To the Editor:
I have read the interesting article by Peruzzi and colleagues1 regarding post-angioplasty pneumopericardium. Theirs is the first reported case of this sequela. In this particular patient, the more frequent causes of pneumopericardium are readily excluded because of the absence of risk factors. Nevertheless, the most apparent explanation for pneumopericardium after angioplasty is the occurrence of a subtle coronary perforation: intrapericardial air might have reached the pericardium from gaseous bubbles introduced during injection of the contrast agent or saline solution if the catheters were not adequately aspirated prior to injection. This could explain the air present in the pericardium on the chest radiograph. The introduction of air into the coronary arteries did not manifest itself, possibly because of its escape into the pericardium.
Coronary air embolism during cardiac catheterization has been reported.2 The introduction of air during cardiac catheterization occurs when catheters are not adequately aspirated and flushed. Air can also be introduced by entrainment during balloon catheter or guidewire withdrawal or introduction. The mainstay of management is prevention of occurrence. It is therefore crucial that the operator conscientiously aspirate air from the sheath, catheter, and lines before injection.
In the case presented here, repeat coronary angiography performed 3 days after the initial procedure did not reveal coronary perforation—but by that time a subtle perforation could well have closed.
In conclusion, I propose that a subtle coronary perforation with introduction of intra-arterial air—due either to incomplete aspiration of catheters or to entrainment of air during balloon catheter introduction or withdrawal—was the most likely cause of pneumopericardium in this specific instance, when all other causes seem to have been excluded.
Hesham R. Omar, MD
Internal Medicine Department, Mercy Hospital and Medical Center, Chicago, Illinois
Footnotes
Letters to the Editor should be no longer than 2 double-spaced typewritten pages and should contain no more than 6 references. They should be signed, with the expectation that the letters will be published if appropriate. The right to edit all correspondence in accordance with Journal style is reserved by the editors.
References
- 1.Peruzzi M, Frati G, Rose D, Chirichilli I, Santo C, Ricci M. Spontaneous pneumopericardium after coronary angioplasty. Tex Heart Inst J 2010;37(6):728–9. [PMC free article] [PubMed]
- 2.Dib J, Boyle AJ, Chan M, Resar JR. Coronary air embolism: a case report and review of the literature. Catheter Cardiovasc Interv 2006;68(6):897–900. [DOI] [PubMed]