Diagnostic Challenges of Regional Cardiac Tamponade in a Severely Volume-Overloaded Dialysis Patient: The Role of Multimodality Imaging

Localized postoperative cardiac tamponade is an uncommon clinical-hemodynamic syndrome that may occur without the classic findings of circumferential tamponade.We present a 22-year-old man with dialysis-dependent kidney failure and multiple recent cardiothoracic operations who was admitted because persistent sinus tachycardia prevented completion of hemodialysis.Despite profound total-body volume overload manifested by anasarca, pulmonary edema, ascites, and recurrent pleural effusions, he developed progressive hypotension, respiratory compromise, and increasing vasopressor requirements.Computed tomography demonstrated an enlarging loculated pericardial collection.Transthoracic echocardiography showed right ventricular compression and a dilated, non-collapsing inferior vena cava, raising concern for obstructive physiology.Intraoperative transesophageal echocardiography did not demonstrate classic global tamponade findings but identified an organized pericardial collection causing focal right atrial impingement.The patient's clinical deterioration, combined with the multimodality imaging findings, supported a diagnosis of clinically significant regional postoperative tamponade.Because the organized collection and extensive adhesions were unlikely to be adequately treated by percutaneous drainage, he underwent urgent surgical decompression through a repeat pericardial window.Approximately 680 mL was drained from the pericardial and right pleural spaces combined.Following decompression and controlled renal replacement therapy, vasopressor requirements, tachycardia, respiratory status, and volume overload improved.This case demonstrates that profound total-body volume overload does not exclude regional cardiac tamponade and emphasizes that echocardiographic findings must be interpreted within the overall clinical and hemodynamic context.