Application of 2-dimensional contrast studies during pericardiocentesis

Computed Tomography-Guided Pericardiocentesis: A Practical Guide

PURPOSE OF REVIEW

The purpose of this article is to serve as a practical guide to computed tomography (CT)-guided pericardiocentesis and to discuss the role of this approach in current clinical practice. An overview of indications, technique, advantages, and limitations specific to CT-guided pericardiocentesis will be provided. The reader will have an enhanced understanding of the use of this imaging modality to guide pericardial drainage.

RECENT FINDINGS

Use of CT guidance to drain the pericardial space is safe, especially when adequate echocardiographic evaluation is precluded and when echocardiography-guided pericardiocentesis is deemed unsafe and or not feasible. Our review and experience indicate that CT-guided pericardiocentesis is technically successful in more than 94% of patients, with a low risk (<1%) of significant complications. CT-guided pericardiocentesis is therefore a viable alternative when echocardiographic guidance is insufficient and can obviate the need for surgery in most patients.

Ultrasound-guided pericardiocentesis: a novel parasternal approach

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Objective

The aim of this study was to evaluate a novel pericardiocentesis technique using an in-plane parasternal medial-to-lateral approach with the use of a high-frequency probe in patients with cardiac tamponade.

Background

Echocardiography is pivotal in the diagnosis of pericardial effusion and tamponade physiology. Ultrasound guidance for pericardiocentesis is currently considered the standard of care. Several approaches have been described recently, which differ mainly on the site of puncture (subxiphoid, apical, or parasternal). Although they share the use of low-frequency probes, there is absence of complete control of needle trajectory and real-time needle visualization. An in-plane and real-time technique has only been described anecdotally.

Methods and results

A retrospective analysis of 11 patients (63% men, mean age: 37.7±21.2 years) presenting with cardiac tamponade admitted to the tertiary-care emergency department and treated with parasternal medial-to-lateral in-plane pericardiocentesis was carried out. The underlying causes of cardiac tamponade were different among the population. All the pericardiocentesis were successfully performed in the emergency department, without complications, relieving the hemodynamic instability. The mean time taken to perform the eight-step procedure was 309±76.4 s, with no procedure-related complications.

Conclusion

The parasternal medial-to-lateral in-plane pericardiocentesis is a new technique theoretically free of complications and it enables real-time monitoring of needle trajectory. For the first time, a pericardiocentesis approach with a medial-to-lateral needle trajectory and real-time, in-plane, needle visualization was performed in a tamponade patient population.

Safety, Efficacy, and Complications of Pericardiocentesis by Real-Time Echo-Monitored Procedure

Pericardiocentesis is useful in the diagnosis and treatment of pericardial effusive disease. To date, a number of methods have been developed to reduce complications and increase the success rate of the procedure. The aim of the present study was to evaluate the efficacy and the safety of echocardiography-guided pericardiocentesis under continuous echocardiographic monitoring in the management of pericardial effusion. We prospectively performed 161 pericardiocentesis procedures in 141 patients admitted from 1993 to 2015 in 3 centers. This procedure was performed for tamponade or large pericardial effusion in 157 cases and for diagnosis in 4 cases. A percutaneous puncture was performed where the largest amount of fluid was detected. To perform a real-time echo-guided procedure, a multi-angle bracket was mounted on the echocardiographic probe to support the needle and enable its continuous visualization during the puncture. The procedure was successful in 160 of 161 cases (99%). Two major complications occurred (1.2%): 1 mediastinal hematoma that required surgical drainage in a patient on anticoagulant therapy and 1 pleuropericardial shunt requiring thoracentesis. Seven minor complications occurred (4.3%): 1 pleuropericardial shunt, 1 case of transient AV type III block, 3 vasovagal reactions (1 with syncope), and 2 cases of acute pulmonary edema managed with medical therapy. No punctures of any cardiac chamber occurred, and emergency surgical drainage was not required in any case. In conclusion, echocardiography-guided pericardiocentesis under continuous visualization is effective, safe, and easy to perform, even in hospitals with low volumes of procedures with or without cardiac surgery.

European Association of Cardiovascular Imaging (EACVI) position paper: Multimodality imaging in pericardial disease

Although pericardial diseases are common in the daily clinical practice and can result in a significant morbidity and mortality, imaging of patients with suspected or known pericardial disorders remain challenging. Multimodality imaging is part of the management of pericardial diseases. Echocardiography, cardiac computed tomography, and cardiovascular magnetic resonance are often used as complementary imaging modalities. The choice of one or multiple imaging modalities is driven by the clinical context or conditions of the patient. The scope of the present document is to highlight the respective role of each technique according to the clinical context in the diagnosis and management of pericardial diseases.

