Abstract
Cardiac tamponade is often managed with pericardiocentesis, carrying a 1% to 4% complication risk, including right ventricle perforation. Small punctures are typically managed conservatively, while larger ones require cardiac surgery. This case describes percutaneous Angio-Seal (Terumo) repair in a high-risk surgical patient. A 46-year-old obese woman with multiple comorbidities presented with recurrent tamponade. After inserting a pericardiocentesis catheter it was noticed that despite draining 1000 mL of blood, tamponade persisted. The catheter was inadvertently placed in the right ventricle. After anticoagulation subsided, an 8F Angio-Seal catheter was deployed under imaging, successfully sealing the perforation. This case highlights the safety of Angio-Seal in high-risk patients with right ventricle perforation.
Keywords: Angio-Seal, iatrogenic cardiac injury, nonsurgical management, percutaneous closure, right ventricle perforation
Introduction
Cardiac tamponade is a medical emergency that is usually managed with urgent pericardiocentesis. This intervention carries a 1% to 4% risk of major complications that is highest in those with significant comorbidities.1,2 Right ventricle (RV) perforation is a rare (<1%) complication of pericardiocentesis. Unlike left ventricular perforations that can heal on their own due to the thickness of the myocardium, RV perforations may require surgical repair. RV myocardial puncture from a pericardiocentesis needle, without sheath dilatation, is often managed conservatively. Myocardial perforation diagnosed after drain placement traditionally requires thoracotomy, followed by a purse string suture or closure with a patch repair. For patients with a prohibitive risk of surgery, nonsurgical interventions have been explored.3, 4, 5, 6, 7, 8, 9, 10 We present a case of RV perforation treated percutaneously with Angio-Seal (Terumo) and aim to describe the procedure, as well as establish a standardized protocol for future operators.
Case presentation
A 46-year-old obese woman presented with cardiac tamponade. The patient had multiple comorbidities including atrial fibrillation treated with a direct acting anticoagulant, severe chronic obstructive pulmonary disease secondary to active smoking, severe pulmonary hypertension, and RV dilation with severe systolic dysfunction. A chronic pericardial effusion had been present with pericardiocentesis 1 month before. On this occasion, she had represented to our emergency department at 10 pm with clinical tamponade confirmed with echocardiography. She had intermittent obliteration and diastolic compression of the right atrium and right ventricle despite a raised RV systolic pressure of 53 mm Hg, dilated inferior vena cava, and abnormal respiratory variations of 126% and 32% in tricuspid and mitral valve inflows, respectively (Figure 1).
Figure 1.
(A) RVand RA collapse. (B) TV inflow respiratory variations. (C) MV inflow respiratory variations. Please refer to video clip 1 (PowerPoint presentation). MV, mitral valve; RA, right atrium; RV, right ventricle; TV, tricuspid valve.
An emergency pericardiocentesis was performed and drained 1000 mL of frank blood, and the tamponade was not relieved. The catheter was inadvertently placed in the right ventricle. This was confirmed through contrast injection under fluoroscopy and the recording of the RV pressure waveform. The initial pigtail catheter was left in situ, and a second pigtail catheter was correctly positioned in the pericardium. A total of 600 mL of hemoserous fluid was drained with improvement in the patient’s hemodynamics. Echocardiography revealed resolution of the pericardial effusion, and the first pigtail catheter was visible in the right ventricle (Figure 2).
Figure 2.
(A) Unchanged effusion after 1 L drained. (B) First pigtail (star) in right ventricle (RV) and second pigtail (arrow) in pericardium. (C) Pigtail catheter (star) in RV. (D) Pigtail (arrow) in RV arrow. Please refer to video clips 2, 3, 4, and 5 (PowerPoint Presentation).
The cardiothoracic team concluded that she was unsuitable for surgical repair. Given her anticoagulation treatment with apixaban, both drains were left in position, and removal of the RV drain was planned within 36 to 48 hours. The perforation was planned to be closed percutaneously using vascular closure devices as the anticoagulation subsided.3, 4, 5, 6, 7
An 8F Angio-Seal STS Plus vascular closure device was chosen to close the defect in the RV wall, with the procedure performed under fluoroscopic and echocardiographic guidance. The pericardial drain, positioned correctly in the pericardium, was retained in place allowing prompt relief of intrapericardial fluid should bleeding occur into pericardial space. Additionally, a 7F sheath was inserted in the right femoral vein to allow for autotransfusion should the need arise.
