Acute pneumopericardium: when echocardiography is not enough.

A 46-year-old female with metastasized rectal adenocarcinoma complained of progressive exertional dyspnea. The physical exam was remarkable for low blood pressure (98/54 mmHg) and tachycardia (115 bpm). A severe pericardium effusion with right chambers’ collapse was identified, and the patient was submitted to echocardiography-guided pericardiocentesis by a subxiphoid approach, employing a handheld ultrasound device, with fluoroscopy available. The puncture was undertaken uneventfully, with prompt drainage of serous fluid (500 cc) through a 6Fr pigtail catheter paralleled by pericardial effusion reduction on echo. However, it was impossible to obtain an ultrasound window to visualize the heart at the end of the procedure. Diagnosis: Immediate fluoroscopy showed a pneumopericardium (image and video 1), which explained the imaging finding on transthoracic ultrasound. The air was instantly drained with a 50-cc syringe (video 2). The patient remained asymptomatic and the discharge chest radiography was normal. Pneumopericardium is a rare complication of pericardiocentesis, and we hypothesize that it was due to air leakage to the pericardial drainage system (1). Conservative management is reasonable in hemodinamically stable patients (2); however, we proceeded to aspiration as the catheter was in position. Fluoroscopy was crucial for this clinically inapparent diagnosis.