Sunday, July 14, 2013

Case Study: Um, A Post-op Chest X-ray

Radiologist: "Um, doctor, there's something funny on your patient's post-operative chest x-ray:"

Post -operative Chest X-ray
(Click to enlarge)

(Remember, you never want to hear the word "Um.")

What did the radiologist see?



Vern Horst said...

Pneumopericardium. But I don't understand the etiology.

Paul Hsieh said...

Pneumopericardium - ?possible perforation of pacemaker wire.

DrWes said...

Vern/Paul -

You are correct: this is an example of pneumopericardium. Careful review of the lateral chest x-ray image demonstrates the pericardial drain that is in place the best.

The patient had complete heart block and was completely dependent on his dual chamber pacemaker for his heart to beat. Over the years, he developed heart failure and his LV function declined. As a result, he was recommended to undergo upgrade of his DDDR pacemaker to a biV pacemaker system. Unfortunately, a perforation of the coronary sinus occurred due to the vessel's very tortuous anatomy. (The event was recogniozed at the time of the procedure due to contrast entering the pericardium.) The patient gradually developed tamponade physiology over an hour. Pericardiocentesis was performed with removal of approximately 250 ml of blood from the pericardium and the drain was left in place connected to a 3-way stopcock and vacutainer assembly to apply continuous suction. The following morning, this chest-x-ray was obtained. It seems the 3-way stopcock was opened to air briefly resulting in air being introduced into the pericardium. The patient was asymptomatic. Suction was re-appied and the drain ultimately removed. The patient did well, but will return at another date for an epicardial LV lead placement.

Pneumopericardium as a comlpication of pericardiocentesis occurs as a result of a leaky drainage system or direct pleura-pericardial communication. Fortunately, the former etiology appears to be the cause for this case.

Anonymous said...

This is interesting even to a rookie. Thanks for the educational stuff!

Anonymous said...

I also find this blog educational
and worth a daily visit. I did try to " decipher" the last sentence and came up with cause for the pneumo..
a. malfunction of appliance or
b. doctor error

Karen said...

Um is definitely not a word you want to hear! I always learn when I read your posts, Thanks!