Tharusan Thevathasan

Background: Emergency pericardiocentesis represents a life-saving intervention in patients with acute cardiac tamponade. During complex percutaneous coronary intervention (PCI), abrupt haemodynamic deterioration secondary to pericardial tamponade may necessitate immediate subxiphoid drainage. Although the procedure is generally safe when performed by experienced operators, catheter malposition can result in ineffective pericardial decompression and may be associated with unexpected and potentially serious complications. Case summary: An 83-year-old patient with multiple cardiovascular risk factors and paroxysmal atrial fibrillation underwent high-risk PCI for severely calcified left main and multivessel coronary artery disease at an external institution. Owing to persistent angina, the patient was transferred directly to our tertiary referral centre. Coronary angiography revealed an iatrogenic left main coronary artery dissection, presumably related to the preceding PCI. The lesion was successfully treated using intravascular imaging guidance, adjunctive plaque modification, and drug-eluting stent implantation, resulting in complete sealing of the dissection and restoration of Thrombolysis in Myocardial Infarction 3 flow. Shortly thereafter, the patient developed acute hypotension accompanied by echocardiographic evidence of rapidly accumulating pericardial effusion with haemodynamic features of cardiac tamponade. Emergency subxiphoid pericardiocentesis led to immediate haemodynamic stabilization. However, persistent abdominal discomfort prompted further diagnostic evaluation. Computed tomography (CT) demonstrated intraperitoneal contrast distribution across multiple abdominal quadrants, consistent with peritoneal perforation by the pigtail catheter and the presence of an iatrogenic pericardio-peritoneal communication. Serial transthoracic echocardiography showed only minimal and stable residual pericardial effusion without recurrence of tamponade physiology. The drainage catheter was therefore removed at an early stage. Follow-up CT confirmed progressive resolution of intraperitoneal contrast. The patient subsequently recovered without further complications. Discussion: Peritoneal perforation during subxiphoid pericardiocentesis is a rare but clinically relevant complication. In cases in which clinical symptoms are disproportionate to echocardiographic findings, or when the effectiveness of pericardial drainage is uncertain, early cross-sectional imaging should be considered to verify catheter position and to identify abnormal extracardiac fluid communication. Prompt recognition and timely catheter removal may prevent further complications and obviate the need for surgical intervention.

Background and Aims: Transcatheter mitral edge-to-edge repair (M-TEER) is an established therapy for severe mitral regurgitation (MR) in patients at increased surgical risk. While procedures are commonly performed under general anaesthesia (GA), dexmedetomidine-based conscious sedation (DCS) may preserve physiological haemodynamics and improve procedural efficiency. Comparative data remain limited. To compare procedural effectiveness, efficiency and safety of M-TEER performed under GA versus DCS. Methods: In this retrospective observational study, patients undergoing M-TEER under anaesthesiologist-guided DCS or GA were analysed using propensity score matching to adjust for baseline differences. The primary endpoint was device effectiveness, defined as successful implantation with MR reduction to ≤2+ post-procedure and sustained at discharge. Procedural duration was analysed as a secondary workflow endpoint. The main safety endpoint was a composite of all-cause death, stroke, cardiac structural complications, cardiogenic shock, acute kidney injury requiring renal replacement therapy, or moderate/severe bleeding according to Mitral Valve Academic Research Consortium criteria. Results: Ninety-seven patients were included (DCS 37; GA 60). Device implantation success was achieved in 98.9% of procedures. Immediate device effectiveness was high and comparable between strategies (100 vs 98.3%; P = 1.0). Procedural duration was shorter with DCS [84 (interquartile range 70.5–111.5) vs 102.5 (78–144) min; P = .019]. In matched analysis (36 pairs), fluoroscopy time, radiation dose, and residual MR at discharge (MR ≤1: 86.1 vs 83.3%; P = .743) were similar. The composite safety endpoint did not differ significantly (P = .436), and no surgical conversions occurred. Conclusions: Dexmedetomidine-based conscious sedation provided procedural effectiveness and safety comparable to GA while improving procedural efficiency. These findings support an individualized anaesthetic strategy and warrant prospective evaluation in contemporary M-TEER practice.