Perforation of Intrapericardial Structures Following Therapeutic Interventions

Objective: Perforation of intrapericardial structures following therapeutic interventions is a life-threatening complication with a high risk of cardiac tamponade. We report our recent experience.

Method: From November 2011 to August 2015, 28 patients with a verified atrial, ventricular or intrapericardial vessel perforation were enrolled in this analysis. Patients with complications following TAVR and percutaneous coronary interventions were excluded. Diagnosis was established by echocardiography or CT scan, and later verified by direct inspection.

Results: Perforation of the right ventricle occurred in 21pts (75%), mostly caused by pacemaker leads (50%) or pig tail catheters (14%). Three patients suffered left ventricle laceration (11%) after ventriculography, venoarterial ECLS implantation, and chest drain insertion. Intrapericardial brachiocephalic vein, superior caval vein, and sinus venosus, as well as left atrial appendage were perforated in 4 cases. Hemodynamically critical tamponade was evident in 14 pts (50%). Eight patients (29%) underwent resuscitation due to hemodynamic collapse, an ECLS device was applied in 3 patients (11%). Sternotomy was required in 15 pts (53%) for adequate hemostasis, two patient underwent repeated sternotomies due to recurring hemorrhage. A subxiphoid approach was sufficient in 1 case and a mere pig tail drainage in 4 (14.3%) cases. 6 (21.4%) patients underwent conservative therapy. Right ventricular perforation mandated surgical repair in 48% of cases, whereas lesions of the left ventricle or intrapericardial vessels required surgery in 83% of cases. Mean length of stay was 15 days (range 1–49 days), overall mortality was 14%.

Conclusion: Perforation of intrapericardial structures is associated a high risk of cardiac tamponade and relevant mortality. Surgical intervention is frequently needed for adequate treatment.