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An Elderly Man With Dyspnea and Chest Pain FREE TO VIEW

R. Elaine Cagnina, MD, PhD; Elizabeth B. Gay, MD
Author and Funding Information

CORRESPONDENCE TO: Elaine Cagnina, MD, PhD, Division of Pulmonary and Critical Care Medicine, UVA Health System, PO Box 800546, Charlottesville, VA 22908


Copyright 2016, . All Rights Reserved.


Chest. 2016;149(1):e7-e9. doi:10.1016/j.chest.2015.11.003
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Published online

An 87-year-old man with a history of rheumatoid arthritis and associated interstitial lung disease was transferred to our ED after presentation to an outside hospital with the chief complaint of increasing dyspnea on exertion as well as new left-sided chest pain. CT of the chest performed prior to transfer was notable for a circumferential pericardial effusion as well as a large pulmonary embolus (PE) in the left main pulmonary artery (Fig 1). On presentation to our ED, his BP was 114/91 mm Hg and oxygen saturation was 98% on 2 L/min via nasal cannula. ECG showed a heart rate of 133 beats/min in atrial fibrillation with low voltages in all leads as well as electrical alternans. Transthoracic echocardiogram performed by cardiology in the ED was concerning for pretamponade physiology with right ventricular (RV) diastolic collapse, and he was admitted to the medical ICU for further management.

Figure Jump LinkFigure 1 Axial CT images of an 87-year-old patient presenting with dyspnea and left-sided chest pain showing massive left main pulmonary embolus (∗, A) and large, circumferential pericardial effusion (white arrows, B).Grahic Jump Location

On admission to the ICU, we performed a goal-directed echocardiogram (GDE); selected views are shown in Video 1. This was notable for a large pericardial effusion with an underfilled right ventricle throughout the cardiac cycle. Additionally, the inferior vena cava (IVC) was large and the diameter did not vary with respiration (image not shown). An emergent pericardiocentesis was performed with 800 mL of bloody fluid removed via subxyphoid approach with pericardial drain placement. Immediately following the procedure, the patient developed refractory shock requiring high-dose vasopressors. An emergent repeat bedside GDE was performed and is shown in Video 2.

Question: After reviewing the case and the ultrasound images, what is the most likely etiology of shock in this postpericardiocentesis patient?

Answer: RV failure resulting from massive PE

We present here an elderly patient who developed refractory shock after pericardiocentesis for impending cardiac tamponade in the setting of massive PE. His pretamponade was recognized early both by the cardiology team who evaluated him in the ED as well as the critical care physicians who assumed his care and performed a focused cardiac ultrasound showing RV collapse secondary to a large pericardial effusion (Video 1). Both right atrial systolic collapse and RV diastolic collapse are markers of a hemodynamically significant pericardial effusion. IVC plethora with loss of respiratory variation on focused echocardiogram is also a sensitive finding for cardiac tamponade; however, it is not a specific finding because many other conditions can cause an enlarged IVC. Given the concern for impending hemodynamic collapse due to the patient’s large effusion, he was sent for emergent pericardiocentesis after which he developed refractory shock.

The differential of his shock state included obstructive shock secondary to massive PE as well as failure to relieve tamponade or procedural complications postpericardiocentesis. In one study of 1,127 echocardiogram-guided pericardiocenteses, complications that could progress to shock were rare but included RV puncture with hemorrhagic tamponade, chamber lacerations, intercostal vessel injuries, pneumothoraces, arrhythmias, and bacteremia. Additional considerations for major complications include mammary or coronary vessel injury or perforation of a hollow viscus. The overall rate of complication of pericardiocentesis in the literature is 1.2% to 7% with a major complication rate of 0.7% to 3%.,,,, GDE at the bedside in the ICU is useful in the generalized setting of shock to assess left and right ventricular pump function, pericardial effusion, septal dynamics, valvular morphology, major valve failure, and fluid responsiveness, but can prove even more useful in the postprocedure period because nearly all of the complications discussed previously can be detected via ultrasound.,,

GDE in this case did not reveal a procedural complication and did confirm that the pericardial effusion had been adequately evacuated. The etiology of the patient’s postprocedural shock was shown to be RV failure secondary to massive PE (Discussion Video). Apical four-chamber view revealed enlargement and hypokinesis of the right ventricle. Notably, there was a distinct pattern to the RV hypokinesis with apical sparing known as the McConnell sign. Originally, this sign was felt to be highly specific for acute PE, but later publications have questioned this specificity because RV infarction can frequently produce this echocardiographic finding.

