A 67 year old woman presented with syncope. Physical examination revealed pulsus paradoxus 20 mm Hg and jugular venous distention, leading to a diagnosis of pericardial effusion and possible tamponade. Echocardiogram showed massive circumferential pericardial effusion, diastolic right ventricular collapse, and dilated inferior vena cava without respiratory changes. Pericardiocentesis yielded 1100 ml of serosanguinous fluid. …