A case report of ventricular dysfunction post pericardiocentesis: stress cardiomyopathy or pericardial decompression syndrome?

Cardiovascular Ultrasound, Jul 2015

We report a case of transient biventricular dysfunction post therapeutic pericardiocentesis, with classic features of stress cardiomyopathy (SCM). In our patient, the clinical and echocardiographic features were more in keeping with Takotsubo-type SCM than pericardial decompression syndrome (PDS). Our case is instructive in challenging our understanding of the aetiology of LV dysfunction complicating pericardiocentesis, and in highlighting the importance of careful clinical evaluation (altered heart rate and dyspnoea) in suspecting acute LV dysfunction after initial clinical improvement with pericardial aspiration.

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A case report of ventricular dysfunction post pericardiocentesis: stress cardiomyopathy or pericardial decompression syndrome?

Ayoub et al. Cardiovascular Ultrasound A case report of ventricular dysfunction post pericardiocentesis: stress cardiomyopathy or pericardial decompression syndrome? Chadi Ayoub 0 1 2 Michael Chang 0 1 2 Leonard Kritharides 1 2 0 Equal contributors 1 The University of Sydney , Sydney, NSW , Australia 2 Department of Cardiology, Concord Repatriation General Hospital , Concord 2139, NSW , Australia We report a case of transient biventricular dysfunction post therapeutic pericardiocentesis, with classic features of stress cardiomyopathy (SCM). In our patient, the clinical and echocardiographic features were more in keeping with Takotsubo-type SCM than pericardial decompression syndrome (PDS). Our case is instructive in challenging our understanding of the aetiology of LV dysfunction complicating pericardiocentesis, and in highlighting the importance of careful clinical evaluation (altered heart rate and dyspnoea) in suspecting acute LV dysfunction after initial clinical improvement with pericardial aspiration. Pericardiocentesis; Stress cardiomyopathy; Pericardial decompression syndrome; Ventricular dysfunction; Echocardiography - Background We report a case of reversible biventricular dysfunction following successful pericardiocentesis with classic features of stress or “Takotsubo” cardiomyopathy (SCM). Reports of SCM after pericardiocentesis are rare [1], as distinct from so-called pericardial decompression syndrome (PDS) which encompasses a spectrum of features of cardiac decompensation after large volume pericardiocentesis, including pulmonary oedema, adult respiratory distress syndrome, severe bi-ventricular failure and cardiogenic shock [2]. Our case is instructive in challenging our understanding of the aetiology of LV dysfunction complicating pericardiocentesis, and in highlighting the importance of careful clinical observations (heart rate and dyspnoea) in suspecting acute LV dysfunction after initial clinical improvement with pericardiocentesis. Case report A 62-year-old male presented with progressive dyspnoea for 10 days. He had a background of stage IV metastatic non-small lung carcinoma treated for 6 months with non-cardiotoxic chemotherapy (carboplatin and gemcitabine), and recently commenced on target therapy (Erlotinib). Clinical examination revealed signs consistent with cardiac tamponade, including significant pulsus paradoxus, tachycardia (heart rate 101), tachypnea (respiratory rate 25), elevated jugular venous pressure and muffled heart sounds. He was normotensive at 130/90mmHg. The patient was extremely anxious and spontaneously expressed concern about his imminent death. His electrocardiogram (ECG) (Fig. 1) demonstrated electrical alternans and bedside transthoracic echocardiography (TTE) revealed a large pericardial effusion with features of cardiac tamponade, including diastolic compression of both right atrium and ventricle (Fig. 2, Additional file 1: Video 1 and Additional file 2: Video 2) and large mitral inflow variation (Fig. 3). Urgent pericardiocentesis was performed with a restricted aspiration of only 600 ml drained initially over the first hour, and a total drainage of 1.8 l of heavily blood-stained pericardial fluid over 36 h. During initial aspiration of pericardial fluid there was immediate symptomatic relief and haemodynamic improvement (heart rate [HR] decreased to 80/min, respiratory rate [RR] decreased to 15 breaths/min and BP increased to 150/70 mmHg). Overnight (9 h post procedure) the patient developed chest discomfort, dyspnea, tachycardia (HR 110) and tachypnoea (RR 24). TTE the next morning showed no re-accumulation of pericardial fluid, but detected new severe impairment in function of both ventricles, with akinesis of the apex and peri-apical region (Figs. 4 and 5, Additional file 3: Video 3 and Additional file 4: Video 4). Biomarkers demonstrated a rise in highly sensitive troponin from 8 to 224ng/L, but creatinine kinase did not rise significantly (107 to 116U/L). ECG after chest pain demonstrated resolution of the electrical alternans, with new loss of R waves in the anterior leads (Fig. 6). Based on a presumptive diagnosis of SCM, angiotensin converting enzyme inhibitor and long acting betablocker were commenced, chemotherapy withheld and the patient discharged for early clinical and echocardiographic review. Serial follow up TTEs showed normalization of bi-ventricular function after two weeks (Figs. 7 and 8, Additional file 5: Video 5 and Additional file 6: Video 6), and restoration of R waves on subsequent ECGs (Fig. 9). Subsequent computed tomography examination showed normal coronary arteries with a calcium score of zero and no evidence of LAD laceration or dissection. The patient presented three months later with reaccumulation of pericardial effusion and tamponade. Therapeutic pericardiocentesis was performed with 500 ml of blood stained pericardial fluid drained immediately, with 1.9 L in total over 36 h. On this presentation he was relaxe (...truncated)


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Chadi Ayoub, Michael Chang, Leonard Kritharides. A case report of ventricular dysfunction post pericardiocentesis: stress cardiomyopathy or pericardial decompression syndrome?, Cardiovascular Ultrasound, 2015, pp. 32, 13, DOI: 10.1186/s12947-015-0026-3