Pericardiocentesis

Presenter
Praveen Gupta
Unit
Dr Santhosh Satheesh
JIPEMER
Pondicherry
India
11/02/2017
1
Cath meet
Pericardiocentesis

History
 22/F came to JIPMER with C/O
 Facial puffiness
 Cough with expectoration
 Dyspnoea since one month
 Atypical chest pain since last one month
2

O/E
 P=116/min
 BP-120/70 mmhg
 RS-Right side decreased air entry
 CVS-S1S2 Present, muffled heart sound
3

Chest X-ray
4
 Massive Right sided pleural
effusion ? Mild cardiomegaly
??Pericardial effusion
 ICD insertion was done for both
therapeutic and diagnostic
pleurocentesis
Chest X-ray showing Massive right sided pleural
effusion
JIPMER, Pulmonary medicine Department, 01/02/2017
JIPMER, Radiology Department, 01/02/2017

Chest X-ray(Post pleurocentesis)
5
PA chest x-ray of the patient showing
right side mild pleural effusion with
ICD insitu
Lateral chest x-ray of the patient
showing right side mild pleural
effusion with ICD insitu

CECT Chest
6
CECT Chest of the patient showing right side mild pleural effusion with ICD
insitu with massive pericardial effusion

CECT chest
7
CECT Chest of the patient showing right side mild pleural effusion with ICD
insitu with massive pericardial effusion

CT chest
 SVC syndrome
 Right hilar lymphadenopathy
 Right pleural effusion
 Massive pericardial effusion
 Pericardial tamponade
8

ECHO showing large Pericardial effuison measureing 4 cm anteriorly, 3 cm laterally, 2 cms
posteriorly, RA/RV collpse was present suggestive of pericardial tamponade
9
JIPMER, Cardiology Department, SSB SIEMEN Cath
lab, 06/02/2017
Apical 4 chamber view showing Massive
pericardial effusion with RA/RV collapse during
diastole suggestive of tamponade physiology
Parasternal short axis view showing Massive
circumferential pericardial effusion

ECHO guided pericardial neddle inetion done…….
10
 18 No. gauge needle was
inserted under both
fluoroscopic and ECHO
guidance.
 Position of the needle was
conformed by injecting
agitated saline into the
pericardium
Apical 4 Chamber showing needle into the pericardium. Position of the needle conformed by injecting
agitated saline into the pericardial space. Presence of bubble into the pericardium conform our needle
position into the pericardium
JIPMER, Cardiology Department, SSB SIEMEN Cath lab, 06/02/2017

ECHO Apical 4 Chamber showing Presence of bubble into the pericardium…….
11 JIPMER, Cardiology Department, SSB SIEMEN Cath lab, 06/02/2017

ECHO guidance pericardiocentesis started…..
12
Apical 4 chamber view: Patient tachycardia started to subsided as soon as
pericardiocentesis was started
JIPMER, Cardiology Department, SSB SIEMEN Cath lab, 06/02/2017

Pericardiocentesis…..

ECHO suggestive of resolution of pericardial effusion with pericardial tamponade suggestive of successful
pericardiocentesis. Procedure was stoped after removing 590 ml of pericardial fluid. Piagtail catheter was kept insitu
for 72 hours

Final diagnosis
 SVC syndrome
 Right hilar lymphadenopathy
 Right pleural effusion
 Massive pericardial effusion
 Pericardial tamponade
 S/P Successful Pericardiocentesis
 Presently patient is admitted in Infection and disease ward and under investigation for the
etiology of the pericardial effusion
16

JIPMER Data (SSB Cath lab)
(1 st Jan 2016-31 Dec 2016)
Pericardiocentesis(All patient had Pericardial effusion with tamponade)
17
Patient
NO
Age/Sex WD Diagnosis
1 40 yr/M CTVS WD Successful
2 50 yr/M SSBCCC
U
VT/S/P
AICD
insertion
Successful
3 53 yr/M SSB
CCCU
Post Left
atrial
appendag
e device
occlusion
Successful
4 40 yr/F Nephro CKD/PE Successful
5 40 yr/F OG CA cervix Successful
6 38 yr/F Medicine
WD
??Diagnos
is
Successful

JIPMER Data (EMS Cath lab)
(1 st Jan 2016-31 Dec 2016)
Pericardiocentesis(All patient had Pericardial effusion with tamponade)
18
Patien
t NO
Age/Sex WD Diagnosis
1 55 yr/M EMS CCCU AWMI/SVD Of LAD Successful
2 44 yr/M Medicine
WD
Pericardial effusion
?etio
Successful
3 60 yr/M Immunology RA/Pericardial
effusion
Successful

Approximate incidence of Pericardial tamponade after
Pacemaker/ICD/CRT at JIPMER
(Jan 2016-Dec 2016)
19
Total no of Device
inserted (Including
both
ICD/CRT/Pacemaker
(Approximate)
Total no of patient
who develop
Pericardial
effusion with
tamponade
Indicence of
PE/PT after
device
implantation at
JIPMER(2016)
300 1 0.33%

Management of pericardial effusion
20
Imazio M, Spodick DH, Brucato A, et al. Controversial issues in the management of
pericardial disease. Circulation 2010;121:916-928.)