Role of echocardiography in the treatment of cardiac tamponade

Accumulation of fluid within the pericardial sac results in elevation of intrapericardial pressure with consequent cardiac compression or tamponade. Cardiac tamponade is a life-threatening condition which requires urgent evacuation of pericardial effusion (PE). Current pericardial evacuation techniques and approaches are varied. Echocardiography provides valuable insights into identifying patients who are suitable candidates and further facilitates pericardiocentesis by improving guidance techniques. Several previous publications have provided excellent reviews of the pathophysiology of cardiac tamponade. We review the clinical presentation and role of echocardiography for diagnosis of tamponade. We focus on medical and surgical approaches for the removal of PE. Moreover, as the clinical and hemodynamic consequences of PE depend on the volume and the rate of accumulation of PE, we review the various scenarios of "small" PE resulting in cardiac tamponade.

Echocardiography-guided or "sided" pericardiocentesis

Echocardiography-guided pericardiocentesis is the first choice method for relieving cardiac tamponade, but the exact role of the echocardiography at the moment of the puncture is still controversial. In this report, detailed echocardiographic evaluation was performed in 21 consecutive patients with cardiac tamponade just before the pericardiocentesis. Appropriate needle position was determined according to the probe position using imaginary x, y, and z axes. Pericardiocentesis was performed successfully using this technique without simultaneous echocardiography and no complications were observed. We concluded that bedside echocardiography with detailed evaluation of the puncture site and angle is enough for pericardiocentesis instead of real time guiding.

"Hands-Free" continuous transthoracic monitoring of pericardiocentesis using a novel ultrasound transducer

BACKGROUND

Pericardiocentesis can be monitored with a hand-held transducer. The purpose of this study was to assess the feasibility of monitoring pericardiocentesis using a novel ultrasound transducer, which can be attached to the chest wall, developed in our laboratory (CONTISON).

METHODS

We studied nine patients with large pericardial effusions. The 2.5-MHz transducer is spherical in its distal part and mounted in an external housing to permit steering in 360 degrees. The external housing is attached to the chest wall using an adhesive patch. The CONTISON transducer was placed at the cardiac apex and an apical four-chamber view obtained. Pericardiocentesis was performed from the subcostal position. The pericardial effusion was continuously imaged. Mitral inflow velocity signals were recorded before and after pericardiocentesis. When fluid was first obtained, 50 mL of fluid were discarded after which 5 mL of agitated saline was injected through the needle.

RESULTS

In the first patient the pericardiocentesis needle was seen in the left ventricular cavity. Saline injection produced a contrast effect in the left ventricle. The needle was gradually withdrawn until contrast was seen in the pericardial sac. A total of 1100 mL was removed without further complications. The second patient had clear fluid followed by blood stained aspirate. The echocardiogram revealed gradual appearance of granular echoes within the pericardial sac, suggestive of intrapericardial clot that was subsequently surgically evacuated. In the remaining seven patients, agitated saline produced a contrast effect in the pericardial sac indicative of proper needle position. Mitral flow velocity paradoxus was noted in five patients, and it resolved after pericardiocentesis in four patients. No adjustment of the transducer was required.

CONCLUSION

The CONTISON transducer permitted continuous monitoring of pericardiocentesis. This technique could potentially facilitate pericardiocentesis.

Pericardiocentesis Guided by Contrast Echocardiography

Although pericardiocentesis is a relatively safe procedure, there are some hazards, particularly when hemorrhagic fluid is aspirated. Having the opportunity to outline the space from which the fluid is withdrawn is of particular interest in this situation. A current technique of echocardiography with contrast enhancement involves injection of a few milliliters of agitated saline solution or reinjection of blood-stained fluid. Performing this procedure, we repeatedly observed a weak and inhomogeneous echo contrast; therefore, we evaluated the applicability of the ultrasound contrast medium SH U 454 (Echovist Schering, Berlin, Germany) for contrast enhancement in hemorrhagic pericardiocentesis. In all patients, pericardiocentesis was performed in a supine position by a subxiphoid approach. A Teflon catheter/needle unit attached to a syringe containing a few milliliters of contrast medium was introduced in the usual way. On the return of hemorrhagic fluid, 1-2 ml of Echovist was injected to provide contrast from the space from which it had been aspirated. We observed excellent contrast clearly outlining the pericardial space through the injection of 1-2 ml of contrast medium. No adverse or side effects were seen resulting from Echovist injection to the pericardial sac. In conclusion, contrast echocardiography appears to be a useful tool to secure the correct position of the needle during pericardiocentesis of hemorrhagic or loculated effusions. It is suggested that injection of Echovist should be considered whenever the contrast obtained by the conventional technique is poor and inconclusive.

