Air bubbles around the heart: a rare case report of pneumohydropericardium in heart transplantation

Background Pneumohydropericardium is a rare but significant condition characterized by the presence of both air and fluid in the pericardial space. It is often associated with trauma, invasive procedures, or thoracic pathologies, and its occurrence following heart transplantation is particularly unusual. Early recognition is essential to prevent complications such as cardiac tamponade, although conservative management can be effective in cases without haemodynamic compromise. Case summary We present the case of a 40-year-old woman with a history of hypokinetic-dilative cardiomyopathy and heterozygous for TNNT2 gene mutation (c.547C>T p.Arg183Trp), who underwent orthotopic heart transplantation. Following the procedure, she developed pneumohydropericardium, identified by echocardiography as air microbubbles and fluid in the pericardial space, without associated haemodynamic instability. The condition was monitored with serial echocardiograms, and no invasive intervention was required. The air microbubbles resolved after 16 days of echocardiographic follow-up, and the patient was discharged in stable condition. At follow-up, she showed no recurrence of the pneumohydropericardium. Discussion This case highlights pneumohydropericardium as a rare post-transplant complication that, when detected early and closely monitored, can be managed conservatively without severe outcomes. While pneumohydropericardium has been previously reported in association with other conditions, its post-transplant manifestation is rare and warrants further awareness. Echocardiographic surveillance played a key role in guiding management, as invasive procedures were avoided, and the patient remained haemodynamically stable throughout. This case underscores the importance of recognizing and managing pneumohydropericardium in heart transplant patients to ensure optimal outcomes