A 47-year-old woman with Noonan syndrome and pneumococcal pneumonia presented with cough, breathlessness, and hypotension caused by cardiac tamponade (Fig. 1a). Due to associated abdominal organomegaly, she underwent the recently described two-step parasternal pericardiocentesis approach [1]. The pericardial pressure was 17 mm Hg (normal < 4 mm Hg). About 1 L of serosanguinous fluid was withdrawn, resulting in immediate symptomatic relief and a doubling of the electrocardiographic R‑wave amplitude—an intuitive phenomenon not widely reported in the medical literature. The drain was removed the following day and a chest X‑ray showed pneumopericardium (Fig. 1b). Her CT scan confirmed the diagnosis and additionally revealed right basal lung consolidation and hepatosplenomegaly, which made subcostal pericardiocentesis challenging. Although there are no published cases of Noonan syndrome and percutaneous pericardiocentesis. The mechanism of pneumopericardium remains unclear but may result from pneumonic intrathoracic suction or potentially air leakage caused by the drain slipping out, exposing a side hole which is 7.5 cm from the tip [2]. Her follow-up echocardiogram however showed no tamponade physiology.
Fig. 1
aLeft Echocardiogram showing the large pericardial effusion causing cardiac tamponade. Middle Guidewire in the pericardial space using the 2‑step parasternal pericardiocentesis technique. Right Doubling of the electrocardiographic R wave amplitude following drainage of the pericardial effusion. bTop left Chest X‑Ray revealing pneumopericardium. Bottom left Coronal CT Scan demonstrating pneumopericardium, residual effusion, in addition to left basal lung consolidation. Right Sagittal CT Scan confirming hepatosplenomegaly, making subcostal pericardiocentesis inadvisable
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Acknowledgements
The authors thank the Department of Cardiology as led by Drs. Rajan Sharma and Manav Sohal, cardiac catheter laboratory managers; Mary Keal and Menene Endaya (nursing), Dinesh Sajnani (radiography); Drs Mark Specterman and Viral A. Sagar who took part in the procedure; and the cardiac catheter laboratory staff. Special thanks to the patient described in this report who consented to allow this case to be described for medical education. Also, the author’s gratitude to coronary care unit and Belgrave ward auxiliary and nursing staff involved in the care of this patient during her stay in the hospital, and last but not least, Farida Ismail who reliably keeps in stock all the equipment the authors use.
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Het Netherlands Heart Journal wordt uitgegeven in samenwerking met de Nederlandse Vereniging voor Cardiologie. Het tijdschrift is Engelstalig en wordt gratis beschikbaa ...