The use of central venous catheters in very low birthweight infants to provide adequate calories for growth is an integral part of the care of the high-risk neonate. The use of surgically placed Broviac catheters has been associated with infectious and mechanical complications. Recently, there has been increasing use of silastic central venous catheters inserted through a peripheral vein and advanced to the right atrium. These catheters have a reported low rate of complications. However, we report a case of a very low birthweight infant in whom a peripherally inserted silastic catheter perforated the wall of the right atrial appendage and led to fatal pericardial tamponade. This is a very rare but nearly always fatal complication. It is potentially avoidable by careful placement of the tip of the central venous catheter, so that it is not impinging on a wall of the heart. Serial venograms may be useful to reconfirm the position of the catheter.