Pericardiocentesis

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W9 Pericardiocentesis

Stefano Maggiolini, Giovanni Vitale

image Before Procedure

Indications

• Pericardial tamponade:

• Pericardiocentesis is the first treatment option in patients with overt tamponade, because only the removal of fluid allows normal ventricular filling and restores adequate cardiac output.

• Pericardial effusion without hemodynamic compromise:

• Persistent (more than 1 week treatment) pericardial effusion >20 mm (anterior plus posterior space) in echocardiography in diastole
• Suspected purulent or tuberculous pericarditis:

image Elective pericardiocentesis is warranted in patients with suspicion of purulent pericarditis. This is a rare disease, but rapid diagnosis and treatment are essential to prevent serious morbidity, especially in children and immunocompromised patients. Among patients treated only with antibiotics without pericardial drainage, purulent pericarditis carries a mortality rate of 70%. Treatment consists of systemic antibiotic therapy and complete evacuation of the effusion. Surgical drainage usually is required because percutaneous drainage alone cannot completely evacuate the effusion, which is often rich in fibrin and can be loculated and associated with dense adhesions. An alternative and less invasive method that can be used to completely evacuate purulent effusions, thus controlling sepsis and avoiding the evolution to constrictive pericarditis, consists of pericardial drainage associated with intrapericardial infusion of streptokinase. Fibrinolytic therapy can enhance removal of material that would otherwise be too viscous or particulate to be removed by tube drainage. This treatment should be considered before undertaking surgery.

• Suspected neoplastic effusion
• Pericardiocentesis for diagnostic purposes in small effusions should be confined to selected cases.

image Pericardiocentesis with a diagnostic purpose is not justified in the majority of cases for the following reasons: its low diagnostic power; the underlying pathology is often already known or identifiable by different noninvasive test; viral pericarditis is usually self-limiting and only requires an antiinflammatory treatment.

Contraindications

• Aortic dissection is a major contraindication.

• In case of pericardial tamponade with shock, there are no other absolute contraindications.

• Relative contraindications include uncorrected coagulopathy, anticoagulant therapy, thrombocytopenia <50,000/mm3, and small, posterior, and loculated effusions.

• Alterations of coagulation can be corrected using:

image Fresh frozen plasma or platelets (may be time consuming)
image Recombinant human factor VIIa, which may be effective in a shorter time
image Vitamin K + prothrombin complex concentrate

Equipment

• Echocardiography
• Multi-angle bracket, to be assembled on the probe (biopsy starter kit for GE 3S, 3S-RS, M3S, and M4S transducers [CIVCO USA, Kalona, Iowa])
• Needle-guide kit with sterile sheath and sterile echo-gel (Ultra Pro II needle guide [CIVCO USA, Kalona, Iowa])
• 14- to 16-gauge Teflon-sheathed needle (technique A)
• 18-gauge, 9-cm needle on a syringe for apical approach (technique B)
• 18-gauge needle, included in the PeriVac set (Boston Scientific USA) for subxiphoid approach
• J-tipped guidewire
• 6F to 8F dilator
• Drainage catheter: pigtail angiocatheter 6F to 8F or pericardiocentesis set (PeriVac)
• Disposable flushing system to maintain patency of the system

image Anatomy

The pericardium is a fibroserous sac that contains the heart and the origin of the main vessels. It is composed of a fibrous outer layer and an inner serous membrane consisting of a single layer of mesothelial cells. The pericardial space normally contains 25 to 50 mL of fluid in adults. If the amount of fluid increases, the pericardium is not immediately distensible, even though stress relaxation may occur within minutes from the beginning of the increase in pericardial pressure. If the fluid accumulates slowly over weeks or months, the pericardium can increase in size to a maximum capacity of 1 to 2 L. The heart, and therefore the pericardium, is located at the center of the mediastinum, partially covered by the lungs, sternum, costal cartilages of the third, fourth, and fifth ribs, and by the intercostal muscles. About two-thirds of the heart is located on the left side of the chest. The heart rests on the diaphragm. The pericardium is innervated by the vagus nerve, the left recurrent laryngeal nerve, the esophageal plexus, and it also has rich sympathetic innervation from the stellate and first dorsal ganglia and the cardiac, aortic, and diaphragmatic plexuses. When performing pericardiocentesis, close attention should be paid to avoid damaging the internal thoracic artery, which runs behind the sternal end of the costal cartilages, and the vascular bundle at the inferior margin of each rib (Figure W9-1).

