A 72-year-old female with a medical history of hypertension, heart disease, and lung cancer on external beam radiation therapy presented to the emergency department with 1 day of chest pain. The pain was sharp, constant, centrally located, and accompanied by shortness of breath intermittently for several weeks. She denied fever, nausea, vomiting, diaphoresis, palpitations, leg swelling, or trauma. Her vital signs at triage were temperature 98.7°F, pulse 89 beats/min, respiratory rate 22 breaths/min, blood pressure 110/32 mm Hg, and oxygen saturation 100% while breathing room air. Physical exam revealed normal heart sounds, rhythm, and rate, and her breath sounds were moderately decreased bilaterally. There was no extremity edema or asymmetry. Given her history of thoracic malignancy, the treating emergency physician performed a focused bedside echocardiogram to evaluate the patient for pericardial effusion or right heart strain.
The cardiac examination was performed with a 5–1 MHz phased array transducer (Model HD11XE, Philips, Andover MA). Initial evaluation in the parasternal long axis view showed a small pleural effusion and no significant pericardial fluid (Figure 1 and Video Clip S1). Despite the normal pericardial findings in the parasternal long-axis view, subcostal examination revealed a giant pericardial effusion with right atrial compression and near-total collapse of the right ventricle (Figure 2 and Video Clip S2). Given the presence of a giant pericardial effusion seen on the subcostal view, but the absence of a circumferential effusion or significant effusion on the parasternal views, the diagnosis of loculated pericardial effusion was made. Cardiology and cardiothoracic surgery services were consulted and a comprehensive echocardiogram was performed, confirming the presence of a large loculated pericardial effusion. After extensive discussions with the patient and her family, she elected to pursue hospice care rather than proceeding with a pericardial window or pericardiocentesis, given the extent of her metastatic disease and her overall poor prognosis.