Pericardiocentesis at 14 Weeks
Effective Treatment of Pericardial Effusion Complicating Right Ventricular Diverticulum
We report the successful outcome of ultrasound-guided pericardiocentesis in a 14-week fetus presenting with a right ventricular diverticulum and large pericardial effusion. Congenital ventricular diverticulum is usually isolated but has a variable clinical course in fetal life. Two women were referred at 14 weeks because fetal ultrasound revealed a large pericardial effusion compressing the lungs. Both fetuses showed 2- to 3-mm blood-filled cyst-like structures at the right ventricular apex (Figure 1, A and B). Abdominal situs and cardiac connections were normal, there was no sign of cardiovascular compromise, no extracardiac abnormalities were present, and infection screen and karyotype were normal in both fetuses. The parents of one fetus opted for termination, and ultrasound findings were confirmed at postmortem: a thin-walled fibrous sac communicating with the right ventricular apex via a pinhole aperture (Figure 1C). The second fetus underwent pericardiocentesis. Guided by ultrasound, a 20-gauge needle was inserted percutaneously into the pericardial effusion and 2 mL of straw-colored fluid was aspirated. The fetal lungs then clearly expanded (Figures 2, A and B). Serial echocardiograms until birth showed no effusion, a collapsed diverticulum, and no cardiovascular compromise. Pericardiocentesis was associated with uncomplicated survival to term and an uneventful postnatal course. Postnatal echocardiography (Figure 2C) confirmed the tiny diverticulum originating from the right ventricular apex with no hemodynamic disturbance. No further treatment is planned. Pericardiocentesis is technically challenging in early gestation, but allowed reexpansion of the compressed lungs, normal pulmonary development, and reduction in systemic venous pressures, avoiding potential hydrops and fetal demise.
Dr Pasquini is supported by echo uk (www.echocharity.org.uk).