Complications in Pericardiocentesis: Right Ventricular Perforation in a 75-Year-Old Patient with Lymphoma

Introduction

Some studies have shown that pericardial effusion, a symptom due to cardiac involvement, is observed in patients with lymphoma. Generally, compared with primary cardiac lymphoma, accounting for 2% of cardiac tumors, secondary cardiac complications caused by lymphoma are more common, including pericardial effusion [1]. As a critical subtype of non-Hodgkin lymphoma, diffuse large B cell lymphoma is associated mostly with pericardial involvement, especially for severe effusion, leading to possible cardiac tamponade [2]. It has been demonstrated that pericardiocentesis is an effective and valuable strategy to drain effusion and alleviate cardiac compression. Moreover, to prevent recurrence of malignant pericardial effusion, recently, a pericardiocentesis with intrapericardial instillation of chemotherapy has been a more preferred option [3]. However, laceration and perforation of the myocardium and coronary artery are the most common major adverse events of pericardiocentesis; therefore, assisted-echocardiography guidance is necessary and valuable during the practical execution of pericardiocentesis [4]. In this report, we describe a 75-year-old man with diffuse large B cell lymphoma and right ventricular perforation during pericardiocentesis for pericardial effusion.

Case Report

A 75-year male patient admitted with concerns of refractory chest tightness and shortness of breath after physical exercise. The past history of diffuse large B cell lymphoma was confirmed by immunohistochemistry from a primary neck mass, with findings of CD20(+), CD79α(+), PAX-5(+), BCI-6(+), MUM1(+), BCL-2(+), and KI-67(50%+), and the patient had not undergone any oncological treatment (Figure 1). Physical examination revealed the heart rate was 110 beats per min, with a sinus rhythm, and blood pressure was 100/72 mmHg; moreover, weaker heart sounds were detected through cardiac auscultation. Echocardiography findings demonstrated a massive pericardial effusion (Figure 2). After a comprehensive assessment, palliative pericardiocentesis under echo-assisted guidance was selected to drain the effusion and alleviate compressive symptoms.

Initially, a puncture needle was inserted at an oblique 30° through a subxyphoid incision. Then, as expected, a wire was inserted into the pericardial cavity under the guidance of echocardiography. Sequentially, a catheter was inserted along the wire and fixed at the depth of 15 cm from skin after wire withdrawal. Nevertheless, accidentally, this catheter was not found within the pericardial cavity, and progressive increased effusion was detected, and the vital signs were unstable, including lower heart rate of 60–70 beats per min and blood pressure of 80–90/50–60 mmHg. Immediately, the pericardiocentesis was ceased. An emergent computed tomography (CT) scan was continued to determine the location of catheter, and it was demonstrated that there was a high-density 2-mm suspected foreign body penetrating from the pericardial cavity and right ventricle to the pulmonary main artery, which indicated that the right ventricle was damaged, possibly caused by a misplaced catheter (Figure 3). At the same time, echocardiography showed that cardiac compression was more severe from the progressive effusion and continuous clot formation, which could lead to tamponade or even sudden cardiac arrest. Therefore, emergent exploratory thoracotomy for hemostasis and pericardial decompression was performed. During the surgical procedure, pooled bloody effusion and more clots were accumulated in the pericardial cavity after pericardiotomy, and the right ventricle wound was misplaced by catheter located at the apex. Next, the effusion and clots were removed, and the wound was sutured tightly with 4-0 prolene using horizontal mattress stitch after the catheter was removed (Video 1). Lastly, the pericardial cavity was washed repeatedly with warm saline. A total of 2 drainage tubes were placed into the pericardial and mediastinum cavity, respectively. The cytology of pericardial effusion was not suitable, due to more fulfilled clots under emergency. Pathologically, it was demonstrated that hyperplasia of fibrillar connective tissue and infiltration of inflammatory cells were observed. Also, local granuloma was found within the incised pericardium (Figure 4). The patient was stable and discharged at day 15 after surgery. The informed consents for both palliative pericardiocentesis and emergent exploratory thoracotomy were signed by the patient and his relatives before these procedures.

