Left ventricular puncture during thoracentesis

Abstract

Left ventricular puncture during a thoracentesis is a rare and unusual complication that has yet to be reported. We report a case in which a 74-year-old woman with dilated ischaemic heart disease suffered from puncture of the left ventricle during a routine ultrasound-guided thoracentesis despite following the recommended protocol and procedures. She became haemodynamically unstable and underwent an emergent thoracotomy for removal of the catheter and repair of the left ventricular wall.

Background

Thoracentesis is a procedure that has diagnostic and therapeutic value for pleural effusions.¹ Well-known complications following this procedure include pain, bleeding, pneumothorax and infection. Less common complications include re-expansion pulmonary oedema,² tumour seeding,³ injury to abdominal viscera and broken catheters.⁴ Ventricular puncture is a known complication post-pericardiocentesis but it has not been reported as a possible complication of a thoracentesis. We report a case in which an elderly woman with severe ischaemic heart disease (IHD) and a widely enlarged left ventricle (LV) suffered from puncture of the LV during a routine ultrasound-guided thoracentesis despite following standard procedures by an experienced interventional radiologist. The goal of this article is to bring awareness to those performing thoracentesis in patients with cardiomegaly or distortion of normal human anatomy.

Case presentation

A 74-year-old African–American woman presented to the emergency room with respiratory distress and chest pain. The patient had a known medical history of gastro-oesophageal disease, Barrett’s oesophagus, chronic systolic heart failure, coronary artery disease, IHD, persistent atrial fibrillation, chronic kidney disease, gout and a history of deep venous thrombosis. She was found to be stable, her ECG and cardiac markers (serial troponins and creatine kinase-muscle/brain [CK-MB]) were unremarkable and she was treated symptomatically.

The patient decompensated shortly after. Her blood pressure dropped to 90/63 mm Hg with a pulse of 94 bpm. The patient’s complete blood count revealed a white blood cell count of 9100 cells/μL with 5% lymphocytes and 86.7% granulocytes. The initial workup included a chest CT that revealed moderate bilateral pleural effusions, cardiomegaly and a biventricular pacemaker (figure 1). Signs of decompensating heart failure prompted a 2D transthoracic echocardiogram, which revealed a dilated LV with a left ventricular internal diameter end diastole and end systole of 53 mm and 48 mm, respectively, and hypokinesis. The left atrial diameter was 37 mm and the right atrium size was within normal range. The LV ejection fraction was determined to be 15%.

Figure 1.

CT of the chest showing significant cardiomegaly, obliterating the left basal lung field and demonstrating the heart’s direct contact with the chest wall. Also denoting the presence of a biventricular pacemaker.

An ultrasound-guided thoracentesis with an eight-French drainage catheter was performed on the patient’s posterolateral left chest while in the recumbent posterior oblique position for symptomatic relief (figure 2). Initially, 5 mL of turbid yellow pleural fluid was drained, but the procedure was discontinued due to the return of blood through the catheter. The distal tip of the catheter was not visualised with ultrasound and a subsequent CT scan revealed that the catheter was unintentionally inserted into the posterior left ventricular myocardium. The patient became haemodynamically unstable and transferred to a tertiary medical centre where a life-saving exploratory thoracotomy was performed. The catheter penetrated the left ventricular wall (figures 3 and 4).

Figure 2.

Ultrasound of the posterolateral left chest wall during ultrasound-guided thoracentesis.

Figure 3.

Axial CT of the chest showing severe cardiomegaly and the thoracentesis catheter inserted into the left ventricular wall.

Figure 4.

Coronal CT of the chest showing cardiomegaly and a thoracentesis catheter inserted into the left ventricular wall.

Treatment

After the LV was punctured during the ultrasound-guided thoracentesis, the patient was transported to a tertiary care centre for surgery. The patient underwent an emergent thoracotomy successfully and was kept on mechanical ventilation and monitoring. The foreign body was removed and the left ventricular wall was repaired with a purse string suture.

