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Abstract: This is a 68-year-old man who was hospitalized for coronary artery disease several times in the past and underwent coronary angiography suggesting three coronary artery lesions, including chronic occlusive lesions in the anterior descending branch. The symptoms were gradually relieved, blood pressure and heart rate recovered, and the condition was controlled.
Basic information】Male, 68 years old
Disease Type】Pericardial hemorrhage
Hospital】Shandong Provincial Third Hospital
Date of Consultation】December 2021
Treatment plan】Surgical treatment (pericardiocentesis and drainage) + medication (sakubatril valsartan sodium tablets, isosorbide mononitrate tablets, nicorandil tablets, dagliflozin tablets)
Treatment period】6 days of inpatient treatment, regular outpatient follow up
Treatment effect] The symptoms of chest tightness and chest pain were relieved and the disease was controlled.
I. Initial consultation
One morning in December 2021, an elderly male patient came to our outpatient clinic. The patient reported recurrent chest tightness and chest pain, which lasted for several minutes each time and could be relieved by taking quick-acting heart pills, and the effect of taking aspirin enteric tablets, Tegretol tablets, metoprolol tartrate tablets, and Rosuvastatin calcium tablets was not good. The patient was discharged from the hospital at the time of symptomatic relief, but the two angiograms revealed that the patient had a chronic occlusive lesion in the anterior descending branch (CTO), and this time he came to the hospital with the plan to review the coronary angiogram and try to open the occlusive lesion in the anterior descending branch.
After the patient was hospitalized, the relevant laboratory tests were firstly completed. The laboratory tests showed that the patient’s blood routine, liver and kidney function, coagulation function, cardiac enzymes, high-sensitivity troponin T and NT-proBNP were all within the normal range, and the cardiac ultrasound showed that the left ventricular ejection fraction was 45%, mild aortic regurgitation and pericardial effusion (small amount).
II. Treatment history
After the contraindications were ruled out, a coronary angiogram was performed on the third day of hospitalization, and the findings indicated that the original stents of the gyral branch and intermediate branch were patent, but there was mild stenosis in the stent of the right crown, and the proximal segment of the anterior descending branch was still occluded. The operation lasted 4 hours, and the angiogram suggested partial myocardial staining, so the operation ended. About half an hour after the operation, the patient showed signs of shock, such as chest tightness, sweating, low blood pressure and slow heart rate. The patient was considered to have a possible coronary artery perforation, and the pericardial fluid was considered to be bloody fluid.
It was decided to perform pericardial puncture, and firstly, the localization was performed, and the subxiphoid route was adopted. The needle was inserted 1 cm below the left subcostal margin of the xiphoid process, and the needle entered the pericardium under ultrasound guidance, and a total of 50 ml of hemopericardial fluid was withdrawn and a drainage tube was placed. Later, the patient was given an adjusted treatment plan with the addition of sakubatril valsartan sodium tablets, isosorbide mononitrate tablets, nicorandil tablets and dagliflozin tablets and other drugs continued to be taken orally for 3 days, and the patient was discharged with relief of chest tightness and chest pain.
III. Treatment effect
At the time of discharge, the patient was instructed to come for follow-up after half, one, three and six months, and the patient complied very well. The patient was satisfied with the therapeutic effect, and was instructed to take the medication and come for regular follow-up. The patient was satisfied with the treatment and was told to adhere to the medication and come for regular follow-up.
IV. Notes
I am glad that the patient’s condition has improved, but I still need to advise the patient to pay attention to keeping the skin at the puncture site clean and hygienic during daily activities, and to avoid bathing and strenuous activities until the wound has completely healed, so as to avoid infection at the puncture site. It is also necessary to pay attention to a light diet and avoid spicy and irritating foods in daily life to avoid vasodilation and bleeding.
V. Personal insight
Patients with coronary artery disease are mostly combined with hypertension, diabetes and other diseases, and once there is a decline in cardiac function, it often indicates severe stenotic lesions in multiple branches of the coronary arteries. For this group of people, complete blood flow reconstruction can bring more benefits, so it is recommended that people in this case should still try coronary intervention. Of course, surgery is bound to involve certain risks, and in the case of pericardial hemorrhage due to conditions like this patient, cardiac ultrasound should be improved in a timely manner, and if necessary, puncture and drainage should be performed in a timely manner to avoid cardiac tamponade, and the patient’s prognosis is often good, while attention should be paid to strengthening care, and the patient can be completely cured.