\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[T2A]{fontenc}
\usepackage[ngerman,polish,english]{babel}



\usepackage{float}








\begin{document}

\title{A Rare Complication of Pericardiocentesis: Pneumopericardium}



\author[1]{Mustafa Yilmaz}%
\author[1]{Okan Gürkan}%
\author[1]{Elif Nur ARSLANBOGA}%
\author[2]{Pelin Karaca Ozer}%
\affil[1]{Gaziosmanpasa Research and Training Hospital}%
\affil[2]{Istanbul University Faculty of Medicine}%


\vspace{-1em}



  
  \date{June 15, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
Pneumopericardium is the presence of air in the pericardial sac.
Pneumopericardium after pericardiocentesis has been rarely reported in
the literature. In the present case, we report a patient who presented
with tamponade physiology during COVID-19 and developed
pneumopericardium after emergency pericardiocentesis. Immediate
recognition and treatment are crucial and chest X-ray, thorax
computerized tomography and transthoracic echocardiography are used for
diagnosis.%
\end{abstract}%



\sloppy


\textbf{A Rare Complication of Pericardiocentesis: Pneumopericardium}

Mustafa Yilmaz\textsuperscript{1} Orcid 0000-0002-2113-9891

Okan Gurkan\textsuperscript{2} Orcid 0000-0002-7934-9154

Elif Nur Arslanboga\textsuperscript{3} Orcid 0000-0002-8903-7373

Pelin Karaca Ozer\textsuperscript{4} Orcid 0000-0002-1085-5462

\textsuperscript{1}Gaziosmanpasa Research and Training Hospital,
Cardiology Department, Istanbul, Turkey

\textsuperscript{2}Gaziosmanpasa Research and Training Hospital,
Radiology Department, Istanbul, Turkey

\textsuperscript{3}Gaziosmanpasa Research and Training Hospital, Family
Medicine Department, Istanbul, Turkey

\textsuperscript{4}Istanbul University Faculty of Medicine, Cardiology
Department, Istanbul, Turkey

\textbf{Declaration of interest}

The authors report no relationships that could be construed as a
conflict of interest.

\textbf{*Corresponding Author}

Mustafa Y\selectlanguage{polish}ı\selectlanguage{english}lmaz, Istanbul University -- Gaziosmanpasa Research and
Training Hospital, Cardiology Department, Istanbul, Turkey

E-mail: drmustafayilmaz@outlook.com

\textbf{ABSTRACT}

Pneumopericardium is the presence of air in the pericardial sac.
Pneumopericardium after pericardiocentesis has been rarely reported in
the literature. In the present case, we report a patient who presented
with tamponade physiology during COVID-19 and developed
pneumopericardium after emergency pericardiocentesis. Immediate
recognition and treatment are crucial and chest X-ray, thorax
computerized tomography and transthoracic echocardiography are used for
diagnosis.

\textbf{Key words:} COVID-19, pericardiocentesis, pneumopericardium,
echocardiography

\textbf{INTRODUCTION}

Pericardiocentesis is a widely used treatment method in the treatment of
pericardial effusion and its complication rate is approximately 1-2\%
(1). Pneumopericardium is known as the accumulation of air in the
pericardial sac and is a rare complication of pericardiocentesis (2). In
this case report, we present a case of iatrogenic pneumopericardium
after pericardicentesis in a patient with COVID-19.

\textbf{CASE PRESENTATION}

A 56-year-old male patient with active COVID-19 disease presented to the
emergency department with worsening general condition and exacerbation
of dyspnea. The patient had a history of scleroderma and coronary artery
disease. Upon detection of approximately 3 cm of pericardial effusion in
thorax computed tomography (CT), cardiology consultation was requested
with the preliminary diagnosis of cardiac tamponade. On physical
examination, his temperature was 37\selectlanguage{ngerman}°C, heart rate was 105 beats/min,
blood pressure was 90/60 mm Hg, respiratory rate was 32 per minute, and
oxygen saturation was 94\% while receiving supplemental oxygen with a
high flow of 15 liters per minute through the cannula. An
Electrocardiogram (ECG) showed normal sinus rhythm at 100 beats per
minute. There were lung crackles and wheezing. S1 and S2 sounds were
weak, rhythmic, and there was no murmur. A transthoracic
echocardiography (TTE) showed normal biventricular volumes and systolic
functions, with a left ventricular ejection fraction of 60\%. There was
a large pericardial effusion, especially along the lateral wall. There
was only a small amount of effusion on the anterior surface of the right
ventricle and adjacent to the apical region. Pulse wave Doppler imaging
showed \textgreater{}40\% tricuspid wave variation. Pericardiocentesis
was planned, but it was difficult to drain the fluid with the subxiphoid
or apical method. Therefore, pericardiocentesis was performed by an
interventional radiologist by placing a drainage catheter with a
lateral-apical approach and 750 ml of pericardial fluid was drained.
After the procedure, his clinical condition improved and saturation
increased. However, the patient started to complain of chest pain three
hours after the procedure. ECG was taken and there was no feature. No
pericardial effusion was observed on bedside TTE. Also, the echogenicity
was found to be much worse than the TTE done before the
pericardiocentesis. On TTE, there was a finding of imaging loss during
systole, which is called the `air gap sign' (Video 1, supplementary
material). Air in the mediastinum was suspected due to crepitation at
the catheter insertion site. Chest radiography showed air in the
pericardial cavity surrounding the heart (Figure 1). Severe
pneumopericardium, pneumothorax and subcutaneous emphysema were detected
on thorax CT (Figure 2). Before underwater drainage, emergency
pericardiocentesis was performed to remove pericardial air and 400 cc of
air was aspirated. After the procedure, the patient's symptoms
alleviated and his clinical condition improved. Four hours after the
procedure, while the patient was going to be transferred to a tertiary
hospital, respiratory and cardiac arrest developed. Despite prolonged
resuscitation, the patient's circulation did not improve and he died.