Pericardiocentesis: Technique
21
 Performed in the cardiac
catheterization laboratory using a
combination of echocardiographic
and fluoroscopic guidance

22
 Two-dimensional echocardiogram just
prior to the procedure
 Document the presence, location, and size
of the effusion
 Determine the presence of loculation or
significant stranding
 Determine location on body surface where
effusion lies closest to the surface
 At which the fluid depth overlying the
heart is maximal
 Optimal direction for needle passage
 Approximate depth of needle insertion

23
 Access to pressure measurement,
continuous ECG and vital sign
monitoring, and fluoroscopy
with the ability to inject
radiographic contrast in the
cardiac catheterization
laboratory to be preferable,
particularly in difficult or
challenging cases, in patients
with small or localized effusions
or when complications ensue

24
 Access to adequate ancillary
support in hemodynamically
unstable patients
 Right heart pressure measurement
required if effusive-constrictive
pericarditis is suspected, the
effusion is small or loculated, or if
the patient is hemodynamically
unstable

25
 Instrument required
 10 ml/50 ml Syringe
 18 No Needle
 Pigtail catheter
 Guidewire
 Dilator
 Scalpal with blade

26
 Patient torso is propped up to a
level of about 45Â°
 Subxiphoid approach
 Skin nick made 1 to 2 cm below
costal margin just left of the
xiphoid process

27
 Needle path toward the
posterior aspect of the left
shoulder, passing anterior to
or through the anterior
capsule of the liver, and
entering the pericardial
space overlying the right
ventricle

28
 Echocardiography from subxiphoid
window confirm the optimal
direction and depth below the skin
 Posterior effusions or patients with
large body habitus, apical or low
parasternal intercostal puncture
sites are alternatives


 Since echocardiography does not image through air (and to avoid
pneumothorax), sites with significant intervening lung should be excluded; care
should be taken in the parasternal approach to avoid the internal mammary
artery that runs 3 to 5 cm from the parasternal border, and also the
neurovascular bundle at the lower margin of each rib
29

30
 Skin and subcutaneous tissues a infiltrated
with lidocaine with a small-gauge needle
along the proposed path of entry.
 Use a 5- to 8-cm, 18-gauge needle attached to
a 10-mL syringe filled with saline or
lidocaine and inserted following the echo-
determined trajectory
 As the needle is advanced, the syringe is
alternately aspirated to determine pericardial
space entry and injected to deliver more local
anesthesia along the route

31
 Three-way stopcock can be used to
connect to a pressure manifold via
a fluid-filled extension tube.

32
 Classically, electrocardiographic
monitoring of the needle (by
attaching its shaft to the V lead of
the ECG system using a sterile
alligator clip) was used to provide
an additional measure of safety

33
 ST segment recorded from the
needle should be isoelectric during
advancement, but dramatic
elevation of the ST segment
appears if the needle contacts the
right ventricular epicardium
 Needle withdrawn slightly until ST
elevation resolves to minimize the
chance of right ventricular puncture
or laceration.

34
 When the needle enters the pericardial
space, a distinct pop is usually felt and
it is possible to aspirate fluid

35
 Entry of the pericardial space
can be confirmed by injection of
radiographic contrast, agitated
saline echo contrast,
JIPMER, Cardiology Department, SSB SIEMEN Cath
lab, 06/02/2017
Apical 4 chamber shows agitated saline
bubble into the pericardium

Guide wire into the pericardium
36
 Entry of the pericardial
space can be confirmed by
advancement of an 0.035-
inch J wire in the
characteristic path
wrapping around the heart

37
 Turn the interposed stopcock to display
intrapericardial pressure, which should
be superimposable on the
simultaneously displayed right atrial
pressure from the right heart catheter
Femoral arterial (FA), right atrial (RA), and pericardial pressure before (A) and after (B) pericardiocentesis
in a patient with cardiac tamponade. Both RA and pericardial pressure are approximately 15 mm Hg before
pericardiocentesis. In this case there was a negligible paradoxical pulse. Note the presence of the x descent
but absence of the y descent before pericardiocentesis

38
 The waveform should
emphatically not resemble that
of right ventricular pressure
 If the pericardial needle tip
displays a right ventricular
waveform, the tip is quickly
but smoothly withdrawn under
continuous hemodynamic
monitoring until the overlying
pericardial space is entered

39
 An 8F dilator is then introduced over the
guidewire, followed by a drainage catheter
(straight or pigtail shaped, with multiple
side holes)
 Attach a 50-mL syringe and three-way
stopcock to the drainage catheter,
connecting an extension tube from the
other port of the three-way stopcock to a
drainage bag or vacuum bottle
 This allows fluid to be aspirated into the
syringe and transferred to the bottle.

