Pericardiocentesis is a common therapeutic procedure for pericardial tamponade due
to pericardial effusion as well as a diagnostic procedure to obtain fluid for cytopathologic
examination. Standard methods include ultrasound or fluoroscopic guidance, which generally
result in high success rates (over 95%).[1],[2] The complication rate of pericardiocentesis
is low with reported incidences of 1%–2%.[3] In the past, the most common indications
for pericardiocentesis include uremia, tuberculous pericarditis or malignant pericardial
effusions. However, with the increasing number of catheter-based interventional cardiac
procedures, iatrogenic pericardial effusions are becoming more frequent.[4]–[6]
Chilaiditi syndrome is a rare anatomic variant with interposition of the colon transverse
between the liver and the right diaphragm. The incidence is increasing along with
the patients' age and is about 0.025 in young but up to 1% in elderly people. Most
patients do not have any symptoms and are diagnosed incidentally by radiographic findings.
When symptoms occur, abdominal pain, bloating, nausea, functional constipation and
some cases of bowel obstruction and perforation are reported.[7],[8]
We report an 81-year-old male who admitted to our clinic because of heart failure.
Clinical findings included a 3/6 diastolic murmur, arrhythmic pulse, pulmonary rales,
and peripheral oedema. Also noted on physical examination were a barrel-shaped thorax
and overall cachexia, consistent with the clinical history of chronic obstructive
pulmonary disease. Electrocardiogram showed tachyarrhythmia and a cardiac ultrasound
revealed severe aortic insufficiency with moderate stenosis and a severe calcification
of the aortic valve and pulmonary hypertension.
After pharmacologic cardiac compensation (diuresis and rate control), we performed
coronary catheterisation and considered transcatheter aortic valve implantation for
the aortic vavular disease (STS score > 6). Coronary angiogram demonstrated severe
calcified stenosis of the left anterior descending coronary artery, so we performed
a prima-vista percutaneous coronary intervention. This complex procedure was initiated
with conventional pre-PTCA (BMW, Boston Scientific, USA and a 2.0 mm balloon, Maverick,
Boston Scientific, USA) and followed by a stent-implantation with a focally under-expanded
3.0 mm stent (Xience 3.0/18 mm; Abbott, USA). Using a double-wire technique (BMW and
Choice PT, Boston Scientific, USA) and despite multiple attempts with high-pressure
balloons of various sizes (2.5/15 mm, 3.0/15 mm, and 3.0/8 mm; Quantum-NC, Boston
Scientific, USA) the intervention was unsuccessful and the stent was still focally
under-expanded. We therefore terminated the procedure and referred the patient to
a conventional surgical management.
However, three hours after the procedure, the patient began complaining of dyspnoea
and showed jugular venous distention including a cardiogenic shock. The pulse was
up to 145 beats/min and the blood pressure low at 90/45 mmHg. He was brought back
to the catheterisation laboratory immediately and a cardiac tamponade by pericardial
effusion was confirmed by echocardiography in the apical four chamber view. Pericardiocentesis
was performed using standard technique with a 14G needle (Angiocath, Lifeguard Emergency
Products, USA), a femoral 7F sheath (Ultimum, SJM Abbott, USA), and a normal J-wire
(Angiodyn, B. Braun, Germany). The procedure was performed under fluoroscopic guidance
in a left anterior oblique 90° view, locating the pericardial effusion by injection
of a mixture of saline and contrast agent. After placing the sheath, we placed a 7F
pigtail catheter (Launcher, Medtronic, USA) in the pericardial space and aspirated
300 mL haemorrhagic fluid. Immediately afterward, the patient's pulse decreased and
his blood pressure stabilised.
The patient was then admitted to the Intensive Care Unit and remained stable. After
48 h and removal of the pigtail catheter, the patient complained of abdominal pain
involving all four quadrants and showed peritoneal guarding and increasing signs of
infection. A computed tomography scan disclosed pneumoperitoneum and free fluid within
the abdominal cavity (Figure 1).
Figure 1.
Puncture of the pericardium with contrast dye injection.
LAO 90° View.
Review of the procedural fluoroscopy images, together with the additional anatomical
information provided by the computed tomography scan (Figure 2), we assumed that we
had punctured through the transverse colon during the emergency pericardiocentesis.
The abnormality of a Chilaiditi syndrome was diagnosed post-interventional without
any clinical symptoms in the patients history and this variant of the interposition
of the colon between liver and diaphragm was the reason for accidental perforation
of the colon by pericardiocentesis.
Figure 2.
