We describe a case of pneumopericardium following emergency pericardiocentesis in a patient with coronavirus disease 2019 (COVID-19).
A 21-year-old man with a background of trisomy 21, previous cardiac surgery and cardiac resynchronisation therapy-pacemaker (CRT-P) was admitted with a one-week history of pleuritic chest pain, dyspnoea and non-productive cough. Cardiac surgery and CRT-P implantation was undertaken in the Middle East, the precise details of which were unavailable. Admission chest radiograph (figure 1A) revealed features suggestive of coronavirus disease 2019 (COVID-19), which was confirmed on nasopharyngeal swab. Electrocardiography (ECG) revealed sinus tachycardia with biventricular pacing markers. Other than an elevated troponin T (225 ng/L; normal range 0–20 ng/L) and C-reactive protein (CRP) 19 mg/dL, laboratory, investigations were unremarkable.
Emergency transthoracic echocardiography (TTE) – undertaken for rapid characterisation of cardiac function and to facilitate exclusion of pertinent differential diagnoses, namely, pulmonary embolism, acute coronary syndrome and myocarditis with associated pericardial effusion – revealed a large circumferential pericardial effusion with features of tamponade (figures 1B and 1C).
Deteriorating haemodynamic status prompted emergency TTE and fluoroscopy-guided pericardiocentesis in the catheterisation laboratory, yielding 750 ml of straw-coloured fluid. Chest radiography undertaken three hours post-pericardiocentesis revealed significant pneumopericardium (figure 1D). Remarkably, the patient remained haemodynamically stable. Given the considerable clinical uncertainty associated with COVID-19 infection, an emergency heart team consensus favoured decompression by syringe aspiration through the pericardial catheter. Air leakage within the pericardial catheter system due to a poorly secured luer lock connection during pericardiocentesis was deemed the likely underlying cause, however, the role played by COVID-19 infection is unclear. Pericardial aspiration yielded 500 ml of air, resulting in near complete resolution of pneumopericardium (figure 1E).
Pneumopericardium is a rare complication associated with pericardiocentesis and is often managed conservatively. In this instance, the significant clinical uncertainty associated with COVID-19 prompted an emergency heart team discussion and consensus for decompression by syringe aspiration. This clinical vignette demonstrates how COVID-19 has substantially altered day-to-day clinical practice in emergency settings, and the ever-increasing need for a multi-disciplinary approach, often at short notice.
Conflicts of interest
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