A 66-year-old woman was admitted to the hospital for intractable
angina. Her medical history was significant for three episodes of acute
myocardial infarction. She had undergone a triple-vessel coronary
artery bypass, a percutaneous transluminal coronary angioplasty, and an
attempted percutaneous transluminal coronary angioplasty 11 years, 10
months, and 5 months, respectively, prior to this admission.
Soon after admission, a transmyocardial revascularization of the
ischemic area was performed using laser. Perioperatively, she required
insertion of an intra-aortic balloon pump in addition to epinephrine,
norepinephrine, and dobutamine drips for hemodynamic support.
Postoperatively, she was weaned off epinephrine and dobutamine drips on
day 1, she was taken off the ventilator on day 2, and the intra-aortic
balloon pump was removed on day 3; however, she required 8 to 10μ
g/min of norepinephrine drip to maintain a systolic BP of 90 mm
Hg. A chest radiograph on postoperative day (POD) 4 revealed a
large left pleural effusion (Fig 1
) that was confirmed on CT scan (Fig 2
). The patient had clinical signs of cardiac tamponade at this stage
(muffled heart sounds, distended neck veins, and hypotension), but a
two-dimensional echocardiogram revealed only minimal pericardial
effusion. The right ventricle was not well visualized during this
study. Following failed attempt at percutaneous drainage, she was taken
back to the operating room on POD 5, where 2 L of sanguineous effusion
and blood clots were removed via a left thoracotomy.
Postoperatively, she had a rapid and complete reversal of the cardiac
tamponade picture. She was easily taken off the norepinephrine drip
within 2 h and was transferred out of the surgical intensive unit
the next day.