Correct!
3. Avoid pericardiocentesis at this time
The patient had a large pericardial effusion (as demonstrated by asterisks) in Figure 1 and Figure 2. Furthermore, the patient had a massively dilated right ventricle (RV). The RV is significantly larger than the left ventricle in the apical 4-chamber view. As demonstrated in Figure 3, the velocity of the jet of tricuspid regurgitation suggests a pressure difference of 57mmHG between right atrium and pulmonary artery.
Figure 3. Spectral continuous-wave Doppler interrogation through the tricuspid valve demonstrating a peak velocity of 3.78 m/s.
The patient had a dilated non-variable inferior vena cava (not shown) which would estimate right atrial pressure at a minimum of 15 mmHG, and thus an estimated systolic pulmonary arterial pressure of 72 mmHG. These findings together suggest the patient likely has severe pulmonary hypertension and RV failure. While the patient did have evidence of past thromboembolism on the CT angiogram, it was not felt to be acute. The pulmonary artery pressures were only slightly elevated from 6 months previous.
Many patients with advanced pulmonary hypertension develop pericardial effusions related to elevated right sided heart pressures, this finding is associated with a poorer prognosis in patients with pulmonary arterial hypertension (1). Furthermore, diagnosis of pericardial tamponade is complicated in these patients in that dilated IVC and exaggerated respiratory variation of mitral and tricuspid inflows is common to both pericardial tamponade and pulmonary hypertension (2). Volume overloaded and hypertrophied right sided chambers are also less likely to demonstrate collapse (2). The lowest pressure chamber in right heart failure is often the left atrium, but due to its extrapericardial nature in many patients, it may not demonstrate evidence of collapse. A diagnosis of pericardial tamponade is exceedingly challenging in this population. Additionally, pericardiocentsis in patients with severe pulmonary arterial hypertension is associated with very poor outcomes. A recent case series by Hemnes et al. (3), showed that 5 of 5 consecutive patients with severe pulmonary arterial hypertension undergoing pericardial drainage died within 24 hours. The outcomes of pericardial effusions in patients with group 3 and 4 pulmonary hypertension (Dana Point classification) as this patient had are much less clear. Extreme caution is advised when considering pericardiocentesis in this population. This patient’s pericardial effusion was managed conservatively.
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