Ann Thorac Surg 2007;83:321
© 2007 The Society of Thoracic Surgeons
Images in Cardiothoracic Surgery
Tension Pneumopericardium Caused by Pericarditis
Jun Li, MD*,
Alfred Omo, MD,
Tao Chen, MD,
Zhi Zheng, MD,
Tiechen Pan, MD
Department of Cardiothoracic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. of China
* Address correspondence to Dr Li, Department of Cardiothoracic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030 P. R. of China (Email: junliulmde{at}yahoo.com.cn).
A 60-year-old man, admitted to our thoracic surgery department with complaint of dyspnea and fever, which had been aggravated for the past 10 days. On arrival, he was fully conscious and alert, but very distressed and could not lie supine comfortably. His vital signs were a pulse rate of 125 beats per minute, blood pressure of 130/50 mm Hg, respiratory rate of 35 breaths per minute, and temperature of 38.8°C. Laboratory examinations were within normal ranges except WBC 9.91 x 109/L, N = 79.8%. On examination he had distended neck veins, muffled heart sounds and a palpable pulsus paradoxus. The central venous pressure measured 25 cmH2O. An electrocardiogram showed diminished QRS complexes with no ST segment elevation. Chest x-ray (AP view) showed the tension pneumopericardium (Fig 1) and chest CT scan confirmed the diagnosis, without significant pathological changes in both lungs (Fig 2).
An emergency operation was performed via subxyphoid incision. The intrapericardial pressure was measured as 27 cmH2O by means of needle insertion before opening the pericardial window. On incision of the pericardial sac, a high-pressure gush of air was expelled and his hemodynamic parameters normalized quickly. Chest x-ray (AP view) showed the successful relief in tension pneumopericardium after the opening pericardial window (Fig 3). The exploration through the pericardial window revealed that the whole heart surface and parietal pericardium were covered with white pyogenic substance. Laparotomy through the same incision found no free air or fluid in the abdomen, and the abdominal organs were in normal position below the diaphragm. The pericardial cavity was lavaged and a pericardial drain was placed. The microbiological culture of the samples of white pyogenic substance revealed combined candida glabrata, Klebsiella pneumoniae and viridans streptococci infection. After antimycotic and antibiotic therapy, the patient had an uneventful recovery. He was discharged on day 7 and was well at his two months postoperative follow-up.
