Perils of pericardiocentesis

A 51-year-old woman underwent elective cardiac surgery for the closure of an atrial septal defect. The surgery was uneventful and the patient was making good progress. On postoperative day 6, she developed shortness of breath, tachycardia and raised jugular venous pressure. Transthoracic echocardiography noted a high pulmonary artery pressure of 65 mmHg (preoperative 78 mmHg), and a 3 cm pericardial effusion with tamponade effect on the right atrium. Pericardiocentesis under echocardiography guidance was performed without difficulty. The drainage from the pericardial catheter was good, and the patient noted immediate improvement in her dyspnoea. However, shortly following the procedure, she complained of increasing breathlessness, dizziness and became visibly pale. The oxygen saturation dropped rapidly from 96% to 53% and then became unrecordable. Systolic blood pressure fell to 52 mmHg and she became severely drowsy (Figure 1). The differential diagnosis included iatrogenic pneumothorax (tension) and myocardial injury. The bedside pericardiocentesis collection bag was then noted to be full to the bursting point of 2 litres with heavily blood-stained fluid. The draining tube was clamped, the bed was put to head down position, resuscitation with oxygen via rebreathable mask, and 1 mg intravenous adrenaline was administered. Intravenous colloid totaling 1.5 litres was actively squeezed into the patient through large intravenous catheters. At that point, the thought of elevating and inverting the pericardiocentesis collection bag to allow return transfusion of its contents did briefly cross the authors' minds. Fortunately, the patient swiftly regained consciousness, but her haemoglobin had fallen from 9.8 to 4.7 g/dl. She was rushed to the operating theatre for emergency surgery, which revealed the pericardiocentesis catheter had punctured and was lying within the right ventricle (Figure 2). The right ventricle was repaired with 3/0 prolene pleget and the pericardial blood clots were removed. The patient recovered well and was discharged 4 days later.