Importance of the heart borders as a fluoroscopic clue for cardiac tamponade

Abstract

Every catheter laboratory is equipped with an X-ray system designed to provide fluoroscopic imaging of the heart. Although cardiac catheters are well visualized in all X-ray imaging, the soft tissue of myocardium is not. Therefore the imaging of the cardiac chambers is indirect through relation to the cardiac silhouette. However, fluoroscopy can be used to detect complications from the invasive procedures in the cardiac catheterization laboratory, such as cardiac tamponade where the excursion of the cardiac silhouette decreases, and visceral and parietal pericardium are seen separated by the blood of accumulation in the pericardial cavity. Even if a transthoracic or intracardiac echocardiography guidance is immediately available, early fluoroscopic detection of tamponade should be remembered during the invasive procedures in the cardiac catheterization laboratory.

Every catheter laboratory is equipped with an X-ray system designed to provide fluoroscopic imaging of the heart. Although cardiac catheters are well visualized in all X-ray imaging, the soft tissue of myocardium is not. However, fluoroscopy can be used to detect complications from the procedure in the cardiac catheterization laboratory, such as cardiac tamponade where the excursion of the cardiac silhouette decreases before the development of any clinical compromise in the patient.1 A 58-year-old woman with a history of two stenting in RCA due to acute inferior myocardial infarction in 2007 was consulted to the cardiology for chest pain, altered mental status and hypotension during dialysis. Electrocardiography revealed a normal rhythm with evidence of a re-inferior MI. Emergency coronary angiography showed that two coronary stents in RCA were totally occluded, and but also we noticed that the visceral and parietal pericardium was separated by the blood of accumulation in the pericardial cavity suggesting large pericardial effusion (Fig. 1). However, asystolic cardiac arrest developed during the coronary angiography. Emergency bedside transthoracic echocardiography confirmed the pericardial tamponade and prompt pericardiosentesis was performed successfully during the cardiopulmonary resuscitation, but the primary percutanous coronary intervention for RCA with ongoing CPR failed due to the inability to cross the long instent occlusion with guidewires. Finally hemodynamic stability was not maintained, and she died despite aggressive CPR. Even if a transthoracic echocardiography guidance is immediately available, early fluoroscopic detection of tamponade should be remembered during the invasive procedures in the cardiac catheterization laboratory.2 Fluoroscopic reduction in the excursion of cardiac silhouette on fluoroscopy is an early diagnostic sign of cardiac tamponade during invasive cardiac catheterization procedures and can be used to detect impending pericardial tamponade before hemodynamic collapse.2 This image highlights the diagnostic value of looking at heart border movement during routine coronary angiography.

Fig. 1.

Fuoroscopic image showing the occluded stents in right coronary artery, and also revealing the visceral and parietal pericardium (arrows indication) was separated by the blood of accumulation in the pericardial cavity.

Conflicts of interest

The authors have none to declare.