A Floating Heart: Large Pericardial Effusion with Extensive Lung Atelectasis

In extraordinary circumstances, large pericardial effusions cause pulmonary atelectasis (Amin et al., Cureus 11:e5287, 2019; Manhas and Gokhale, Indian J Crit Care Med 22: 191–194, 2018). Fluid builds up slowly and enlarges the pericardial sac, which can then compress the lung with minimal hemodynamic consequences. However, these patients are at risk of life-threatening tamponade. A morbidly obese 57-year-old man presented for mild chest pain and shortness of breath developed within several days. His medical history included an episode of idiopathic acute pericarditis, recurrent atrial fibrillation-flutter, and obstructive sleep apnea syndrome. There were no definite signs of cardiac tamponade. At first, the chest radiograph suggested a large effusion, which the computed tomography (CT) scans revealed to be the heart ‘floating’ within a large pericardial sac, together with extensive atelectasis. Considering the hazard of puncturing the heart, an intercostal catheter was inserted under Visiport optical guidance. An ultrasound-guided pericardiocentesis completed the procedure, draining 1.6 l of blood-stained fluid in total. The floating heart, coupled with extensive atelectasis, poses a therapeutic challenge. This case shows that an optical trocar allows for controlled drainage, thus reversing both the effusion and the atelectasis.