Pneumopericardium After the Removal of a Pericardiocentesis Drain

A 47-year-old woman who had undergone cord blood transplantation for acute myeloid leukemia a year earlier was examined for fatigue and edema. Chest X-ray revealed a cardiothoracic ratio of 62% (Figure A). Echocardiography revealed a large pericardial effusion, following which she was diagnosed with cardiac tamponade and underwent pericardiocentesis via the substernal approach. An 8-Fr sheath and pigtail catheter were inserted, and 400 mL yellow pericardial fluid was drained (Figure B). The pericardial effusion was suspected to be a graft-vs.-host disease manifestation, and thus methylprednisolone therapy was started. Echocardiography performed 2 days after pericardiocentesis showed no increase in pericardial effusion; therefore, the sheath and catheter were removed. Although not confirmed on the chest X-ray in the supine position (Figure C), the chest X-ray in the upright position the day following catheter removal showed a cardiac shadow with niveau formation (Figure D). Furthermore, echocardiography showed poor delineation of the heart. Computed tomography revealed the absence of pneumothorax, and pneumopericardium was diagnosed (Figure E). The patient was closely monitored, and her vital signs were stable; the free air in the pericardial cavity gradually reduced, leading to complete improvement a week after sheath and catheter removal (Figure F). After catheter removal, air may have infiltrated the pericardial sac through a small fistula with a check-valve mechanism. In addition, pneumopericardium may occur after pericardial drain removal. Poor echocardiographic visibility due to air may help suspect pneumopericardium and a chest X-ray should be evaluated in the upright rather than supine position.

Figure.

Chest X-ray (A) before pericardiocentesis, (B) after pericardiocentesis, (C) in the supine position immediately after sheath and catheter removal, (D) in the upright position the day after sheath and catheter removal, and (F) 1 week after sheath and catheter removal. Air in the pericardial sac (yellow arrowheads) as suspected, and niveau (red arrowhead) being noted in the cardiac shadow. (E) Computed tomography scan the day after sheath and catheter removal.