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Unusual Presentation of Postcardiotomy Hemorrhage in an Infant with Congenital Heart Disease

Peterson, Marsha J. MD*; Havemann, Luke M. CVT; McKenzie, E Dean MD; Miller-Hance, Wanda C. MD*†

doi: 10.1213/01.ANE.0000149545.77783.5D
Cardiovascular Anesthesia: Echo Didactics & Rounds

*Department of Anesthesiology, Division of Pediatric Cardiovascular Anesthesiology, †Department of Pediatrics, Division of Pediatric Cardiology, and ‡Department of Surgery, Division of Congenital Heart Surgery, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas 77030

Supplemental data available at www.anesthesia-analgesia.org.

Accepted for publication October 20, 2004.

Address correspondence and reprint requests to Marsha J. Peterson, MD, Department of Anesthesiology, Division of Pediatric Cardiovascular Anesthesiology, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX 77030. Address e-mail to marshajp@bcm.tmc.edu.

A 4-month-old, 2.4-kg female infant with medically refractory heart failure underwent uneventful surgical repair of a perimembranous ventricular septal defect, a secundum atrial septal defect, and a vascular ring (right aortic arch, aberrant left subclavian artery, left posterior patent ductus arteriosus). Surgery was uneventful, but 6 hours after surgery, in the intensive care unit, transthoracic echocardiographic (TTE) examination revealed a small echodensity along the right atrial free wall. Repeated TTE examination 18 hours later showed the echodense mass nearly obliterating the right atrial cavity (Fig. 1) (video clip; see supplemental data on www.anesthesia-analgesia.org). Heparin therapy was initiated for a presumed right atrial thrombus. The infant remained hemodynamically stable without evidence of compromised cardiac output. Due to unchanged echocardiographic findings, mediastinal exploration was performed on postoperative day 3. Surgical exploration unexpectedly revealed a large organized extracardiac hematoma adherent to and markedly distorting the right atrial wall (Fig. 2). Ambiguity of echocardiography in the diagnosis of pericardial and intramural cardiac hematomas versus intracavitary masses has been reported in adults and an adolescent after cardiovascular surgery (1,2). The impression that the echodensity represented an intracardiac thrombus in this case led to inappropriate anticoagulation therapy, which may have contributed to hematoma expansion. While a valuable tool in the perioperative care of pediatric patients with congenital heart disease, clinicians must understand diagnostic “pitfalls” of echocardiography.

Figure 1

Figure 1

Figure 2

Figure 2

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References

1. Gologorsky E, Gologorsky A, Galbut DL, Wolfenson A. Left atrial compression by a pericardial hematoma presenting as an obstructing intracavitary mass: a difficult differential diagnosis. Anesth Analg 2002;95:567–9.
2. Momenah TS, McElhinney DB, Brook MM, et al. Intramyocardial hematoma causing cardiac tamponade after repair of Ebstein malformation: erroneous echocardiographic diagnosis as intracavitary thrombus. J Am Soc Echocardiogr 1998;11:1087–9.
© 2005 International Anesthesia Research Society