Cardiology

Pericardial Intervention

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General description of procedure, equipment, technique

Pericardial effusions, presentation, tamponade, and etiology

Pericardial effusions

  • The normal pericardium is composed of visceral and parietal layers separated and lubricated by a thin layer of straw-colored fluid (20-50 ml).

  • Transudative fluids result from obstruction of fluid drainage through lymphatic channels. Exudative fluids occur secondary to inflammatory, infectious, malignant, or autoimmune processes.

  • The frequency of specific etiologies varies greatly based on geography.

  • A pericardial effusion is associated with a known systemic disease in approximately 60% of cases. Large pericardial effusions in the absence of inflammatory signs and symptoms are often neoplastic.

Cardiac tamponade

  • Cardiac tamponade is a life-threatening condition that results from the accumulation of intrapericardial fluid that impairs ventricular diastolic filling. Ultimately, cardiac chambers are compressed and fail to fill when their pressures are exceeded by the intrapericardial pressure. Because of their lower pressures, the right heart chambers are more prone to compression.

  • The intrapericardial pressure depends on the volume of the effusion, the speed of accumulation, and the pericardial elasticity. Rapidly accumulating effusions result in cardiac tamponade at relatively small volumes because the pericardium does not have adequate time to stretch. When effusions accumulate slowly, pericardial compliance gradually increases allowing the pericardium to accommodate large volumes (as much as 2-3 L).

  • Malignancy is the most common cause of pericardial effusion with tamponade (approximately 50%).

What symptoms are suggestive of a pericardial effusion?

  • Pericarditis-related chest pain is typically relieved by sitting up and worsened by lying supine and deep breathing.

  • Palpitations are most frequently due to atrial arrhythmias

  • Dyspnea and cough

  • Presyncope or syncope

  • Dysphagia

  • Abdominal fullness

  • Anxiety

  • Fever

  • Cyanosis

What are the causes of pericardial effusion?

  • Idiopathic

  • Infectious

    • Viral: Coxsackievirus, echovirus, Cytomegalovirus, Ebstein-Barr virus, herpes, Varicella zoster virus, hepatitis

    • Bacterial: tuberculosis, Staphylococcus, Streptococcus, gram-negative bacteria, gonococcus, Rickettsia

    • Fungal

    • Parasitic

  • Metabolic

    • Uremia

    • Myxedema

  • Autoimmune and inflammatory diseases

    • Rheumatoid arthritis

    • Acute rheumatic fever

    • Systemic lupus erythematosus

    • Systemic sclerosis

    • Still disease

    • Mixed connective tissue disease

    • Dressler syndrome

    • Other vasculitides

  • Neoplastic

    • Primary

    • Metastatic

  • Miscellaneous

    • Adverse drug reactions

    • Radiation injury

    • Traumatic

    • Aortic dissection

    • Myocardial infarction

    • Post cardiac surgery effusion

Indications and patient selection

How to diagnose and when to intervene on a pericardial effusion:

What should I look for to make the diagnosis?

  • Findings suggestive of pericardial tamponade include:

    • Beck’s triad of tamponade: hypotension, distant heart sounds, jugular venous distention

    • Pulsus paradoxus: a decrease in systolic blood pressure of more than 10mm Hg with inspiration due to a reduction in cardiac output during inspiration. With inspiration, negative intrathoracic pressures increase venous return and filling of the right-sided chambers. The interventricular septum consequently bows to the left, reducing left ventricular filling and output. This is quantified during the physical examination using a manual sphygmomanometer cuff during normal respirations by listening for Korotkoff sounds. As the cuff pressure is slowly reduced, Korotkoff sounds will initially be intermittent and become continuous with further reduction in the cuff pressure. The difference in the pressure measurement at which Korotkoff sounds are first audible and become continuous define the pulsus

    • Elevated jugular venous pressure with loss of the Y descent of the jugular venous pulse

  • Pericardial friction rub is associated with acute pericarditis and can occur with effusions. This high-pitched, scratching sound is best auscultated at the left lower sternal border with the patient leaning forward. A rub typically consists of three components, namely ventricular systole, ventricular diastole, and atrial systole. Frequently, only one or two of the components are audible.

  • Tachycardia

  • Tachypnea

  • Ascites and hepatosplenomegaly

  • Lower extremity edema

  • Electrocardiographic markers of pericarditis with effusion include:

    • Widespread ST-segment elevation (>25% of the height of the T-wave)

    • PR depression (elevation is often seen in lead aVR)

    • Low voltage can be indicative of a large pericardial effusion

    • Electrical alternans may result as the heart swings within a large pericardial effusion

When should I perform a pericardiocentesis?

  • Pericardiocentesis may serve diagnostic purposes; however, the etiology of pericardial effusion is rarely identified by analysis of pericardial fluid.

  • Pericardiocentesis is emergently required in the setting of cardiac tamponade or nonemergently for pretamponade. This may be performed blindly, if emergent, or under echocardiographic or fluoroscopic guidance.

