Unexpected occurrence of cardiac tamponade following temporary pacemaker lead extraction

Excerpt

A 71-year-old female patient was admitted to our hospital for a primary percutaneous coronary intervention (PCI) because of acute myocardial infarction with ST-segment elevation of the inferior and posterior wall and the right ventricle with complete third-degree atrioventricular (AV) block. A temporary pacing wire (6-Fr flexible electrode) was advanced through the right femoral vein to the right ventricle under fluoroscopic guidance smoothly and without incident. Subsequently, coronary angiography and primary PCI of the right coronary artery with implantation of two bare metal stents was performed. Tirofiban infusion was continually administered during and after PCI. Although the patient returned to sinus rhythm after unblocking the right coronary artery (RCA), a temporary pacemaker lead was left in overnight. On the following day the pacemaker lead was extracted without any resistance. Only a few minutes later, the patient experienced severe chest pain and hemodynamic collapse. Urgent bedside transthoracic echocardiography demonstrated moderate but enlarging Horowitz type D circumferential pericardial effusion (echo-free space in diastole 18 mm wide; Fig. 1) with signs of compression of the heart (exaggerated respiratory variability in mitral inflow velocity with the lowest velocity during inspiration; Fig. 2) and inferior vena cava plethora. In addition, fluctuating masses looking like blood clots inside the pericardial space and adhering to the epicardium over the apex of the right ventricle were observed (Fig. 3) as well as akinesia of the ventricular septum. The infusion of tirofiban was immediately stopped. Urgent coronary angiography showed no evidence of coronary artery rupture at the treated site as well as TIMI-III flow in the RCA. Accordingly, urgent percutaneous pericardiocentesis was performed via the subxiphoid approach under fluoroscopic guidance and initially 400 ml of blood was drained. A 5-Fr pigtail catheter was left in the pericardial space for continuous drainage and over the next 4 h an additional 300 ml blood was drained. Drainage gradually decreased after 24 h. Anticoagulation therapy was stopped as soon as pericardial effusion was confirmed but dual antiplatelet therapy (Aspirin, clopidogrel) was continued throughout. The draining catheter was removed after 4 days when echocardiography confirmed persistence of only a discrete pericardial effusion of 3–4 mm behind the posterior and lateral wall in diastole. In total, 950 ml of blood was drained in 4 days. However, the net drop in complete blood count did not require blood transfusion (hemoglobin dropped from 131 g/l to 105 g/l and platelets dropped from 310 × 10⁹/l to 201 × 10⁹/l). The condition of patient remained stable during the rest of the hospital stay and she was discharged on the tenth hospital day, after echocardiography confirmed no residual pericardial effusion (Fig. 4). At the 6-month follow-up, the clinical and echocardiographic examination was uneventful. …