A contemporary look at pericardiocentesis

The Jack-in-the-Box: Pericardial Decompression Syndrome Managed by a Multidisciplinary Approach with Early Initiation of Veno-Arterial Extracorporeal Membrane Oxygenation: A Case Report

Post decompression syndrome (PDS) is a rare and life-threatening complication of pericardiocentesis, especially after rapid drainage of large amounts of pericardial fluid. We present the case of a 21-year-old man who presented with cardiac tamponade of unknown etiology. After preoperative optimization, surgical drainage of the pericardial effusion was performed and approximately 2500 mL of fluid was released over 30 min. The patient rapidly developed hemodynamic collapse with severe biventricular dysfunction, with a left ventricle ejection fraction of 15%. Vasopressor and inotropic support were initiated with Noradrenaline and Dobutamine, further escalated to Adrenaline and Levosimendan with no improvement in clinical and hemodynamic parameters. Considering the high doses of vasoactive drugs, rescue veno-arterial extracorporeal membrane oxygenation (V-A ECMO) was started within the first 24 h. After 10 days on V-A ECMO, the cardiac function slowly recovered, and the extracorporeal mechanical support was successfully weaned. The diagnosis of paraneoplastic PDS secondary to angiosarcoma was made and the patient was successfully discharged to the ward on the 24th day. In conclusion, far from being the last option in the management of PDS, V-A ECMO deserves early consideration for securing adequate myocardial and systemic perfusion, while the cardiac function recovers, but a risk-to-benefit assessment should be made by an experienced multidisciplinary team.

Is pulmonary hypertension protective against cardiac tamponade? A systematic review

The presence of pulmonary hypertension (PH) may affect whether cardiac tamponade physiology develops from a pericardial effusion. Specifically, the increased intracardiac pressure and right ventricular hypertrophy associated with PH would seemingly increase the intrapericardial pressure threshold at which the right-sided chambers collapse. In this systematic review, we examined the impact of PH on the incidence, in-hospital and long-term mortality, and echocardiographic findings of patients with cardiac tamponade. Using the PRISMA guideline, a systematic search was conducted in PubMed, Academic Search Premier, Web of Science, Google Scholar, and the Cochrane Database for studies investigating PH and cardiac tamponade. The Newcastle-Ottawa Scale was used to analyze the quality of returned studies. Primary outcomes included the incidence of cardiac tamponade, as well as in-hospital and long-term mortality rates. Secondary outcomes were the presence or absence of echocardiographic findings of cardiac tamponade in patients with PH. Forty-three studies (9 cohort studies and 34 case reports) with 1054 patients were included. The incidence of cardiac tamponade was significantly higher in patients with PH compared to those without PH, 2.0% (95% CI 1.2-3.2%) vs. 0.05% (95% CI 0.05-0.05%), p < 0.0001, OR 40.76 (95% CI 24.8-66.9). The incidence of tamponade in patients with a known pericardial effusion was similar in those with and without PH, 20.3% (95% CI 12.0-32.3%) and 20.9% (95% CI 18.0-24.1%), p = 0.9267, OR 0.97 (95% CI 0.50-1.87). In patients with tamponade, those with PH demonstrated a significantly higher in-hospital mortality than those without PH, 38.8% (95% CI 26.4-52.8%) vs. 14.4% (95% CI 14.2-14.6%), p < 0.0001, OR 3.77 (95% CI 2.12-6.70). Long-term mortality in patients with tamponade was significantly lower in those with PH than in those without PH, 45.5% (95% CI 33.0-58.5%) vs. 59.1% (95% CI 54.7-63.4%), p = 0.0258, OR 0.576 (95% CI 0.33-1.01). However, after stratifying by non-malignant etiologies, the long-term mortality benefit for those with PH disappeared. In the studies that described specific echocardiographic findings of cardiac tamponade, only 10.5% of patients with PH and tamponade showed right atrial and right ventricular collapse. When evaluating patients with pericardial effusions, physicians must recognize the effects of underlying PH on the incidence, in-hospital and long-term mortality rates, and potentially atypical echocardiographic presentation of cardiac tamponade.