Outcome and follow-up

After the surgery, the patient was kept on mechanical ventilation and monitoring for 2 days. Gradually, the patient improved and was extubated. After extubation, the patient was found to have a persistent pleural effusion, which required another thoracentesis. The patient, however, declined the procedure. She was stabilised to an appropriate level and discharged for rehabilitation. A follow-up appointment took place in clinic 4 weeks later. The patient is currently doing well.

Discussion

Thoracentesis is minimally invasive and can be done at the bedside for rapid fluid removal from the thoracic cavity and fluid analysis. The most commonly documented complication is pneumothorax. A 2010 meta-analysis determined that the thoracentesis-associated pneumothorax rate was 6%. This value was significantly decreased to 2% if the physicians performed the thoracentesis under ultrasound guide. Operator experience accounted for a decrease in the rate of thoracentesis-associated complications. Therapeutic thoracenteses were associated with higher complication rates when compared with diagnostic procedures.⁴ There have been reports of damage to other thoracic cavity structures. Studies have described puncture of solid abdominal viscera, such as the spleen or liver.⁵ Although rare, iatrogenic perforation of the LV during chest procedures has been previously reported, namely during chest tube drainage. The patient in this report presented with similar pathology and distorted anatomy. Kim et al’s report discusses both the possibility of under-reporting this complication and improving safety with the use of image-guided techniques for chest tube insertion.⁶

The use of ultrasound and CT guidance during the procedure has been used to effectively visualise the patients’ anatomy and to decrease possible complications. In this case, the operator utilised an ultrasound-guided thoracentesis approach. Even though this is the standard of care and the risk is decreased, due to the patient’s distortion of normal anatomy, the catheter perforated the LV. Her moderately enlarged LV was in direct contact with the chest wall and made it difficult to enter the pleural space without encountering the heart.

There have been previous reports where the puncture of an abnormally large left atrium was averted with the use of image-guided thoracentesis, but puncture of the LV has not been reported. This complication was previously avoided by the use of ultrasound-guided thoracentesis and because the physician had reviewed previous relevant diagnostic imaging.⁷ Left ventricular puncture has been previously performed as a medical procedure in order to provide haemodynamic data in the presence of mechanical prosthetic valves. These previous cases of left ventricular puncture have been managed via thoracotomy with evacuation of tamponade and repair of the ventricular free wall while achieving haemostasis.⁸ This, however, is no longer considered standard of care in the USA and is used for rare procedures, such as transcatheter aortic valve implantation, not amenable by other routes.

Another caveat that should be addressed is how to transport the patient after an incident has taken place. Once a foreign object has penetrated viscera (LV), it is paramount that the operator leaves the foreign object in place and not remove it. The patient should be immediately transported to the operating room for thoracotomy and object retrieval.

This rare complication should be kept in consideration by any physician performing a thoracentesis procedure. This is especially true for patients with a history of distorted anatomy (cardiomegaly, dextrocardia and aortic aneurysm). The importance of reviewing pertinent previous diagnostic imaging before a radiological procedure should be stressed in order to avoid catastrophe. We suggest the use of CT-guided techniques to perform the thoracentesis in patients that are considered to be at high risk of having distorted anatomy. While both techniques are considered to be standard of care and have similar complication rates, the ultrasound-guided technique is generally preferred due to the reduced time to procedure. However, the CT-guided thoracentesis is a more elegant procedure with improved visualisation and less dependence on operator aptitude. It is our opinion that CT-guided thoracentesis may be the safer option because of more optimal visualisation of the visceral organs. The use of an experienced operator is also recommended for these high-risk patients.

Learning points.

• We report a case in which a 74-year-old woman with cardiomegaly from ischaemic heart disease suffered from a puncture of the left ventricle during a routine ultrasound-guided thoracentesis.

• This article appears to be the first to report a left ventricular puncture during an ultrasound-guided thoracentesis.

• Although an extremely rare complication, clinicians should take special precaution with patients who have distorted anatomy, such as cardiomegaly, and are at higher risk for morbidity.

• The importance of reviewing pertinent previous diagnostic imaging before radiological procedures should be stressed in order to minimise the risk of this complication.

• We suggest the use of CT-guided techniques might be more useful for patients with severely distorted anatomy.

• An experienced operator is highly recommended to perform these procedures for patients that may have a history of distorted anatomy.