  • Many have advocated for pericardiocentesis in the presence of very large (>20 mm) pericardial effusions, even in the absence of cardiac tamponade, although evidence suggests that these patients rarely progress to cardiac tamponade.

  • Elective pericardiocentesis is contraindicated in nonemergent situations when patients are receiving systemic anticoagulation or in those with bleeding disorders or thrombocytopenia (platelet count <50,000/μL).

Contraindications

How to perform a pericardiocentesis, the potential contraindications and complications of the procedure, and how to manage a drainage catheter

How do I perform a pericardiocentesis?

  • Pericardiocentesis is most often performed within the catheterization laboratory under fluoroscopic and electrocardiographic guidance.

  • The procedure can also be safely performed at the bedside under echocardiographic guidance.

  • The most common approach is subxiphoid, although apical and parasternal approaches are also feasible. The subxiphoid is the safest approach when echocardiographic guidance is not available.

  • An electrocardiography (ECG) electrode is attached to a large-bore needle at least 5cm in length using an alligator clip.

  • After application antiseptic solution and administration of local anesthetic, the needle is slowly advanced towards the pericardial space.

  • For the subxiphoid approach, the needle is inserted in the angle between the xiphoid process and the left costal margin and advanced at a 45° angle towards the left shoulder.

  • For the apical approach, ECG is often used to identify the spot where the pericardium is closest to the skin. Alternatively, the needle is inserted 1cm outside the point of maximal impulse within the intercostal space and directed towards the right shoulder.

  • For the parasternal approach, the needle is inserted immediately adjacent to the sternum, usually in the 5th intercostal space, with care being taken to avoid the vessels coursing along the inferior border of each rib.

  • Regardless of approach, the needle is slowly advanced with periodic attempts to gently aspirate fluid. While advancing the needle, special attention is given to the attached ECG electrode lead. Elevation of the ST- or PR-segment is seen when the needle is in direct contact with the myocardium. Atrial or ventricular ectopic beats can also be seen. If this occurs, slow withdrawal of the needle until ECG changes resolve should position the needle tip within the pericardial space.

  • A discrete pop is often felt upon entering the pericardial space. Once the pericardial space is entered, contrast or agitated saline injection can confirm needle position. This is recommended if hemorrhagic fluid is obtained. Alternatively, the aspirate can be placed injected into a cup. Pericardial fluid, even when hemorrhagic, will not clot, whereas intracardiac blood will.

  • A stiff guidewire is introduced into the pericardial space through the needle. A dilator is used to dilate the soft tissue track, and a pericardial drainage catheter then inserted over the stiff guidewire. In the catheterization laboratory, the intrapericardial pressures should then be documented by transducing the pericardial catheter. Additionally, radiographic contrast material can be injected through the catheter to confirm position and freedom within the pericardial space.

  • The pericardial fluid is then drained. Once complete, pericardial pressures are often remeasured to document the degree of improvement. The pericardial catheter is often left in place to allow for continuous drainage or as a route to instill sclerosing or chemotherapeutic agents. In this situation, the catheter is sutured in place and a sterile dressing applied.

What are the potential complications of pericardiocentesis?

  • Cardiac perforation: most often, cardiac perforation involves the right ventricle when using the subxiphoid approach for pericardiocentesis. Bleeding from a right ventricular puncture is often not severe due to the chamber’s relatively low pressures. However, the thin right ventricular wall is vulnerable to laceration, which frequently leads to substantial bleeding. This is especially possible in patients with pulmonary arterial hypertension and right ventricular dysfunction.

  • Cardiac arrhythmias: ectopic atrial or ventricular beats may occur when the pericardiocentesis needle is in direct contact or perforates the myocardium. Sustained arrhythmias are also possible, although less common.

  • Arterial injury: the right coronary artery is most frequently perforated or lacerated during the subxiphoid approach. The left anterior descending artery and its branches can similarly be injured during apical pericardiocentesis. The internal mammary artery and inferior phrenic arteries are prone to injury during the parasternal and subxiphoid approaches, respectively.

  • Pneumothorax

  • Pneumopericardium

  • Hemothorax

  • Hepatic injury

  • Stomach or colon penetration

What tests should I perform on the pericardial fluid?

  • Routine tests:

    • Lactic acid dehydrogenase (LDH)

    • Total protein

    • Specific gravity

    • Glucose

    • Cell count

    • Gram stain

    • Cultures, both aerobic and anaerobic

    • Fluid hematocrit

  • The evaluation of routine tests is largely to assess for infectious etiologies (Gram stain and cultures) and to identify exudative versus transudative effusions. Exudative effusions are suggested by:

    • Total protein: fluid:serum greater than 0.5

    • LDH: fluid:serum greater than 0.6

    • LDH fluid level greater than two-thirds the upper-limit of the normal serum level

    • Glucose: fluid:serum greater than 1

    • Specific gravity greater than 1.015

    • Total protein greater than 3.0mg/dL

    • LDH greater than 300 U/dl

  • Specialized testing can be guided by the clinical scenario:

    • Cultures: viral or tuberculous

    • Acid-fast staining

    • Adenosine deaminase

    • Polymerase chain reaction

    • Tumor markers

How should I manage a pericardial catheter?