Pericardiocentesis results in rapid lowering of intrapericardial pressures resulting in increased RV filling and, under normal circumstances, an increase in cardiac output. There have been previous case reports of RV failure following pericardiocentesis in the absence of PE secondary to an immediate increase in venous return leading to volume overload and RV dilation., In the case of the patient in our report, the etiology was felt to be massive PE. RV failure is well described in the setting of acute PE and is associated with increased risk of death as well as recurrent PE.,, We theorized that in this patient the increased intrapericardial pressure from his large pericardial effusion augmented RV function in the setting of massive PE, outweighing the negative impact of the effusion on RV filling. Upon draining the effusion and increasing RV filling, the right ventricle could not function against the high pulmonary artery pressures caused by massive PE, and a clinical shock state developed. In this setting, he was started on inotrope therapy in addition to vasopressors and his hemodynamics subsequently stabilized. Thrombolytic therapy was not administered because of ongoing sanguinous output from his pericardial drain and the overall risk of this intervention in the setting of largely palliative treatment goals.

Cytology on the pericardial fluid was positive for metastatic adenocarcinoma of unknown primary. To our review, all other prior case reports of a patient presenting with coexisting pericardial tamponade and massive PE were also in the setting of advanced malignancy., Given his age and comorbidities, the patient and his family elected for no further treatment of his malignancy. His inotropes were gradually weaned and his vitals remained stable; he was discharged to hospice care after removal of his pericardial drain.

  • 1.

    Critical care physicians should be trained to use GDE to recognize patients at risk for tamponade to facilitate early intervention.

  • 2.

    GDE by the ICU clinician is a useful tool in assessing shock states, particularly when there is concern about a complication of an intrathoracic procedure such as pericardiocentesis.

  • 3.

    Patients are at risk for developing right ventricular failure following pericardiocentesis for tamponade. This risk is particularly high in the setting of coexisting PE.

Financial/nonfinancial disclosures: None declared.

Other contributions:CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met.

Additional information: To analyze this case with the videos, see the online version of this article.

Himelman R.B. .Kircher B. .Rockey D.C. .Schiller N.B. . Inferior vena cava plethora with blunted respiratory response: a sensitive echocardiographic sign of cardiac tamponade. J Am Coll Cardiol. 1988;12:1470-1477 [PubMed]journal. [CrossRef] [PubMed]
 
Tsang T.S.M. .Enriquez-Sarano M. .Freeman W.K. .et al Consecutive 1127 therapeutic echocardiographically guided pericardiocenteses: clinical profile, practice patterns, and outcomes spanning 21 years. Mayo Clin Proc. 2002;77:429-436 [PubMed]journal. [CrossRef] [PubMed]
 
Maisch B. .Seferović P.M. .Ristić A.D. .et al Guidelines on the diagnosis and management of pericardial diseases executive summary; The Task force on the diagnosis and management of pericardial diseases of the European society of cardiology. Eur Heart J. 2004;25:587-610 [PubMed]journal. [CrossRef] [PubMed]
 
Cho B.C. .Kang S.M. .Kim D.H. .et al Clinical and echocardiographic characteristics of pericardial effusion in patients who underwent echocardiographically guided pericardiocentesis: Yonsei Cardiovascular Center experience, 1993-2003. Yonsei Med J. 2004;45:462-468 [PubMed]journal. [CrossRef] [PubMed]
 
Nguyen C.T. .Lee E. .Luo H. .Siegel R.J. . Echocardiographic guidance for diagnostic and therapeutic percutaneous procedures. Cardiovasc Diagn Ther. 2011;1:11-36 [PubMed]journal. [PubMed]
 
Tsang T.S. .Seward J.B. .Barnes M.E. .et al Outcomes of primary and secondary treatment of pericardial effusion in patients with malignancy. Mayo Clin Proc. 2000;75:248-253 [PubMed]journal. [CrossRef] [PubMed]
 
