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Cardiac Tamponade ComplicatingProximal Aortic DissectionIs Pericardiocentesis Harmful?

Eric M. Isselbacher, MD; Joaquin E. Cigarroa, MD; Kim A. Eagle, MD, FACC

Background Cardiac tamponade frequently complicatesacute proximal aortic dissection and is one of the mostcommon causes of death from aortic dissection. Well-definedstrategies for the management of acute aortic dissection nowexist; however, little is known about how best to manage thehemopericardium that may complicate it.Methods and Results Using a computer-based review, we

retrospectively identified 10 patients presenting to our hospitalover a 13-year period who were diagnosed with both aorticdissection and cardiac tamponade. All 10 had proximal dissec-tions. Three of the 10 presented as the sudden onset of fatalelectromechanical dissociation, 6 presented with hypotension,and 1 was normotensive on presentation. Of the 7 hypotensiveor normotensive patients diagnosed with cardiac tamponade, 4underwent successful pericardiocentesis while awaiting sur-gery. At time intervals of 5 to 40 minutes after their pericar-diocenteses, 3 of the 4 patients experienced sudden onset ofelectromechanical dissociation and death; the fourth patient

survived and underwent surgical repair. Of the 3 hypotensiveor normotensive patients who had either no pericardiocentesisor an unsuccessful pericardiocentesis, all 3 underwent success-ful surgical repair and survived.

Conclusions In this study, patients with an aortic dissectioncomplicated by cardiac tamponade have an early mortality of60%. While 3 of the 10 died from electromechanical dissocia-tion immediately upon presentation, the 3 other deaths alloccurred shortly after successful pericardiocentesis, a proce-dure undertaken to stabilize them. While the number ofpatients in this series is small, the observations do raise thepossibility that in patients with cardiac tamponade complicat-ing aortic dissection pericardiocentesis could be harmfulrather than beneficial. Possible mechanisms for why the per-formance of pericardiocentesis might destabilize such patientsare proposed. (Circulation. 1994;90:2375-2378.)Key Words * aorta * tamponade * pericardiocentesis .

pericardium

A cute aortic dissection has an early mortality ashigh as 1% per hour,' with nearly two thirds ofdeaths in cases of proximal dissection resulting

from the extension of the dissection into the aortic rootproducing hemopericardium and cardiac tamponade.2"3Extensive clinical investigation has resulted in a well-defined strategy for prompt treatment of aortic dissec-tion, which has greatly improved survival rates. Despiteadvances in treatment for aortic dissection, little isknown about how best to manage the hemopericardiumthat frequently complicates proximal aortic dissectionand may lead to death.4,5

Since pericardiocentesis is considered the standardtreatment for patients suffering from cardiac tampon-ade, it is not surprising that it has been used as aninterim treatment for patients with cardiac tamponadecomplicating aortic dissection while they await definitivesurgical repair.67 However, some authors have raisedconcerns that performing pericardiocentesis in suchcases may in fact be dangerous-possibly precipitatinghemodynamic collapse and death4-and should there-fore be avoided. To assess the utility and safety ofpericardiocentesis in the management of cardiac tam-ponade complicating aortic dissection, we reviewed the

Received March 9, 1994; revision accepted June 6, 1994.From the Cardiac Unit, Massachusetts General Hospital,

Boston.Correspondence to Kim A. Eagle, MD, FACC, Cardiac Unit,

ACC 469, Massachusetts General Hospital, 15 Parkman St, Bos-ton, MA 02114.0 1994 American Heart Association, Inc.

care and outcome of all patients at our institution whopresented over the past 13 years with this condition.

MethodsWe identified all patients presenting with acute aortic

dissection and suspected or documented cardiac tamponadeadmitted to the Massachusetts General Hospital during theperiod from January 1980 through September 1993. A com-puter-based review of all discharge diagnoses was performedwith the inclusion criteria of (1) the diagnosis of aorticdissection and (2) the diagnosis of cardiac tamponade or theperformance of pericardiocentesis. Demographic information,clinical and hemodynamic data, the performance and results ofdiagnostic studies, and information on each patient's hospitalcourse and in-hospital (early) mortality were collected retro-spectively by review of the medical record.