  • If keeping the pericardial drain in place, antibiotics covering skin flora should be administered.

  • The pericardial catheter can be drained by gravity continuously or alternatively drained manually using sterile technique every 4 to 6 hours. Heparinized saline (2-3 cc) should be instilled into the catheter after each drainage attempt.

  • Attempts to drain the pericardium should continue until less than 50 cc of fluid is drained within a 24-hour period. However, the catheter should be removed as soon as possible in order to minimize the risk of infection within the pericardial space.

  • Intravenous antibiotics are given whilst the drain remains in place for prophylaxis against pericardial infection. It is our institutional practice to administer cefotaxime 1g every 8 hours, or vancomycin 500 to 1,000 mg every 12 hours if the patient has a penicillin allergy or methicillin-resistant Staphylococcus aureus colonization.

Malignant, reaccumulating, or persistent pericardial effusions—how to manage them.

Malignant pericardial effusion and persistently draining pericardial effusions

  • The commonest cause (50%) of adult pericardial effusion in the industrialized world is malignancy.

  • Cancers that commonly cause malignant pericardial effusions in decreasing frequency include lung carcinoma, breast carcinoma, lymphoma or leukemia, pancreatic carcinoma, ovarian carcinoma, carcinoma of unknown primary, and melanoma.

  • Primary pericardial tumors such as fibrosarcomas or mesotheliomas are rare.

  • Autopsy series of patients with a pre-existing diagnosis of malignancy demonstrate pericardial metastatic involvement in up to 15 to 30%.

  • However, only approximately 20% of patients with malignant pericardial disease present with effusion and in up to two-thirds of patients the pericardial effusion can be due to other, nonmalignant mechanisms.

  • Malignancy can result in pericardial effusion by a number of mechanisms—direct invasion, metastasis from distant primary cancers, lymphatic obstruction, chemotherapeutic or radiation induced toxicities (such as cyclophosphamide induced myopericarditis or radiation induced effusive-constrictive pericarditis), or opportunistic infection from chemotherapy-induced immunosuppression (such as tuberculous, fungal, or Cytomegalovirus pericarditis).

  • Following catheter drainage as described above, malignancy related pericardial effusion will reaccumulate in 15 to 50% of cases.

  • Persistent pericardial drainage is defined as greater than 100 ml per 24 hour day drainage 3 days following pericardial catheter placement.

How should I manage reaccumulation or persistent drainage?

  • Guidelines recommend more aggressive therapy for patients with persistent drainage or reaccumulation, including chemotherapeutic or sclerosant agents, percutaneous balloon pericardiotomy, or surgical pericardiotomy. (Level of evidence B; class of recommendation IIb).

  • Systemic chemotherapy or radiation therapy following catheter drainage has been shown to prevent reaccumulation in malignant effusions, reducing reaccumulation rates to approximately 30 to 40%.

  • Intrapericardial chemotherapeutic or sclerosant agents have also been used. A number of agents have been used including tetracyclines, bleomycin, cisplatin, nitrogen mustard, fluorouracil, teniposide, and thiopeta with varying morbidities and success rates. One reported advantage of intrapericardial therapy is that it avoids spread of malignant cells into other body cavities as can occur with surgical or percutaneous approaches. Overall, however, reaccumulation rates in malignancy remain disappointing at 40%.

  • Three surgical approaches to malignant effusion have been described: (1) subxiphoid pericardial "window," (2) thoracotomy with creation of a pleuropericardial" window," and (3) thoracotomy with pericardiectomy. Surgery has the additional advantage of allowing tissue to be obtained for diagnostic purposes.

  • However, surgical window procedures, whilst successful, have reported reaccumulation rates of up to 15% depending on the technique, and substantial morbidity (30%) and mortality (up to 13.8%).

  • Patients with advanced malignancy are often poor candidates for general anesthesia and surgery. In addition, malnutrition and chemotherapy related side effects increase the risk of infection and other perioperative complications.

  • Finally, overall prognosis is poor in this group of patients, with mortality related to the underlying malignancy, estimated at 80% in the reported case series, and increasing their length of hospital stay associated with a surgical procedure may compromise the quality of their remaining lifespan.

  • In 1991 Palacios et al first proposed percutaneous balloon pericardiotomy under local anesthesia with conscious sedation as a less invasive alternative technique to surgical pericardial window procedures.