image

Figure W9-1 Projection of cardiac area on the anterior thoracic wall.

image Procedure

Echo-Guided Technique (A)

• Perform a two-dimensional and Doppler study to assess the size, distribution, and hemodynamic effect of the effusion.
• Place the patient in a semireclining position at an angle of about 30 degrees and slightly rotated leftward to enhance fluid collection in the infero-anterior part of the chest.
• Ensure that a central venous catheter is in place. The catheter is essential for monitoring right atrial pressure and permitting rapid infusion of fluids and drugs as indicated.
• Continuous arterial pressure monitoring is indicated to detect the presence of pulsus paradoxus and to rapidly detect and correct sudden hemodynamic instability.
• Medical management:

• In the unstable patient, during preparation for pericardiocentesis, measures aimed to stabilize the patient should be instituted. Intravenous fluid administration is the best treatment option before and during drainage.
• Intravenous administration of diuretics is contraindicated and could be fatal in patients on the edge of their compensatory mechanism in tamponade.
• Both dopamine and dobutamine improved hemodynamics in cardiac tamponade; dobutamine has greater beta activity, and therefore it may be considered preferable. However, the usefulness of inotropes is generally limited because endogenous adrenergic stimulation is already enhanced under tamponade conditions, and ejection fraction is preserved, but stroke volume is critically depressed.
• Packed red cell units should be readily available before starting nonemergency procedures.

• Respiratory management:

• Pulse oximetry and supplemental O2 should be warranted.
• Influence of respiratory parameters: spontaneous versus mechanical ventilation and PaCO2 levels significantly influence the evolution of pericardial tamponade. Pericardial pressure decreases 3 to 6 mm Hg when PaCO2 decreases to 24 mm Hg; conversely, pericardial pressures increase 2 to 4 mm Hg when PaCO2 reaches 57 mm Hg. Increased intrathoracic pressures during the inspiratory phase of mechanical ventilation can decrease cardiac output up to 25% in patients with tamponade. To avoid further hemodynamic compromise, patients with suspected cardiac tamponade should not receive positive-pressure ventilation unless absolutely necessary.

• After appropriate disinfection of the operative field, local anesthesia of the skin is obtained by injecting with 2% lidocaine subcutaneously.
• The trajectory of the needle is defined by the angle between the probe and the chest wall. Ultrasound does not cross aerial spaces. Therefore, if cardiac structures are identified, there is no lung tissue interposed between the probe and the pericardium.
• The proper landmark for needle insertion corresponds to the area where the pericardial space is closest to the probe and fluid accumulation is maximal; this site is para-apical more often than subxiphoid. The subcostal route is less frequently used because it requires a longer path to reach the fluid, it passes anterior to the liver capsule, and it is directed toward the right chamber of the heart.
• The optimal needle trajectory should be visualized in the operator’s mind, and then a 14- to 16-gauge Teflon-sheathed needle with an attached saline-filled syringe is advanced in the direction of the fluid-filled space.
• Para-apical approach: insert the needle at 3 to 5 cm from the parasternal border (to avoid the internal thoracic artery) and close to the superior edge of the rib (to avoid the intercostal artery).
• Subxiphoid approach: direct the needle posteriorly until the tip passes posterior to the bony cage. Press the hub of the needle toward the diaphragm, and advance the needle with a 15-degree posterior tilt, either directly toward the patient’s head or toward the right or left shoulder.
• When fluid is aspirated, the needle should be advanced approximately 2 mm farther. The sheath should be advanced over the needle and the steel core withdrawn.
• If bloody fluid has been aspirated or if the position of the sheath is questionable, the position of the catheter can be confirmed by injecting 5 mL of agitated saline through the sheath. The bubbles in the solution provide a contrast effect that can be observed by two-dimensional echocardiography. Thus, if contrast agent appears in the pericardial space, the procedure can be continued.
• A guidewire should be advanced through the sheath, and then the sheath should be removed over the guidewire.
• A small incision should be made at the entry site, followed by introduction of a dilator (6F to 8F) over the guidewire. Predilatation of the chest wall passage facilitates subsequent insertion of the introducer sheath-dilator (6F to 8F).
• The guidewire and the dilator should be removed and only the sheath left in the pericardial sac. A pigtail angiocatheter should be inserted through the introducer sheath and the fluid aspirated.

