Postcardiac Surgery Tamponade: Should We Rely on Classical Signs?

fresh frozen plasma units and platelets per institutional protocol.Subsequently, over the next 2 hours, her MAP further reduced to <50 mm Hg.Her MAP increased with fluid administration, with a rise in CVP up to 16 mm Hg.However, this was transient, and her MAP and CVP again decreased.Immediately, bedside transthoracic echocardiography was performed.ECG gating was unavailable due to technical limitations, and the echo windows were also limited.The parasternal short axis view demonstrated a normal shape of the LV throughout the cardiac cycle, making the possibility of pulmonary hypertension as the cause of hypotension less likely.The apical four-chamber view demonstrated normal filling of the left and right ventricles during diastole, but the atria were not well-visualized as they were in the far field.Color Doppler across the prosthetic mitral and aortic valves revealed normal flow.At the same time, color Doppler across the right ventricle (RV) inflow showed turbulence which was not present in the immediate postbypass period IntroductIonPericardial effusion leading to tamponade is one of the most common complications after cardiac surgery, with an incidence of 0.5-8.8%. 1 The diagnosis of tamponade mainly relies on clinical and echocardiography signs.The clinical signs are low volume pulse, high central venous pressure (CVP), and muffled heart sound (Beck's triad); echocardiography signs are right ventricular diastolic collapse, right atrial systolic collapse, a swinging heart, and enlarged nonpulsatile inferior vena cava.Many clinical and echocardiographic features depend on the equal pressure distribution in all chambers with an intact pericardium, global effusion, intact ventricular function, and absence of pulmonary hypertension.1 Most of these are not satisfied in postcardiac surgery and confound the clinical judgment.Here we present a case of localized right atrial tamponade, which initially masqueraded as hypovolemic shock, was obscured on transthoracic echocardiography and clinical signs, and was finally identified on transesophageal echocardiography.It led to immediate reexploration and evacuation of the tamponade.