Off-plane technique ultrasound-guided pericardiocentesis via anterior approach: short communication

The pericardiocentesis procedure is common, often performed via the subxiphoid approach, although other transthoracic approaches have been described. This short communication describes an off-plane technique ultrasound-guided pericardiocentesis using an anterior approach, performed using a linear transducer and guided in real-time by ultrasound, offering the advantage of continuous needle tracking to reduce complications associated with this approach such as pneumothorax, inadvertent cardiac puncture, and injury to the left internal mammary artery (LIMA).

A Patient in Their 70s With Bright Red Blood in the Pericardiocentesis Catheter

This case report discusses a finding of blood in the pericardiocentesis catheter of a patient with a recent history of aortic valve replacement and recurrent postsurgical pericardial and pleural effusions.

Variations in current clinical practice of postoperative pericardial effusion: a questionnaire study

OBJECTIVE

Postoperative pericardial effusion (PPE) occurs frequently after cardiac surgery, potentially leading to life-threatening cardiac tamponade. Specific treatment guidelines are currently lacking, possibly leading to variations in clinical practice. Our goal was to assess clinical PPE management and evaluate variation between centres and clinicians.

METHODS

A nationwide survey was sent to all interventional cardiologists and cardiothoracic surgeons in the Netherlands, regarding their preferred diagnostic and treatment modality of PPE. Clinical preferences were explored utilising four patient scenarios, each with a high/low echocardiographic and clinical suspicion of cardiac tamponade. Scenarios were also stratified by three PPE sizes (<1 cm, 1-2 cm, >2 cm).

RESULTS

In total, 46/140 interventional cardiologists and 48/120 cardiothoracic surgeons responded (27/31 contacted centres). Cardiologists favoured routine postoperative echocardiography in all patients (44%), whereas cardiothoracic surgeons preferred routine imaging after specific procedures, especially mitral (85%) and tricuspid (79%) valve surgery. Overall, pericardiocentesis (83%) was preferred over surgical evacuation (17%). Regarding all patient scenarios, cardiothoracic surgeons significantly preferred evacuation compared with cardiologists (51% vs 37%, p<0.001). This was also observed with cardiologists employed in surgical centres compared with non-surgical centres (43% vs 31%, p=0.02). Inter-rater analysis varied from poor to near-excellent (к 0.22-0.67), suggesting varying PPE treatment preferences within one centre.

CONCLUSION

There is significant variation in the preferred management of PPE between hospitals and clinicians, even within the same centre, possibly due to the lack of specific guidelines. Therefore, robust results of a systematic approach to PPE diagnosis and treatment are needed to formulate evidence-based recommendations and optimise patient outcome.

Unveiling the causes of pericardial effusion in a contemporary case series of pericardiocentesis in Latin America

Pericardial effusions requiring pericardiocentesis have multiple causes that vary among geographical regions and health contexts. This procedure can be performed for diagnostic or therapeutic indications. The purpose of this study was to identify the principal causes of pericardial effusions and indications for pericardiocentesis, exploring differences among groups. This was a retrospective case series of patients who underwent pericardiocentesis for pericardial effusion in a single center in Latin America. Demographic, clinical, echocardiographic, and procedural variables were recorded and analyzed. The primary outcome was to determine the causes of pericardial effusions in these patients and the indication (diagnostic, therapeutic, or both). The results are presented in two groups (inflammatory and noninflammatory) according to the cause of the pericardial effusion. One hundred sixteen patients with pericardial effusion underwent pericardiocentesis. The median age was 58 years (IQR 46.2–70.7), and 50% were male. In the noninflammatory pericardial effusion group, there were 61 cases (53%), among which neoplastic pericardial effusion was the most frequent cause (n = 25, 40.9%). In the inflammatory group, there were 55 cases (47%), and the main cause was postpericardiectomy syndrome after cardiac surgery (n = 31, 56.4%). The principal indication for pericardiocentesis was therapeutic (n = 66, 56.8%). Large pericardial effusion without hemodynamic effect of cardiac tamponade was significantly more frequent in the inflammatory group (p = 0.03). In conclusion, the principal cause of pericardial effusion in patients who underwent pericardiocentesis was postpericardiectomy syndrome after cardiac surgery, followed by neoplastic pericardial effusion. Pericardiocentesis is mainly a therapeutic procedure.

