Atypical Cause of Cardiac Tamponade Following ICD Extraction

Oct 19, 2020   |  Todd Brophy, MD, FACC; Alan Kiang, MD; Allan L. Klein, MD, CM, FACC
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A 57-year-old female with a history of idiopathic ventricular tachycardia status post dual-chamber implantable cardioverter-defibrillator (ICD), paroxysmal atrial fibrillation, and hypothyroidism presents to her local emergency department with a chief complaint of dyspnea. The patient's recent medical history is notable for an ICD lead extraction 3 weeks prior to her current presentation that was complicated by superior vena cava (SVC) laceration. The procedure required emergent sternotomy for pericardial hematoma evacuation and repair of the SVC laceration via a bovine pericardial patch repair. Since discharge, she has noted progressively worsening dyspnea and fatigue, and she presented to the emergency department after development of lightheadedness over the past 2 days.

On examination, she appeared distressed with vital signs noting afebrile temperature, heart rate 127 beats per minute and irregular, blood pressure 107/66 mmHg, respiratory rate 20, and oxygen saturation 99% by pulse oximetry on 2 liters of supplemental oxygen via nasal cannula. Heart sounds were distant on auscultation, and jugular venous distension was evident to the angle of the mandible sitting upright.

Electrocardiogram was notable for atrial fibrillation and low voltage across the precordium. Chest x-ray showed an enlarged cardiac silhouette. A limited point of care echocardiogram was notable for a very large pericardial effusion (Figure 1a). The patient underwent emergent pericardiocentesis via the apical approach with removal of 500 mL of pericardial fluid (Image 1). The patient had rapid improvement in symptoms and vital signs following drainage (Figure 1b).

Figure 1: Point of care echocardiogram with representative parasternal long axis images identifying a large pericardial effusion and tamponade physiology (a) and resolution of effusion following pericardiocentesis (b).

Figure 1a

Figure 1A

Figure 1b

Figure 1B

Image 1: Pericardial fluid following aspiration via pericardiocentesis.

Image 1

Pericardial fluid analysis is shown below (Table 1), which was notable for turbid fluid with elevated red blood cells, a lymphocytic predominance, and triglycerides with the presence of chylomicrons.

Table 1: Pericardial fluid analysis.

pH Clarity RBC WBC Lymph % Protein LDH Gram stain Cytology Triglycerides Chylomicrons
7.36 Turbid 34,000/uL 2,736/uL 88% 4.4 g/dL 390 U/L Negative Negative 663 mg/dL Present

What is the etiology of this patient's pericardial effusion?

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