Discussion

For this patient, we have recognized that, because pericardiocentesis is a risky procedure, perioperative measurements should be fully prepared in order to prevent accidental events. Clinically, the mechanism of pericardial effusion can be varied and is summarized with some main origins, such as infection, inflammation or rheumatology, malignancy, trauma, cardiac and vascular events, idiopathy, and secondary to other diseases. If massive effusion is found, pericardiocentesis is significant for diagnosis, etiology evaluation, and symptom alleviation [5]. Among all origins of effusion, malignancy accounts for 12% to 23% of cases [6]. As mentioned above, the subtype of diffuse large B cell lymphoma of this patient was associated with the occurrence of pericardial effusion. It is also considered that, when conservative treatment is ineffective, massive/progressive pericardial effusion should be drained and collected by invasive interventions, such as pericardiocentesis or surgical drainage, for cardiac decompression and pathological testing [7,8]. Notably, taking the variety of pericardial effusion and the baseline condition of patients into consideration, pericardiocentesis should be performed with caution, to prevent puncture-related complications. Kanda et al [9] have presented a case with coronary perforation during the pericardiocentesis, which indicates that this procedure is more challenging and difficult for inexperienced medical stuff. Importantly, the puncture access and angle are critical, and generally, subxyphoid access is the preferred option, with an oblique 30° suitable for needle insertion [10,11]. Bedside echocardiography is convenient, economical and available; hence, it is recommended as the preferable option of guidance during pericardiocentesis. In summary, enough effusion drainage and guidance of assisted hemodynamic and echocardiography should be optimal for successful pericardiocentesis [5].

For this patient, although the procedure was performed as per standard instructions, unexpected misplacement of the catheter still occurred during the pericardiocentesis, suggesting that, clinically, caution should always be used with invasive puncture. Also, due to the past history of percutaneous coronary stent implantation and long-term oral use of aspirin, the uncertainty of coagulation was more challenging for emergent salvage. Fortunately, exploratory thoracotomy is a feasible alternative strategy when facing this emergency. Alerhand et al [12] concluded a series of preparations for pericardiocentesis: preoperatively, necessary and sufficient blood products should be ready for traumatic hemopericardium and fluid supplementation; also, vasoactive medications are equally critical for patients with hypotension or hypovolemia. Low-depth sonographic views are suitable for needle guidance and catheter placement. Positive-pressure ventilation and intravenous sedation should be avoided due to the potential risk of lower cardiac output. Appropriate positioning of the patient is useful to avoid hypoxia, and local anesthesia is better to maintain mental consciousness. Anticoagulation, coagulopathies, and anemia should be adjusted in a timely manner. The lower platelet count should be cautiously considered in decision-making [13]. Furthermore, there is another explanation, stating that pericardial effusion with high-density is similar to the imaging of a catheter leading to final misplacement into the cardiac chamber. Therefore, Bafna et al [14] have suggested that, instead of echocardiography, an assisted CT-guidance pericardiocentesis is safer and more effective, with even fewer complications. The left anterior chest wall is the favored access under the guidance of CT, with minor complications less than 6% [15]. In our opinion, when the misplacement of a catheter is confirmed, if hemodynamic measures are stable, a redo should be performed gently, and the misplaced catheter should be removed. Additionally, hemostatic agents are used in the case of pericardiotomy; whereas, if the condition is unstable, surgical intervention should be considered. For this patient, we performed an emergent surgery, since neoplastic pericardial effusion and hemodynamic instability are the independent risk factors of in-hospital adverse events and medium-term mortality for patients undergoing pericardiocentesis due to pericardial effusion [16]. Lastly, we need to emphasize that although the patient was stable at discharge, similar symptoms, including chest tightness and shortness of breath, recurred at 2 months after surgery, which indicates that the outcome of older patients with malignant pericardial effusion is not optimistic [17].

Conclusions

The procedure of pericardiocentesis should be performed under the guidance of echocardiography or X-ray to avoid possible complications. Particularly, patients with malignancy, including lymphoma, and hemodynamic instability, should be assessed with caution before pericardiocentesis, and transfusion, vasoactive medications, appropriate position, local anesthesia, and coagulation adjustment should be prepared completely. If echocardiography fails, CT is a qualified alternative to assist as the guidance of pericardiocentesis. Once complications are found, effective interventions must be available, including surgical treatment.