Pericardial Decompression Syndrome After Large-Volume Pericardiocentesis in Systemic Sclerosis

Pericardial decompression syndrome (PDS) is a rare and underrecognized complication of pericardiocentesis, characterized by paradoxical hemodynamic deterioration after relief of pericardial effusion.

A 32-year-old woman with systemic sclerosis presented with chest pain and was found to have a large pericardial effusion with early tamponade physiology. She underwent rapid, large-volume pericardiocentesis. Hours later, she developed acute respiratory failure and cardiac arrest. Repeat echocardiography demonstrated new severe left ventricular systolic dysfunction without recurrent effusion, consistent with PDS. Misinterpretation as recurrent tamponade led to emergent repeat pericardiocentesis complicated by right ventricular perforation requiring surgical repair. Ventricular function fully recovered with supportive care.

PDS is infrequently recognized and may be precipitated by rapid drainage in patients with chronic effusions and underlying myocardial disease, such as systemic sclerosis.

Postpericardiocentesis deterioration should prompt consideration of PDS rather than reflexive repeat drainage. Slower or staged pericardial drainage may reduce the risk of catastrophic complications.