Pericardial effusions in infants and children: injection of echo contrast medium enhances the safety of echocardiographically-guided pericardiocentesis

Pericardiocentesis is usually an easy and uncomplicated procedure when guided by cross-sectional echocardiography, but an abnormal intracardiac or extrapericardial position of the puncture system can occur, especially in children. Injection of echo contrast medium through the puncture needle is a very sensitive, quick, easy and harmless procedure which can be performed at the bedside in all cases in which doubt remains concerning the location of the needle. Prompt enhancement of signal intensity of the pericardial fluid validates the correct intrapericardial position, and permits visualization of the tip of the needle. Absence of echodense formations excludes an intrapericardial position. We recommend the use of echo contrast medium during pericardiocentesis whenever blood is aspirated through the needle, or if there is any doubt concerning its location.

Pericardiocentesis Guided by Two-Dimensional Echocardiography

Echodirected pericardiocentesis has become the method of choice for the initial treatment of clinically significant pericardial effusions since it was introduced into the regular practice at the Mayo Medical Center in April 1980. Between April 1980 and January 1, 1994, 610 consecutive two-dimensional (2-D) echodirected pericardiocenteses were performed at the Mayo Clinic. There have been no deaths in the series of consecutive cases. In the first 500 consecutive cases examined in detail, there were five serious complications and 18 nonthreatening complications. Echodirected pericardiocentesis is a safe, humane, and cost-effective means of performing a pericardial tap. Excellent results have been obtained even with a large number of physician operators. This technique is well suited to the primary care setting. Physicians performing this procedure should be familiar with reading and performing 2-D echocardiography. Qualified physicians can be trained, fairly easily, to perform echodirected pericardiocentesis.

Echocardiography-guided pericardiocentesis with a needle attached to a probe

Pericardiocentesis with a needle attached to a probe was performed under two-dimensional echocardiographic guidance in 9 patients with pericardial effusion after cardiac operations. The first 5 mm of the tip of a puncture needle for percutaneous transhepatic cholangiodrainage is scratched with a scalpel to give the tip high echo intensity. When the probe is placed on the skin, the direction of puncture at that probe angle appears automatically on the monitor.

Microbubble image enhancement and pericardiocentesis

When performing pericardiocentesis, if blood-stained fluid is aspirated, one must ensure that the aspirating needle is not within one of the cardiac chambers. To clarify the position of the needle some contrast material may be injected using X-ray screening and for this reason pericardiocentesis is often performed in the catheter laboratory, particularly if the effusion is small, loculated or the heart is in an unusual position. Ultrasound immaging is now commonly used to guide the aspirating needle and if blood-stained fluid is withdrawn we reinject a few millilitres and this outlines the space from which the fluid is withdrawn with microbubbles. This modification of ultrasound immaging adds to the safety of the procedure and allows difficult procedures to be carried out in the ward or intensive care unit, where X-rays screening is not easily available.

Pericardiocentesis guided by two-dimensional contrast echocardiography

The clinical application of two-dimensional contrast echocardiography to pericardiocentesis was investigated in 20 patients with pericardial effusion. Multiple views were obtained to determine the ideal needle entry route. During pericardiocentesis, after 5 to 10 mL of pericardial fluid was withdrawn, 3 to 5 mL of agitated saline solution was injected through the exploring needle into the pericardium and a cloud of echoes indicated the needle's position. Contrast echoes were observed in all 20 patients. The procedure was performed smoothly in all patients except two (10%): the exploring needle was inserted into the right atrium in one patient and into the right ventricle in the other patient. The former promptly underwent a surgical drainage procedure, and the latter a second pericardiocentesis successfully guided by contrast echocardiography. The pericardial fluid was simply, safely, and successfully aspirated in the other 18 patients. We conclude that two-dimensional contrast echocardiography is valuable for locating needle position, thus facilitating successful pericardiocentesis in clinical practice.

Percutaneous pericardiocentesis versus subxiphoid pericardiotomy in cardiac tamponade due to postoperative pericardial effusion

In a retrospective study, 42 patients with acute cardiac tamponade due to pericardial effusion were evaluated following cardiac surgery, and the pericardial fluid was drained by one of two alternative methods: two-dimensional echocardiographic-guided pericardiocentesis (2D-echo) or subxiphoid surgical pericardiotomy. During the first period (from 1982 to 1986), one of the two methods was chosen by the treating physicians, whereas in the second period (from 1986 to 1991), 2D-echo-guided pericardiocentesis was the treatment of choice. Percutaneous pericardiocentesis was performed using local anesthesia in 29 patients. A Tuohy needle was inserted at the left xipho-costal junction and, when fluid was obtained, 6 mL of saline solution was injected during 2D-echo contrast monitoring, and a multiple-hole, 6F, 30-cm catheter was inserted by means of a guidewire and positioned into the posterior pericardium, as near as possible to the atrioventricular groove. Complete drainage of pericardial fluid by percutaneous pericardiocentesis was obtained in 26 patients (89%). This procedure also allowed the evacuation of posterior and loculated effusions. Complications included two right ventricular punctures, which were immediately recognized by 2D-echo contrast and produced no serious consequences. Sixteen patients who underwent surgical pericardiotomy had complete evacuation of pericardial fluid without major complications (two of them suffered atrial arrhythmias during the procedure). The average amount of fluid drained, as well as the localization of the effusions, were the same for both groups. 2D-echo-guided pericardiocentesis was found to be a useful, safe, and simple technique. It can be used as an alternative treatment to subxiphoid pericardiotomy for cardiac tamponade due to postoperative pericardial effusions.