image Procedure

Echo-Guided Technique Under Continuous Visualization (This Technique Is Preferred by the Authors) (B)

• A different approach utilizes a needle carrier mounted on the transducer to advance the needle to the pericardial space under continuous visualization.
• Patient’s preparation and supportive management are the same as those described earlier.
• Mount the bracket on the probe to support the needle-guide kit. The bracket supports the needle with different angles, and the operator can choose between a closer angle for the subcostal approach and a wider angle for the apical approach (Figure W9-2).

image

Figure W9-2 Echocardiographic probe with bracket, needle guide, and syringe.

• Cover the probe with the sterile sheath, and mount the needle-guide kit on the sheathed probe (Figure W9-3).

image

Figure W9-3 After bracket is mounted, probe is protected by sterile wrap.

• Once placement and direction of the needle are chosen, the needle (SDN 18-gauge, 9-cm Cook for apical approach, or the needle included in the PeriVac set for subxiphoid approach) is connected to a syringe for constant gentle aspiration and is slowly introduced through the tissues until there is echographic visualization of the tip (Figure W9-4, A-C).

image

Figure W9-4 Two-dimensional echocardiographic image (apical four-chamber view) during needle introduction through tissues. A, Detection of pericardial effusion. B, Visualization of needle tip. C, Needle is advanced through tissues. D, Needle enters pericardial space and guidewire is introduced. LV, left ventricle; RV, right ventricle.

(From Maggiolini S, Bozzano A, Russo P, et al. Echocardiography-guided pericardiocentesis with probe-mounted needle: report of 53 cases. J Am Soc Echocardiogr 2001;14:821-824.)

• When the pericardial effusion is reached and the placement of the needle inside the pericardial space is echographically confirmed, a J-tipped guidewire is introduced into the pericardial space (see Figure W9-4, D).
• The technique is summarized in Figure W9-5.

image

Figure W9-5 Representation of pericardiocentesis using apical approach. Pericardial needle is continuously monitored by apical four-chamber echocardiographic view while entering pericardial space. When pericardial effusion is reached, guidewire is introduced into pericardial space.

• Remove the needle and make a small skin incision at the site of insertion.
• The drainage catheter (a pigtail angiocatheter 6F to 8F or pericardiocentesis set [PeriVac]) is subsequently introduced along the guidewire according to the Seldinger technique, after introducing a 6F to 8F dilator over the guidewire.
• Completely aspirate the pericardial effusion by syringe suction, and connect the catheter to a disposable flushing system that infuses saline solution at a rate of 3 mL/h to maintain patency of the system.
• In patients with very large pericardial effusions (>1 L), quick emptying of the pericardial sac may cause (in very rare cases) an acute pulmonary edema. In these patients, it may be advisable to limit aspiration to 1 L every 24 hours.

