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A 61-Year-Old Woman With New Pericardial Effusion

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 61-year-old woman presented with pleuritic chest pain, shortness of breath, and syncope. She had a medical history of end-stage renal disease secondary to autosomal dominant polycystic kidney disease, after renal transplant 5 years prior. She had concomitant polycystic liver disease and had undergone right hepatectomy and cyst fenestration, plus inferior vena cava (IVC) stent placement for intrahepatic caval compression due to hepatic cysts 9 years earlier. Initial laboratory evaluation results revealed elevated creatinine levels with concern of renal graft failure. Physical examination results revealed a blood pressure of 96/65 mm Hg, an elevated jugular venous pressure with blunted Y-descent, Kussmaul sign, and distant heart sounds. Chest radiography results revealed cardiomegaly and the IVC stent was evident, adjacent to her heart (Figure, A). Echocardiography (Video 1 and Figure, B) revealed a large circumferential pericardial effusion, diastolic right ventricular collapse, and exaggerated respiratory variation (>25%) in the mitral inflow velocity but a normal inferior vena cava size.

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Pericardial effusion with tamponade caused by an IVC stent impinging on the coronary sinus

B. Pericardiocentesis with pericardial drain placement

This patient presented with evidence of clinical cardiac tamponade and tamponade physiology on transthoracic echocardiography, including right ventricular diastolic collapse and a mitral inflow variation of more than 25% with respiration. The IVC is not plethoric, but this could be secondary to residual compression from hepatic cysts. The presenting chest pain was most likely associated with pericardial inflammation. Nonsteroidal anti-inflammatory agents would be contraindicated in the setting of renal failure and medical therapy and observation alone are not appropriate given the evidence of tamponade. A pericardiocentesis with pericardial drain placement for 24 to 48 hours is the most appropriate first course of action. For this case, urgent cardiac surgery would be appropriate if urgent pericardiocentesis is not feasible or is unsuccessful in relieving tamponade. Given the IVC stent was placed 9 years prior, it was well incorporated into the endothelium of the vessel and removal was not feasible. Therefore, vascular surgery consultation should not be prioritized over addressing cardiac tamponade.

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Article Information

Corresponding Author: Melissa A. Lyle, MD, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (lyle.melissa@mayo.edu).

Published Online: January 22, 2020. doi:10.1001/jamacardio.2019.5276

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
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2.
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Tsang  TS, Enriquez-Sarano  M, Freeman  WK,  et al.  Consecutive 1127 therapeutic echocardiographically guided pericardiocenteses: clinical profile, practice patterns, and outcomes spanning 21 years.  Mayo Clin Proc. 2002;77(5):429-436. doi:10.1016/S0025-6196(11)62211-8PubMedGoogle ScholarCrossref
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Tsang  TS, Freeman  WK, Barnes  ME, Reeder  GS, Packer  DL, Seward  JB.  Rescue echocardiographically guided pericardiocentesis for cardiac perforation complicating catheter-based procedures: the Mayo Clinic experience.  J Am Coll Cardiol. 1998;32(5):1345-1350. doi:10.1016/S0735-1097(98)00390-8PubMedGoogle ScholarCrossref
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Lekhakul  A, Fenstad  ER, Assawakawintip  C,  et al.  Incidence and management of hemopericardium: impact of changing trends in invasive cardiology.  Mayo Clin Proc. 2018;93(8):1086-1095. doi:10.1016/j.mayocp.2018.01.023PubMedGoogle ScholarCrossref
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