“Trap within a Trap”–A Case of Takotsubo Cardiomyopathy Following Drainage of a Large Pericardial Effusion

Abstract

A 52-year-old female presented for evaluation of dyspnoea. Background history was significant for ischaemic heart disease with previous PCI to the LAD and Crohn's disease managed with balsalazide and budesonide. On examination, she appeared distressed and unwell. She had a narrow pulse pressure (blood pressure, 120/100 mmHg), sinus tachycardia (heart rate, 110 beats/min), tachypnoea (respiratory rate 24 breaths/min) and hypoxia (O2 sats 91% on RA). The JVP was elevated 5 cm. Heart sounds were soft and the chest was clear to auscultation. Bedside echo demonstrated a large pericardial effusion with signs of cardiac tamponade including diastolic collapse of the RA/RV. Pericardiocentesis drained 1.2L of blood stained fluid. Post-pericardiocentesis echo showed normal right heart filling and normal left ventricular systolic function. A few hours post the procedure the patient complained of chest discomfort. ECG showed new T wave inversion antero-laterally. Serial troponins were 20 and 472 ng/L. Coronary angiography was performed which revealed a patent stent in the LAD with non-obstructive disease elsewhere. Left ventriculogram confirmed classical Takotsubo cardiomyopathy. She was managed with bisoprolol and ramipril. Echo ten days later showed normal LV size and function. Cytology from the pericardial aspirate was consistent with adenocarcinoma. A PET scan suggested a primary lung malignancy with widespread metastatic disease. Unfortunately the patient had a rapid decline and passed away with her family by her side. In conclusion Takotsubo cardiomyopathy is rare occurrence post pericardiocentesis. Pericardial decompression syndrome, myocardial perforation and coronary artery laceration should be also be considered in the unstable patient post pericardiocentesis.