Coronal (A) and sagittal (B) CT scan showing free air and fluid, Chialiditi-Syndrome
(arrow marks pneumoperitoneum).
After intensive discussions with attending general surgeons, we decided to forego
exploratory laparotomy and to treat the patient conservatively with intravenous fluid
resuscitation, antibiotics (piperacillin/tazobactam), and analgesic agents.
After 48 h of conservative therapy, the patient's symptoms were diminishing and signs
of peritoneal infection abated. On the fourth day after pericardiocentesis the patient
referred for conventional surgical aortic valve replacement with left internal mammary
artery bypass graft to the left anterior descending coronary artery. The operation
and his subsequent post-operative course were uneventful. Signs of bacterial infection
were not observed intra-operatively.
The most common aetiology of pericardial effusion has changed over the last three
decades due to the increasing number of iatrogenic pericardial effusions arising as
complications of interventional cardiac procedures. Most patients undergoing these
procedures receive anticoagulant or antiplatelet therapy (or both), which increases
the risk of haemorrhagic pericardial effusion.[3] However, the incidence of pericardial
effusion after cardiac intervention is still low (approximately 1%).[3],[9]–[11] Pericardial
effusions developing after percutaneous coronary intervention often result in pericardial
tamponade, possibly because of anticoagulation/antiplatelet therapy.
Complication rates from pericardiocentesis of acute pericardial tamponade are higher
than in cases of large, chronic pericardial effusions because of the limited pericardial
space available for needle insertion.[12] Other complications described previously
include cardiac puncture with intrapericardial thrombus formation, cardiac arrhythmias,
traumatic injury of adjacent organs such as laceration of the liver or spleen, and
haemorrhagic peritonitis due to perforation of the diaphragm.[3],[13],[14] Complications
such as bowel perforation due to interposition of the colon between liver and diaphragm
in case of Chilaiditi syndrome are not reported yet. The incidence of a Chilaiditi
syndrome is age depended and is up to 1% in geriatric patients like in our case.[8]
Duvernoy, et al.[1] described two patients presenting with acute abdominal pain after
pericardiocentesis, presumptively caused by bowel perforation. As in the case presented
herein, these two patients experienced spontaneous resolution of their symptoms without
surgical intervention.[1] Management of bowel perforation secondary to pericardiocentesis
is rare and lacks of clinical guidelines.
Colonic perforation during colonoscopy or therapeutic polypectomy is a similar scenario
to perforation by a 7F pigtail catheter often used in pericardiocentesis. Even though
this is a more common clinical scenario, there are no evidence-based, consensus recommendations
for surgical or non-surgical management. Most authors recommend operative therapy
in cases with large perforations and signs of peritonitis, whereas smaller perforations
may often be treated non-surgically.[15],[16] A prototypical example is colonic perforation
during polypectomy. In most of these cases, the perforation is small and closes spontaneously
because of the omental response; limited contamination of the peritoneal space occurs
in these circumstances.[15]
In our case, the perforation caused by a 7F pigtail catheter is around 2 mm in diameter.
Since the bowel wall was dilated in the region of the perforation, the probability
of spontaneous closure was high in this case. In previous studies, patients with high
American Society of Anaesthesiologists Physical Status Classification scores (> 3),
advanced age, or on antiplatelet therapy (like our patient) have poor outcomes in
case of colon perforation.[16] Nevertheless, we opted for conservative, non-surgical
management: nil per os, nasogastric tube decompression, intravenous fluid therapy,
broad-spectrum antibiotics, and adequate pain management. After 24 h, peritoneal signs
were absent and signs of infection were deceasing, suggestive of successful non-operative
treatment. The patient was finally referred for aortic valve replacement and coronary
artery bypass grafting on the fourth day after the pericardiocentesis. There was no
sign of pericardial infection secondary to colonic puncture during pericardiocentesis.
Bowel perforation due to pericardiocentesis in the setting of an anatomic variant
of Chilaiditi syndrome is a very rare complication. Because of the higher rise of
Chilaiditi syndrome in elderly, subxiphoidal ultrasound could exclude Chilaiditi syndrom
before fluoroscopic guided pericardiocentesis. Management of bowel perforation due
to pericardiocentesis can be deduced by previous clinical experience with perforation
secondary to polypectomy or colonoscopy. Because the perforation caused by the pigtail
catheter was presumed to be relatively small, conservative treatment (nil per os,
decompression by nasogastric tube, intravenous fluid therapy, broad-spectrum antibiotics,
and pain management) was considered as the best management strategy in this case.