Author + information
- Received September 6, 2016
- Revision received September 15, 2016
- Accepted September 15, 2016
- Published online November 28, 2016.
- Anita Saxena, MD, DM,
- Suman Karmakar, MD and
- Rajiv Narang, MD, DM∗ ()
- ↵∗Reprint requests and correspondence:
Dr. Rajiv Narang, Department of Cardiology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India.
A 47-year-old woman with known metastatic ovarian carcinoma presented to the emergency department with cardiac tamponade. During pericardiocentesis using subxiphoid approach and a 6-F sheath, the guidewire was noted to go into the right ventricle (RV) and pulmonary artery, indicating perforation of the RV, which was confirmed by contrast injection (Figure 1A). The patient remained hemodynamically stable, and there was no increase in pericardial effusion. It was decided to close the perforation with an occluder device. There are only occasional previous reports of device closure of RV perforation (1–4). A 6 × 4 (waist 6 mm, length 4 mm) Amplatzer duct occluder II device (St. Jude Medical, St. Paul, Minnesota) was chosen because this device has expanded skirts on both sides, reducing the chance of embolization. Moreover, only a device that could be delivered through a 6-F sheath alongside a 0.028-inch wire could be used. The wire was kept in place before loading the device to ensure that access to perforation remains available. The positioning of the device across the RV wall was challenging in the absence of any fluoroscopic landmarks. It was guided by transthoracic echocardiography and RV angiography in 2 orthogonal views performed though femoral venous access (Figure 1B).
The distal disc of the device was deployed in the RV, keeping it very close to the perforation (Figure 1C). The sheath was gently withdrawn and proximal disc was deployed under echo guidance (Figure 1D). The 0.028-inch wire remained across the perforation site. This wire was gradually pulled out and placed into the pericardial cavity. Its position in the pericardium was confirmed on fluoroscopy (Figure 1E). A 5-F pigtail catheter was passed over it and 500 ml of hemorrhagic pericardial fluid was drained. The patient’s heart rate and blood pressure improved with the drainage of pericardial fluid. A follow-up echocardiography done 4 days after the procedure showed minimal pericardial effusion. There was no drainage after 3 days and the pigtail was removed after 5 days. Echocardiography and fluoroscopy performed 2 weeks later showed the device to be in the proper place (Figure 1F).
We conclude that device closure is feasible for inadvertent perforation of the RV during pericardiocentesis and should be considered as an alternative to surgery in such patients.
The authors are grateful to Dr. Rajnish Juneja for his contribution in managing this case.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received September 6, 2016.
- Revision received September 15, 2016.
- Accepted September 15, 2016.
- American College of Cardiology Foundation
- Pawelec-Wojtalik M.,
- Antosik P.,
- Wasiatycz G.,
- Wojtalik M.