Tsang T.S. .Freeman W.K. .Barnes M.E. .Reeder G.S. .Packer D.L. .Seward J.B. . Rescue echocardiographically guided pericardiocentesis for cardiac perforation complicating catheter-based procedures. The Mayo Clinic experience. J Am Coll Cardiol. 1998;32:1345-1350 [PubMed]journal. [CrossRef] [PubMed]
 
Beaulieu Y. . Bedside echocardiography in the assessment of the critically ill. Crit Care Med. 2007;35:S235-S249 [PubMed]journal. [CrossRef] [PubMed]
 
Beaulieu Y. . Specific skill set and goals of focused echocardiography for critical care clinicians. Crit Care Med. 2007;35:S144-S149 [PubMed]journal. [CrossRef] [PubMed]
 
Schmidt G.A. .Koenig S. .Mayo P.H. . Shock: ultrasound to guide diagnosis and therapy. CHEST. 2012;142:1042-1048 [PubMed]journal. [CrossRef] [PubMed]
 
McConnell M.V. .Solomon S.D. .Rayan M.E. .Come P.C. .Goldhaber S.Z. .Lee R.T. . Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism. Am J Cardiol. 1996;78:469-473 [PubMed]journal. [CrossRef] [PubMed]
 
Casazza F. .Bongarzoni A. .Capozi A. .Agostoni O. . Regional right ventricular dysfunction in acute pulmonary embolism and right ventricular infarction. Eur J Echocardiogr. 2005;6:11-14 [PubMed]journal. [CrossRef] [PubMed]
 
Anguera I. .Paré C. .Perez-Villa F. . Severe right ventricular dysfunction following pericardiocentesis for cardiac tamponade. Int J Cardiol. 1997;59:212-214 [PubMed]journal. [CrossRef] [PubMed]
 
Armstrong W.F. .Feigenbaum H. .Dillon J.C. . Acute right ventricular dilation and echocardiographic volume overload following pericardiocentesis for relief of cardiac tamponade. Am Heart J. 1984;107:1266-1270 [PubMed]journal. [CrossRef] [PubMed]
 
Grifoni S. .Vanni S. .Magazzini S. .et al Association of persistent right ventricular dysfunction at hospital discharge after acute pulmonary embolism with recurrent thromboembolic events. Arch Intern Med. 2006;166:2151-2156 [PubMed]journal. [CrossRef] [PubMed]
 
Grifoni S. .Olivotto I. .Cecchini P. .et al Short-term clinical outcome of patients with acute pulmonary embolism, normal blood pressure, and echocardiographic right ventricular dysfunction. Circulation. 2000;101:2817-2822 [PubMed]journal. [CrossRef] [PubMed]
 
Akhbour S. .Khennine B.A. .Oukerraj L. .Zarzur J. .Cherti M. . Pericardial tamponade and coexisting pulmonary embolism as first manifestation of non-advanced lung adenocarcinoma. Pan Afr Med J. 2014;18:15- [PubMed]journal
 
Thomas C. .Lane K. .Cecconi M. . Pulmonary embolism with haemorrhagic pericardial effusion and tamponade: a clinical dilemma. BMJ Case Rep. 2014;2014:- [PubMed]journal
 

Figures

Figure Jump LinkFigure 1 Axial CT images of an 87-year-old patient presenting with dyspnea and left-sided chest pain showing massive left main pulmonary embolus (∗, A) and large, circumferential pericardial effusion (white arrows, B).Grahic Jump Location

Tables

References

Himelman R.B. .Kircher B. .Rockey D.C. .Schiller N.B. . Inferior vena cava plethora with blunted respiratory response: a sensitive echocardiographic sign of cardiac tamponade. J Am Coll Cardiol. 1988;12:1470-1477 [PubMed]journal. [CrossRef] [PubMed]
 
Tsang T.S.M. .Enriquez-Sarano M. .Freeman W.K. .et al Consecutive 1127 therapeutic echocardiographically guided pericardiocenteses: clinical profile, practice patterns, and outcomes spanning 21 years. Mayo Clin Proc. 2002;77:429-436 [PubMed]journal. [CrossRef] [PubMed]
 
Maisch B. .Seferović P.M. .Ristić A.D. .et al Guidelines on the diagnosis and management of pericardial diseases executive summary; The Task force on the diagnosis and management of pericardial diseases of the European society of cardiology. Eur Heart J. 2004;25:587-610 [PubMed]journal. [CrossRef] [PubMed]
 