Details of how the procedure is performed

Technique of percutaneous balloon pericardiotomy, its contraindications and complications

Technique of percutaneous balloon pericardiotomy

  • Percutaneous balloon pericardiotomy (PBP) is a relatively simple and safe procedure performed under local anesthesia with conscious sedation using benzodiazepines and intravenous narcotics.

  • PBP can be performed in patients with an existing pericardial drainage catheter and ongoing persistent drainage, and de novo for the first time in patients presenting for initial pericardiocentesis.

  • In patients with a pre-existing pericardial drainage pigtail catheter, the catheter can be removed over a stiff J-tipped 0.035 inches or 0.038 inches Amplatz guidewire, leaving the guidewire in the pericardial space.

  • As with pericardiocentesis, the guidewire position should be confirmed by forming a loop within the pericardial space.

  • The skin tract into the parietal pericardium should be dilated usually up to 10Fr over the guidewire to allow passage of the dilating balloon catheter. This may cause pain.

  • Typically a 12 to 20mm diameter balloon (Maxi Balloon, Cordis), 3 to 4cm in length is advanced over the guidewire to the straddle the parietal pericardium.

  • It is important to ensure the proximal end of the balloon is within the subcutaneous tissue and not extending through the skin, which can cause extreme discomfort.

  • The optimal balloon position is confirmed by gentle inflation of the balloon to reveal a waist at the location of the parietal pericardium.

  • The balloon is then manually inflated until the waist disappears. We advocate two to three inflations in order to ensure successful PBP.

  • Biplane fluoroscopy if available should be used to allow fluoroscopic confirmation of the correct positioning of the balloon.

  • If there is difficulty in identifying the parietal pericardium, 5 to 15 ml of radiographic contrast can be injected to identify the pericardial borders.

  • If the parietal pericardium is adherent to the chest, with failure of proximal balloon inflation, then a counter traction technique can be used to pull the skin and tissue away from the pericardium as the balloon is advanced forward.

  • After balloon dilatation, the balloon catheter is removed over the stiff 0.035 inch guidewire and replaced with a new pigtail catheter, which is sutured in place.

  • In the setting of de novo pericardiotomy at the time of pericardiocentesis then the pericardium is entered in standard fashion and a drainage catheter placed to allow pericardial pressure measurement. After confirming the opening pericardial pressure, most of the pericardial fluid is aspirated, although some may be left behind to allow ease of position of the balloon dilatation catheter.

  • A number of variations on this standard technique have been described including, apical puncture, adjacent side-by-side pericardial balloon placement, double balloon pericardiotomy, Inoue balloon pericardiotomy, and use of a combination of a long and short dilating balloon.

  • Following PBP, the pericardial catheter should be managed according to the protocol outlined in the pericardiocentesis section.

  • Once there is no significant persistent drainage (<75-100 ml per 24 hours), the catheter can be removed.

  • Follow-up transthoracic echocardiography should be performed 48 hours after drainage catheter removal. Additionally, chest X-ray imaging should be performed to assess for possible pleural effusion development post-PBP drainage.

  • The mechanism by which PBP works remains unclear. It is assumed that localized tearing of the parietal pericardium produces a communication between the pericardial space and the pleural space and/or the peritoneum.

  • Prior pericardioscopy and radiographic contrast injection analysis has demonstrated a communication between the pericardium and the pleural space.

  • Additionally, Chow et al showed an oval 18.6 by 16.4 mm window after 23 mm Inoue balloon inflation.

  • It is unlikely that a permanent communication persists. It is much more likely that drainage of the pericardial fluid allows the visceral and parietal pericardium to undergo inflammatory fusion.

Outcomes and complications of percutaneous balloon pericardiotomy

  • Palacios et al first described their initial experience with PBP in eight patients with malignant effusion/tamponade.

  • Procedural success was 100%. There were no immediate or late complications attributed to the procedure. The mean time to development of a new or significantly increased left pleural effusion was 2.9 ± 0.4 days. The mean follow-up was 6 ± 2 months.

  • No patients had recurrent effusion or tamponade. However, the prognosis of these patients was poor in keeping with their underlying primary diagnosis, with death occurring in five cases.

  • A subsequent multicenter registry evaluated the therapeutic role of PBP in 130 patients in 16 centers from 1987 to 1996.

  • 85% had a known diagnosis of malignancy (majority lung carcinoma), with 58% presenting with cardiac tamponade and had already undergone pericardiocentesis.

  • PBP was defined as success if there was no recurrence of effusion on echocardiography and if there were no procedural complications.

  • 85% ( 111/130) were successful, with no effusion recurrences during a mean follow-up of 5 months ± 5.8 months. Chest tube placement was required in 15% of patients with pre-existing effusions, compared with 9% in patients without a prior effusion.

  • Of the 104 patients with malignancy, 86 died at a mean time of 3.8 ± 3.3 months after PBP. There were no predictors of survival or freedom from effusion reaccumulation.

