SCAI/EAPCI/ACVC Expert Consensus Statement on Cardiogenic Shock in Women-Dr. Bortnick slides

Dr. Bortnick slides

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This case report by Dr. Anna Bortnick highlights the complex management of a 65-year-old woman with multiple comorbidities—including sickle cell disease, end-stage renal disease on hemodialysis, heart failure with preserved ejection fraction, hypertension, peripheral arterial disease, and active tobacco use—who presented after a fall with shortness of breath and hypoxia. Imaging revealed subsegmental pulmonary emboli and pleural effusions. She was hypoxic and declined hemodialysis.<br /><br />Right heart catheterization demonstrated elevated right atrial and pulmonary pressures consistent with right heart strain. After slow drainage of 170 mL of sanguinous pericardial fluid, the patient deteriorated rapidly with hypotension, requiring escalating vasopressors, dobutamine, emergent hemodialysis, and intensive management of metabolic derangements. The clinical course was complicated by pulseless electrical activity arrest and bradycardic arrest, requiring resuscitation and advanced support, culminating in palliative extubation after 10 days.<br /><br />The case underscores the phenomenon of pericardial decompression syndrome (PDS), a potentially fatal complication following pericardiocentesis where rapid reduction of pericardial fluid paradoxically worsens hemodynamics, particularly in patients with pulmonary arterial hypertension. Literature referenced notes high mortality rates (20-50%), predominance in women with connective tissue disorders, and unclear best practices. European Society of Cardiology guidelines recommend limiting pericardial drainage increments and suggest using pressure transducers to monitor intrapericardial pressure to avoid PDS.<br /><br />Key learning points emphasize the challenges of managing women presenting with cardiogenic shock and multiple comorbidities, the difficulty in obtaining adequate vascular access, especially femoral, and the critical consideration of low-volume, cautious pericardiocentesis in patients with right-sided heart failure or pulmonary hypertension to avoid PDS.<br /><br />This case illustrates the delicate balance needed in critical care cardiology when managing complex shock patients with combined pulmonary and pericardial pathologies.

Keywords

pericardial decompression syndrome

pericardiocentesis complications

right heart strain

pulmonary arterial hypertension

sickle cell disease

end-stage renal disease

hemodialysis complications

cardiogenic shock management

pulmonary embolism

pleural effusions