The safety of pericardiocentesis in patients under antithrombotic therapy: A single-center experience

Objective

This study aimed to analyze the characteristics of patients with pericardial effusion requiring pericardiocentesis and to evaluate the safety of pericardiocentesis without discontinuation of anticoagulant or antiplatelet drugs.

Methods

We performed a retrospective study of patients undergoing pericardiocentesis in our hospital between 2012 and 2022. Patients were categorized into the Antithrombotic Group if they had used any antiplatelet or anticoagulant drugs on the day of pericardiocentesis; otherwise they were categorized into the Non-antithrombotic Group. All procedures were performed by experienced cardiologists with echocardiographic guidance. Bleeding events were defined using the National Institutes of Health scale of adverse events.

Results

A total of 501 consecutive patients were identified and 70 cases were under antithrombotic drugs (Antithrombotic Group). Patients in Antithrombotic Group were older, had more comorbidities, presented with lower platelet counts and prolonged activated partial thromboplastin time (all p < 0.05). Malignancy was the most common etiology for pericardial effusion in both groups (28.6% in Antithrombotic Group and 54.7% in Non-antithrombotic Group) and tuberculosis was the second etiology in the Non-antithrombotic Group (21.9%), while procedure-related effusion (17.1%) accounted for the second cause in the Antithrombotic Group. Two patients in the Antithrombotic Group had mild oozing at the puncture site that resolved without interventions (2.9 vs. 0%, p = 0.019), and no bleeding events higher than Grade 1 occurred in either group.

Conclusion

Although antiplatelet or anticoagulant drugs may put patients undergoing pericardiocentesis at theoretically higher risk of bleeding, our study demonstrated that they are not associated with increased major bleeding complications.

Pericardial Drain Placement in Interventional Radiology: An Overview

Pericardial effusions can occur from multiple different etiologies. Although often incidentally noted or clinically silent, pericardial effusions may cause significant hemodynamic compromise. In some of these patients, pericardiocentesis may be temporizing only and either repeat procedures or placement of pericardial drains may be preferable. While cardiologists typically perform pericardial drain placement, it is a procedure that may also be performed by interventional radiologists. This article describes for the interventional radiologist the indications and placement technique, as well as potential complications occurring from pericardial drain placement.

Pericardial effusion among children: Retrospective analysis of the etiology and short-term outcome in a referral center in the south of Iran

Background and Aims

We reinvestigated the causes, symptoms, and management of childhood pericardial effusion (PE) and its gradual changes during recent years in a referral pediatric cardiology center in the south of Iran.

Methods

We retrospectively analyzed the profile of PE patients who were under 18 years old from 2015 to 2020. The patient's demographic, clinical, and paraclinical information was extracted and analyzed using SPSS software.

Result

In general, 150 out of 63,736 admitted patients (0.23% of the total pediatric admissions) were diagnosed with PE (male/female 1:1.17). The median age was 3.25 years (range:\ 2 days to 18 years; interquartile range: 9.5), and 50% of them were under 3 years of age. 32.6% had moderate to severe PE. Most patients presented with acute symptoms (68%) and respiratory problems, as the most common symptoms (30.6%). Tamponade signs were presented in 2% (n = 3) of the patients, and 80.7% (n = 121) were in a stable hemodynamic condition. In total, renal failure (22%) and parapneumonic effusion were the leading etiologies. Viral (7%) and bacterial (5%) pericarditis were the seventh and eighth causes; however, in severe cases, renal failure (22%) and bacterial pericarditis (14%) were dominant. In total, 14.1% (n = 21) of the patients needed pericardiocentesis that increased to 78.3% (n = 18) in severe cases. Only 6% had persistent PE for more than 3 months.

