BACKGROUND: Coronary perforation during percutaneous coronary intervention (PCI) can cause pericardial bleeding and shock. Emergency pericardiocentesis may be lifesaving, but persistent bloody drainage after apparently successful coronary sealing creates a diagnostic trap: clinicians may assume ongoing coronary leakage and miss catheter-related injury. We report a safety lesson from this setting.

CASE REPORT: A 63-year-old woman weighing 37 kg underwent PCI for a severely calcified right coronary artery lesion. Coronary perforation after stenting was sealed with a covered stent. After transfer to the ward, she developed shock and increased apical pericardial effusion. Our treating team performed real-time echocardiography-guided apical pericardiocentesis, draining 200 mL of bloody fluid with transient improvement. Routine catheter-position checks, including agitated saline injection, contrast fluoroscopy through the catheter, pressure-waveform recording, and blood gas or oxygen saturation testing, were not performed or not documented. Drainage remained bloody, with approximately 1000 mL additional output, recurrent hypotension, and a hemoglobin decrease from 102 to 67 g/L. Repeat coronary angiography showed no recurrent extravasation. Fluoroscopy/digital subtraction angiography showed an abnormal catheter trajectory, with the distal tip projected over the aortic region. Computed tomography was not performed because the patient proceeded directly to emergency surgery. Surgical exploration confirmed left ventricular free-wall penetration. The catheter was removed only after pledgeted repair was secured. The patient recovered well.

CONCLUSIONS: This case emphasizes a safety message rather than a proven intravascular route. After PCI-related perforation, persistent bloody drainage with shock should prompt immediate drain-position reassessment and controlled removal if intracardiac or intravascular malposition is possible.

Keywords: Iatrogenic Disease, Pericardiocentesis