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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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Corresponding Author: Melissa A. Lyle, MD, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (firstname.lastname@example.org).
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.
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