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Research Snapshot Theater: Cardiovascular/Shock, Adult II

Sequential Tamponade due to Warfarin-Associated Hemopericardium and Iatrogenic Pneumopericardium

Sunday, March 22, 2026
9:45 AM - 10:45 AM Central Time
Location: Connections Central - RST 03

  • Austin D. Corpuz, MD (he/him/his)

    Hawaii

    Disclosure(s): No relevant financial relationship(s) to disclose.

  • SK

    Shunsuke Kondo, MD

    Resident Physician
    University of Hawaii Internal Medicine Residency Program, Hawaii

    Disclosure information not submitted.

  • JG

    Joshua Garcia, DO

    Resident Physician
    University of Hawaii Internal Medicine Residency Program, Hawaii

    Disclosure information not submitted.

  • SG

    Stephanie Guo, MD

    Attending Physician, Pulmonary and Critical Care Medicine
    The Queen's Medical Center, Hawaii

    Disclosure information not submitted.

  • MT

    Michael T. Tanoue, MD

    Attending Physician, General Cardiology
    The Queen's Medical Center, Hawaii

    Disclosure information not submitted.

Introduction: Pericardial tamponade may present with vague symptoms and rapidly progress to hemodynamic collapse. Hemopericardium due to supratherapeutic INR is a rare but life-threatening complication of warfarin therapy. Iatrogenic pneumopericardium is a similarly uncommon and potentially fatal complication of pericardiocentesis. We describe a case of successive cardiac tamponade caused by warfarin-associated hemopericardium and subsequent pneumopericardium.


Description: A 51‑year‑old man with a history of mechanical aortic valve replacement on warfarin presented with acute-onset lightheadedness and dyspnea following three days of myalgias, abdominal pain, and diarrhea, which he had attempted to treat by consuming large amounts of mango. On arrival, BP was 72/52 mmHg, and INR was 13.4. He received IV fluids and underwent CTA aorta. During imaging, he developed asystole; ROSC was achieved after one round of CPR. Point-of-care ultrasound showed a large pericardial effusion. He was stabilized with fluids, vasopressors, prothrombin complex concentrate, and vitamin K, then transferred for pericardiocentesis. Following drainage of 690 cc of blood and drain placement, he was admitted to the ICU. That night, he developed recurrent hypotension; CT revealed pneumopericardium compressing the right atrium. Symptoms resolved after 60 cc of air was aspirated. He remained hemodynamically stable thereafter, although pericardial cultures grew Cutibacterium acnes. Given his history of poor wound healing following valve replacement, he was treated with 4 weeks of IV ceftriaxone.


Discussion: This case highlights the importance of considering hemopericardium in anticoagulated patients presenting with shock, as well as the sensitivity of INR levels to abrupt dietary changes. Warfarin–mango interactions have been increasingly documented in the medical literature. Additionally, pneumopericardium causing tamponade is an exceedingly rare complication of pericardiocentesis, and its resolution with simple aspiration underscores the value of close post-procedural monitoring. The incidental isolation of Cutibacterium acnes from pericardial fluid is also uncommon and raises concern for subclinical prosthetic valve infection, supporting the decision to initiate prolonged antibiotic therapy.