Intra-pericardial thrombin injection in iatrogenic cardiac tamponade: a case report

Juana Perez Morales, Ana Spaccavento, Santiago Ordoñez, Rocío Baro, Diego Conde, Juan Pablo Costabel
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Abstract

Nowadays, percutaneous procedures are expanding in use, and this comes with complications associated with the procedure itself. Cardiac tamponade is rare but may be life threatening since it can involve hemodynamic instability. It is known that after pleural effusion during a percutaneous procedure, pericardiocentesis should be used as drainage of the cavity. However, that does not achieve hemostasis in some cases, and in those patients who are hemodynamically unstable, a sealing agent to promote hemostasis might be useful, like thrombin. We present a case report of 89-year-old patient with history of melanoma undergoing treatment with pembrolizumab, who attended the emergency department referring chest pain (intensity 5/10) and palpitations that have lasted hours. He had TnTUs 554/566 ng/L and an echocardiogram that showed dilated right chambers, hypertrophy and global hypokinesia of the left ventricle, increased filling pressures of the left ventricle and pulmonary hypertension. Myocarditis associated with pembrolizumab was suspected, so high dose steroids were initiated and endomyocardial biopsy was conducted, resulting in iatrogenic cardiac tamponade. To determine the etiology of the suspected myocarditis, an endomyocardial biopsy was performed. Unfortunately, an intraprocedural complication arose: pleural effusion resulting in iatrogenic cardiac tamponade, leading to hemodynamic instability. It required immediate pericardial drainage via subxiphoid puncture, obtaining a 550 mL hematic debit. Clinical manifestations raised suspicion of tamponade, prompting a bedside echocardiogram for a definitive diagnosis. Despite these efforts, the patient remained hemodynamically unstable, and due to the elevated surgical risk, intrapericardial thrombin was employed to achieve successful hemostasis. Cardiac tamponade is a life-threatening condition that can sometimes be induced iatrogenically, resulting from percutaneous interventions. Despite limited evidence regarding this therapeutic strategy, in patients experiencing iatrogenic cardiac tamponade with hemodynamic instability and high surgical risk, the administration of intra-pericardial thrombin could be contemplated.
心包内注射凝血酶治疗先天性心脏填塞:一份病例报告
如今,经皮手术的使用范围不断扩大,同时也带来了与手术本身相关的并发症。心脏填塞虽然罕见,但可能危及生命,因为它会导致血流动力学不稳定。众所周知,在经皮手术过程中出现胸腔积液后,应采用心包穿刺术作为腔内引流。然而,在某些情况下这并不能达到止血的目的,对于那些血流动力学不稳定的患者来说,一种促进止血的封闭剂(如凝血酶)可能是有用的。我们报告了一例 89 岁患者的病例,该患者有黑色素瘤病史,正在接受 pembrolizumab 治疗。他的 TnTU 值为 554/566 纳克/升,超声心动图显示右心室扩张、左心室肥大和整体运动减弱、左心室充盈压升高和肺动脉高压。怀疑心肌炎与彭博利珠单抗有关,因此开始使用大剂量类固醇,并进行了心内膜活检,结果导致先天性心脏填塞。为了确定疑似心肌炎的病因,进行了心内膜活检。不幸的是,手术中出现了并发症:胸腔积液造成先天性心脏填塞,导致血流动力学不稳定。需要立即通过剑突下穿刺进行心包引流,获得550毫升的血液。临床表现引起了对心脏填塞的怀疑,因此需要进行床旁超声心动图检查以明确诊断。尽管做了这些努力,但患者的血流动力学仍然不稳定,由于手术风险较高,为了成功止血,患者使用了心包内凝血酶。心脏填塞是一种危及生命的病症,有时可因经皮介入治疗而诱发。尽管有关这种治疗策略的证据有限,但对于血流动力学不稳定、手术风险高的先天性心脏填塞患者,可以考虑使用心包内凝血酶。
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