Echocardiography-guided pericardiocentesis with a needle attached to a probe

Clinical outcomes of image-guided percutaneous drainage of pericardial effusion in cancer patients: A single-center retrospective analysis

AIM

Catheter removal, survival, and recurrence rates after percutaneous pericardial effusion drainage in cancer patients are not fully understood. We evaluated the clinical outcomes of image-guided percutaneous pericardial effusion drainage in cancer patients.

METHODS

From January 2014 to September 2017, 113 percutaneous drainages for symptomatic pericardial effusion were performed in 100 cancer patients (median 60 years; range, 7-84 years) using ultrasound or angio-computed tomography. An 8-Fr drainage catheter was placed using the Seldinger technique via the subxiphoid (n = 73), apical (n = 23), or left parasternal (n = 17) routes. Success rates, complications, and postprocedural clinical outcomes of drainages were retrospectively assessed.

RESULTS

The technical and clinical success rates were 100% and 99%, respectively, without major complications. The median duration of catheterization and evacuated pericardial effusion volume were 6 days (range, 1-72 days) and 970 ml (range, 140-7635 ml), respectively. Catheters were removed after the first drainage in 86 cases (86%). Symptomatic pericardial effusion recurred in nine patients after catheter removal, in whom redrainages were performed 13 times with a median duration to redrainage time of 48 days (range, 13-529 days). During the follow-up period (median 106 days [range, 1-1396 days]), 61 patients died. The median survival was 140 days (95% confidence interval [CI], 95-276 days), and the median catheter-free survival was 111 days (95% CI, 60-152 days).

CONCLUSIONS

Image-guided percutaneous pericardial effusion drainage for cancer patients is safe and helps alleviate symptoms. Additionally, catheter removal is possible in most patients, allowing a catheter-free period for patients.

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.

Procedural applications of ultrasound

Many invasive procedures are now safer and more efficient with the use of ultrasound guidance. As emergency physicians continue to develop skills in sonography, new applications of this technology will continue to impact the practice of emergency medicine.

Consecutive 1127 therapeutic echocardiographically guided pericardiocenteses: clinical profile, practice patterns, and outcomes spanning 21 years

OBJECTIVES

To evaluate consecutive therapeutic echocardiographically (echo)-guided pericardiocenteses performed at Mayo Clinic, Rochester, Minn, from 1979 to 2000 and to determine whether patient profiles, practice patterns, and outcomes have changed over time.

PATIENTS AND METHODS

Consecutive echo-guided pericardiocenteses performed between February 1, 1979, and January 31, 2000, for treatment of clinically significant pericardial effusions were identified in the Mayo Clinic Echocardiographic-guided Pericardiocentesis Registry. The medical records of these patients were examined, and a follow-up survey was conducted. Clinical profiles, echocardiographic findings, procedural details, and outcomes were determined for 3 periods: February 1, 1979, through January 31, 1986; February 1, 1986, through January 31, 1993; and February 1, 1993, through January 31, 2000.

RESULTS

During the 21-year study period, 1127 therapeutic echo-guided pericardiocenteses were performed in 977 patients. The mean +/- SD age at pericardiocentesis increased from 49+/-14 years in period 1 to 57+/-14 years in period 3. In recent years, cardiothoracic surgery replaced malignancy as the leading cause of an effusion requiring pericardiocentesis and together with malignancy and perforation from catheter-based procedures accounted for nearly 70% of all pericardiocenteses performed. The procedural success rate was 97% overall, with a total complication rate of 4.7% (major, 1.2%; minor, 3.5%). These rates did not change significantly over time. The use of a pericardial catheter for extended drainage increased from 23% in period 1 to 75% in period 3 (P<.001), whereas rates of effusion recurrence and pericardial surgery decreased significantly (P<.001).

CONCLUSIONS

The profile of patients presenting with clinically significant pericardial effusion has changed over time. Increasing numbers of older patients and those who have undergone cardiothoracic surgery or catheter-based procedures develop effusions that can be rapidly, safely, and effectively managed with echo-guided pericardiocentesis. Extended drainage with use of a pericardial catheter has become standard practice, and concomitantly, recurrence rates and need for surgical management have decreased considerably.

Accurate guidance for percutaneous access to a specific target in soft tissues: preclinical study of computer-assisted pericardiocentesis

In the field of percutaneous access to soft tissues, our project was to improve classical pericardiocentesis by performing accurate guidance to a selected target, according to a model of the pericardial effusion acquired through three-dimensional (3D) data recording. Required hardware is an echocardiographic device and a needle, both linked to a 3D localizer, and a computer. After acquiring echographic data, a modeling procedure allows definition of the optimal puncture strategy, taking into consideration the mobility of the heart, by determining a stable region, whatever the period of the cardiac cycle. A passive guidance system is then used to reach the planned target accurately, generally a site in the middle of the stable region. After validation on a dynamic phantom and a feasibility study in dogs, an accuracy and reliability analysis protocol was realized on pigs with experimental pericardial effusion. Ten consecutive successful punctures using various trajectories were performed on eight pigs. Nonbloody liquid was collected from pericardial effusions in the stable region (5 to 9 mm wide) within 10 to 15 minutes from echographic acquisition to drainage. Accuracy of at least 2.5 mm was demonstrated. This study demonstrates the feasibility of computer-assisted pericardiocentesis. Beyond the simple improvement of the current technique, this method could be a new way to reach the heart or a new tool for percutaneous access and image-guided puncture of soft tissues. Further investigation will be necessary before routine human application.

Minimally invasive access of the normal pericardium: initial clinical experience with a novel device

The pericardial space is being investigated as a reservoir for local drug delivery to the heart and coronary arteries. Intrapericardial drug delivery is currently limited because the pericardial space is normally small and difficult to access by standard pericardiocentesis without invasive surgery or risk of cardiac injury. Clinical trials are being conducted to evaluate a novel, minimally invasive, pericardial access device (PerDUCER, Comedicus Inc., Columbia Heights, Minn.). As of October 26, 1998, 12 clinical trials have been completed on patients undergoing cardiac surgical procedures. In all patients, a stab incision was made 1" subxiphoid and a 17G angled cannula, with preloaded guidewire, was advanced into the mediastinal space. After cannula removal, a 19F sheath/dilator was inserted over the wire. In eight patients, a median sternotomy was performed and the position of the sheath over the anterior pericardium (PC) was visually verified. Four patients underwent a closed-chest, fluoroscopy-assisted procedure. In all patients, the PerDUCER was inserted into the chest, via the sheath, and positioned over the PC. The PC was captured by suction and a bleb was formed within a side-hole on the PerDUCER tip. A sheathed needle was advanced, puncturing the isolated bleb of PC. A guidewire was advanced through the needle into the pericardial space and the PerDUCER was removed. Guidewire insertion was successful in 10 patients (7 on first attempt, 3 on second) without adverse hemodynamic effects or arrhythmia. Other than the guidewire insertion site, there was no evidence of injury to the PC or the heart. These initial clinical trials suggest that the PerDUCER may provide safe, rapid and effective percutaneous insertion of a guidewire into the normal pericardial space.

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.