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Case Reports
. 2022 Jun 1;4(11):671-676.
doi: 10.1016/j.jaccas.2022.03.030.

Pneumopericardium- An Unusual Complication Following Transseptal Puncture: A Series of 3 Cases

Varun Marimuthu  1 , K H Srinivasa  1 , Subramani Khamitkar Shankar Rao  1 , Nagamani Alur  1 , Manjunath Cholenahalli Nanjappa  1 , N M Prasad  1
Affiliations
Case Reports

Pneumopericardium- An Unusual Complication Following Transseptal Puncture: A Series of 3 Cases

Varun Marimuthu et al. JACC Case Rep. .

Abstract

Transseptal puncture (TSP) is performed to access the left side of the heart from the venous circulation. Performed under fluoroscopy with echocardiographic guidance, it is a procedure associated with complications. Pneumopericardium leading to cardiac tamponade is rare following TSP. We present 3 cases of pneumopericardium during TSP and its identification, probable mechanism, and management. (Level of Difficulty: Advanced.).

Keywords: BMV, balloon mitral valvotomy; ICE, intracardiac echocardiography; LA, left atrial; MS, mitral stenosis; RA, right atrial; RAA, right atrial appendage; TEE, transesophageal echocardiography; TSP, transseptal puncture; mitral valve; rheumatic heart disease; tamponade.

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Conflict of interest statement

The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Figures

None
Graphical abstract
Figure 1
Figure 1
Patient 1: Balloon Mitral Valvotomy (A and B) The pigtail catheter in the aortic root and the septal dilator in the right atrium. After inadvertent puncture into the pericardial space, pneumopericardium with tamponade effect was seen, and the patient became hemodynamically unstable. (C) Pericardiocentesis was performed from the subxiphoid approach, air was aspirated, and the patient was stabilized. (D) A repeat transseptal puncture was performed after stabilization, and balloon mitral valvotomy was completed (Video 1).
Figure 2
Figure 2
Patient 2: Balloon Mitral Valvotomy (A) Transseptal puncture performed in the left anterior oblique view. The pigtail catheter is in the aortic root. (B) Pneumopericardium after the transseptal puncture; all hardware was removed, and the patient was monitored. (C) Because the patient was hemodynamically stable, repeat transseptal puncture was performed. Note the air in the pericardium compared with A. (D) Balloon mitral valvotomy was completed (Figure 3, Video 2).
Figure 3
Figure 3
Trajectory of the Left Atrial Wire (A) Coiled stainless steel left atrial wire in the pericardial cavity. (B) Coiled stainless steel wire as it normally appears in the left atrium. This abnormal trajectory can alert the operator to an inadvertent puncture into the pericardial space.
Figure 4
Figure 4
Patient 3: Left Atrial Appendage Device Closure (A) Transesophageal echocardiogram-guided transseptal puncture was performed, and as the dilator of the delivery sheath was being removed, pneumopericardium was noticed. (B) The coiled left atrial wire is in the pericardial cavity. (C) Contrast injection confirmed that the catheter was in the pericardial space. (D) All hardware was removed, and the patient was hemodynamically stable. A small pocket of air was present, and it resolved in a few days (Videos 8, 9, and 10).
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References

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