Reversed Pulsus Paradoxus in Right Ventricular Failure

Reversed pulsus paradoxus was first described in 1973 as a rise in peak systolic pressure on inspiration in patients with idiopathic hypertrophic subaortic stenosis or isorhythmic ventricular rhythm and in patients with left ventricular systolic dysfunction on positive pressure ventilation. Positive pressure ventilation, for example, may impel blood from the pulmonary capillaries and venules into the left atrium. This may increase left ventricular preload and accelerate ventricular emptying, which in turn may cause the systolic arterial pressure to rise during inspiration. We observed this phenomenon in a patient with a large pericardial effusion, right ventricular failure, and pulmonary arterial hypertension, and we noted the lack of echocardiographic features of tamponade in the presence of right ventricular hypertrophy and pulmonary hypertension. This case report discusses the subsequent occurrence of acute congestive heart failure after pericardiocentesis.