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Logo of thijTexas Heart Institute JournalSee also Cardiovascular Diseases Journal in PMCSubscribeSubmissionsTHI Journal Website
 
Tex Heart Inst J. 2009; 36(1): 58–60.
PMCID: PMC2676533

Cardiac Tamponade as a Sequela to Ventriculoatrial Shunting for Congenital Hydrocephalus

Abstract

Cardiac tamponade is a life-threatening condition that demands prompt diagnosis and emergency intervention to prevent the sequelae of persistent low cardiac output, cardiopulmonary failure, and death. Cardiac tamponade due to pericardial collection of cerebrospinal fluid is a rare but recognized sequela associated with ventriculoatrial shunts used in the management of congenital hydrocephalus.

Herein, we describe the treatment of an 8-month-old infant with multiple congenital anomalies who presented with cardiac tamponade. This condition was caused by cardiac perforation by the distal tip of a ventriculoatrial shunt catheter. Timely pericardiostomy and repair of the cardiac perforation through a left anterior thoracotomy resulted in an uneventful recovery.

Key words: Cardiac tamponade/diagnosis/etiology/surgery, cerebrospinal fluid shunts/adverse effects, hydrocephalus/surgery, thoracotomy, left anterior, pericardial effusion/diagnosis/etiology/surgery, pericardiostomy

Cardiac tamponade is a hemodynamically significant cardiac compression caused by the accumulation of pericardial contents that evoke and defeat compensatory mechanisms.1 Up to one quarter of cases of pericardial effusions are eventually complicated by cardiac tamponade,2 which is usually associated with a crisis of diminishing venous return and impaired diastolic ventricular filling. If unresolved, cardiac tamponade leads to low cardiac output, cardiac arrest, and death.

Pericardial effusions can be caused by a variety of conditions, such as malignancies, tuberculosis, bacterial and viral infections, and idiopathic causes; they can also occur after cardiac surgery and chest and upper abdominal trauma.3–5 Symptomatic effusions after intravenous device insertion have been described.6,7 These consist mainly of bloody intrapericardial collections due to catheter-tip perforation of the right atrium or right ventricle. Herein, we describe an unusual case of cardiac tamponade due to a massive cerebrospinal-fluid pericardial effusion after ventriculoatrial shunt insertion in an infant who had multiple cardiovascular, neurologic, and vertebral anomalies.

Case Report

In April 2007, an 8-month-old infant was referred to us after the acute onset of severe dyspnea at rest and respiratory distress. She had no history of fever, cough, or chest trauma. She was a full-term child who had been born with congenital hydrocephalus in association with aqueductal stenosis, lumbosacral myelomeningocele with paraplegia, patent ductus arteriosus, and pectus excavatum. She had undergone ventriculoatrial shunt insertion at the age of 2 months, and patent ductus ligation through a left lateral thoracotomy at the age of 6 months.

Physical examination at the current admission showed an acutely ill infant in severe respiratory distress, with tachycardia, prominent jugular vein distention, and muffled heart sounds. The head circumference was normal. Pulse oximetry at room temperature indicated 88% to 92% oxygen saturation. Emergency chest radiography showed an enlarged cardiac silhouette, clear lung fields (Fig. 1), and the known anomalies of the sternum and rib cage. Transthoracic echocardiography indicated cardiac tamponade with massive pericardial effusion and diastolic collapse of the right atrium and the right ventricle. The intracardiac distal ventriculoatrial catheter could not be seen on echocardiography; therefore, a computed tomographic scan of the chest was obtained, which revealed the pericardial effusion and the extracardiac location of the catheter tip (Fig. 2).

figure 13FF1
Fig. 1 Chest radiograph shows the severe chest wall asymmetry and the massively enlarged cardiac silhouette.
figure 13FF2
Fig. 2 Computed tomographic scan at the level of the diaphragm shows the intracardiac distal ventriculoatrial shunt catheter (white arrow) and pericardial effusion (black arrow). Shown also are the bifid spinal vertebrae and the chest wall asymmetry.

After unsuccessful pericardiocentesis (due to the patient's severe chest wall deformities), emergency pericardiostomy was performed through a left anterior thoracotomy. The initial operative finding was 200 mL of clear fluid in the pericardial cavity; this fluid was sent for chemical and bacteriologic studies. We also found the source of the clear fluid: a fibrotic puncture wound on the free wall of the right ventricle caused by the distal tip of the patent ventriculoatrial shunt catheter, which was protruding into the pericardial cavity. After the fluid was drained, the tip of the catheter was trimmed and was returned to the right ventricle. The hole in the ventricular wall was repaired with Prolene sutures. The infant recovered uneventfully and was discharged from the hospital on postoperative day 4. Follow-up chest computed tomography showed resolution of the pericardial effusion and an appropriate intraventricular catheter tip location. The child's last follow-up visit was in April 2008. The shunt was functioning normally. There were no cardiovascular problems, and no repeat effusion was seen on echocardiography.

Discussion

Cardiac tamponade is a life-threatening condition that demands prompt diagnosis as well as emergency intervention to prevent the sequelae of persistent low cardiac output, cardiopulmonary failure, and death. Several unusual causes of pericardial effusion and cardiac tamponade have been described6,8–11; such cases require emergency-room physicians to have a comprehensive knowledge of both the common and the rare causes of pericardial collections in order to provide expeditious treatment to the patient.

We approached this pericardial effusion through a left anterior thoracotomy because of the severe pectus excavatum and because of a suspected catheter-induced cardiac perforation. This approach gave us access to the right ventricle so that we could repair the perforation. The distal catheter had slowly eroded the free wall of the right ventricle, as evidenced by fibrosis around the perforation. This gradual erosion and fibrosis of the surrounding right ventricular wall may explain the absence of blood in the effusion, contrary to what would be expected from a cardiac perforation.

Cardiac perforation is a recognized complication of intracardiac devices. Due to this and other severe and life-threatening infectious and thrombotic complications of ventriculoatrial shunts, many neurosurgeons now avoid the ventriculoatrial route and use it only after failed ventriculoperitoneal shunting.12

Footnotes

Address for reprints: Uvie Onakpoya, MD, FWACS, Cardiothoracic Surgery Unit, Department of Surgery, Obafemi Awolowo University Teaching Hospital, Ilesa Road, P.O. Box 5538, Il-Ife 220001, Osun State, Nigeria. E-mail: moc.oohay@niyotvu

References

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Articles from Texas Heart Institute Journal are provided here courtesy of Texas Heart Institute