Conclusion

Childhood PE is mostly a result of renal failure and noninfectious causes. True pericarditis cases are not common, except in severe cases. It is more common in less than 3-year-old patients, and chronicity is rare. Severe cases had a high chance of pericardiocentesis, but other cases were mainly managed by treatment of the underlying causes.

Acute Marginal Artery Laceration as a Complication of Pericardiocentesis

The safety of pericardiocentesis as a therapy for cardiac tamponade has improved since the advent of echocardiography-guided pericardiocentesis. The most life-threatening, albeit rare, complication is injury to the coronary vessels or ventricular wall resulting in recurrent tamponade. We present a rare case of acute marginal artery laceration resulting from pericardiocentesis. (Level of Difficulty: Beginner.)

Feasibility and safety of CT-aided pericardiocentesis from a subxiphoid anterior approach by using fluoroscopy in patients with chronic pericardial effusions

Background

Pericardiocentesis is an essential procedure for the diagnosis and treatment of pericardial effusions. The purpose of this study was to evaluate the feasibility and safety of a subxiphoid anterior approach using fluoroscopy aided by a sagittal axis chest computed tomography (CT) view in comparison with an ultrasound‐guided apical approach in patients with chronic pericardial effusion.

Methods

Among 72 consecutive patients (68.8 ± 14.4 years old, 52 males) with hemodynamically stable chronic pericardial effusions, a total of 85 procedures were retrospectively analyzed. We divided them into two groups according to the site of the approach for the pericardiocentesis.

Results

A subxiphoid anterior approach (n = 53) was performed guided by fluoroscopy. The sagittal axis view of the chest CT was constructed to determine the puncture angle and direction for the subxiphoid anterior approach. An apical approach (n = 32) was performed by ultrasound guidance. The success rates of the anterior and apical approaches were 98.1% and 93.8%, respectively. There were two cases with cardiac perforations in the apical approach group, while no cases developed perforations in the subxiphoid anterior approach group.

Conclusion

The subxiphoid anterior approach for pericardiocentesis was feasible and safe for managing chronic pericardial effusions. A reconstruction of the sagittal axis view of the chest CT imaging was helpful to identify the direction and depth to access the pericardial space from the subxiphoid puncture site before the pericardiocentesis using the lateral fluoroscopic view.

Evaluation and management of cancer patients presenting with acute cardiovascular disease: a Consensus Document of the Acute CardioVascular Care (ACVC) association and the ESC council of Cardio-Oncology-Part 1: acute coronary syndromes and acute pericardial diseases

Advances in treatment, common cardiovascular (CV) risk factors and the ageing of the population have led to an increasing number of cancer patients presenting with acute CV diseases. These events may be related to the cancer itself or the cancer treatment. Acute cardiac care specialists must be aware of these acute CV complications and be able to manage them. This may require an individualized and multidisciplinary approach. We summarize the most common acute CV complications of cytotoxic, targeted, and immune-based therapies. This is followed by a proposal for a multidisciplinary approach where acute cardiologists work close together with the treating oncologists, haematologists, and radiation specialists, especially in situations where immediate therapeutic decisions are needed. In this first part, we further focus on the management of acute coronary syndromes and acute pericardial diseases in patients with cancer.

