The Presentation of Pericardial

Decompression syndrome

Thomas Caranasos MDJames Bardes MD

Donnie Goodwin NP

Case Presentation• 38 year old female transferred from an referring hospital with

a diagnosis of pericardial effusion.  

• She presented to the referring facility with a 3 day history of increasing shortness of breath and chest pain.  

• A Chest CT revealed a pericardial effusion and bilateral pleural effusions.  

• She had no significant past medical or surgical history.  She took no medications.  She was a non-smoker, with no significant family history or occupational exposures.  

• Physical exam findings included midline trachea, decreased breath sounds at the bases, muffled heart sounds, and increased JVP.   

Case Presentation• Labs revealed only a mild anemia.  

• EKG revealed tachycardia and incomplete right bundle branch block.  

• Transthoracic echocardiogram revealed a large pericardial effusion, without tamponade physiology.  

• The patient was taken to the OR for subxiphoid pericardial window with placement of right pleural chest tube and two pericardial blake drains.  Initially 1400cc of hemorrhagic pericardial fluid and 800cc of pleural fluid were drained.  Pericardial biopsies were taken.  Post operatively the patient was transferred to the cardiothoracic intensive care unit.  

Case Presentation• On postoperative day 0 the patient became hypotensive,

requiring Neo-Synephrine and Epinephrine drip to maintain a MAP>60mmHg.  She was intubated and placed on mechanical ventillation.  

• An intra-aortic balloon pump was placed to assist with cardiac perfusion.  

• The patient underwent emergent transesophageal echocardiogram for poor visualization on TTE which showed an EF of 30-35% and no underlying valvular disease.

• A pulmonary embolus was ruled out by pulmonary arteriography.  Cardiac catheterization revealed poor left ventricular function, approximately 25% with diffuse hyopkineses.  EKG revealed only sinus tachycardia.  

Case Presentation• The patient stabilized on inotropes and pressors. Over the

following three days she was able to wean off the drips, the intra-aortic balloon pump was discontinued and the patient was extubated.  

• Pathology results from the pericardial fluid revealed cells consistent with adenocarcinoma.  Pericardial biopsy showed metastatic adenocarcinoma.  Immunohistochemistry stains identified lung as the most likely primary site.  

• A non-small cell lung cancer would be diagnosed later.  Pleural fluid was negative for malignant cells.  The patient continued to progress and was able to be discharge home on post-operative day 9.   Outpatient follow up echo at 1 month showed a EF of 50-55%.  

Pericardial Decompression Syndrome

• Pericardial decompression syndrome is a recognized phenomenon after drainage of pericardial fluid.  

• Three main hypotheses for PDS have been presented in the literature.  

• The hemodynamic hypothesis suggests that the sudden increase in venous return and greater right ventricular output overwhelms the left ventricle.  

• The ischemic hypothesis states that the myocardium is damaged due to diminished coronary artery blood flow from compression by the pericardial fluid (1).  

• The sympathetic overdrive hypothesis purports that the pericardial fluid was a stimulus for the sympathetic nervous system.  Once that stimulus was removed any underlying dysfunction was revealed (2).  

•

Pericardial Decompression Syndrome

• While reviewing literature for our case, a developing pattern was noticed.  We describe one case and find four more in the literature where all of the patients had a malignant effusion drained from the heart.  

• Subsequent drainage of that effusion led to cardiac failure and pulmonary edema in all of these cases.  Three were drained by peridcadiocentesis and two by subxiphoid window.  The patients range in age from 38-56.  Two of them had previously been given chemotherapy for an identified primary cancer.  

• None received an agent that would be expected to cause myocardial damage.  All of these patients developed significant areas of left ventricular hypokinesia within hours of their procedure.  All would return to baseline with just supportive measures.

•  

Pericardial Decompression Syndrome

Author JournalAge

Sex

Time Post Drainage

Volume Removed

Type of Drainage Type of Failure

WVU Pt 1 38 F ~12 hours 1400mL subxiphoid window left ventricle hypokinesia

LigeroEur J Heart

Failure41 F 3 hours 1000mL pericardiocentesis

akinesis of the anterior wall, septum and apex

WolfeAnn Internal

Med46 F ~12 hrs 650mL pericardiocentesis left ventricle hypokinesia

WolfeAnn Internal

Med50 F

Never back to baseline

650mL pericardiocentesisglobal left ventricular

systolic function

Shenoy Chest 56 M <1 hour 1000mL subxiphoid window IV septum hypokinesia

*All patients presented had an underlying adenocarcinoma

Pericardial Decompression Syndrome

• While it is a recognized phenomenon, it is uncommon.  Few have published on the topic but there seems to be a fair number that have a history of a primary adenocarcinoma.  

• In 1993 Wolfe noted that both of his patients had cancer and it could not be excluded as a cause.  

• We feel that further investigation is warranted into the pathogenesis of pericarial decompression syndrome. We have obtained IRB approval for a retrospective review of all patients who underwent pericardiocentesis.

•  There seems to be connection between adenocarcinoma, these malignant effusions, and the presentation of pericaridal decompression syndrome.  

• Until this phenomenon can be investigated further patients should be monitored closely after draining a suspected malignant effusion.  It’s possible there are varying degrees of this condition that go unrecognized.