Case Presentation

A 43-year-old African American woman with recurrent breast cancer presented with increasing shortness of breath and lower extremity edema. She was known to have recurrent pleural effusions, so a computed tomographic scan of the chest was performed. This demonstrated a large, circumferential pericardial effusion as well as a moderately sized pleural effusion ( Figure 1 ). She was referred to cardiology for consultation and consideration for pericardiocentesis.

Computed tomography of the chest demonstrating a large pericardial effusion (asterisk) as well as a large left-sided pleural effusion (arrow) .

Although the patient did not clinically have “tamponade,” echocardiography demonstrated a large pericardial effusion ( Figures 2 A-C), with partial right-sided chamber collapse ( Figure 2 A, Video 1 ). It was decided that removal of the fluid using percutaneous drainage would improve her symptoms as well as allow for diagnostic evaluation.

(A) Two-dimensional echocardiography demonstrating a large pericardial effusion (asterisks) causing partial collapse of the right-sided chambers (arrow) ( Video 1 ). (B) Initial introduction of agitated saline indicated that the tip of the pericardiocentesis needle was in the right-sided chambers of the heart, rather than the pericardial sac ( Video 2 ). (C) The needle was pulled back, and repeat injection confirmed correct placement of the needle in the pericardial space ( Video 3 ) prior to insertion of the tract dilator and pericardial drain.

The patient was brought to the cardiac catheterization laboratory, and pericardiocentesis was performed using both fluoroscopic as well as echocardiographic guidance. To prevent the inadvertent placement of a pericardial drainage catheter in a structure other than the pericardial sac, agitated saline was injected through the tip of the pericardiocentesis needle to ascertain its location prior to tract dilation and insertion of a drainage catheter. To create the agitated saline, approximately 5 cm ³ of saline and 0.5 cm ³ of air were rapidly shuttled back and forth through a stopcock attached to two 10-cm ³ syringes. The liquid was then infused through the pericardiocentesis needle.

The initial bubble injection clearly demonstrated opacification of the right-sided cardiac chambers ( Figure 2 B, Video 2 ). The needle was pulled back, and a second bubble injection demonstrated localization in the pericardial space ( Figure 2 C, Video 3 ). The guidewire was inserted, the tract was dilated, and a pericardial drainage catheter was successfully placed in the pericardial space. Approximately 800 cm ³ of pericardial fluid was removed.