148 Pericardial Decompression Syndrome - a Case Report of Transient Ventricular Failure Post-pericardiocentesis

Abstract

Pericardial decompression syndrome (PDS) is a rare syndrome characterised by cardiac dysfunction following pericardiocentesis for large pericardial effusions with suspected tamponade [[1]Vandyke Jr., W.H. Cure J. Chakko C.S. Gheorghiade M. Pulmonary edema after pericardiocentesis for cardiac tamponade.The New England Journal of Medicine. 1983; 309: 595-596Crossref PubMed Scopus (55) Google Scholar]. It is a significant cause of morbidity in patients with metastatic malignancies [[2]Pradhan R. Okabe T. Yoshida K. Angouras D.C. DeCaro M.V. Marhefka G.D. Patient characteristics and predictors of mortality associated with pericardial decompression syndrome: a comprehensive analysis of published cases. [Review].European Heart Journal Acute Cardiovascular Care. 2015; 4: 113-120Crossref PubMed Scopus (18) Google Scholar]. A 36-year-old male with metastatic lung adenocarcinoma presented with dyspnoea, tachycardia, hypotension, and right heart failure. Electrocardiogram showed electrical alternans and chest x-ray revealed cardiac enlargement. A transthoracic echocardiogram (TTE) demonstrated a large global pericardial effusion with features of tamponade. Pericardiocentesis immediately removed 1.2L of haemoserous fluid. Eleven hours later, the patient developed pulmonary oedema requiring diuretics and non-invasive ventilation. TTE revealed biventricular dilatation with severe global systolic dysfunction, and raised pulmonary pressures. A small residual pericardial effusion remained. CT coronary angiogram revealed calcium score of zero. He was discharged on bisoprolol, ramipril, and ivabradine. Progress TTE 6 weeks post-pericardiocentesis revealed resolution of systolic function. Three possible mechanisms include pre/afterload mismatch [[1]Vandyke Jr., W.H. Cure J. Chakko C.S. Gheorghiade M. Pulmonary edema after pericardiocentesis for cardiac tamponade.The New England Journal of Medicine. 1983; 309: 595-596Crossref PubMed Scopus (55) Google Scholar], unmasking of pre-existing LV dysfunction [[3]Wolfe M.W. Edelman E.R. Transient systolic dysfunction after relief of cardiac tamponade.Annals of Internal Medicine. 1993; 119: 42-44Crossref PubMed Scopus (42) Google Scholar], and myocardial stunning from compression of epicardial vessels [[4]Braverman A.C. Sundaresan S. Cardiac tamponade and severe ventricular dysfunction.Annals of Internal Medicine. 1994; 120: 442Crossref PubMed Scopus (20) Google Scholar]. Literature reviews [2Pradhan R. Okabe T. Yoshida K. Angouras D.C. DeCaro M.V. Marhefka G.D. Patient characteristics and predictors of mortality associated with pericardial decompression syndrome: a comprehensive analysis of published cases. [Review].European Heart Journal Acute Cardiovascular Care. 2015; 4: 113-120Crossref PubMed Scopus (18) Google Scholar, 5Ayoub C. Chang M. Kritharides L. A case report of ventricular dysfunction post pericardiocentesis: stress cardiomyopathy or pericardial decompression syndrome?.Cardiovascular Ultrasound. 2015; 13: 1-12PubMed Google Scholar] note that PDS occurred after drainage of 450-2100ml, onset within seconds to weeks, a third of cases were fatal, and two thirds of systolic dysfunction normalised. Intercostal catheters are routinely clamped to prevent re-expansion pulmonary oedema, however no such guidelines exist for pericardiocentesis. Here we suggest limiting immediate drainage to 200ml in order to reduce the likelihood of PDS. Further research on limiting the rate and volume of drainage may clarify how to prevent PDS.