Cho B.C. .Kang S.M. .Kim D.H. .et al Clinical and echocardiographic characteristics of pericardial effusion in patients who underwent echocardiographically guided pericardiocentesis: Yonsei Cardiovascular Center experience, 1993-2003. Yonsei Med J. 2004;45:462-468 [PubMed]journal. [CrossRef] [PubMed]
 
Nguyen C.T. .Lee E. .Luo H. .Siegel R.J. . Echocardiographic guidance for diagnostic and therapeutic percutaneous procedures. Cardiovasc Diagn Ther. 2011;1:11-36 [PubMed]journal. [PubMed]
 
Tsang T.S. .Seward J.B. .Barnes M.E. .et al Outcomes of primary and secondary treatment of pericardial effusion in patients with malignancy. Mayo Clin Proc. 2000;75:248-253 [PubMed]journal. [CrossRef] [PubMed]
 
Tsang T.S. .Freeman W.K. .Barnes M.E. .Reeder G.S. .Packer D.L. .Seward J.B. . Rescue echocardiographically guided pericardiocentesis for cardiac perforation complicating catheter-based procedures. The Mayo Clinic experience. J Am Coll Cardiol. 1998;32:1345-1350 [PubMed]journal. [CrossRef] [PubMed]
 
Beaulieu Y. . Bedside echocardiography in the assessment of the critically ill. Crit Care Med. 2007;35:S235-S249 [PubMed]journal. [CrossRef] [PubMed]
 
Beaulieu Y. . Specific skill set and goals of focused echocardiography for critical care clinicians. Crit Care Med. 2007;35:S144-S149 [PubMed]journal. [CrossRef] [PubMed]
 
Schmidt G.A. .Koenig S. .Mayo P.H. . Shock: ultrasound to guide diagnosis and therapy. CHEST. 2012;142:1042-1048 [PubMed]journal. [CrossRef] [PubMed]
 
McConnell M.V. .Solomon S.D. .Rayan M.E. .Come P.C. .Goldhaber S.Z. .Lee R.T. . Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism. Am J Cardiol. 1996;78:469-473 [PubMed]journal. [CrossRef] [PubMed]
 
Casazza F. .Bongarzoni A. .Capozi A. .Agostoni O. . Regional right ventricular dysfunction in acute pulmonary embolism and right ventricular infarction. Eur J Echocardiogr. 2005;6:11-14 [PubMed]journal. [CrossRef] [PubMed]
 
Anguera I. .Paré C. .Perez-Villa F. . Severe right ventricular dysfunction following pericardiocentesis for cardiac tamponade. Int J Cardiol. 1997;59:212-214 [PubMed]journal. [CrossRef] [PubMed]
 
Armstrong W.F. .Feigenbaum H. .Dillon J.C. . Acute right ventricular dilation and echocardiographic volume overload following pericardiocentesis for relief of cardiac tamponade. Am Heart J. 1984;107:1266-1270 [PubMed]journal. [CrossRef] [PubMed]
 
Grifoni S. .Vanni S. .Magazzini S. .et al Association of persistent right ventricular dysfunction at hospital discharge after acute pulmonary embolism with recurrent thromboembolic events. Arch Intern Med. 2006;166:2151-2156 [PubMed]journal. [CrossRef] [PubMed]
 
Grifoni S. .Olivotto I. .Cecchini P. .et al Short-term clinical outcome of patients with acute pulmonary embolism, normal blood pressure, and echocardiographic right ventricular dysfunction. Circulation. 2000;101:2817-2822 [PubMed]journal. [CrossRef] [PubMed]
 
Akhbour S. .Khennine B.A. .Oukerraj L. .Zarzur J. .Cherti M. . Pericardial tamponade and coexisting pulmonary embolism as first manifestation of non-advanced lung adenocarcinoma. Pan Afr Med J. 2014;18:15- [PubMed]journal
 
Thomas C. .Lane K. .Cecconi M. . Pulmonary embolism with haemorrhagic pericardial effusion and tamponade: a clinical dilemma. BMJ Case Rep. 2014;2014:- [PubMed]journal
 
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