Iatrogenic Pneumopericardium After Pericardiocentesis

Abstract: A 65-year-old patient underwent pericardiocentesis for cardiac tamponade after radiofrequency ablation for ventricular tachycardia. Subsequent to stabilization, the patient developed pneumopericardium, which was detected in the catheterization laboratory and managed successfully by pericardial aspiration.

J INVASIVE CARDIOL 2016;28(12):E225-E226.

Key words: pericardiocentesis, pneumopericardium, iatrogenic, cardiac tamponade, radiofrequency ablation

Case Presentation

A 65-year-old man underwent successful radiofrequency ablation of scar-related ventricular tachycardia in the setting of remote inferior wall myocardial infarction. One hour later, the patient developed breathlessness. His blood pressure dropped to 80/60 mm Hg with tachycardia. Transthoracic echocardiography confirmed moderate pericardial effusion with cardiac tamponade physiology. 

Emergent pericardiocentesis was performed by fluoroscopy-guided subxiphoidal approach. In the catheterization laboratory, a 7 Fr sheath was used to access the pericardial cavity using an over-the-wire technique. A 6 Fr pigtail was inserted through the 7 Fr sheath, following which 540 mL of blood were aspirated by pericardiocentesis. Concomitant blood transfusion was started. Blood pressure started improving and tachycardia settled. However, 5 minutes later, the patient again developed breathlessness with fall in systemic pressures. The transthoracic echocardiographic window became abruptly poor, with poor visualization of cardiac structures. Fluoroscopy was done immediately, which showed presence of air in the pericardial cavity (Figures 1 and 2; Videos 1 and 2). The side port of the 7 Fr sheath was accidentally opened and air was sucked into the pericardial cavity causing pneumopericardium and hemodynamic compromise. Closure of the side port followed by immediate aspiration of the air was performed (Figures 3 and 4; Videos 3 and 4). The patient became hemodynamically stable thereafter.

Iatrogenic pneumopericardium as a consequence of pericardiocentesis is rare and mostly results from leakage of drainage system or formation of communication between pleura and pericardium. In our case, it was a result of accidental leakage from the side port of the sheath. Although pericardiocentesis is rarely associated with serious complications, meticulous procedural technique and postprocedure monitoring are necessary.

From the Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

Manuscript submitted June 6, 2016, final acceptance given June 9, 2016.

Address for correspondence: Dr Narayanan Namboodiri, Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India – 695011. Email: kknnamboodiri@sctimst.ac.in