Correct!
4. Thoracic surgery consult for pericardotomy
The repeat echocardiogram explains the pulsus paradoxus and the decreased urine output. There is a large pericardial effusion (Figure 5).
Figure 6. Beside echocardiogram with 5 cm accumulation of pericardial fluid shown at the cardiac apex.
This was also shown by a thoracic CT scan (Figure 7).
Figure 7. Thoracic and abdominal CT scans. Panel A: thoracic axial view. Panel B: abdominal CT scan coronal view. In each panel the pericardial fluid is indicated by the arrows.
Since the patient is not hypotensive but is anticoagulated, the safest treatment is an operative intervention to remove the clot. Pericardiocentesis carries some risk especially for patients on anticoagulation.
The patient was taken to the operating room for a mediastinal exploration. He became hypotensive just prior to operation and required fluids and vasopressors. A clot was evacuated from the pericardial wall. Post-operatively the patient did well regaining his urinary function and was discharged after 13 days.
Bleeding into the pericardium can occur, especially when the patient is on anticoagulants as this patient was for his mechanical valve. This can present with hypotension or subacutely with decreased organ perfusion as in this case.
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References