Giant pericardial thrombus and cardiac tamponade

Abstract

A 74-year-old man with no previous cardiovascular history was admitted to our intensive care unit because of anterior ST-elevation myocardial infarction. Coronary angiography showed two severe stenoses in the left anterior descending artery, which were successfully treated with two-stent implantation. As complication, the patient presented post-myocardial infarction pericarditis. Pre-discharge transthoracic echocardiogram showed no abnormal findings and the patient was treated with high doses of acetylsalicylic acid. A month later, the patient attended to the emergency room because of sudden syncope. Physical examination showed tachycardia, hypotension, and paradoxical pulse. A transthoracic echocardiogram was performed revealing severe pericardial effusion and a large mass in the pericardial space at the level of the right atrioventricular groove causing severe compression and collapse of right heart chambers (Panels A and B, white arrows; see Supplementary data online, Videos S1 and S2). Doppler echocardiography reported large respiratory variations in both transtricuspid and transmitral inflow (Panels C and D) and the absence of A-wave on the transtricuspid spectral Doppler strip, suggestive of severe right atrium compression resulting in a very small right atrial stroke volume (Panel C). Dilated inferior vena cava was noticed (Panel E). Chest computed tomography confirmed the presence of a 6 × 3 cm low attenuation mass in the pericardial sac (Panel F). The patient underwent emergency cardiac surgery and a large organized thrombus attached to the right chambers was found, which was removed. Ventricular free wall rupture was not detected. The patient had satisfactory post-operative outcome.