40
 Removal of 50 mL fluid sufficient
to relieve tamponade and improve
hemodynamics.
 After removal of 100 to 200 mL of
fluid, it is informative to remeasure
the pericardial and right atrial
pressure before resuming aspiration

41
 When fluid can no longer be aspirated,
fluoroscopy should show that the
previously immobile cardiac silhouette
now exhibits a normal pulsation pattern,
and a repeat echocardiogram should show
only minimal posterior effusion
 . Occasional patients will experience
pericardial pain when the effusion is
tapped dry. Parenteral narcotic analgesics
and benzodiazepines can be administered,
and if the pain is severe, 50 mL of
pericardial fluid, sterile saline, or 10 to 20
mL of 1% Xylocaine can be reintroduced
to help ease the pain

42
Cardiac tamponade relieved if
(a) Pericardial pressure falls to a level 0 mm Hg
and separates from the right atrial pressure
(b) Right atrial pressure itself falls to the normal
range and exhibits return of the normal
diastolic y descent
c) Pulsus paradoxus is relieved

43
 Systemic arterial pressure rises in association with an increase in mixed venous
oxygen content, indicative of an increase in cardiac output
 Failure of pericardial pressure to fall close to 0 indicates reference height of
transducers incorrect or free or loculated pericardial fluid is still under pressure

44
 If the pericardial pressure falls
appropriately but the right atrial
pressures remain elevated with
prominent x and y descents, the
diagnosis of effusive-constrictive
pericarditis must be entertained,
with an ongoing element of
constriction after the tamponade
physiology has been relieved Pericardiocentesis results in a marked increase in FA pressure and
a marked decrease in RA pressure. During inspiration, pericardial
pressure becomes negative, there is clear separation between RA
and pericardial pressure, and the y descent is now prominent, thus
suggesting the possibility of an effusive-constrictive picture.

 We then sew the drainage catheter in place attached to a sterile fluid path (stopcock,
syringe, and drainage bag) to allow the postprocedure nursing staff to periodically
attempt additional aspiration.
 Sterility must be tightly maintained with this technique
 Catheter is removed when the drainage has decreased to <25 to 50 mL per 24 hours and
there is no echocardiographic evidence of reaccumulation of fluid
 Periodic echo reassessment for fluid reaccumulation should be performed.
 Larger effusions may benefit from slightly more prolonged drainage, but >48-hour dwell
time should be avoided to reduce the risk of infection
45

Pericardiocentesis: Complications
 The safety and success related to choice of entry site/ size of effusion
 Ùncomplicated if both anterior and posterior echo-free spaces 10 mm
 Avoided in minimally symptomatic patients with small incidental
effusions
 Risk increased in patients who are anticoagulated with warfarin
 Deferred if possible until INR within normal range
46

 If hemodynamic status demands urgent pericardiocentesis in the patient with
elevated INR, fresh frozen plasma should be administered in the catheterization
suite immediately after catheter access to the pericardium is achieved by an
expert operator and drainage is initiated (to avoid conversion of a free
hemorrhagic effusion into mixture of fluid and gelatinous clot)
47

 Laceration of a chamber wall or laceration of a coronary artery or vein
 Perforation of the ventricular myocardium with just the needle usually
does not result in significant bleeding and is usually well tolerated, but
reflex hypotension occur
 Ventricular and atrial arrhythmia,transient and not life threatening
48

 Pneumothorax
 Laceration of the liver or penetration of the stomach, colon, or spleen
 Right and left ventricular failure
 Pulmonary edema
 Exacerbation of bleeding from an ascending aortic dissection
49

Take home message
50
 Performed in the cardiac catheterization laboratory using a combination
of echocardiographic and fluoroscopic guidance
 Access to adequate ancillary support in hemodynamically unstable
patients is important
 Avoided in minimally symptomatic patients with small incidental
effusions

Reference
51
 Thank to Department of cardiology, Department of Pulmonary
medicine, Department of Radiodiagnosis JIPMER, Pondicherrry, India
 JIPMER SSB Cath lab staff
 Fang JC, Borlaug BA. Grossman & Baim's Cardiac Catheterization,
Angiography, and Intervention. InWolters Kluwer Health Adis (ESP)
2013 Oct 5.
 Goggle Image

Pericardiocentesis

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