (74%) had evidence of CT. The mean age of the patients with CT was 61 years. Coronary artery bypass grafting (CABG) had been performed in 24% of these patients, valve +/- CABG in 73%, and other OHS procedures in 3%. The incidence of CT following CABG alone was 0.2%, whereas it was 0.6% after valve +/- CABG. Females had a higher risk for developing CT, and this occurred earlier in the postoperative period when compared with men. Aspirin, heparin, or warfarin were given to 84% of patients within 3 days of surgery. Mean time to diagnosis of CT was 10 +/- 1 days after OHS. Prior to diagnosis of CT, the maximum international normalized ratio (INR) and partial thromboplastin time (PTT) were 2.7 +/- 0.3 and 68 +/- 5 seconds, respectively. Forty-nine percent of pericardial effusions were posterior and 46% were circumferential; one-third of the effusions were considered large by echocardiography. There was one in-hospital cardiovascular death. CONCLUSIONS: CT after OHS is more common following valve surgery than CABG alone and may be related to the preoperative use of anticoagulants. Females appear to be at higher risk for developing early postoperative CT. When diagnosed and treated promptly, postoperative CT should not significantly increase mortality.