A Remarkable Finding Complicating Pericardiocentesis

Right ventricular perforation during emergent pericardiocentesis is an unfortunate but known complication of the procedure. However, right ventricular perforation with resultant endocardial and epicardial thrombi has never been described as a complication of pericardiocentesis. We describe a patient with this unusual finding. Although exceedingly uncommon, this is a rare but important complication of pericardiocentesis.

Case Report

A 76-year-old man with a history of metastatic non-small cell lung cancer, chronic obstructive pulmonary disease, and deep venous thrombosis presented with complaints of worsening dyspnea to the hospital. During initial evaluation, the patient was hypoxic and developed respiratory failure requiring urgent intubation. Shortly following, the patient became asystolic and suffered a cardiac arrest. He was successfully resuscitated with return of spontaneous circulation; however, he remained hypotensive without a clear etiology. A bedside echocardiogram was performed, revealing a large pericardial effusion with tamponade physiology.  

An emergent bedside pericardiocentesis was performed with withdrawal of bloody fluid and a pericardial drain was left in place. The pericardial drain continued to drain bloody fluid, raising the suspicion that the drain was in the right ventricle. A repeat echocardiogram confirmed the drain was through the right ventricular free wall. The catheter was repositioned, resulting in resolution of drainage. The catheter was then removed. Serial echocardiograms were performed, revealing the development of thrombus on the epicardial right ventricular free wall, as well as on the endocardial surface, consistent with the track of the pericardial drain (Figures 1-3). A small to moderate residual effusion persisted, without evidence of tamponade physiology.  

Discussion

Right ventricular perforation is a well-described iatrogenic phenomenon seen in association with traumatic pericardiocentesis. Prior to the 1970’s, pericardiocentesis was associated with considerably more morbidity. A panel of patients, 20 of whom had blind pericardiocentesis performed, resulted in 7 cardiac punctures. The development of two-dimensional echocardiography and other imaging modalities have proven useful in pre-procedure evaluation and as part of direct visualization of cardiac structures during pericardiocentesis, leading to a decrease in the rate of morbidity associated with complications from pericardiocentesis. Duvernoy et al demonstrated that only 3 of 352 cases of fluoroscopic-guided percutaneous pericardiocentesis by subxiphoid approach resulted in cardiac perforation. This was concordant with a study describing right ventricular laceration in 1 of the 91 cases with use of echocardiography for rescue pericardiocentesis (after complications of catheter-based procedures).

Pericardial thrombus has been also been described following pericardiocentesis in several case reports. It is often documented within 24 hours following the procedure.  There currently is no clear evidence to the frequency of this phenomenon or how it may affect outcomes.

The case described herein is the only case in the literature of both an epicardial and endocardial thrombus as a complication of a pericardiocentesis. This case raises the clinical dilemma regarding the use of anticoagulation in a patient with an intracardiac thrombus, but with a new hemorrhagic effusion.

References

1. Bastian A, Meiber A, Lins M, Siegel EG, Moller F, Simon R. Pericardiocentesis: differential aspects of a common procedure. Intensive Care Med. 2000; 26: 572-576.
2. Tsang T, Enriquez-Sarano M, Freeman WK, Barnes M, Sinak LJ, Gersh BJ, et al. Consecutive 1127 therapeutic echocardiographically guided pericardiocenteses: clinical profile, practice patterns, and outcomes spanning 21 years. Mayo Clinic Proceedings. 2002; 77(5): 429-436.
3. Duvernoy O, Borowiec J, Helmius G, Erikson U. Complications of percutaneous pericardiocentesis under fluoroscopic guidance. Acta Radiol. 1992; 33(4): 309-313.
4. Tsang T, Freeman WK, Barnes ME, Reeder GS, Packer DL, Seward LB. Rescue echocardiographically guided pericardiocentesis for cardiac perforation complicating catheter-based procedures. J Am Coll Cardiol. 1998; 32(5): 1345-1350.

Disclosure: The authors report no conflicts of interest regarding the content herein.

The authors can be contacted via Dr. Nissi Suppogu at nissi.suppogu@hhchealth.org.