Left atrial tamponade. Report of a case after right heart catheterization.

Left atrial tamponade after right heart catheterization is described. It was associated with a low cardiac output but without signs ofgeneralized cardiac tamponade. Failure to remove the cause of obstruction resulted in irreversible cerebral damage. Left atrial tamponade after heart operations has been described by Yacoub, Cleland, and Deal (I966). They reported 2 patients whose condition deteriorated suddenly some hours after operation, with signs of a low cardiac output but without evidence of generalized cardiac tamponade. After thoracotomy a clot was evacuated from behind the left atrium with rapid recovery in one patient but without effect in the other. In the patient to be described, myocardial perforation occurred during cardiac catheterization and resulted in left atrial tamponade. Though full myo-cardial recovery was achieved, cerebral damage was irreversible. Clinical history An obese man aged 58, who was known to be hyperten-sive and in atrial fibrillation before operation, had a left meniscectomy performed under general anaesthesia in November I970. Six days after operation he developed a painful, swollen, and tender left calf. Ascending veno-graphy showed a deep vein thrombosis extending into the left popliteal vein. Twenty-four hours later the patient complained of left-sided pleuritic chest pain associated with diminished breath sounds on that side, but without radiological changes. The patient was ill, but his blood pressure remained at i8o/Ioo mmHg without gallop rhythm or an increase of the jugular venous pressure. A tentative diagnosis of pulmonary embolism was made. At right heart catheterization for pulmonary angio-graphy, a No. 8 NIH angiocatheter was passed into the heart via a left antebrachial vein with difficulty due to venospasm. While attempting to pass the catheter into the main pulmonary artery, the right ventricular trace changed to a lower pressure. Injection of o 5 ml 65 per cent Hypaque showed contrast in the pericardial sac. The catheter was withdrawn. Five minutes later, the patient complained of severe pain between the shoulder blades after which he vomited. He became shocked, with profuse sweating. The radial pulses were absent and the left carotid and subclavian pulses were reduced but both femoral pulses were palpable. The cardiac silhouette was not enlarged by comparison with chest x-rays taken at the beginning of the procedure, nor had the electrocardiogram changed. After I5 minutes the jugular venous pressure rose, at which time only 50 ml bloodstained fluid could be aspirated by sub-xiphister-nal pericardial tap. The patient continued to deteriorate and asystole occurred. …