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An 86 year old physician with a history of advanced ischaemic cardiomyopathy and inducible ventricular tachycardia requiring an implantable cardioverter-defibrillator (ICD) presented with orthostatic symptoms and hypotension felt to be secondary to dehydration. ICD interrogation revealed no recent events. An ECG showed atrioventricular sequential pacing. The chest radiograph was remarkable for lucency under the pericardium (arrows in left hand panel below) which appears to extend into the mediastinum. A computed tomographic (CT) scan revealed large anterior pneumopericardium (arrows in right hand panel) extending from the inferior apex to the aortic root. Multiple bullae were present adjacent to the mediastinal air collection. Emergency echocardiography showed no evidence of cardiac temponade. The patient’s hypotension resolved with fluid administration. He was treated conservatively and a follow up chest x ray three months later revealed complete resolution of the pneumopericardium.