Pericardiocentesis under two-dimensional echocardiographic guidance in loculated pericardial effusion

Pericardiocentesis to relieve tamponade from a loculated pericardial effusion in patients following cardiac surgery is greatly aided by two-dimensional echocardiographic imaging guidance. This technique delineates the fluid distribution and the site of adhesions, defines the path for introduction of an aspiration needle, alerts to the possibility of myocardial contact, and helps in positioning the drainage catheter. Two-dimensional echocardiographic imaging can be performed at the patient's bedside, and the images are easy to interpret. This technique simplifies pericardiocentesis and helps to avoid complications.

Catheter drainage of the pericardium. Practical method to maintain long-term patency

Pericardiocentesis with catheter insertion and drainage is widely used in management of large pericardial effusions and cardiac tamponade. Two potential problems with an indwelling pericardial catheter system are catheter blockage and infection. We have utilized slow infusion of heparinized saline solution (3 ml/hr) via a continuous flush device to maintain catheter patency for up to seven days (mean 3.6) in 16 patients. Pericardial effusions were secondary to malignancy, uremia, and cardiac surgery. This article describes practical aspects of the technique. Most pericardial effusions can be successfully treated with pericardiocentesis and catheter drainage, provided the drainage is continued reliably and safely for several days. Surgical treatment such as subxiphoid pericardiostomy or partial pericardiectomy should be reserved for loculated effusions, clotted blood, subacute effusive-constrictive pericarditis, or significant recurrences after initial drainage.

Percutaneous pericardial catheter drainage: report of 42 consecutive cases

Test results of 42 consecutive patients with pericardial effusion treated with percutaneous pericardial drainage were analyzed. Intermittent (79%) or continuous (21%) drainage through a 60-cm pigtail catheter (No. 6Fr to 8Fr) was used. Clinical indications were urgent or semiurgent treatment of large (38%), life-threatening (24%), recurrent (21%) or acute (traumatic) (17%) pericardial effusion. Sixteen patients had a malignant cause for the effusion. Mean duration of use of the indwelling pericardial catheter was 3.5 days (range less than 1 day to 19 days). Two of the 9 catheters in patients on continuous drainage but only 1 of 33 catheters in patients on intermittent drainage became occluded. There was only 1 possible infective complication. Six patients had subsequent elective surgical intervention for persistent or recurrent effusion. Placement of an indwelling pericardial catheter guided by 2-dimensional echocardiography is safe and effective for initial treatment of selected pericardial effusions.

Two-dimensional echocardiographically guided pericardiocentesis: experience in 117 consecutive patients

Pericardiocentesis guided by 2-dimensional echocardiography has been used at the Mayo Clinic since April 1980. The 2-dimensional examination localizes the pericardial fluid. Particular note is made of the place on the body wall closest to the fluid. An entry track that permits puncture of the pericardial sac without damage to any vital structure is then selected for the pericardiocentesis needle. Between April 1980 and March 1984, 132 consecutive pericardiocenteses in 117 patients were done by this technique. The volume of fluid obtained ranged from 75 to 1,700 ml (mean 650). Seventy percent of the taps were done for therapy, 21% for diagnosis, and 9% for both therapy and diagnosis. A Teflon-sheathed "intracath" needle was used to complete 80% of the pericardiocenteses. In the other 20%, a large catheter was secondarily introduced and connected to a closed drainage system. There were no deaths related to the procedure. One symptomatic pneumothorax occurred. There were 3 minor complications. Two-dimensional echocardiographic imaging of the heart and pericardial fluid permits a safe and effective means of performing pericardiocentesis.

Pericardial mesothelioma masquerading as a benign pericardial effusion

A 53 year old asymptomatic man presented with a primary pericardial mesothelioma masquerading as a benign pericardial effusion. Although M-mode echocardiography showed an echo-free space, two-dimensional echocardiography and thoracic computed tomography demonstrated that the suspected effusion was caused by a mass surrounding the heart. Newer noninvasive techniques can be valuable for the early detection of pericardial tumor.