By: Lawrence Ang, MD, FSCAI, and Jayant Bagai, MD, FSCAI

Introduction

While the basic concepts of pericardiocentesis remain unchanged, high-quality imaging and new interventional techniques have resulted in contemporary approaches to this procedure. The goal is to access the pericardial space, avoid injury to surrounding structures, and confirm the correct position before final drain insertion. In this Tip of the Month, we describe a contemporary approach to pericardiocentesis in the cath lab.

 

Technique

  1. Puncture site and echo guidance. “The sub-xiphoid approach is classic”1 given its setup for stereotyped needle insertion and distance from the lungs.2 For these reasons, it is the most commonly described approach of cardiac electrophysiologists for high-risk “dry” pericardiocentesis.3-5 The echo-guided approach from the Mayo Clinic identified the site where probe distance to maximal fluid accumulation is minimized (primarily apical, secondarily sub-xiphoid) and intervening organs are absent, as ideal.6 Additional series prescribing strict echo guidance (primarily sub-xiphoid) demonstrated similar results.7-8 Blind pericardiocentesis, without echo or fluoroscopic guidance, is reserved for truly emergent cardiac tamponade.2 It is generally agreed that pericardiocentesis with echo guidance is safer than doing so blindly.1-10 The parasternal site is seldom used due to its proximity to underlying thoracic arteries and the lungs as well as a lower success rate.2, 6-9 A classic semireclining patient position anecdotally encourages fluid pooling into the inferior pericardial space, but it is not necessary.
  2. Needle selection and preplanning. Pericardiocentesis kits typically include a long 18-gauge needle and inner stylet, which are advanced stepwise with serial stylet removal/insertion to check for fluid return. A contemporary approach uses a Micropuncture® kit (Cook Medical, Bloomington, IN) instead. Its thinner 21-gauge needle may lower tactile sensation, but it also potentially reduces iatrogenic injury (see Table).3 Echo guidance allows the operator to memorize the preplanned location of needle entry into the skin, direction toward the heart, and distance from skin to fluid.9 Following this path helps operators to avoid liver and lung injury from the subxiphoid and apical approaches, respectively. Real-time echo imaging during needle advancement is more cumbersome than beneficial unless a specialized setup is used.10
  3. Needle advancement. After local anesthesia, the 21-gauge needle is slowly advanced along the echo-guided path into the pericardial space, all the while maintaining gentle suction from an attached slip-tip syringe and intermittently injecting local anesthesia to clear the needle. Aspirating fluid at a needle depth shallower than anticipated can indicate peritoneal or pleural access. If no fluid is freely aspirated beyond the anticipated depth, the needle should be withdrawn and appropriate skin puncture location and needle direction reconfirmed. If the needle encounters a rib (apical approach), withdraw and redirect the needle above the rib to avoid the neurovascular bundle coursing inferiorly along the costal groove.
  4. Pericardial access and confirmation. Pericardial fluid can be aspirated intermittently into the syringe if the needle tip only partially enters the pericardial space. Advancing the needle another 1-2 mm allows for free aspiration. A Micropuncture® guidewire advanced into the pericardial space will appear to span multiple cardiac chambers (see Figure 1). Signs of cardiac puncture include: needle movement with each heartbeat, premature ventricular complexes, blood briskly dripping from the needle lumen, flailing wire movements during systole, and wire tracking along the pulmonary artery or aorta. Following signs of correct needle and guidewire positioning, a 4-French Micropuncture® catheter is advanced into the pericardial space. Signs of a correct catheter position include transducing a nonventricular pressure waveform and identifying agitated saline microbubbles injected into the pericardial space on echo (or contrast medium by fluoroscopy). Inadequate bubble visualization can occur in very large or loculated effusions, warranting additional views. Bubbles observed within the heart, liver, or pleural space indicate an incorrect catheter location. Generally speaking, a puncture of the relatively lower-pressure right atrium or ventricle (caveat: severe pulmonary hypertension) should self-seal upon removal of the Micropuncture® needle/wire/catheter. Self-sealing of a left ventricular puncture is less certain and generally should be attempted with the smallest caliber devices (i.e., needle and wire only) to minimize the chances of needing surgical repair.
  5. Catheter or drain insertion. Following pericardial access confirmation, a 0.035-inch guidewire is generously advanced into the pericardial space and observed abutting the outer cardiac borders under fluoroscopy (see Figure 2). A drainage catheter is then advanced over the wire. A more supportive 0.035-inch guidewire and predilation may be needed for scar tissue or significant adiposity. If a pigtail drain is used, its tip should return to its original shape rather than remaining unfurled under tension against the myocardium (see Figure 3). Resolution of pericardial effusion and tamponade should be confirmed after complete fluid aspiration and before patient transfer. The catheter is sutured in place and attached to a bag for intermittent drainage.6