A 0.035-inch J-tip guidewire was advanced into the RV pericardial drain under fluoroscopy, allowing for the retraction of the pigtail drain over the guide wire. This was followed by the prompt deployment of an 8F Angio-Seal to close the RV perforation. Transthoracic echocardiography showed a small circumferential pericardial effusion, which remained stable throughout the procedure. At the start of the procedure, the pigtail catheter was visible in both the right ventricle and right atrium. By the end of the procedure, the Angio-Seal plug was seen resting against the inner RV wall (Figure 3).
Figure 3.
(A) First pigtail (arrow) in right ventricle (RV) wired, and second pigtail (star) in pericardium. (B) Guide wire in RV and right ventricle outflow tract (RVOT). (C) Angio-Seal sheath over the guidewire. (D) Guide wire in RV and RVOT. (E) Pigtail catheter entering the RV wall. (F) Angio-Seal Plug in RV wall. Please refer to video clips 6, 7, and 8 (PowerPoint Presentation).
The patient had serial echocardiograms at 3, 24, and 72 hours, then at 2 weeks, and at 3 and 6 months. The pericardial drain, placed in the true pericardium, was removed after 24 hours of stability without drainage. The small pericardial effusion resolved by 3 months. Angio-Seal plug was not seen on follow-up echocardiograms, suggesting its resorption. At 19 months, echocardiography showed no effusion but persistent severe RV dysfunction and dilation. At 22 months, she had a pulseless electrical activity arrest at home and passed away despite 90 minutes of resuscitation. Her death was attributed to progressive respiratory failure.
Discussion
This case highlights the effectiveness of the Angio-Seal vascular closure device as a vital lifesaving tool for managing RV injuries sustained during pericardiocentesis. The use of Angio-Seal for this purpose has been reported on 5 occasions in the literature. Petrov and Dimitrov3 were the first to report this approach. However, they initially repaired the RV perforation before placing a second pericardial drain, a method that may not be feasible for unstable patients.3 In 2014, Pourdjabbar et al4 also reported RV perforation repair with Angio-Seal in a patient with large B cell lymphoma. Suspected pericardial effusion was actually tumor encasement. The patient passed away days later due his terminal cancer. The autopsy showed no effusion.4 Moreover in 2014, Bakos et al6 managed another accidental RV catheter placement using Angio-Seal closure device, followed by correct placement of a new drainage catheter. In 2020, Coughlan et al5 managed RV perforation postpercutaneous coronary intervention by leaving the misplaced drain in situ, relieving tamponade with a second pericardial drain, and then sealing the RV perforation using an Angio-Seal device.5 More recently, Skalidis et al7 reported another successful case of treating accidental RV perforation during pericardiocentesis using the Angio-Seal device. Other percutaneous options have also been explored. One case report describes an unsuccessful attempt using a suture-based device, with the patient requiring surgical intervention.8 Case series and reports have described the use of Amplatzer septal occluder devices (Abbott), with both successful and unsuccessful outcomes.9,10
This case adds to the growing body of literature supporting the use of Angio-Seal for repairing iatrogenic RV perforations. Along with previously reported cases, it demonstrates that this procedure is safe for patients with prohibitive surgical risk. This technique could be considered for patients with lower surgical risk for cardiac surgery.
Acknowledgments
Declaration of competing interest
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding sources
This work was not supported by funding agencies in the public, commercial, or not-for-profit sectors.
Ethics statement and patient consent
The authors adhered to the relevant ethical guidelines. Formal patient consent was not required as this case report does not contain any patient-identifiable information. Furthermore, the patient could not be informed as a matter of courtesy due to her passing prior to the preparation of this report. All relevant ethical considerations were observed during the compilation of this case.
Supplementary material
References
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