Matters of the Heart: Pericardial Tamponade

A 70-year-old woman with no previous medical problems had had progressive dyspnea and generalized weakness for the past several days. She was hypotensive (73/31 mm Hg), tachycardic (120 beats per minute), and tachypneic (28 breaths per minute); oxygen saturation (room air) via pulse oximetry was 84%. The patient was alert and well oriented. Her skin was cool, cyanotic, and mottled—especially on the arms and legs. Her neck veins were massively distended, and she had pulsus paradoxus. Cardiac sounds were decreased, and there was decreased air entry localized to the left side of the chest. An enlarged lymph node was found over the left supraclavicular region. An ECG revealed sinus tachycardia with low voltage. The chest film seen here shows a bottle-shaped heart, and the echocardiogram demonstrates a large effusion (arrowheads) encompassing the heart. Pericardiocentesis successfully alleviated the patient’s symptoms and produced 1100 mL of grossly hemorrhagic, free-flowing fluid. Cytologic examination of the fluid revealed metastatic adenocarcinoma. The primary site of the malignancy was determined to be a mass between the uterus and the anterior wall of the rectum. Before the scheduled exploratory laparotomy, however, the patient left the hospital against medical advice and was lost to follow-up.