 

Conclusion

A contemporary pericardiocentesis approach using a Micropuncture® kit, along with echo and fluoro guidance, can be safely and successfully performed in the cath lab. This simple approach uses smaller caliber devices to reduce patient injury and produces various signs of successful pericardial access before final drain insertion.

 

References

  1. Robb, John F. and Roger J. Laham. “Profiles in Pericardial Disease.” Grossman & Baim’s Cardiac Catheterization, Angiography, and Intervention, edited by Donald S. Baim, Lippincott Williams & Wilkins, 2006, pp. 725-31.
  2. Petri N, Ertel B, Gassenmaier T, et al. “Blind” pericardiocentesis: A comparison of different puncture directions. Catheter Cardiovasc Interv. 2018 Nov 1;92(5):E327-32.
  3. Killu AM, Asirvatham SJ. Percutaneous pericardial access for electrophysiological studies in patients with prior cardiac surgery: approach and understanding the risks. Expert Rev Cardiovasc Ther. 2019 Feb;17(2):143-50.
  4. Bradfield JS, Tung R, Boyle NG, et al. Our approach to minimize risk of epicardial access: standard techniques with the addition of electroanatomic mapping guidance. J Cardiovasc Electrophysiol. 2013 Jun;24(6):723-7.
  5. Kumar S, Bazaz R, Barbhaiya CR, et al. “Needle-in-needle” epicardial access: Preliminary observations with a modified technique for facilitating epicardial interventional procedures. Heart Rhythm. 2015 Jul;12(7):1691-7.
  6. 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 May;77(5):429-36.
  7. Akyuz S, Zengin A, Arugaslan E, et al.Echo-guided pericardiocentesis in patients with clinically significant pericardial effusion. Outcomes over a 10-year period. Herz. 2015 Apr;40 Suppl 2:153-9. 
  8. Lindenberg M, Kjellberg M, Karlsson E, et al. Pericardiocentesis guided by 2-D echocardiography: the method of choice for treatment of pericardial effusion. J Intern Med. 2003 Apr;253(4):411-7.
  9. De Carlini CC, Maggiolini S. Pericardiocentesis in cardiac tamponade: indications and practical aspects. E-Journal Cardiol Pract. 2017 Oct 11;15(19). Available at: https://www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-15/Pericardiocentesis-in-cardiac-tamponade-indications-and-practical-aspects.
  10. Maggiolini S, Gentile G, Farina A, et al. Safety, Efficacy, and Complications of Pericardiocentesis by Real-Time Echo-Monitored Procedure. Am J Cardiol. 2016 Apr 15;117(8):1369-74.

 

Figure 1
Figure 1: A successfully positioned Micropuncture® guidewire courses around the heart within the cardiac silhouette and abuts the superior border of the pericardial space.

 

Figure 2
Figure 2: A long 0.035-inch guidewire is looped within the cardiac silhouette, abutting multiple borders of the pericardial space, over which a pigtail drain is advanced.

 

Figure 3
Figure 3: The tip of the pigtail drain returns to its original curved conformation once the guidewire is retracted.

 

Table: Outer diameters of Micropuncture® components used for pericardiocentesis.

Item

Outer diameter, mm (inch)

Micropuncture® wire

0.43 (0.017)

21-gauge Micropuncture® needle

0.81 (0.032)

18-gauge needle

1.27 (0.050)

4-French Micropuncture® catheter

1.37 (0.054)

5-French Micropuncture® catheter

1.65 (0.065)

 

Measurements performed using a digital caliper (Mitutoyo Corporation, Kanagawa, Japan). Micropuncture® Access Set (Cook Medical, Bloomington, Indiana).

 

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