A rare tamponade after percutaneous ablation operation

The mass specimen resected and intraoperative field view.

Central Message.

A rare tamponade caused by malignant tumor.

A 54-year-old woman was admitted to our cardiac surgery intensive care unit complaining of chest oppression, anhelation, and weakness. Initial impressions included New York Heart Association functional class IV and a diminished pulse pressure of 20 mm Hg. She was also diagnosed with a history of hyperlipidemia, fatty liver, and hypertension, but had no family history of tumors or risk factors. Five months ago, she was seen in the cardiology department of another hospital for palpitations. Her body check result was paroxysmal atrial fibrillation (41.8%). Then she underwent a percutaneous mini-maze operation (radiofrequency ablation of bilateral pulmonary veins), resulting in restoration of sinus rhythm and continued anticoagulant therapy with rivaroxaban. However, her chest tightness reappeared and even worsened 4 months postoperatively, as shown in Figure 1. The local doctor offered her some diuretic therapy as well as dexamethasone. But they didn't work very well and she was transferred to our heart center.

Figure 1.

a, b and c, Echocardiogram (ECG) and chest computed tomography (CT) before maze procedure. d and e, ECG and magnetic resonance imaging 4 months after maze procedure. f, CT 1 year after tumor resection. A and C, Cardiac CT angiography of the patient, Cardiac tumors were marked by triangular symbols. As shown in the CT reconstruction images, the tumor originated in the left atrium, expended into the pericardial cavity, invaded the lateral wall of the left ventricle, the epicardium of the left ventricular outflow tract, the right ventricular free wall, and the right ventricular outflow tract, and formed pericardial tamponade. B and D, After emergency surgical treatment, the tumor in the left atrium was removed, and most of the blood clot and mass in the pericardial cavity were removed, but there was still a small amount of tissue invading the pericardium and posterior ventricular wall that could not be removed (triangle symbol). CTA images show unobstructed blood flow signals in the heart. E, As echocardiography showed, cardiac chamber size significant recovered and left ventricular ejection fraction rose to 61.4%. F, Histopathology sections show that the atypical cells grew in sheets, with abundant cytoplasm and many nuclear divisions. Immunohistochemistry showed SMA+, ERG+, SDK4+, MDM2+, and Ki-67 (60%) were existed. The pathologist finally diagnosed the case as high-grade endocardial sarcoma.

An emergency transthoracic echocardiogram (ECG) revealed a large mixed echogenic mass within the pericardial cavity, constricting both ventricular outflow tracts. Additionally, a homogeneous solid mass occupied the left atrium, characterized by a broad pedicle and limited mobility. Despite these findings, her left ventricular ejection fraction remained within the normal range at 61.4%. A subsequent computed tomography angiography scan confirmed these observations (Video 1 and Figure 1). Within 3 hours of admission, successful surgery was performed without complications such as bleeding or cardiac insufficiency. We chose a median thoracotomy incision. The location of the tumor is shown in Figure 1. Older thrombus and tumor tissue were seen near the left atrial appendage. The tumor on the surface of the right ventricle was carefully dissected while her heart was beating. After the heart was paralyzed, the tumor and thrombus were removed and a small rupture on the left atrial roof was noted. The left atrial tumor measured 30 × 40 × 20 mm, with a 2.5-mm gap noted on the roof of the left atrium, potentially attributable to the maze operation. The pericardial mass originated from a left atrial roof rupture and encased both outflow tracts of the heart. The tumor adhesion in the left lung vessels was serious and accompanied by severe calcification. The tumor was not completely removed to avoid uncontrollable bleeding.

The remainder of the therapeutic procedures was unremarkable. Histologic examination revealed that although the left atrial mass resembled a combination of old blood clots and tumor tissue, the epicardial mass appeared more consistent with a malignant tumor (Figure 2). Shockingly, both samples were diagnosed as high-grade differentiated endocardial sarcoma, prompting her transfer to a cancer hospital for further management. One year after surgery, the patient returned to our outpatient service, remarkably surviving her ordeal with tumors (Figure 1).

Figure 2.

The mass specimen resected and intraoperative field view. A, The ovoid mass on the left is in the left atrium. The large amount of thrombus attached to the mass had been completely removed. The mass on the right side was an epicardial attached mass. The texture is fragile, like fish. B, The arrow points to the rupture in the roof of left atrium. C, The arrow points to the suction tube.

The equivalent ethics committee of Guangdong Provincial People's Hospital's Nanhai Hospital approved the study. The institutional review board approval number was 2024104H (March 26, 2024). The patient provided informed written consent for the publication of the study data.

To our knowledge, she represents a rare case of delayed pericardial tamponade secondary to cardiac sarcoma following a maze procedure.¹ Most similar cases are either identified and managed during hospitalization or result in fatalities at home due to perioperative bleeding.^2,3 Her endurance of 5 months of progressive cardiac oppression was fortunate, although her survival with such a rare complication was equally unfortunate. Reviewing her maze procedure records, neither transthoracic nor transesophageal echocardiograms detected any abnormalities before the procedure as well as the chest computed tomography scan (Figure 1). It appeared that tumors rapidly developed alongside atrial rupture and bleeding, leading to delayed cardiac tamponade 5 months after radiofrequency ablation. Although the direct relationship between tumor formation and radiofrequency ablation for atrial fibrillation remains unclear, it was conceivable that this procedure might contribute to tumor development.⁴ Even in the case of definite liquid pericardial tamponade, thoracotomy is still faster, safer, and more effective than pericardiocentesis in qualified heart centers, especially in patients with previous cardiac surgery.

Conflict of Interest Statement

The authors reported no conflicts of interest.

The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.

Supplementary Data

Video 1

CT image 1. Video available at: https://www.jtcvs.org/article/S2666-2507(24)00235-9/fulltext.