  • Wang et al reported their experience with double balloon PBP in a cohort of 50 patients. Again, the natural history of their malignancy determined the long-term outcome in this cohort. Minor complications such as fever and small pneumothorax were described. 25% developed a large left pleural effusion after PBP.

  • In this study, positive cytology, elevated serum calcium, and reduced fluid albumin/globulin ratio were independent predictors of an adverse outcome.

  • PBP should be avoided in loculated pericardial effusions as it is unlikely to provide complete drainage. Intrapericardial administration of urokinase or mechanical disruption of fibrinous debris using guidewires and pigtail catheters remains controversial.

  • Additionally, PBP should be avoided in patients with tenuous pulmonary function as it may result in a significant left pleural effusion further compromising their lung function.

  • Fever has been described following PBP in patients in whom no antibiotic prophylaxis has been administered. It is therefore routine standard of care to administer antibiotics at the time of the procedure.

  • Bleeding from the pericardiotomy site has been described in patients with platelet and coagulation cascade abnormalities, so this treatment should be avoided in these patient groups.

  • Right ventricular injury and perforation are technically possible but in experienced hands this represents a safe procedure.

  • The development of a left pleural effusion has been described to occur in up to 25% of cases, higher in patients with pre-existing effusions prior to PBP. It is theorized that near complete drainage of the pericardial effusion prior to PBP may help prevent this.

  • Rarely, balloon rupture and fracture has been reported.

Interpretation of results

Percutaneous pericardial biopsy

  • As described above, large pericardial effusion is a common clinical presentation of a number of disease states. The first step towards definitive diagnosis is pericardiocentesis.

  • Although helpful, pericardiocentesis provides a definitive diagnosis in only approximately 25% of cases. Tuberculosis is the most commonly missed diagnosis.

  • In malignant pericardial effusions, fluid cytology is positive in 50% to 85% of cases, although cell typing remains limited, albeit, improving with immunohistochemical staining. To increase diagnostic yield, pericardial biopsy is often required. Traditionally, this has required open surgical biopsy under general anesthesia.

  • Percutaneous techniques for obtaining multiple pericardial tissue samples have been described over the last 20 years.

  • Percutaneous pericardial biopsy was first performed by Endrys et al in 1988, who reported a series of 18 consecutive patients who needed pericardiocentesis for large pericardial effusion.

  • Using a subxiphoid approach, the authors advanced a 7 Fr Teflon sheath into the pericardial space and drained the pericardial effusion. This sheath was then exchanged for an 8 Fr Teflon sheath with a curved tip and multiple side holes. An endomyocardial bioptome was inserted through the sheath and air was allowed to enter the pericardium to delineate the visceral and parietal pericardium layers. An average of eight separate samples was obtained, with no complications. At the end of the procedure, the air was aspirated and a drainage catheter placed as usual.

  • In nine of the 18 cases a definitive diagnosis could be obtained from the biopsy specimens.

  • Mehan et al noted that the floppy nature of the bioptome made it difficult to direct towards an appropriate target in the pericardial cavity. Therefore, they modified Endrys’ technique to use the distal portion of 9Fr Judkins coronary guiding catheter to target specific sites.

  • Ziskind et al subsequently used a similar fluoroscopic approach but used a special pericardial bioptome with a central needle and serrated jaws. They did not install air into the pericardial cavity, but rather maintained visceral-parietal pericardial separation by not removing all the pericardial fluid at the start of the procedure.

  • In their study of 15 patients, tissue adequate for a tissue diagnosis was obtained in all patients. For patients with a history of malignancy, the addition of biopsy to cytology increased the diagnostic yield from 46% to 62%.

  • Selig et al further modified the technique using echocardiographic rather than fluoroscopic guidance for biopsy.

  • Finally, Margey and Palacios et al recently described the outcome of pericardial biopsy in seven consecutive patients presenting with suspected malignant effusion. They obtained a total of five biopsy specimens per procedure without any complications, and demonstrated that pericardial biopsy adds incremental diagnostic yield to cytology alone. In this series, biopsy confirmed no malignant invasion in four patients with known malignancy, and the presence of lymphocytic and organizing effusive pericarditis in one and two patients, respectively.

Performance characteristics of the procedure

How to perform pericardial biopsy, its complications, and the role of pericardioscopy in improving sampling yield

Technique of percutaneous pericardial biopsy

  • Pericardial biopsy can either be performed in the setting of a previously drained pericardial effusion with a pigtail catheter still in place or at the same time as de novo pericardiocentesis.

  • Standard pericardiocentesis is performed as outlined above. Care is made to ensure that not all of the fluid is drained completely. This is best ascertained on echocardiography or by injection of 5 to 15 cc of radiographic contrast material into the pericardial space.

  • The pigtail catheter is exchanged over a J-tipped 0.035 inches or 0.038 inches Amplatz Stiff guidewire for a 7 Fr 23 cm braided sheath. The sheath is advanced into the retrocardiac pericardial space, and aspirated and flushed. Further local installation of radiographic contrast material can be performed to outline the visceral pericardial layer.

