Images in. Cardiovascular. Medicine. Mariangela Peruzzi, MD. Giacomo Frati, MD. David Rose, MD. Ilaria Chirichilli, MD. Chiara Santo, MD. Massimo Ricci, MD.
Images in Cardiovascular Medicine
Mariangela Peruzzi, MD Giacomo Frati, MD David Rose, MD Ilaria Chirichilli, MD Chiara Santo, MD Massimo Ricci, MD
Spontaneous Pneumopericardium after Coronary Angioplasty
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n 85-year-old man with a history of mild chronic obstructive pulmonary disease underwent cardiac catheterization. Preoperative chest radiography had shown clear lungs and a normal cardiothoracic index (Fig. 1). Coronary angiography showed significant stenoses on the proximal segment of the left anterior descending coronary artery and at the origin of the 1st diagonal branch. At angioplasty, 2 bare-metal stents were implanted. Two days later, ultrasonography showed a pericardial effusion that was not hemodynamically significant. By the next day, however, it had enlarged to 25 mm, sufficient to produce diastolic compression of the heart. Because no ventricular wire had been inserted, and all of the other possible causes were excluded, the patient underwent coronary angiography again, to check for the presence of coronary artery perforation. The stents were patent, and there was no sign of perforation. A chest radiograph taken 2 hours after the intervention showed the onset of pneumopericardium: air–fluid levels in the pericardial cavity and enlargement of the cardiac silhouette (Fig. 2). Therefore, we decided to create a subxiphoid pericardial window. About 500 mL of serosanguineous liquid was removed via a pericardial drainage tube. Thereafter, a chest radiograph confirmed resolution of pericardial air. The precipitating mechanism of pneumopericardium in this case might have been an inflammatory response, but we are not aware of similar reports in the medical literature and the cause is still unclear.
Comment Section Editor: Raymond F. Stainback, MD, Department of Adult Cardiology, Texas Heart Institute at St. Luke’s Episcopal Hospital, 6624 Fannin St., Suite 2480, Houston, TX 77030
Pneumopericardium is an unusual but potentially critical event, characterized by the presence of air–fluid levels in the pericardial sac.1 It is frequent in premature babies who require positive pressure ventilation for respiratory distress. In adults it can be observed as an unusual complication of invasive procedures or surgical interventions,2,3 as an effect of fistulae or perforation of structures containing air,4 or as a result of penetrating or blunt thoracoabdominal trauma.5 Spontaneous cases of pneumopericardium have been observed during asthmatic crises or during the course of infection in association with severe injury.6 Our patient was affected by mild chronic obstruc-
From: Departments of Cardiology (Dr. Peruzzi) and Cardiac Surgery (Drs. Chirichilli, Frati, Ricci, Rose, and Santo), University of Rome Sapienza – Polo Pontino, 04100 Latina, Italy Address for reprints: Massimo Ricci, MD, via Pyre 15, 04100 Latina, Italy E-mail: massimo.ricci@ hotmail.it © 2010 by the Texas Heart ® Institute, Houston
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Spontaneous Pneumopericardium after Coronary Angioplasty
Fig. 1 Normal preoperative chest radiograph.
Volume 37, Number 6, 2010
References
Fig. 2 Pneumopericardium (arrow) after coronary angioplasty.
1. Van Trigt P, Douglas J, Smith PK, Campbell PT, Wall TC, Kenney RT, et al. A prospective trial of subxiphoid pericardiotomy in the diagnosis and treatment of large pericardial effusion. A follow-up report. Ann Surg 1993;218(6):777-82. 2. Baranchuk A, Simpson CS, Pinto S, Redfearn DP. Pneumopericardium after attempted left ventricular lead insertion. Can J Cardiol 2008;24(8):e56. 3. Celik T, Iyisoy A, Kursaklioglu H, Gunay C, Yuksel UC, Isik E. A case of pneumopericardium following endomyocardial biopsy. J Card Surg 2007;22(6):519-21. 4. Varol E, Ozaydin M, Agcal C. Iatrogenic pneumopericardium. Anadolu Kardiyol Derg 2006;6(3):298. 5. Di Filippo A, Batacchi S, Ciapetti M, Spina R, Peris A. Pneumopericardium after major trauma. J Trauma 2009;66 (4):1260. 6. Ameh V, Jenner R, Jilani N, Bradbury A. Spontaneous pneumopericardium, pneumomediastinum and subcutaneous emphysema: unusual complications of asthma in a 2-year-old boy. Emerg Med J 2006;23(6):466-7.
tive pulmonary disease, but this condition does not explain the onset of pneumopericardium. The mechanism of pneumopericardium in this case could not be determined in the absence of a link to any similar reported case. Surgical drainage resulted in immediate hemodynamic improvement and in resolution of our patient’s symptoms.
Texas Heart Institute Journal
Spontaneous Pneumopericardium after Coronary Angioplasty
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