Interventional closure in the treatment of cardiac cavity perforation caused by pericardial puncture: a case report

Abstract

Interventional treatment for left ventricular free wall or apex perforation is rarely reported. This current case report describes a male patient in his 70 s with left ventricular perforation caused by pericardiocentesis that was successfully treated through interventional means. The patient was admitted to the hospital due to chest pain accompanied by asthmatic breathing difficulties that had lasted for the previous 10 h. Two years previously, the patient had a history of thymoma, during which pericardial effusion was discovered, leading to multiple hospitalizations for pericardial fluid aspiration. On the 10th day of admission, a chest computed tomography scan confirmed iatrogenic left ventricular apical perforation and haemorrhagic anaemia, after which interventional transcatheter left ventricular perforation sealing was performed. Postoperatively, the patient was conscious, with stable vital signs and no particular discomfort. The successful implementation of this interventional procedure suggests a new minimally invasive solution for treating left ventricular perforation caused by pericardiocentesis or interventional catheterization.

Introduction

Pericardiocentesis is a crucial procedure used to identify the cause of pericardial effusion and alleviate symptoms of pericardial tamponade. However, complications such as infection, bleeding, cardiac chamber perforation, myocardial injury and damage to adjacent organs can occur. ¹ Among these, cardiac chamber perforation is rare. In the past, the treatment of iatrogenic perforation of the heart cavity was mainly limited to conservative treatment or surgical treatment. Interventional treatment for left ventricular free wall or apex perforation was rarely reported. This current report describes a case of left ventricular perforation caused by pericardiocentesis that was treated using interventional methods. The successful execution of this interventional procedure offers a novel, minimally invasive solution for managing left ventricular perforation caused by pericardiocentesis or interventional catheter procedures.

Case report

In July 2023, a male patient in his 70 s was admitted to the Department of Critical Care Medicine, Harrison International Peace Hospital Affiliated to Hebei Medical University, Hengshui, Hebei Province, China with a primary complaint of chest pain and asthmatic breathing difficulties for 10 h. The patient had a history of thymoma diagnosed 2 years previously, during which “pericardial effusion” was identified, requiring multiple hospitalizations for pericardial fluid aspiration. Upon this admission, the patient's vital signs were stable. A physical examination revealed distant heart sounds, with the leftmost edge of the heart boundary located approximately 0.5 cm outside the left midclavicular line at the fifth intercostal space. The patient's routine blood test showed a white blood cell count of 23.45 × 10⁹/l and a neutrophil percentage of 96.9%, with no abnormalities in blood biochemical markers. Cardiac ultrasound revealed a significant amount of pericardial effusion, so a pericardiocentesis with catheter drainage was performed to manage it. The needle specifications were 9G (Gauge) and 70 mm in length; and the drainage tube had an inner diameter of 8F (French). After a successful puncture, 1120 ml of haemorrhagic effusion was drained on the first postoperative day and his haemoglobin level decreased from 105 g/l to 79 g/l. Timely blood transfusions and fluid resuscitation were administered to manage the situation, which stabilized the patient's vital signs. After draining the haemorrhagic effusion on the first day, considering the risk of active bleeding post-pericardiocentesis, the drainage tube was clamped, which temporarily paused the pericardial drainage. Echocardiography was used for dynamic monitoring of the pericardial effusion. Due to the occlusion of the drainage tube lumen at the perforation site, the patient's bleeding rate remained relatively slow.

Chest computed tomography (CT) on the 10th day of admission showed pericardial effusion and high-density striated shadow in the cardiac silhouette area (Figures 1A–1C). The patient was diagnosed with iatrogenic left ventricular apical perforation and haemorrhagic anaemia. After thorough communication with the patient and his family and after explaining all surgical risks, the patient agreed to proceed with catheter-based closure of the left ventricular perforation as the next step in their treatment.

Figure 1.