  • Subsequently, a 7 Fr BiPal Cordis bioptome is advanced through the sheath, the jaws opened, and angled by rotation away from the cardiac shadow towards the parietal pericardial layer. Ideally, this is confirmed in two fluoroscopic planes, usually an anteroposterior and lateral projection. Biplane cineangiography capability is useful for this reason.

  • Once the operator is satisfied that the biopsy jaws are not directed towards the epicardial pericardial layer, up to five biopsy specimens are obtained.

  • Following successful biopsy, the guidewire is readvanced through the sheath into the pericardial space and the sheath exchanged for a new drainage pigtail catheter.

  • As outlined above, the pigtail is removed once the total drainage is less than 75 to 100 cc per 24 hours.

Complications of percutaneous pericardial biopsy

  • Less invasive than open surgical biopsy

  • If performed at the same time as de novo pericardiocentesis, then the complications outlined earlier when discussing pericardiocentesis apply.

  • If separation of the visceral and parietal pericardial layers cannot be obtained, there is a risk of cardiac laceration or perforation, and coronary injury. Additionally, ventricular ectopy, pain, and fever can also occur.

Role of pericardioscopy

  • Seferovic et al reported their experience on the use of pericardioscopy in conjunction with pericardial biopsy to improve the diagnostic yield of isolated fluoroscopy guided biopsy.

  • This paper included 49 patients with large pericardial effusion undergoing percutaneous biopsy.

  • In 12 cases, standard fluoroscopy was used to guide biopsy, with three to six biopsy samples obtained per case. In 22 patients, four to six biopsies were obtained using pericardioscopy guidance with a 16Fr flexible endoscope. Finally, in 15 patients, extensive pericardial sampling guided by pericardioscopy was performed, with 18 to 20 samples obtained.

  • Sampling efficiency was significantly better with pericardioscopy versus fluoroscopy (84.9% vs 43.7%).

  • Pericardial biopsy in the extensive sampling group had a much higher yield than fluoroscopy alone in establishing etiology, (53.3% vs 8.3%, p<0.05).

  • The addition of the 16Fr endoscope access port did not result in any complications.

Alternative and/or additional procedures to consider

Future uses of percutaneous pericardial access and the pericardial space

Novel future use of percutaneous pericardial access and the pericardial space

  • Accessing and utilizing the pericardial space as a therapeutic delivery site has progressively grown over the last 10 years.

  • The pericardial space not only allows epicardial catheter mapping of complex arrhythmias and their subsequent ablation, which previously could only be performed surgically, but it also allows access to structures such as the left atrial appendage allowing successful external snare closure of this structure for stroke prevention.

  • Additionally, the pericardial space provides a novel access route for possible local myocardial drug delivery or stem cell transfer for patients post acute myocardial infarction or with heart failure.

  • Epicardial scar related re-entry has been recognized as a potential cause of ventricular tachycardia in both ischemic and nonischemic cardiomyopathy. Catheter-based intervention techniques in the pericardial space have gained momentum after safe percutaneous access techniques to the pericardium have been developed.

  • Sosa et al described their initial experience with percutaneous entry of the pericardial space in patients with Chagas disease, to facilitate epicardial arrhythmia mapping. Subsequently, it was established that epicardial access could be used for catheter ablation also.

  • It has been established that in patients with failed endocardial ablation procedures, attempted epicardial arrhythmia induction and ablation is a safe and effective alternative.

  • Additionally, in animal models, epicardial access for cardiac resynchronization lead placement has been developed.

  • Prior work has listed potential complications of epicardial access for electrophysiologic procedures, including: right ventricular pseudoaneurysm, hepatic puncture, intrahepatic hematoma, coronary vascular injury and spasm, right ventricle to abdominal fistula, post-procedure pericarditis, and hemorrhagic pericardial effusion.

  • Intrapericardial echocardiography remains an investigational tool, but may well evolve into a useful tool to guide epicardial mapping and ablation procedures.

  • Finally, the pericardial space is used to aid in left atrial appendage exclusion using the LARIAT snare device, an investigational device for left atrial appendage exclusion for stroke prevention. This is a novel catheter based suture ligation of the left atrial appendage, using both a transseptal and epicardial approach to snare and tie off the left atrial appendage. This device, which is available in Europe, is awaiting evaluation in the United States in a clinical trial to determine its efficacy.

What’s the evidence?

Little, WC, Freeman, GL. "Pericardial disease". Circulation. vol. 113. 2006. pp. 1622-1632.

An excellent overview of the global burden, presentation, causes and management of pericardial disease.

Sagristà-Sauleda, J, Mercé, J, Permanyer-Miralda, G. "Clinical clues to the causes of large pericardial effusions". Am J Med. vol. 109. 2000. pp. 95-101.

