Guideline case report on perioperative tamponade and protamine reaction in DeBakey type I aortic dissection repair

Hemorrhagic cardiac tamponade is a rare but potentially fatal complication of endovascular aortic intervention, mostly caused by aortic rupture or cardiac perforation; cases without arterial/cardiac injury are extremely uncommon. Protamine anaphylactic reaction is a common perioperative adverse event, and its synergistic effect with cardiac tamponade on hemodynamic instability is often overlooked in clinical practice. We report a 63-year-old man with 10 years of poorly controlled hypertension and a 2-year history of stroke who was diagnosed with DeBakey type I aortic dissection. The patient underwent hemi-arch replacement combined with Bentall operation as the first-stage surgery, and the second-stage descending aorta stent implantation (femoral artery retrograde implantation, chimney stent placement in the innominate artery, and carotid-carotid cross-over bypass) was performed on the 20th postoperative day in line with clinical consensus. During the second-stage surgery, protamine anaphylaxis occurred first, followed by progressive hemodynamic instability; the patient then suffered cardiac arrest due to acute cardiac tamponade. Transesophageal echocardiography (TEE) confirmed a large amount of pericardial effusion with right heart chamber collapse, and subxiphoid surgical pericardial window and drainage were immediately performed, with 300 mL of bloody fluid aspirated. Anticoagulant/antiplatelet therapy was timely adjusted after drainage, and the patient was discharged without neurological complications 2 weeks later. Serial perioperative biological and physiological data were comprehensively monitored and recorded during the whole process. Cardiac tamponade can be readily reversed with timely recognition and intervention, and TEE is the gold standard for its rapid perioperative diagnosis. For patients undergoing staged TEVAR for DeBakey type I aortic dissection with a history of cardiac surgery, long procedural duration, and systemic anticoagulation, tamponade should be highly vigilant even without obvious aortic/cardiac injury. The protamine reaction can synergize with tamponade to aggravate hemodynamic disorder and mask its early manifestations, requiring enhanced multi-modal monitoring. Timely subxiphoid surgical pericardial window drainage is an effective intervention for tamponade-induced cardiac arrest, and individualized adjustment of anticoagulation therapy is crucial for avoiding rebleeding.