Cardiac tamponade from compression of the pulmonary arterial outflow graft of a biventricular assist device.

A 19-year-old patient with a Thoratec Paracorporeal Biventricular Assist Device implanted 15 weeks previously complained of discomfort in his back and chest area, lightheadedness, and diaphoresis, and was noted to have a blood pressure of 62/26 mm Hg. Device alarms sounded for both the left and right ventricular assist devices indicating that the paracorporeal pumps were not filling normally. An ECG showed sinus tachycardia with low voltage (Figure 1). A portable chest radiograph showed enlargement of the cardiac silhouette, loss of the left hemidiaphragmatic contour, and mild left midlung atelectasis (Figure 2). Transthoracic and transesophageal echocardiography showed a large pericardial hematoma with compression of the right ventricle and diastolic compression of the pulmonary arterial outflow graft (Figure 3 and Movies I and II in the online-only Data Supplement). The aortic outflow graft and the right atrium did not appear to be compressed. Computed tomographic scanning confirmed the extent of the pericardial hematoma and demonstrated a mass effect on the right ventricle (Figure 4). After minimal response to fluid boluses and an increased pressor requirement, the patient was taken to surgery and the hematoma was evacuated. The cause of the hematoma was determined intraoperatively to be a small perforation, of unclear origin, in the left ventricular outflow graft. The perforation was closed surgically. Postoperative transesophageal echocardiography showed a small, residual circumferential pericardial effusion without any compression of the outflow grafts (Figure 5 and Movies III and IV in the online-only Data Supplement). The patient’s hemodynamics improved significantly.