Case presentation

A 65-year-old woman presents with a recurrent pericardial effusion. Her history began 4 years earlier when she was diagnosed with adenocarcinoma of the breast. She underwent lumpectomy without adjunctive chemotherapy or radiation. Several months earlier, she had complained of shortness of breath and was found to have a large, malignant left pleural effusion treated with thoracentesis. Beginning 3 weeks prior to the present admission, she again developed progressive shortness of breath along with cough, fatigue and a 12-pound weight loss. Evaluation at a local hospital demonstrated an enlarged cardiac silhouette on chest x-ray consistent with a pericardial effusion, and a left-sided pleural effusion with mild pulmonary vascular congestion. A CT scan of the chest suggested neoplastic disease progression. There was left upper lobe atelectasis and consolidation, encasement of the pulmonary artery with a mass, pathological mediastinal lymphadenopathy, and a large pericardial effusion. She was referred for further management of the effusion.

Upon presentation, she was in mild distress from dyspnea, but remained hemodynamically stable with a blood pressure of 150/70 mmHg and, although physical examination confirmed elevation of the jugular venous pressure, there was no pathologic pulsus paradoxus. The electrocardiogram showed sinus tachycardia with low voltage and echocardiography revealed a large circumferential pericardial effusion (Figure 46-1) along with right ventricular collapse and right atrial inversion consistent with tamponade. She underwent pericardiocentesis with removal of 750 mL of serosanguineous fluid. Cytological analysis of the fluid subsequently confirmed adenocarcinoma. A pericardial drain remained in place and she was admitted for continued observation. Over the ensuing 2 days, more than 200 mL of fluid drained from the pericardial space each day. She was referred to the cardiac catheterization laboratory for a balloon pericardial window.

FIGURE 46-1 Transthoracic echocardiogram demonstrating a large, circumferential pericardial effusion (arrow).

Cardiac catheterization

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