This patient had hemorrhagic cardiac tamponade as a complication of her recent aortic valve procedure. Patients with her degree of instability should have immediate pericardiocentesis in the emergency department, preferably but not necessarily guided by ultrasonography. This patient initially responded to pericardiocentesis, allowing further workup, which showed a 1.5-cm rupture of the ventricular wall. Despite repeated catheter drainage, her condition rapidly deteriorated and precluded surgical repair; she expired shortly after hospital admission.
Cardiac tamponade is accumulation of blood in the pericardial sac of sufficient volume and pressure to impair cardiac filling. Patients typically have hypotension, muffled heart tones, and distended neck veins. Diagnosis is made clinically and often with bedside echocardiography. Treatment is immediate pericardiocentesis or pericardiotomy.
Fluid in the pericardial sac can impair cardiac filling, leading to low cardiac output and sometimes shock and death. If fluid accumulates slowly (eg, due to chronic inflammation), the pericardium can stretch to accommodate up to 1 to 1.5 L of fluid before cardiac output is compromised. However, with rapid fluid accumulation, as occurs with traumatic hemorrhage, as little as 150 mL may cause tamponade.
See Cardiac Tamponade in The Manuals.