Computed tomography scans of a male patient in his 70 s who was admitted with a primary complaint of chest pain and asthmatic breathing difficulties and subsequently underwent pericardiocentesis with catheter drainage. On the 10th day of admission, computed tomography scans showed the distal end of the pericardial puncture drainage tube located within the cardiac cavity: (A) pericardial drainage tube passes through the left atrium; (B) pericardial drainage tube passes through the left atrium; (C) pericardial drainage tube is located in the left ventricle.

Ten days after the pericardiocentesis catheterization, a cardiac chamber perforation was discovered. One day later, an interventional procedure to treat the perforation was performed. The surgery lasted 2 h and 20 min, with a 30-min fluoroscopy. Intraoperative blood loss was approximately 100 ml. A 6F sheath was inserted into the right femoral artery, followed by a straight supersmooth guide wire into the aorta via the primary pericardial puncture tube. The guide wire was then advanced through the femoral artery to the endovascular arrest system to establish a wire bridge (Figure 2A). A 5F MPA1 catheter (125 cm in length) was inserted at the anterior left ventricular wall rupture site and a 5F ADO II occluder delivery sheath was delivered from the left chest wall end. A PDA2-06-06 occluder was selected to seal the break. Its position, size and shape within the tunnel of the left ventricular wall were deemed appropriate; and no leakage of contrast agent leakage was observed (Figure 2B). Ultrasonography and contrast examination showed no signs of pressure near the occluder in the anterior descending branch and no increase in pericardial effusion compared with that before surgery (Figure 2C). The delivery sheath of the ADO II occluder was then removed from the left chest wall (Figure 2D).

Figure 2.

The intervention to remove the pericardial puncture drainage tube and apply a plug to seal the perforation in a male patient in his 70 s who was admitted with a primary complaint of chest pain and asthmatic breathing difficulties and subsequently underwent pericardiocentesis with catheter drainage: (A) a left ventricular catheter-aortic valve-ascent of aorta-aortic arch-descending aorta-right femoral artery pathway was established; (B) the plug in the left ventricular wall tunnel was appropriately positioned, sized and shaped without contrast agent leakage; (C) coronary angiography revealed no signs of compression near the plug site in the anterior descending branch; (D) the delivery sheath for removing left chest wall ADO II plug was withdrawn.

After the operation, the patient was conscious, had stable vital signs and had no extraordinary discomfort. Postoperative re-examination showed an occluder echo in the lateral wall of the left ventricular apex with a fixed position. Colour Doppler measurements were not obtained and there was no shunt between the left ventricular and pericardial space. Systolic activity in all segments of the left ventricle was regular, with only a minimal amount of pericardial effusion noted. Postoperative blood tests showed haemoglobin at 81 g/l, white blood cells at 7.12 × 10⁹/l and platelets at 219 × 10⁹/l. Myocardial markers indicated cTnT at 0.024 ng/ml and NT-proBNP at 485.4 pg/ml. After transfusing four units of red blood cells, the patient's haemoglobin concentration fluctuated between 106 and 113 g/l. The patient did not regularly take any medication in daily life and did not take anticoagulants during the hospital stay. Due to the patient’s concurrent malignant tumour and poor prognosis, the family chose to forgo further treatment and the patient was discharged 1 month after the operation. The patient passed away 1 month later.

After fully informing the patient's family about the purpose of this study and obtaining their informed consent, they agreed to the publication for medical research purposes. This study was also approved and authorized by the Ethics Committee of Harrison International Peace Hospital, affiliated with Hebei Medical University (no. 2024255). The reporting of this case report conforms to the CARE guidelines. ²

