Accidental Cannulation of the Cardiac Venous System During Pericardiocentesis

J INVASIVE CARDIOL 2021;33(3):E225-E226. 

Key words: cardiac imaging, pericardiocentesis

A 52-year-old woman presented to another hospital with progressive dyspnea of 10-day duration. The patient was diagnosed with a massive pericardial effusion and underwent pericardiocentesis. However, the patient’s symptoms did not improve and she was referred to our hospital with a pericardial sheath in situ. On evaluation, the patient had a large pericardial effusion and evidence of cardiac tamponade, but no fluid could be aspirated from the sheath. We attempted intrapericardial placement of a guidewire through the sheath to allow the insertion of a pigtail catheter. A 0.035˝ J-tipped Terumo wire was inserted, and it coursed through the right ventricle into the right atrium and inferior vena cava (Figure 1). Angiogram (Video 1) showed the sheath to be communicating with a tributary of the middle cardiac vein with contrast opacification of the coronary sinus and right atrium (Figure 2), and spillage of dye into the pericardium. The patient underwent surgical exploration. The sheath was inside the pericardial cavity; however, no damage was observed to the right ventricle or coronary venous system. The exact communication could not be documented as the sheath was likely pulled into the pericardial space during manipulation. The guidewire likely passed through one of the tributaries of the middle cardiac vein connected to the thebesian veins that drained directly into the right ventricle, as can be seen from the course of the wire (Figure 1). The patient was diagnosed to have pericardial tuberculosis and treated with antitubercular therapy. She was discharged and is doing well on follow-up. The current case underscores the importance of image-guided pericardiocentesis.

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From the Department of Cardiology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted March 31, 2020.

Address for correspondence: Anunay Gupta, MBBS, MD, DM, Assistant Professor of Cardiology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi-110029, India. Email: dranunaygupta@gmail.com