Provides a clinical decision outline of the potential varied causes of pericardial effusions and the diagnostic clues to their etiology.

Roy, CL, Minor, MA, Brookhart, MA. "Does this patient with a pericardial effusion have cardiac tamponade?". JAMA. vol. 297. 2007. pp. 1810-1818.

Outlines the non-invasive clinical and invasive clinical signs of impending and actual tamponade physiology.

Reddy, PS, Curtiss, EI, O'Toole, JD. "Cardiac tamponade: hemodynamic observations in man". Circulation. vol. 58. 1978. pp. 265-272.

Original catheterizations based hemodynamic findings in cardiac tamponade.

Callahan, JA, Seward, JB. "Pericardiocentesis guided by two-dimensional echocardiography". Echocardiography. vol. 14. 1997. pp. 497-504.

Technical description of echocardiographic guided pericardiocentesis.

Loukas, M, Walters, A, Boon, JM. "Pericardiocentesis: a clinical anatomy review". Clin Anat. vol. 25. 2012. pp. 872-881.

Excellent overview of the anatomic landmarks used to guide pericardiocentesis and the pericardial anatomy relevant to drainage catheter placement.

Hoit, BD. "Management of effusive and constrictive pericardial heart disease". Circulation. vol. 105. 2002. pp. 2939-2942.

Overview of the causes, diagnosis, presentation, and management of effusive constrictive pericardial disease.

Maisch, B, Seferovic, PM, Ristic, AD. "Guidelines on the diagnosis and management of pericardial diseases executive summary; the Task Force on the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology". Eur Heart J. vol. 25. 2004. pp. 587-610.

European Society of Cardiology guidelines regarding the diagnosis and management of pericardial disease, the most recent inter-society guidelines on pericardial disease.

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

Paper describing the diagnostic utility of large effusion drainage in the absence of tamponade.

Jneid, H, Maree, AO, Palacios, IF, Parillo J, DP. "Pericardial tamponade: clinical presentation, diagnosis and catheter-based therapies". Critical Care Medicine. Mosby. 2008.

Excellent overview of the presentation and catheter-based management of pericardial disease.

Jneid, H, Maree, AO, Palacios, IF, Mebazza A, GM, Zannad, FM, Parillo, J. "Acute pericardial disease: pericardiocentesis and percutaneous pericardiotomy". Acute Heart Failure. Springer. 2008.

Overview of catheter-based pericardial drainage and pericardiotomy.

Markiewicz, W, Borovik, R, Ecker, S. "Cardiac tamponade in medical patients: treatment and prognosis in an echocardiographic era". Am Heart J. vol. 111. 1986. pp. 1138-1142.

Reviews the causes and outcomes for patients in contemporary medical practice with large pericardial effusions causing tamponade.

Flannery, EP, Gergoratos, G, Corder, MP. "Pericardial effusions in patients with malignant diseases". Arch Intern Med. vol. 135. 1975. pp. 976-977.

Reviews the malignant causes and diagnosis of malignant pericardial disease.

Shepard, FA, Morgan, C, Evans, WK. "Medical management of malignant pericardial effusion by tetracycline sclerosis". Am J Cardiol. vol. 60. 1987. pp. 1161-1166.

Describes the outcomes of intra-pericardial tetracycline sclerosant therapy for malignant pericardial effusions.

Fontenelle, LJ, Cuello, L, Dooley, BN. "Subxiphoid pericardial window. A simple and safe method for diagnosing and treating acute and chronic pericardial effusions". J Thorac Cardiovasc Surg. vol. 62. 1971. pp. 95-97.

Describes the surgical technique of subxiphoid pericardial window creation.

Palacios, IF, Tuzcu, EM, Ziskind, AA. "Percutaneous balloon pericardial window for patients with malignant pericardial effusion and tamponade". Cathet Cardiovasc Diagn. vol. 22. 1991. pp. 244-249.

Original description and case series of percutaneous pericardial window creation.

Ziskind, AA, Rodriguez, S, Lemmon, C. "Percutaneous pericardial biopsy as an adjunctive technique for the diagnosis of pericardial disease". Am J Cardiol. vol. 74. 1994. pp. 288-291.

Original case series of percutaneous pericardial biopsy.

Chow, WH, Chow, TC, Cheung, KL. "Nonsurgical creation of a pericardial window using the Inoue balloon catheter". Am Heart J. vol. 124. 1992. pp. 1100-1102.

Clinical series of balloon pericardial window creation.

Chow, WH, Chow, TC, Yip, AS. "Inoue balloon pericardiotomy for patients with recurrent pericardial effusion". Angiology. vol. 47. 1996. pp. 57-60.

Clinical series of balloon pericardial window creation.

Iaffaldano, RA, Jones, P, Lewis, BE. "Percutaneous balloon pericardiotomy: a double balloon technique". Cathet Cardiovasc Diagn. vol. 36. 1995. pp. 79-81.

