The authors report the case of a 75-year-old male patient with the following medical history: controlled hypertension, type 2 diabetes and hyperlipidemia, heavy cigarette smoking history, rectal cancer in remission for ten years, a small chronic pericardial effusion of unknown origin, coronary heart disease with the need for implantation of two drug-eluting stents two months ago and since then medicated with dual antiplatelet therapy (ticagrelor 90 mg twice a day and acetylsalicylic acid 100 mg once a day), and stage 5 chronic kidney disease resulting from atherosclerotic renal artery stenosis and recently initiated on hemodialysis.

A recent routine transthoracic echocardiogram (TE) revealed moderate pericardial effusion (14.9 mm) with mild right atrial collapse and the electrocardiogram (ECG) showed a sinus rhythm with a heart rate of 72 and normal QRS wave progression (Figure 1A). One week later, during hemodialysis session, the patient presented to the emergency department with nausea, vomiting, abdominal pain, pallor, cyanosis, weak central pulse, hypotension, jugular vein distention, and muffled hearth sounds (Beck triad). Electrocardiogram (ECG) showed a low QRS voltage in precordial leads compared to previous ECG (Figure 1B). Chest computed tomography (CT) scan revealed a large pericardial effusion. Ultrasound-guided pericardiocentesis was promptly performed and 650 mL of hemorrhagic pericardial effusion was immediately drained with cardiogenic shock clinical improvement. A pericardial catheter was applied and the patient was admitted to intensive care unit.

Pericardial fluid cultures were negative to bacterial and fungal infection. Biochemical and cytologic pericardial fluid analysis was not made in order to proceed to chronic pericardial effusion investigation.

After three days of hemodynamic stability and decreasing pericardial effusion in drainage, confirmed by TE, pericardial catheter was removed and the patient discharged. Ticagrelor treatment was discontinued.

One month later the patient did a new TE that showed a mild to moderate pericardial effusion. Because of his previous disease he further did a cardiac CT that revealed a right ventricular (RV) pseudoaneurysm (Figure 2 and Figure 3), likely related to the previous pericardiocentesis.

Right ventricular pseudoaneurysm is a rare and potentially fatal condition [1],[2]. Ventricular pseudoaneurysm is a contained rupture of the ventricular wall that may occur due to cardiac surgery, infective endocarditis, myocardial ischemia, syphilis, after penetrating chest trauma, endomyocardial biopsy, central venous or pulmonary artery catheterization, and transcatheter valve replacement [1],[2],[3],[4].

A cardiac pseudoaneurysm differs from a true aneurysm by its wall which does not contain myocardial tissue and connects to the ventricle by a narrow neck. Thus, ventricular pseudoaneurysm is prone to fatal rupture and subsequent high mortality [3].

The diagnosis of RV pseudoaneurysm is often a challenge because of its rarity and lack of typical clinical features [3]. Most patients present with chest pain and dyspnoea; however, up to 10% can be asymptomatic [2]. As a result, advanced imaging techniques have become the hallmark of RV pseudoaneurysm identification [5]. Optimal management remains unclear. However, the primary goal is to reduce the incidence of rupture [2].

Furthermore, heparin, a commonly used anticoagulant agent, is frequently used in patients undergoing hemodialysis [6]. The use of heparin is often perceived as a possible risk factor for the development of a worsening or hemorrhagic pericardial effusion that may result in cardiac tamponade [7].

This patient presented with cardiogenic shock possibly due to heparin-induced hemopericardium following hemodialysis. The use of dual antiplatelet therapy increased the risk of bleeding complications.

Cardiac tamponade was diagnosed by the authors in the setting of relevant clinical presentation in combination with ECG and chest CT findings.

Emergent pericardiocentesis was performed with clinical improvement. After this technique he developed an iatrogenic pseudoaneurysm, as it was confirmed by cardiac CT, which is corroborated by the literature.

We add to the literature a case of right ventricular pseudoaneurysm after pericardiocentesis, an extremely rare complication.