A High-Echoic Layer Surrounding the Heart Suggesting Cardiac Tamponade by Clotting

Abstract

A 16-year-old boy experienced a sudden loss of consciousness. On arrival, he was in cardiac arrest. An ultrasound study revealed a high-echoic layer surrounding the heart. He received a diagnosis of clotting cardiac tamponade. Urgent thoracotomy with pericardiotomy was performed, but he failed to obtain return of spontaneous circulation. Physicians should focus on not only low-echoic but also high-echoic areas to accurately diagnose clotting, which can result in a critical condition if not managed properly.

Keywords

aortic dissection - tamponade - Loeys–Dietz syndrome

A 16-year-old boy experienced a sudden loss of consciousness at home in front of his parents. On arrival, he was in cardiac arrest with pulseless electrical activity. An ultrasound study revealed a high-echoic layer surrounding the heart with a high-echoic layer surrounding the ascending aorta as well ([Figs. 1] and [2]). He received a diagnosis of clotting cardiac tamponade. Urgent thoracotomy with pericardiotomy was performed ([Fig. 3]), but he failed to obtain return of spontaneous circulation. Autopsy imaging indicated residual pericardiac hematoma ([Fig. 4]). Based on his features, he was suspected of having Loeys–Dietz or Marfan syndrome. We postulated that connective tissue disease had induced Type A aortic dissection with subsequent rupture that had resulted in cardiac tamponade and cardiac arrest. Permission to perform a genetic analysis was not obtained from his parents.

Fig. 1 The ultrasound study revealed a high-echoic layer (arrow) surrounding the heart (arrowheads) suggesting clotting cardiac tamponade.

Fig. 2 The ultrasound study revealed a high-echoic layer (arrow) surrounding the ascending aorta, suggesting aortic dissection.

Fig. 3 Urgent thoracotomy with pericardiotomy revealed a clot weighing approximately 1 kg.

Fig. 4 Autopsy imaging. Computed tomography indicated residual pericardiac hematoma.

In cases of hemorrhaging into a closed space, the blood forms a blood clot to achieve hemostasis. During this process, the whole blood separates into a blood clot and serum. When the serum accumulates in one space, it may be detected as fluid by ultrasound. However, it takes some time for the serum to accumulate. Accordingly, a focused assessment with sonography in trauma, which focuses on low-echoic areas to detect serum, is well known to have a high false-negative rate for the acute hemorrhaging state in traumatized patients.[1] Clots are scanned as high-echoic areas on ultrasound studies. If physicians focus not only on low-echoic but also high-echoic areas, the sensitivity for detecting clinically significant blood clots in the human body may be improved.

Unfortunately, the present patient failed to obtain a favorable outcome; however, the urgent resolution of cardiac tamponade by clotting and subsequent treatments might result in a favorable outcome in other patients.[2] [3]

Conflict of Interest

The authors declare no conflict of interest related to this article.

Acknowledgment

None.

• References

• 1 Do WS, Chang R, Fox EE, Wade CE, Holcomb JB, Martin MJ. NCTH Study Group. Too fast, or not fast enough? The FAST exam in patients with non-compressible torso hemorrhage. Am J Surg 2019; 217 (05) 882-886
• 2 Keiko T, Yanagawa Y, Isoda S. A successful treatment of cardiac tamponade due to an aortic dissection using open-chest massage. Am J Emerg Med 2012; 30 (04) 634.e1-634.e2
• 3 Yatsu S, Yanagawa Y, Nagasawa H, Tambara K, Suwa S. Successful treatment of cardiac tamponade due to rupture of the heart using open-chest pericardiotomy. Cureus 2020; 12 (02) e7101

Publication History

Received: 02 April 2020

Accepted: 25 February 2021

Article published online:
12 October 2021