ResultsA total of 148 patients were identified with the

diagnosis of acute aortic dissection over a 13-yearperiod, and 10 of the patients were also diagnosed ashaving cardiac tamponade. All 10 had proximal aorticdissections that were documented with either aortogra-phy or computed tomographic (CT) scanning. In allcases, the diagnosis of cardiac tamponade was made byeither echocardiography, the finding of equal pressuresat right heart catheterization, opening of the chestduring cardiopulmonary resuscitation, or on postmor-tem examination.The Table provides a summary of the signs, symp-

toms, and findings that suggested the diagnosis ofcardiac tamponade, the time at which cardiac tampon-

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2376 Circulation Vol 90, No 5 November 1994

Summary of Symptoms, Blood Pressure, Management, and Outcomes of the 10 Patients With Cardiac TamponadeComplicating Aortic Dissection

In-hospitalSurvival,

When (Time of DeathTamponade Presence of BP When BP After IV Pericardio- Volume of BP After if After

Case Age, First Tamponade Tamponade Fluid centesis Fluid Pericardio- Pericardio-No. y Sex Presented Suggested by: Presented Resuscitation Attempted Aspirated centesis centesis)

1 57 F 2 Days after Equalization of EMD EMD No ... Diedaorticdissectiondiagnosed*

pressures atright heartcatheterizationfollowed byEMD

2 78 M Postopera- Sudden onsettiveday6 of EMDafter cardiacsurgery

3 52 M 9th Day Sudden onsetafter aortic of EMDdissectiondiagnosed*

4 63 F During Recurrence ofemergency chest painroom followed byevaluation hypotension

5 60 M During Recurrence ofemergency chest painroom followed byevaluation hypotension

6 73 F On arrival to Hypotensionemergencyroom

7 83 M On Hypotensionadmission and

cardiomegalyon chestradiograph

EMD

EMD

EMD

EMD

60/palp 70/palp

80/palp

80/palp

100/60

120/70

80/palp 90/palp

No ... ...

Yes 0 EMD

No

No

Yes 100 mL 170/80

Yes 300 mL 90/palp

8 59 F Onadmission

Hypotension 70/palp

9 61 M 2 Weeks Acute onset ofafter aortic hypotensiondissectionoccurred*

10 65 M On Low cardiacadmission output and high

central venouspressure

100/50

60/palp 165/105

130/80 130/80

Yes 0 100/50 Survived

Yes 1200 mL 170/83 Survived

Yes 250 mL 170/80 Died(40 minutes)

BP indicates blood pressure; EMD, electromechanical dissociation.*After the diagnosis of aortic dissection, surgery was delayed in patient 1 due to a variety of preoperative issues and delayed in patient

3 due to a complicating stroke. In patient 9 (presenting with chest pain), the diagnosis of aortic dissection was unsuspected until 6 daysafter pericardiocentesis (which was itself performed 14 days after the original onset of chest pain).

ade was diagnosed, each patient's presenting bloodpressure and subsequent blood pressure after intrave-nous fluid resuscitation, the results of pericardiocentesis(if performed), and the hospital course. Pericardiocen-tesis, when performed, was done so in an effort toimprove the hemodynamic consequences of cardiactamponade while such patients awaited definitive ther-apy for aortic dissection. A more detailed description ofone patient (patient 10) follows as an illustrative exam-

ple. A 65-year-old man with long-standing hypertensionpresented to an outside hospital with the acute onset oftearing anterior chest pain radiating to his back. Acontrast-enhanced CT scan was negative for aortic

dissection. On the fourth hospital day he developedrecurrent chest pain accompanied by hypotension,briefly requiring vasopressors for hemodynamic sup-

port. A transthoracic echocardiogram was performed,which revealed an intimal flap in the ascending aortaconsistent with aortic dissection together with a largepericardial effusion with signs of cardiac tamponade. Hewas transferred to Massachusetts General Hospital,where aortography (Figure) revealed a type I aorticdissection (involving the innominate and right commoncarotid arteries with total occlusion of the left renalartery) as well as mild aortic insufficiency. It was

believed that his acute renal failure would increase his

Died

Died

... Survived

... ... Survived

Died(5 minutes)

Died(20 minutes)

