Hemoperitoneum, Hepatic Laceration, and Hepatic Artery Pseudoaneurysm as a Complication of Emergent Pericardiocentesis

Emergent pericardiocentesis is a potentially life-saving therapeutic procedure. We report a case of hemoperitoneum, a rare but known complication of pericardiocentesis; due to hepatic artery laceration and hepatic artery pseudoaneurysm formation resulting in delayed hemorrhagic shock as a complication of emergent pericardiocentesis. (Level of Difficulty: Intermediate.)

A n 82-year-old woman with severe degenerative mitral regurgitation (MR) and NYHA functional class III symptoms, who was using maximally tolerated medical therapy, presented for elective transcatheter mitral valve edge-to-edge repair (TEER).
The patient underwent successful TEER with a MitraClip device by the use of fluoroscopy and transesophageal echocardiography (TEE). After the procedure, good hemostasis was accomplished. and TEE did not reveal any pericardial effusion. The patient was extubated and transferred to the recovery room in stable condition.
Ninety minutes after the procedure, the patient became hypotensive; her mean arterial pressure (MAP) was 37 mm Hg, and she was tachycardic (heart rate 144 beats/min), and encephalopathic. A rapid response was called, and a bedside transthoracic echocardiogram (TTE) revealed new-onset moderate, predominantly anterior, pericardial effusion with pericardial tamponade (Figure 1, Video 1).
The patient was resuscitated with intravenous (IV) fluids and vasopressors for hemodynamic support. No chest compressions were done. Bedside attempts to perform pericardiocentesis by a substernal approach using ultrasound guidance were unsuccessful because of her inability to lie flat and her small body frame. The patient was taken to the catheterization laboratory and underwent

LEARNING OBJECTIVES
To describe a rare complication of pericardiocentesis including hemoperitoneum secondary to hepatic laceration and hepatic artery pseudoaneurysm formation. To discuss management of hepatic artery laceration and pseudoaneurysm. To recognize unforeseen complications resulting from prolonged hospital stay. The patient continued to require a relatively low dose of IV norepinephrine for vasopressor support.
Continued TTE monitoring did not reveal any significant pericardial effusion, although the patient continued to have pericardial drain output.
On postprocedure day 3, the patient became unresponsive during placement of a peripherally inserted central catheter (PICC). Her MAP decreased to 40s mm Hg, with palpable pulses. IV norepinephrine was uptitrated. A bedside examination revealed soft but significantly distended abdomen.

MEDICAL HISTORY
The patient's medical history included hypertension, right subclavian artery stenosis, carotid stenosis, coronary artery disease, atrial fibrillation, COPD, thyroid cancer, heart failure with mildly reduced EF at 45%, and MR.

DIFFERENTIAL DIAGNOSIS
The differential diagnosis included pericardial effusion and hemoperitoneum secondary to pericardiocentesis.

DISCUSSION
Pericardiocentesis, when performed with imaging guidance, is a relatively safe procedure, with the risk of complications ranging from 4% to 10%.

FOLLOW-UP
Because of the continued significant drain output, the pericardial drain was kept in situ with monitoring of drain output and TTEs. The pericardial drain was removed on postprocedure day 12. Follow-up TTE did

FIGURE 5 Computed Tomography Angiogram With Intravenous Contrast Material
Arrow points to the adjacent hyperenhancement on arterial phase representing shunting.

CONCLUSIONS
Pericardiocentesis is a potentially life-saving procedure that carries a high risk of complications. In this regard, imaging support and careful planning of the Image demonstrating complete occlusion of the pseudoaneurysm.
JACC: CASE REPORTS, VOL. 5, NO. C, 2023 Farooq and Iyer J A N U A R Y 4 , 2 0 2 3 : 1 0 1 6 8 6 Complication of Emergent Pericardiocentesis proper entry site are fundamental for a safe and successful procedure.

FUNDING SUPPORT AND AUTHOR DISCLOSURES
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.