Figure 2 - angiogram after PCI of RCA obstructive lesions (left anterior oblique projection).
After the procedure, the patient remained asymptomatic and hemodynamically stable. Echocardiography did not reveal pericardial effusion either any other change in relation to the previous exam. Patient was discharged next day with the following medication: acetylsalicylic acid 100mg, Clopidogrel 75 mg, bisoprolol 2,5 mg, atorvastatin 40 mg , ramipril 5 mg, metformin 1000mg and sitagliptin 5 mg. He maintained follow-up in cardiology consultation during 3 years without any clinical intercurrence during this period.
Three years later the patient was admitted in the emergency department after a syncopal episode preceded by chest discomfort and diaphoresis. At admission patient presented with chest discomfort, diaphoresis and widespread weakness and had signs of shock as hypotension, impaired tissue peripheral perfusion (hiperlactacidemia 5,1 mmol/L), tachycardia (120 bpm) and tachypnea (30 cpm) . EKG showed sinus rythm, 120 bpm, with Q waves in DIII and aVF and 1 millimeter horizontal ST-segment depression in V4, V5 and V6 derivations. Emergence echocardiography showed a pericardial effusion with 25 mm in posteroinferior topography and collapse of right cardiac cavities. It was performed an emergent pericardiocentesis with immediate drainage of 1500mL of hematic-looking liquid.
After clinical and hemodynamic stabilization of the patient, taking into account his clinical background and the possible iatrogenic etiology of hemopericardium, the cardiac surgery reference center was contacted and the patient was transferred to that department to be submitted to an emergent exploratory sternotomy.