Discussion

Clinically, left ventricular perforation from various causes is not uncommon, but cardiac perforation resulting from pericardiocentesis is rarely reported and is often fatal.^3,4 A previous report described a 67-year-old male patient who underwent pericardiocentesis for cardiac tamponade. ⁵ A CT scan revealed that the pericardiocentesis drainage tube had perforated the left ventricle. ⁵ The surgeons repaired the perforation with 5-0 monofilament mattress sutures reinforced with felt pads while the heart was still beating. ⁵ The authors suggested that following proper procedures when placing a pericardiocentesis catheter may reduce the risk of such fatal complications. ⁵ In this current case, the potential causes of ventricular wall perforation might have included: (i) the patient’s low body mass index (around 16 kg/m²), which reduced the distance between the skin and ventricular wall, and the operator’s rapid needle insertion, possibly causing myocardial injury; (ii) the absence of guidance from a specialized ultrasound technician making precise localization of the puncture site challenging; (iii) skin pressure from the ultrasound probe, which, while displacing lung tissue for a clear view of the pericardial space, might have led to underestimating the distance to the effusion, increasing the risk of perforation; (iv) deviation from the intended needle trajectory, as the needle should align with the angle formed by the ultrasound probe and skin. All of these factors might have contributed to the pericardiocentesis failure. The iatrogenic perforation caused by pericardiocentesis in this current patient was mainly due to inaccurate puncture positioning. In addition, the patient's blood pressure and the coagulation status of the fluid were not thoroughly assessed when the haemorrhagic fluid was punctured and bleeding was not promptly controlled. Therefore, before performing pericardiocentesis, the surgeon should work closely with ultrasound specialists to repeatedly confirm the puncture site, needle direction and depth using colour Doppler imaging.

Iatrogenic cardiac perforation, except in rare cases where self-sealing occurs, ⁶ typically requires thoracotomy to repair the perforation.^7,8 Interventional treatment for left ventricular free wall or apex perforation is rarely reported.^1,3 Previous studies have indicated that only 13% of patients with atrial perforations and up to 55% of those with ventricular perforations required cardiac surgery.^9,10 In this current case, the perforation was discovered 10 days after pericardial puncture and drainage, when spontaneous closure was lost. In addition, the patient had multiple underlying conditions, making thoracotomy highly traumatic and risky. After a comprehensive evaluation, it was ultimately decided to proceed with interventional occlusion treatment.

In this current patient, the perforation was discovered 10 days after pericardiocentesis and its prolonged duration and large aperture increased the complexity of the procedure. Initially, the surgeon tried to remove the left ventricular catheter along the track and immediately insert an occluder to seal the perforation site. However, pericardial tamponade occurred immediately after the left ventricular catheter was withdrawn, necessitating the reinsertion of the left ventricular catheter to seal the perforation in the ventricular wall temporarily. Subsequently, the cardiac catheter was replaced with a 125-cm long 5F MPA1 catheter and the withdrawal catheter was accurately positioned to seal the perforation. The success of this case hinged on the establishment of the femoral artery perforation to left ventricular catheter track. In addition, given the occluder’s proximity to the anterior descending artery, coronary angiography was performed after closure, revealing no signs of coronary artery compression, a critical detail not addressed in previously reported cases.^11,12

Unlike open-heart surgery, interventional procedures offer a minimal field of vision for the operator, requiring precise medical equipment and coordinated technical skills to complete. Any improper handling can lead to postoperative complications for the patient. During the procedure, when the surgeon pulled back the left ventricular catheter, the patient immediately developed cardiac tamponade. The surgical team were compelled to reinsert (pull back) the left ventricular catheter and re-block the entry route through the ventricular wall as an emergency response. This issue underscores a significant safety risk inherent in such procedures. However, this case also provides valuable insights for other surgeons, offering strategies to better address similar complications and improve patient outcomes.

In conclusion, this current case underwent a successful interventional closure of a left ventricular apical perforation, which suggests the feasibility, safety and effectiveness of this treatment method, and thus provides a valuable reference for the clinical management of similar situations. In addition, strict adherence to standardized pericardiocentesis procedures is crucial to prevent the occurrence of iatrogenic cardiac injury complications.