(252) To Pull or Not to Pull: Pericardial Decompression Syndrome as a Complication of Pericardiocentesis

Introduction: Cardiac tamponade is a pathological condition often caused by a large pericardial effusion, leading to equalization of intracardiac pressures and hemodynamic instability. Pericardiocentesis is the standard treatment, designed to enhance hemodynamics and restore cardiac function (3). In this case, we describe a patient who developed a rare but life-threatening complication of pericardiocentesis known as pericardial decompression syndrome (PDS), which occurs in approximately 5% of total pericardiocentesis procedures (2).

Description: The patient, a 73-year-old female with a history of hypertension, hyperlipidemia, sick sinus syndrome with a pacemaker, and persistent atrial fibrillation, presented with exertional chest pain. Acute coronary syndrome was initially suspected, but guideline-directed therapy did not relieve her symptoms. An echocardiogram revealed a large-sized pericardial effusion with tamponade physiology, leading to a pericardiocentesis that removed approximately one liter of fluid. Despite additional treatments, her condition rapidly worsened into cardiogenic shock. A repeat echocardiogram indicated severe right ventricular dysfunction, raising the possibility of a pulmonary embolism, which was later ruled out by a pulmonary arteriogram. The likely cause of her decompensated heart failure was PDS. The patient was supported with an Impella 2.5 device but ultimately succumbed to multi-organ failure and death.

Discussion: This case underscores a rare but significant complication of pericardiocentesis called PDS which involves various mechanisms, primarily hemodynamic and ischemic disturbances. It occurs when the right heart chamber rapidly expands after pericardial fluid removal, leading to mechanical obstruction of the left ventricle, which in turn reduces cardiac output and can result in overt heart failure (1,2). In our patient, approximately 1 liter of fluid was removed from the pericardial sac. Research indicates that drainage volume is an independent risk factor for PDS, with a mean volume of 647 ± 217 mL being associated with the condition. Further clinical research is needed to establish safe practices for performing pericardiocentesis, as current guidelines on this procedure are limited (2).