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Late onset pneumopericardium after lung transplantation

A 24 year old man with end stage cystic fibrosis underwent bilateral lung transplantation by sequential left and right anterior thoracotomy. The postoperative phase was uneventful; he was extubated on day 1 and transferred from the Intensive Care Unit to the pneumology department on day 10 after transplantation. A chest X-ray showed no abnormalities. On day 20 after transplantation, however, a chest X-ray showed an important pneumopericardium (Figure 1). The patient was asymptomatic and there were no signs of hemodynamic impact. An echocardiography confirmed the absence of tamponade. A CT scan confirmed a large pneumopericardium (Figure 2) without a pneumothorax or bronchopericardial fistula. The bronchial sutures seemed normal. Subsequently a fiberoptic bronchoscopy was performed, which confirmed the absence of bronchial dehiscence. A conservative treatment was suggested, although there were some concerns because of persistent colonization with MRSA in the transplanted lungs and the possibility of spreading infection into the pericardial sac, especially because of the highly immune compromised status of the patient. The patient was monitored intensively, but his further postoperative recovery was uneventful and the pneumopericardium spontaneously diminished and finally completely disappeared on day 32 after transplantation. He is doing well 4months after transplantation. Pneumopericardium is an exceptional complication of lung transplantation. The opening of the pericardial sac during intervention, necessary for the anastomosis of the pulmonary venous drainage, establishes a connection between the pleural and pericardial cavities, which is mostly maintained after the transplant. Other, often pathogenic, mechanisms can also be involved, including infections of the pericardium, barotrauma as a consequence of mechanical ventilation, formation of fistulas to the pericardial sac, bronchial dehiscence at the anastomosis and complications of invasive procedures. In our case the pneumopericardium developed 20 days after transplantation, raising suspicion of a small bronchopericardial fistula, although a CT scan or fiberoptic bronchoscopy could not confirm this. In the