Pericardiocentesis Complicated by Pneumopericardium

This report presents the case of pneumopericardium with trapped air in the pericardial sac occurring after a pericardiocentesis, probably caused by air leakage secondary…

Abstract

This report presents the case of pneumopericardium with trapped air in the pericardial sac occurring after a pericardiocentesis, probably caused by air leakage secondary to a defect in the drainage system and/or accidental removal of the pericardial tube. This condition is very rare and should be considered in case of hemodynamic worsening despite complete evacuation of the pericardial effusion, since immediate recognition and treatment are crucial. (Level of Difficulty: Intermediate.)

Graphical abstract

A 73-year-old female patient with metastatic pulmonary neoplasia, a right-sided malignant pleural effusion, and a large pericardial effusion (Figure 1A, stars) was referred for diagnostic and therapeutic pericardiocentesis. On arrival, she was in respiratory distress with distended jugular veins, tachypnea, and sinus tachycardia but normal blood pressure. Pericardial drainage was performed, and the effusion was evacuated completely.

Figure 1.

Pericardiocentesis Complicated by Pneumopericardium

(A) Echocardiographic parasternal short-axis view in which a large pericardial effusion (stars) can be appreciated. The image was taken before the first pericardiocentesis. (B) Subcostal echocardiographic view showing swirling microbubbles of trapped air in the pericardial sac (arrows). This image was taken after the patient had accidentally removed the pericardial tube and her clinical condition worsened. See Video 1. (C) Chest radiograph obtained immediately after the echocardiography image in B; air surrounding the cardiac silhouette (arrows) can be seen. (D) Intraprocedural fluoroscopy image after injection of contrast agent during the second pericardiocentesis, where bubbles of trapped air in the pericardial sac (arrows) can be appreciated. See Video 2.

Unfortunately, the patient accidentally removed the pericardial tube, and her clinical condition and hemodynamic status worsened progressively during the night (heart rate 109 beats/min; blood pressure 92/63 mm Hg). Echocardiography was repeated and showed recurrent formation of pericardial effusion and unexpectedly swirling microbubbles within the pericardial fluid, which were interpreted as trapped air (Figure 1B, arrows, Video 1). Pneumopericardium was suspected and confirmed by chest radiograph, which showed air surrounding the cardiac silhouette (Figure 1C, arrows). This condition was probably caused by air leakage secondary to a defect in the drainage system and/or accidental removal of the pericardial tube. Immediate pericardiocentesis was performed, and pericardial fluid and 100 ml of trapped air were removed (Figure 1D, Video 2). This procedure led to prompt hemodynamic stabilization.

Online Video 1.

Download video file ^{(1.3MB, mp4)}

Subcostal Echocardiography View

The loop was recorded after the first pericardiocentesis and shows swirling microbubbles of trapped air in the pericardial fluid.

Online Video 2.

Download video file ^{(1.2MB, mp4)}

Fluoroscopic Loop Recorded During the Second Pericardiocentesis

After the injection of contrast agent, swirling bubbles of trapped air within the pericardial sac can be appreciated.

Pneumopericardium is a rare but potentially severe condition. In the literature, different causes, such as intestinopericardial or pneumopericardial fistula 1, 2, penetrating chest trauma, and pericarditis with gas-forming organisms, have been described (3).

Fortunately, iatrogenic pneumopericardium caused by pericardiocentesis is very rare. However, in case of hemodynamic worsening despite complete evacuation of a hemodynamically significant pericardial effusion, it should be considered in the differential diagnosis because immediate recognition and treatment are crucial.