A 27-year-old Hispanic man with a history of hypertension and end-stage renal disease for 4 years became unresponsive, apneic, and pulseless during hemodialysis. During his 4 year period on dialysis, vascular access had become increasingly difficult and ultimately a transhepatic catheter had been placed 9 months prior to this event. Resuscitation was unsuccessful. At autopsy, death was determined to be due to cardiac tamponade secondary to perforation of the right atrium by the transhepatic catheter. Cardiac tamponade is a rare cause of sudden death during hemodialysis with a long-standing catheter.