Letter by Kern regarding article, "High-pressure loculated pericardial effusion in postpericardiotomy syndrome".

Letter by Kern Regarding Article, “High-Pressure Loculated Pericardial Effusion in Postpericardiotomy Syndrome” To the Editor: Drs Syros and Maysky1 present a remarkable case of pericardial effusion due to post pericardiotomy syndrome in an 81-year-old man. I am confused about the hemodynamics displayed in Figure 2, which shows a pericardial pressure that appears to be exactly like that of a right ventricular tracing (52/20 mm Hg) and a right atrial pressure of 19 mm Hg with notable respiratory V waves. Although the authors assure us that the contrast echo confirmed the intrapericardial location, it is a physiological impossibility to have right ventricle–like pressure in the pericardium without transmission to the right atrial pressure wave contour as well. Perhaps the tip of the needle moved out of the right ventricle during injection of the contrast. Moreover, pericardial pressure exceeding right atrial pressure at all times during the cardiac cycle would produce a marked reduction in right atrial filling and lead to hemodynamic collapse, which was not the case here. Although the proposed mechanism was the outward movement of the left ventricle free wall in systole after the left ventricular diastolic collapse, the pressure relationship of the left ventricle, right ventricle, and right atrium do not make complete hemodynamic sense. No pressures after pericardial effusion drainage were provided. Because the pericardial and right atrial pressures are coupled tightly when effusion is present, I think I am missing something about the hemodynamic presentation that the authors may be able to explain.