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Isselbacher et al Cardiac Tamponade Complicating Aortic Dissection 2377

Aortogram in the left oblique view confirming the presence of aproximal aortic dissection. The ascending aorta is dilated, andboth true (T) and false (F) lumens are readily identified. Theintimal flap, seen here as a thin radiolucent line, is found also toextend into the innominate artery.

surgical risk, so before undertaking direct aortic repair,an attempt was made to improve his hemodynamics andrenal perfusion by performing pericardiocentesis. Rightheart catheterization confirmed the presence of cardiactamponade, and at pericardiocentesis, 250 mL of dark,nonclotting blood was removed, producing a promptrise in blood pressure from 130/80 to 170/80 mm Hg(nitroprusside was therefore begun to control this hy-pertension). A pigtail catheter was left in place in thepericardial space. He was transferred to the coronary

care unit, where, upon arrival, he suffered a cardiacarrest with electromechanical dissociation; it was thennoted that the pigtail catheter had begun actively drain-ing bright red blood (different from the darker bloodobserved at pericardiocentesis). Cardiopulmonary re-

suscitation was unsuccessful, and the patient died 40minutes after the pericardiocentesis.As shown in the Table, in 3 of the 10 study patients,

cardiac tamponade presented as the sudden onset offatal electromechanical dissociation; 6 others presentedwith mild to moderate hypotension, and 1 normotensivepatient presented only with jugular venous distention.Of the 6 patients presenting with hypotension, 2 re-mained hypotensive after intravenous fluid resuscita-tion, although both patients had normal mental status.Of the 7 hypotensive or normotesive patients diag-

nosed with cardiac tamponade, 4 underwent successfulpericardiocentesis. At intervals of 5, 20, and 40 minutes,

respectively, after their pericardiocenteses, 3 of the 4patients suffered sudden electromechanical dissociationand death. The fourth suffered no complications beforesuccessful surgical repair (with surgery taking place 6days later due to a late diagnosis of the then unsus-pected aortic dissection). In 1 other patient, pericardi-ocentesis was attempted unsuccessfully, and the patientthen underwent successful surgical repair of the dissec-tion. The final 2 patients with cardiac tamponade werenot subjected to pericardiocentesis but were insteadtaken urgently to the operating room for direct aorticrepair. The decision to take patients directly to surgeryversus first performing pericardiocentesis reflected thepreferences of the individual cardiologist and cardiacsurgeon involved in each case. All 4 patients whounderwent surgical repair of their aortic dissectionssurvived the hospitalization.The mortality among all 10 patients with aortic

dissection complicated by cardiac tamponade was 60%.The mortality among those patients presenting withelectromechanical dissociation was 100% (3 of 3); theearly mortality among those presenting hypotensive ornormotensive was 43% (3 of 7). Of the latter group, theearly mortality for those undergoing successful pericar-diocentesis was 75% (3 of 4), whereas none of thosehaving either no pericardiocentesis or an unsuccessfulpericardiocentesis before surgery died (3 of 3).

DiscussionWhile cardiac tamponade occurs in a minority of

patients suffering acute aortic dissection, it is the mostcommon cause of death among these patients.23 In thepresent study, it is associated with an early mortality of60% in patients surviving long enough to reach thehospital. While 3 of our 10 patients died from electro-mechanical dissociation immediately upon presentationof cardiac tamponade, the other 7 remained stableenough to allow consideration of several therapeuticoptions. The two patients taken directly to the operatingroom for aortic repair did well. However, in 5 otherpatients, efforts to stabilize the patients before surgerythrough pericardiocentesis to relieve cardiac tampon-ade resulted in unexpected death in 3, which may havebeen directly precipitated by successful pericardiocen-tesis. While the number of patients in this study is small,the observations do raise the possibility that pericardi-ocentesis could be harmful rather than beneficial amongpatients with cardiac tamponade complicating aorticdissection.Although pericardiocentesis is safe and effective in

treating cardiac tamponade of other causes, particularaspects of the pathophysiology of aortic dissection com-plicated by hemopericardium could explain the pooroutcomes among the patients we studied. The hemo-pericardium complicating proximal aortic dissection de-velops as a result of blood leaking into the pericardialspace from the false lumen as it dissects back to theaortic root. If such a leak were to become a freecommunication with the aorta, then the marked eleva-tion of intrapericardial pressure would quickly compressthe cardiac chambers and prevent filling, thus resultingin electromechanical dissociation. Pericardiocentesiswould probably be futile in such patients because freecommunication with the false lumen would preventadequate drainage of the pericardial space.