image After Procedure

Postprocedure Care

• After the procedure, perform chest radiography to exclude the presence of pneumothorax or pneumopericardium.
• Repeat aspiration by syringe every 4 to 6 hours.
• Remove the catheter once the drainage has decreased to less than 25 to 30 mL in 24 hours.
• Pericardial drainage for 24 to 72 hours is sufficient to avoid recurrence of pericardial tamponade in the majority of cases.
• It is important to empty the pericardial sac as completely as possible, leaving the catheter in place up to 72 hours (or more) if the fluid has a rate of accumulation greater than 30 mL in 24 hours.
• The omission of extended catheter drainage is an important independent predictor of recurrence.
• Reaccumulation of pericardial fluid is common in patients with malignant pericardial effusions. In these patients, several procedures have been suggested to prevent recurrence of tamponade. Approaches include repeated pericardiocentesis (which is probably the procedure of choice in patients with end-stage disease), intrapericardial sclerosis, systemic chemotherapy, radiation therapy, surgical intervention, or percutaneous balloon pericardiotomy. It has been observed that an indwelling pericardial catheter can increase the success rate of treatment of malignant pericardial effusion from 50%, as in the case of pericardiocentesis only, to 80%.
• Perform a complete echocardiographic study in all patients before removing the catheter and before discharge from the intensive care or coronary care unit.

Complications

• Common:

• Puncture of cardiac chambers (1.5%)
• Pneumothorax (1%)
• Pleuropericardial fistulas (0.8%)

• Infrequent:

• Laceration of coronary arteries or intercostal vessels
• Arrhythmias (usually vasovagal bradycardia)
• Bacteriemia
• Pneumopericardium

• Serious rare complications:

• Death (0.1%–0.5%)
• Chamber laceration requiring surgery

In a series of 53 pericardiocenteses performed under continuous echocardiographic visualization (technique B), no major complications occurred, no perforations or ruptures of cardiac chambers were reported, and the incidence of minor complications was 3.7%.

image Outcomes and Evidence

• Randomized studies comparing different techniques do not presently exist.
• Pericardiocentesis-related mortality and serious complications are low when the procedure is performed by trained professionals following consolidated techniques.
• Percutaneous pericardiocentesis has been performed for many years using the blind subxiphoid approach. This technique is associated with high incidence of morbidity and mortality, and using electrocardiographic needle monitoring does not lead to significantly better outcomes. Accordingly, blind approaches are no longer justified.

Suggested Reading

Roy CL, Minor MA, Brookhart MA, et al. Does this patient with pericardial effusion have cardiac tamponade? JAMA. 2007;297:1810-1824.

Mercè J, Sagristà-Sauleda J, Permanyer-Miralda G, et al. Correlation between clinical and Doppler echocardiographic findings in patients with moderate and large pericardial effusion: Implication for the diagnosis of cardiac tamponade. Am Heart J. 1999;138:759-764.

Maggiolini S, Bozzano A, Russo P, et al. Echocardiography-guided pericardiocentesis with probe-mounted needle: report of 53 cases. J Am Soc Echocardiogr. 2001;14:821-824.

Tsang TS, Enriquez-Sarano M, Freeman WK, et al. Consecutive 1127 therapeutic echocardiographically guided pericardiocentesis: clinical profile, practice patterns, and outcomes spanning 21 years. Mayo Clin Proc. 2002;77:429-436.

Soler-Soler J, Sagristà-Sauleda J, Permanyer-Miralda G. Management of pericardial effusion. Heart. 2001;86:235-240.

Mercé J, Sagristà-Sauleda J, Permanyer-Miralda G, et al. Should pericardial drainage be performed routinely in patients who have a large pericardial effusion without tamponade? Am J Med. 1998;105:106-109.

Permanyer-Miralda G. Acute Pericardial disease: approach to the aetiological diagnosis. Heart. 2004;90:252-254.

Seferović PM, Ristić AD, Imazio M, et al. Management strategies in pericardial emergencies. Herz. 2006;31:891-900.

Sagristà-Sauleda J, Angel J, Sambola A, et al. Low pressure cardiaca tamponade. Circulation. 2006;114:945-952.

Vaitkus PT, Herrmann HC, LeWinter MM. Treatment of malignant pericardial effusion. JAMA. 1994;272:59-64.

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