Discussion:
COVID-19 was confirmed in a cluster of patients by the Chinese health
authorities on January 7, 2020. The first case in the United States was
reported on January 20, 2020. With its continued spread globally, a
range of complications affecting almost every organ system have been
reported.
Cardiac tamponade is most commonly idiopathic, with a smaller subset of
cases resulting from infectious causes. It can be due to collection of
transudate, exudate or blood in the pericardium. Viral pericarditis is
usually characterized by a gradual accumulation of transudate.
Interestingly, in COVID-19 patients with cardiac tamponade, some develop
sanguineous fluid collection while others have an exudative or
transudative pericardial fluid, as evidenced in our patients.
The pathophysiology of COVID-19 cardiac tamponade is possibly a result
of the marked systemic inflammatory response to the virus, leading to
myocarditis and pericarditis. Myocardial ischemia, as evidenced by
elevated or up-trending troponin levels, can also be explained by the
hyper-coagulability (resulting from endothelial damage and the
inflammatory response) in these patients. Thus, prophylactic use of
corticosteroids and therapeutic anti-coagulation have been proposed in
COVID-19 patients.
Cardiac tamponade should be suspected in COVID-19 patients with
progressive hemodynamic compromise, especially if the usual
constellation of physical exam findings associated with cardiac
tamponade is present. An echocardiogram showing late diastolic collapse
of the right atrium and early diastolic collapse of the right ventricle
(occurring when the intra-pericardial pressure exceeds intracavitary
pressure) is diagnostic. Of note, CXR does not demonstrate cardiac
enlargement until at least 200 mL of pericardial fluid has accumulated
and thus has low sensitivity.
After pericardial fluid drainage management is largely supportive, and
recurrent cardiac tamponade is possible. While the use of therapeutic
anticoagulation has been shown to improve prognosis in severe COVID-19
patients the development of sanguineous cardiac tamponade (as seen in
Case 1) may point towards increased risks of therapeutic anticoagulation
after initial drainage. However, given the documented benefits of
therapeutic anticoagulation in COVID-19 patients, particularly in
patients with elevated D-dimers, it might be judicious to resume
anti-coagulation 12 hours post-operatively, with a high index of
suspicion for rebleeding in case of progressive worsening of hemodynamic
status. The role of NSAIDs in this subpopulation is yet to be
determined. High suspicion for recurrence of cardiac tamponade is
warranted as risk of recurrence is as high as 20%.
While current data on cardiac tamponade, with possible concomitant
biventricular failure, in COVID-19 patients are limited, we hypothesize
that short-term prognosis in this subpopulation is primarily dependent
upon ventricular function at the time of development of tamponade. In
our case series, the two patients with cardiac tamponade with
concomitant biventricular failure (Cases 2 and 3) experienced rapid
deterioration leading to death, while the patient with preserved
ventricular function (Case 1) survived. However, the observed
ventricular dysfunction – possibly stress cardiomyopathy or
cytokine-related myocardial dysfunction – may just be a manifestation
of the overall severity of inflammatory response and the associated
fulminant cytokine release (Tables 1-3). Further, the long-term
prognosis, sequelae and predictors of survival in COVID-19 patients
developing transient myocarditis or cardiac tamponade remain yet to be
Importantly, surgical intervention and drainage of pericardial fluid in
COVID-19 patients, while allowing for rapid relief from tamponade
physiology, is associated with intra- and post-operative risks.
Anesthesia, mechanical ventilation, and use of vasopressors and
inotropic medications may contribute to long-term pulmonary and
cardiovascular compromise and increased mortality in COVID-19 patients.
Thus, pericardiocentesis, with its minimal risk of anesthesia, may be
preferable in this subpopulation.