Precautions When Performing Pericardiocentesis in Patients with Cardiac Tamponade-complicated Malignancy: A Case Report and Review of the Literature

Figure 1.. Images of computed tomography. (A) Twenty-three days prior to admission for cardiac tamponade. No thrombi were observed in either the pulmonary arteries or deep veins of the lower extremities. No pericardial or pleural effusion was observed. (B) Four days prior to admission. A large amount of pericardial and bilateral pleural effusion was observed. (C) After pericardiocentesis. The patient was intubated, and percutaneous cardiopulmonary support was initiated. Massive thrombi were observed in the bilateral pulmonary arteries (white arrows). In addition, there was a small thrombus in the left popliteal vein (yellow arrow).

Figure 2.. Chest X-ray findings. (A) Approximately one month prior to admission. Neither enlargement of the mediastinum nor bilateral pleural effusion was observed. (B) Four days prior to admission. Enlargement of the mediastinum and bilateral pleural effusion were observed (black arrow). Therefore, drainage of 450 mL of exudative right pleural fluid was performed through right thoracentesis. (C) On admission. Right-side dominant bilateral pleural effusion was observed despite drainage of the right thoracic cavity four days prior (black arrows). Further enlargement of the mediastinum was also observed (white arrows).

Figure 3.. Electrocardiogram findings. (A) Before the development of cardiac tamponade. No abnormality was observed. (B) On admission due to cardiac tamponade. Sinus tachycardia and low voltages in the broad limb and precordial leads were observed. (C) Immediately after pericardiocentesis. Right-axis deviation and an incomplete right bundle branch block appeared newly.

Figure 4.. Echocardiogram findings before pericardiocentesis. (A) Apical four-chamber image. A large amount of pericardial effusion was observed. The right ventricle was slightly collapsed. (B) Tricuspid regurgitant jet velocity measured by continuous Doppler imaging. The peak tricuspid regurgitant velocity was 3.56 m/s, corresponding to a pressure gradient of 51 mmHg.

Figure 5.. Possible underlying pathogenesis of concurrent cardiac tamponade and venous thromboembolism in patients with malignancy.

Figure 6.. Possible underlying pathogenesis. (A) Newly developed pulmonary thromboembolism following pericardiocentesis (Mechanism A). (B) Manifestation of right ventricular dysfunction due to coexisting pulmonary thromboembolism (Mechanism B). PTE: pulmonary thromboembolism, CVP: central venous pressure, DVT: deep venous thrombosis, RV: right ventricle