sternal bone marrow biopsy belongs to invasive diagnostic methods for differential diagnosis of whole spectrum of hematological diseases . as an invasive procedure , local complications ( bleeding and infection from puncture site ) are considered as minor ones . major ones are due to improper technique or instrument usage and are as follows : manubrio - sternal dehiscence , sternal fracture , pneumopericardium , pneumotorax and biopsy needle breakage . life threatening complications are because of pericardial tamponade caused by ascending aorta or right ventricle injury . an 80-year - old man was brought to the regional hospital because of unclear abdominal pain , diarrhea and concomitant dehydration . later , on the basis of laboratory examination of anemia ( ery 3.7710l , hb 112 g / l , hct 0.35 ) and thrombocytopenia ( 7210l ) , sternal bone marrow aspiration biopsy was performed . approximately 45 minutes after the procedure the patient was complaining about general weakness and backache . because of slowly ongoing hemodynamic stability deterioration , the patient was transported to cardiac surgical facility . transoesophageal echocardiography confirmed pericardial tamponade with right atrium and ventricle compression and dyskinesis ( figure 1a ) . immediate surgery was indicated . before surgical field draping off , puncture site on sternum was clearly visible ( figure 1b ) . when pericardial sac was opened , approximately 300 ml of blood were evacuated and hemodynamic stability was immediately achieved . this location was sutured with pericardial pledgets . during postoperative course rehydration and short - time full parenteral nutrition was necessary . overall state of health gradually improved and the patient was transferred back to regional hospital on 7 post - operative day for further rehabilitation . aspiration may be done at several sites , but sternum is supposed to be the easiest site from which to obtain the most cellular marrow . heart injury with pericardial tamponade due to sternal puncture bone marrow biopsy has been rarely subscribed in literature . in 2003 issue of british journal of haematology , overall complications were found in 26 cases , bleeding in 14 . no case of heart or aortic injury was observed . they have studied 34 sternal aspiration death - complication cases published and have identified performing physician lack of experience and wrong location of puncture site as a cause of trouble . german authors have published five cases of periprocedural right ventricle injury where one patient only was saved by emergent surgery . sternal biopsy peri - procedural death was studied by american authors also . as a main cause of injury these studies are 10 - 30 years old and probable reason for late diagnosis of pericardial tamponade was lack of bedside echocardiography examination . midline sternotomy and direct suture of injury site is a principle of successful surgical treatment . according to aforementioned studies , case reports and our clinical practice , several essential suggestions for sternal bone marrow biopsy arise : i ) proper indication , clinical benefit must always outweigh potential risks ; ii ) experience of performing physician ; iii ) proper biopsy needle and its length ; iv ) site of puncture , medial part of sternal manubrium at the level of first intercostal space ( should never be performed lower ) ; v ) follow up of the patient and timely echocardiography examination in case of any clinical status uncertainty ; vi ) in case of hemopericardium , fast cardiac surgery is indicated .
injury of the heart with concomitant pericardial tamponade as a result of sternal bone marrow biopsy is rare . 
 an 80-year - old man was admitted with dehydration and non - specified abdominal pain to the regional hospital . 
 sternal aspiration biopsy was performed because of anemia and thrombocytopenia . 
 later on , because of the back pain , general weakness and blood pressure drop , an echocardiography examination was indicated . 
 pericardial fluid collection was found . 
 anticipated ascending aortic dissection was excluded on computed tomography scan , but pericardial fluid collection was confirmed . 
 transfer to our cardiac surgical facility ensued . 
 limited heart tamponade was affirmed on echocardiography and surgery was immediately indicated . 
 blood effusion was found in upper mediastinal fat tissue and 300 ml of blood were evacuated from opened pericardial space . 
 stab wound by sternal biopsy needle at the upper part of ascending aorta was repaired by pledgeted suture . 
 postoperative course was uneventful .