Pericardial Window Formation Complicated by Intrapericardial Diaphragmatic Hernia

In rare circumstances, a diaphragmatic defect may allow for herniation of intra-abdominal contents into the pericardial space. These occurrences are exceedingly rare and may be due to trauma or congenital defects of the septum transversum or as the result of surgical procedures. We describe a 73-year-old female who presented with cardiac and abdominal symptoms one month after undergoing a subxiphoid pericardioperitoneal window for treatment and evaluation of a symptomatic pericardial effusion. 1. Introduction We report a case of intrapericardial herniation occurring one month after pericardioperitoneal window formation. We further discuss the controversies surrounding the choice of therapy in the treatment of pericardial tamponade. 2. Case Report The first reported case of intrapericardial diaphragmatic hernia was published in 1903, which was congenital in origin [1]. The vast majority of these cases are due to blunt trauma of the chest or abdomen [2]. In comparison to trauma, iatrogenic causes of intrapericardial herniation are exceedingly rare [2, 3]. Surgical procedures which have been complicated by the herniation of intra-abdominal contents into the pericardial cavity include coronary artery bypass grafting, subxiphoid epicardial pacemaker insertion, and after-creation of a pericardial window [3]; see Figure 2. A 73-year-old female, with a history of renal transplant occurring in 2008, developed shortness of breath and fatigue while on immunosuppressive agents. The patient was subsequently found to have a moderate sized pericardial effusion with tamponade physiology by echocardiography and large bilateral pleural effusions. The woman underwent subxiphoid pericardioperitoneal window formation with the subsequent extraction of approximately 400？mL of free flowing serous fluid. In addition, the patient underwent bilateral pleural drainage via chest tubes placed during the same procedure. The patient tolerated the procedure well with symptomatic relief and was discharged home without complication. One month after pericardial window formation, the patient presented to the emergency room with acute epigastric abdominal pain. The patient also described a nonproductive cough, mild shortness of breath, obstipation, and vomiting. At the time of admission, the patient’s vital sounds were notable for decreased pulse pressure. A systolic ejection murmur was auscultated on cardiac exam. Pulmonary examination demonstrated adventitious inspiratory breath sounds, dullness to percussion, and egophony at the right lung base. Additionally, the patient’s abdomen was