Beck's Quadrad? A Rare Case of Pericardial Tamponade Presenting as Transient Pre-Excitation Early after Cardiac Transplantation

Introduction Cardiac tamponade is a potentially fatal complication after cardiac surgery. An acute accumulation of fluid generally presents as Beck's triad, however, a slowly accumulating pericardial effusion can have variable clinical presentations. We report a case of transient pre-excitation on post-operative electrocardiogram (ECG) after cardiac transplantation with resolution of aberrant conduction following pericardiocentesis for cardiac tamponade. Case Report A 46-year-old African American male with NICM HFrEF (EF 18%) presented in cardiogenic shock, COVID pneumonia requiring milrinone infusion and intra-aortic balloon pump support for stabilization. After clearance of his viral replicon, he underwent orthotopic heart transplantation. His postoperative course was complicated by monomorphic non-sustained ventricular tachycardia. His ECGs revealed a right bundle branch block with prominent delta waves concerning for pre-excitation through an accessory pathway. Electrophysiology was consulted and confirmed an accessory pathway localized to the right superior paraseptal region. He subsequently developed atrial fibrillation and his mean blood pressure dropped from 80 to 60mmHg. A bedside echocardiogram showed a large, circumferential pericardial effusion concerning for cardiac tamponade. He was emergently taken to the catheterization lab for pericardiocentesis with drainage of 500cc of serosanguinous fluid. Post-pericardiocentesis ECG revealed resolution of his atrial fibrillation, and unexpectedly, his wide QRS and pre-excitation pattern was replaced by narrow complex sinus rhythm. Summary This case illustrates the atypical presentation of cardiac tamponade in patients who have undergone orthotopic heart transplantation. The pre-excitation and wide QRS pattern may be secondary to pericardial irritation from the effusion leading to changes in the conduction properties of a previously concealed accessory cardiac pathway.