Halloween in the Cath Lab: Spider web pericardial effusion

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European Heart Journal - Cardiovascular Imaging


A 70-year-old male patient with refractory diffuse large B-cell lymphoma on dexamethasone, fludarabine, and cyclophosphamide was admitted to the intensive care unit for fever and hypotension. Central line-associated blood stream infection with Escherichiacoli and fungal pneumonia were diagnosed. Symptoms resolved following treatment with vasopressors and antimicrobials. Computed tomography 1 month later revealed resolving pulmonary lesions and a large pericardial effusion (Panel A) leading to a transthoracic echocardiogram (TTE) that suggested tamponade physiology (Panel B, asterisks). Percutaneous pericardiocentesis was performed under fluoroscopic and echocardiographic guidance. An apical approach was used due to severe thrombocytopenia (platelet count 25 K/µL). Multiple intrapericardial loculations were observed on intraprocedural TTE (Panel C; Supplementary data online, Video S1). Agitated saline initially filled one loculation (Supplementary data online, Video S2) and gradually expanded as blunt dissection was performed with a 0.35″ guidewire and 5-Fr Cook pericardial catheter (Panel D; Supplementary data online, Video S3). Approximately 300 cc of haemorrhagic fluid were removed. Repeat TTE showed resolution of the effusion adjacent to the right atrium and ventricle, but persistent moderate loculated effusion posterior to the left ventricle (Panels E and F, asterisks). On repeat pericardiocentesis, additional blunt dissection was performed and 220 cc of haemorrhagic fluid negative for malignant cells were removed, with complete resolution of the effusion.

Pericardial effusions in cancer patients may be accompanied by thrombocytopenia as a marker of disease severity, limiting surgical options. Percutaneous pericardiocentesis is a safe approach with good procedural results and low recurrence rates. The loculated distribution of the fluid further complicated an already challenging case.





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