A case of coagula tamponade 4 years after Bentall procedure

A 76-year-old man was admitted to hospital because of shortness of breath, and a pericardial clot with left ventricular diastolic collapse was detected by echocardiography. Approximately 4 years earlier, the patient had undertaken the Bentall procedure with a bioprosthesis (Freestyle ) because of aortic regurgitation and dilatation of the aortic root. A transthoracic echocardiogram (TTE) obtained 1 year after the operation showed a mild pericardial effusion and no evidence of tamponade. Six months before admission, the patient noticed increased fatigue and shortness of breath. On physical examination, the patient’s blood pressure was 102/68 mmHg, heart rate 80 beats per min, respiratory rate 14 breaths per min, and his temperature was 36.7 C. The breath sounds were clear. An examination of the heart showed no significant murmurs. The arms and legs were warm, with symmetric pulses and no edema. Because the patient had a bioprosthetic valve, anticoagulant therapy was not performed, and activated partial thromboplastin time and prothrombin time were normal. The transthoracic echocardiographic study on admission showed a large localized pericardial clot mass in the postero-lateral region and the inward motion of the left ventricular posterior wall was noted during diastole (i.e., left ventricular diastolic collapse) (Figs. 1 and 2), which are findings consistent with coagula tamponade [1–3]. There were no classical echocardiographic signs of tamponade (i.e., right ventricular diastolic collapse and right atrial collapse) [4, 5]. The patient underwent elective surgery, and the pericardial clot and bloody fluid were removed. Biopsy specimens were taken from the pericardium, and the pericardial biopsy section showed a lymphocyte-rich inflammatory infiltrate. Idiopathic pericarditis was thought to be the cause of slight but continuous oozing into the pericardium, which may produce a localized clot. An echocardiogram obtained after the re-operation showed no re-accumulation of the pericardial effusion. The patient was discharged 21 days after the operation, and has remained stable at home.