Case description of double balloon technique for balloon pericardial window.

Hsu, KL, Tsai, CH, Chaing, FT. "Percutaneous balloon pericardiotomy for patients with recurrent pericardial effusion: using a double balloon technique with one long and one short balloon". Am J Cardiol. vol. 80. 1997. pp. 1635-1637.

Case description of double balloon percutaneous pericardial window creation for recurrent pericardial effusions.

Ziskind, AA, Pearce, AC, Lemmon, CC. "Percutaneous balloon pericardiotomy for the treatment of cardiac tamponade and large pericardial effusions: description of technique and report of first 50 cases". J Am Coll Cardiol. vol. 21. 1993. pp. 1-5.

Multicenter case series of percutaneous balloon pericardial window creation.

Chow, LT, Chow, WH. "Mechanism of pericardial window creation by balloon pericardiotomy". Am J Cardiol. vol. 72. 1993. pp. 1321-1322.

Description of mechanisms of pericardial effusion drainage after creation of a balloon pericardial window.

Sugimoto, JT, Little, AG, Ferguson, MK. "Pericardial Window: mechanisms of efficacy". Ann Thorac Surg. vol. 50. 1990. pp. 442-445.

Describes the mechanism of efficacy of pericardial window creation.

Sosa, E, Scanavacca, M, d'Avila, A. "A new technique to perform epicardial mapping in the electrophysiology laboratory". J Cardiovasc Electrophysiol. vol. 7. 1996. pp. 531-536.

Original description of trans-pericardial epicardial EP technique

Strickerberger, SA. "Pericardial space exploration for ventricular tachycardia mapping: should the countdown begin?". J Cardiovasc Electrophysiol.. vol. 7. 1996. pp. 537-538.

Editorial regarding potential of pericardial approach to allow epicardial mapping and ablation in EP.

Sosa, E, Scanavacca, M, d'Avila, A. "Endocardial and epicardial ablation guided by nonsurgical transthoracic epicardial mapping to treat recurrent ventricular tachycardia". J Cardiovasc Electrophysiol. vol. 9. 1998. pp. 229-239.

Original case series of epicardial EP ablation via a pericardial approach.

Schweikert, RA, Saliba, WI, Tomassoni, G. "Percutaneous pericardial instrumentation for endo-epicardial mapping of previously failed ablations". Circulation. vol. 108. 2003. pp. 1329-1335.

Use of a pericardial approach for mapping of arrhythmias.

Laham, RJ, Simons, M, Hung, D. "Subxyphoid access of the normal pericardium: a novel drug delivery technique". Catheter Cardiovasc Interv. vol. 47. 1999. pp. 109-111.

Description of using subxiphoid pericardial access to deliver drug therapy locally to the heart.

Mickelsen, SR, Ashikaga, H, DeSilva, R. "Transvenous access to the pericardial space: an approach to epicardial lead implantation for cardiac resynchronization therapy". Pacing Clin Electrophysiol. vol. 28. 2005. pp. 1018-1024.

Rodrigues, AC, d'Avila, A, Houghtaling, C. "Intrapericardial echocardiography: a novel catheter-based approach to cardiac imaging". J Am Soc Echocardiogr Mar. vol. 17. 2004. pp. 269-274.

Description of using pericardially placed echo probe for cardiac imaging.

Endrys, J, Simo, M, Shafie, MZ. "New nonsurgical technique for multiple pericardial biopsies". Cathet Cardiovasc Diagn. vol. 15. 1988. pp. 92-94.

Description of percutaneous pericardial biopsy technique

Mehan, VK, Dalvi, BV, Lokhandwala, YY. "Use of guiding catheters to target pericardial and endomyocardial biopsy sites". Am Heart J. vol. 122. 1991. pp. 882-883.

Description of the use of guiding catheters to select areas for pericardial biopsy.

Selig, MB. "Percutaneous pericardial biopsy under echocardiographic guidance". Am Heart J. vol. 122. 1991. pp. 879-882.

Descriptive case series of echocardiographic guided percutaneous pericardial biopsy.

Margey, R, Suh, W, Witzke, C. "Percutaneous pericardial biopsy—a novel interventional technique to aid diagnosis and management of pericardial disease".

Descriptive case series of percutaneous pericardial biopsy to help aid diagnosis in recurrent large pericardial effusion.

Seferovic, PM, Ristic, AD, Maksimovic, R. "Diagnostic value of pericardial biopsy: improvement with extensive sampling enabled by pericardioscopy". Circulation. vol. 107. 2003. pp. 978-983.

Clinical paper describing the improved yield with pericardioscopic guided pericardial biopsy.

Bartus, K, Bednarek, J, Myc, J. "Feasibility of closed chest ligation of the left atrial appendage in humans". Heart Rhythm. vol. 8. 2011. pp. 188-193.

Original description of trans-pericardial facilitated percutaneous left atrial appendage closure.

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