\textbf{DISCUSSION}

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has
infected millions of people and caused enormous morbidity and mortality
worldwide, and still continues. With the increasing number of COVID-19
cases, various manifestations of the coronavirus have emerged. A large
pericardial effusion has been presented as early or late complication,
from isolated form to cases associated with pericarditis, myocarditis,
and even respiratory symptoms (3). Our patient was a case of cardiac
tamponade caused by large pericardial effusion accompanied by
COVID-19-related lung involvement and respiratory symptoms.

Pneumopericardium is the collection of air in the pericardium and is a
rare pericardiocentesis complication (2). Pneumopericardium is most
commonly caused by trauma, nevertheless it may also emerge following
interventional procedures. Although the most common cause of cardiac
tamponade is the collection of blood and other fluids in the
pericardium, it is known that air accumulation can also cause it (4).
Pneumopericardium should be one of the differential diagnoses in
patients with chest pain after pericardiocentesis, and chest radiography
and thorax CT are the first-line methods in diagnosis (5). Besides CT
and chest radiography, the 'air gap sign,' defined as cyclic loss of
myocardial imaging during systole on echocardiography, is a useful
diagnostic finding (6). Treatment of the etiology and close hemodynamic
follow-up is an appropriate option in patients whose clinical condition
is stable. In a patient with pneumopericardium, acute haemodynamic
worsening should urge further evaluation, and cardiac tamponade should
be actively ruled out (7). In the event of tension pneumopericardium, an
emergency pericardiocentesis with echocardiography is required to drain
the air surrounding the heart (8).

The main etiology in our patient was thought to be injury to the
visceral and mediastinal pleura while reaching the pericardium, and air
escaping from the lungs to the pleura was considered to reach the
pericardium by passing through the mediastinum. Complications involving
the lung and pleura are likely to be more common in pericardiocentesis
performed via the apical method than in those performed via the
subxiphoid technique (9). As a result, the apical-lateral approach of
pericardiocentesis was deemed to be a factor in our patient. In
addition, our patient has the 'air gap sign', which is a unique finding
of pneumopericardium. Investigation of the presence of this finding will
give very valuable information while performing echocardiography in
patients with suspected pneumopericardium.

\textbf{CONCLUSION}

In conclusion, it can be noted that the presence of significant
pericardial effusion indicates a poorer prognosis in COVID-19 patients.
Pneumopericardium is a rare but life-threatening complication of
pericardiocentesis and the most common symptom is chest pain. The main
diagnostic methods are chest radiography, thorax CT and TTE.

\textbf{Declaration of interest:} The authors report no relationships
that could be construed as a conflict of interest.

\textbf{Informed Consent} : Written informed consent has been obtained
from the patients' family to publish this paper.

\textbf{REFERENCES}

\begin{enumerate}
\tightlist
\item
  Schulte-Hermes M, Klein-Wiele O, Vorpahl M, et al. Peritonitis and
  pneumoperitoneum after successful emergency pericardiocentesis in the
  case of a Chilaiditi syndrome. J Geriatr Cardiol. 2019
  Jan;16(1):60-62.
\item
  Satyavolu B, Lodhi HA, Mathews A, et al. A Rare Iatrogenic Trio:
  Pneumopericardium, Pneumoperitoneum, and Pericarditis. \emph{JACC Case
  Rep} . 2021;3(13):1519-1523.
\item
  Kermani-Alghoraishi M, Pouramini A, Kafi F, et al. Coronavirus Disease
  2019 (COVID-19) and Severe Pericardial Effusion: From Pathogenesis to
  Management: A Case Report Based Systematic Review. Curr Probl Cardiol.
  2022 Feb;47(2):100933.
\item
  Ouachaou J, Laaribi I, Mimouni H, et al. Post-traumatic compressive
  pneumopericardium with spontaneous ventilation: Case report. Respir
  Med Case Rep. 2021;32:101354.
\item
  Choi WH, Hwang YM, Park MY, et al. Pneumopericardium as a complication
  of pericardiocentesis. Korean Circ J. 2011;41(5):280-282.
\item
  Reid CL, Chandraratna AN, Kawanishi D, et al. Echocardiographic
  detection of pneumomediastinum and pneumopericardium: the air gap
  sign. J Am Coll Cardiol. 1983 Mar;1(3):916-21.
\item
  Brander L, Ramsay D, Dreier D, et al. Continuous left hemidiaphragm
  sign revisited: a case of spontaneous pneumopericardium and literature
  review. Heart. 2002;88(4):e5.
\item
  Lamba A, Dutta R, Chand RK. Pneumopericardium after minimally invasive
  atrial septal defect closure. Ann Card Anaesth. 2018;21(1):99-100.
\item
  Osman A, Wan Chuan T, Ab Rahman J, et al. Ultrasound-guided
  pericardiocentesis: a novel parasternal approach. Eur J Emerg Med.
  2018;25(5):322-327.
\end{enumerate}

\textbf{FIGURE LEGENDS}

\textbf{Figure 1} : Chest radiography shows air around the heart in the
pericardial cavity.

\textbf{Figure 2} : Thorax CT image showing severe pneumopericardium,
pneumothorax and subcutaneous emphysema.

\textbf{VIDEO LEGENDS}

\textbf{Video 1:} Echocardiography image showing `air gap sign'.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/figure1/figure1}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/figure2/figure2}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{document}