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2378 Circulation Vol 90, No 5 November 1994

Because many patients with hemopericardium com-plicating aortic dissection do not present with electro-mechanical dissociation, it must be that in such cases,the communication between the pericardial space andthe aorta is transient rather than continuous. Themechanisms of the transient nature of such communi-cations are unknown. It may be that the communicationbetween the false lumen closes off due to the intimalflap or local tissues acting as a valve or that thrombusforms in the false lumen or at the site of communicationand closes the leak. The hemodynamic effect fromcardiac tamponade may help reduce the risk of furtherbleeding into the pericardial space through a reductionin cardiac output, aortic pressure, and dP/dT. In effect,the tamponade itself reduces further leakage into thepericardium by reducing the pressure gradient betweenthe false lumen and the pericardial space,48 and per-haps this allows for a tissue valve effect and/or thrombusto seal off the communication. Meanwhile, both the fallin blood pressure and the reduction of dP/dT wouldhelp minimize the chance that the aortic dissectionmight propagate further.Although hemopericardium may stabilize for a brief

time, such stability must be viewed as an extremelytenuous state. Performing pericardiocentesis in thissetting would likely reverse the stabilizing hemodynamicconsequences of cardiac tamponade. An acute rise inblood pressure would increase the pressure gradientbetween the false lumen and the pericardial space,which could dislodge a thrombus and cause a closedcommunication to reopen, with recurrence of bleedingand cardiac tamponade. Furthermore, the acute rise insystemic blood pressure and dP/dT might cause propa-gation of the aortic dissection such that the false lumendissects further retrograde into the aortic root produc-ing free communication with the pericardial space.Such a course of hemodynamic improvement fol-

lowed by acute decompensation after pericardiocentesisis consistent with the events described in the patientdescribed above. A very similar patient was reported byCoplan et al,4 who also performed pericardiocentesis ina patient with cardiac tamponade complicating a prox-imal aortic dissection: After successful pericardiocente-sis, the patient had an acute rise in systemic blood

pressure that was quickly followed by precipitous hypo-tension, electromechanical dissociation, and death.

This retrospective study confirms that cardiac tam-ponade complicating acute aortic dissection is associ-ated with a high early mortality. Prompt treatment iscertainly indicated, but the findings presented heresuggest that performing pericardiocentesis to stabilize ahypotensive patient in this setting may instead precipi-tate hemodynamic collapse and death. When cardiactamponade is discovered in a patient with aortic dissec-tion, it should be considered a surgical emergency, andpericardiocentesis should be avoided while every effortis be made to proceed as urgently as possible to theoperating room for direct repair of the aorta withintraoperative drainage of the hemopericardium. How-ever, if a patient's blood pressure is so low that itcompromises cerebral or vital organ perfusion, theremay simply not be enough time to wait for surgery inorder to save the patient, and in this setting, urgentpericardiocentesis would still be warranted. A prudentstrategy in such a case might be to aspirate only enoughpericardial fluid to raise the patient's blood pressure tothe lowest acceptable level, thereby minimizing thechance of precipitating a rapid increase in blood pres-sure and dP/dT, which could prompt a catastrophicrecurrence of hemorrhage or induce further extensionof the dissection.

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5. Marcus RH, Chua KG, Josephson M, Neumann A, Borrow KM,Lang RM. Vagolytic therapy in acute cardiac tamponade associatedwith aortic dissection. Am Heart J. 1991;121:926-929.

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E M Isselbacher, J E Cigarroa and K A Eagleharmful?

Cardiac tamponade complicating proximal aortic dissection. Is pericardiocentesis

Print ISSN: 0009-7322. Online ISSN: 1524-4539 Copyright © 1994 American Heart Association, Inc. All rights reserved.

is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231Circulation doi: 10.1161/01.CIR.90.5.2375

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