Case presentation

An active 76-year-old man underwent elective coronary angiography for evaluation of a several-month history of exertional chest pain. This identified a severe stenosis in the midportion of a large caliber right coronary artery and a normal appearing left coronary artery. He was referred for percutaneous coronary intervention of the right coronary artery. Past medical history was notable only for hypertension, gout, and paroxysmal atrial fibrillation, and his medications included aspirin, atenolol, atorvastatin, and amlodipine. Physical examination was unremarkable, and his baseline electrocardiogram was notable for sinus rhythm and bifascicular block (right bundle branch and left anterior fascicular block).

Cardiac catheterization

He was administered 300 mg of clopidogrel as a loading dose prior to the intervention, and procedural anticoagulation was accomplished with a bolus of 6000 units of heparin, followed by eptifibatide bolus and infusion. An activated clotting time measured 230 seconds prior to intervention. An 8 French, Judkins 4.0 guide catheter was positioned in the right coronary ostium and a 0.014 inch floppy-tipped guidewire placed distally in the posterior descending artery. After predilating the stenosis with a 4.0 mm diameter by 15 mm long balloon, a 5.0 mm diameter by 24 mm bare-metal stent was positioned and successfully deployed and postdilated with a 5.0 mm diameter by 22 mm long semicompliant balloon. The operator achieved an excellent angiographic result with no residual stenosis and no apparent angiographic complications. The patient felt well and was hemodynamically stable and transferred to a recovery room adjacent to the catheterization laboratory with the arterial sheath in place to await his hospital bed.

Shortly after arrival in the recovery room, the patient developed diaphoresis and nausea. His blood pressure fell to 52/30 mmHg with a heart rate of 60 beats per minute. Physical exam demonstrated marked elevation of his jugular veins. The monitor leads (lead II) showed no ST-segment abnormalities. An infusion of normal saline was initiated and additional venous access obtained in order to infuse dopamine. An emergent echocardiogram confirmed a large circumferential pericardial effusion and the patient was immediately transported back to the cardiac catheterization laboratory. The patient was given 30 mg of protamine intravenously and the eptifibatide infusion was discontinued. The operator performed an emergent pericardiocentesis and aspirated a large volume of blood from the pericardial space. This stabilized the patient’s hemodynamic status, with a rise in systolic blood pressure to 100 mmHg. The pigtail catheter remained in the pericardial space and blood was continually aspirated. Meanwhile, a blood sample was collected and sent to the blood bank for transfusion crossmatching.

The operator performed right coronary angiography to determine the source of the bleeding. This showed wide patency of the stent in the right coronary artery with no evidence of a perforation at the site of the stent (Figure 21-1); however, contrast was observed in the pericardial space (Video 21-1) and the pigtail catheter continued to drain blood. Additional views were performed; free-flowing contrast was apparent from the distal tip of the posterior descending artery in an anteroposterior view with cranial angulation (Video 21-2). A 2.5 mm balloon was inflated in the posterior descending artery proximal to the perforation and effectively stopped the bleeding (Figure 21-2). While the balloon remained inflated, the patient remained hemodynamically stable with no additional blood accumulation from the pericardial drain. A cardiothoracic surgeon was informed of the patient’s condition and alerted to the possible need for emergency surgery to correct the problem. Meanwhile, 12 units of platelets were rapidly infused and an infusion of packed red blood cells begun. After 10 minutes, the balloon in the posterior descending artery was deflated. Repeat angiography showed ongoing contrast extravasation from the distal posterior descending artery. The balloon was then reinflated for 20 minutes. Angiography after balloon deflation confirmed no further evidence of contrast extravasation (Video 21-3). The patient was observed in the cardiac catheterization laboratory and another angiogram performed 10 minutes later showed no further contrast extravasation. No additional blood was aspirated from the pericardial catheter. In total, 2.6 L of blood drained from the pericardial catheter and he received a total of 4 units of packed red blood cells in the cath lab.