Cardiac tamponade: an educational review

Cardiac tamponade is a pericardial syndrome characterised by an impairment of the diastolic filling of the ventricles causing reduction of cardiac output, usually producing signs and symptoms of cardiac arrest, if untreated. The main causes of cardiac tamponade include percutaneous cardiac interventions, malignacies, infectious/inflammatory causes, mechanical complications of myocardial infarction and aortic dissection. The diagnosis of cardiac tamponade is a clinical diagnosis based on a suggestive history and clinical presentation with worsening dyspnoea, distended jugular veins, muffled heart sounds and pulsus paradoxus, and should be confirmed by echocardiography. Cardiac tamponade is a life-threatening syndrome that requires urgent treatment by pericardiocentesis. Pericardiocentesis is an interventional technique to drain pericardial fluid by a percutaneous route. The standard technique for pericardiocentesis is guided by echocardiography or fluoroscopy under local anaesthesia. Pericardiocentesis should be performed by experienced operators and carries a variable risk of complications, mainly cardiac chamber puncture, arrhythmias (ventricular arrhythmias suggest puncture of the ventricle), coronary artery puncture or haemothorax, pneumothorax, pneumopericardium and hepatic injury. The prognosis of cardiac tamponade is essentially related to aetiology. Cardiac tamponade in patients with cancer and metastatic involvement of the pericardium has a bad short-term prognosis because it is a sign of advanced cancer, on the contrary, patients with cardiac tamponade and a final diagnosis of idiopathic pericarditis generally have a good long-term prognosis.

Treatment of acute cardiac tamponade: A retrospective analysis of classical intermittent versus continuous pericardial drainage

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Acute cardiac tamponade is a highly relevant complication in modern cardiology.

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Continuous pericardial drainage is safe and does not increase total drainage volume.

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Continuous drainage associates with lower rates of open-heart surgical interventions.

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Continuous drainage associates with reduced re-tamponades and mortality on day 5.

Background

Acute cardiac tamponade is a life-threatening pathology in modern cardiology as catheter-based interventions become increasingly relevant. Pericardiocentesis is usually the primary treatment of choice. However, protocols for handling of draining pigtail catheters are very variable due to limit data and require further investigation.

Methods

We retrospectively analyzed 52 patients with acute cardiac tamponade requiring immediate pericardiocentesis from January 2017 to August 2020. Patients were treated with a classical approach of intermittent manual aspiration or continuous pericardial drainage using a redon drainage system.

Results

Mean age of patients was 74 years in both groups. Most common causes for cardiac tamponade were percutaneous coronary interventions in about 50% and transaortic valve implantations in 25% of all cases. 28 patients were treated with classic intermittent drainage from 2017 to 2020. 24 patients were treated with continuous drainage from December 2018–2020. Compared to classical intermittent drainage treatment, continuous drainage was associated with a lower rate of a surgical intervention or cardiac re-tamponade and a lower mortality at 5 days (HR 0.2, 95% CI 0.1–0.9, log-rank p = 0.03). Despite a longer total drainage time under continuous suction, drainage volumes were comparable in both groups.

Conclusion

Acute cardiac tamponade can be efficiently treated by pericardiocentesis with subsequent continuous negative pressure drainage via a pigtail catheter. Our retrospective analysis shows a significantly lower mortality, a decreased rate of interventions and lower rates of cardiac re-tamponade without any relevant side effects when compared to classical intermittent manual drainage. These findings require further investigations in larger, randomized trials.

Coronary artery perforation secondary to lifesaving pericardiocentesis for cardiac tamponade: a case report

BACKGROUND

Pericardiocentesis is frequently performed when fluid needs to be removed from the pericardial sac, for both therapeutic and diagnostic purposes, however, it can still be a high-risk procedure in inexperienced hands and/or an emergent setting.

CASE PRESENTATION

A 78-year-old male made an emergency call complaining of the back pain. When the ambulance crew arrived at his home, he was in a state of shock due to cardiac tamponade diagnosed by portable echocardiography. The pericardiocentesis was performed using a puncture needle on site, and the patient was immediately transferred to our hospital by helicopter. Contrast-enhanced computed tomography showed a small protrusion of contrast media on the inferior wall of the left ventricle, suggesting cardiac rupture due to acute myocardial infarction. Emergency coronary angiography was then performed, which confirmed occlusion of the posterior descending branch of the left circumflex coronary artery. In addition, extravasation of contrast medium due to coronary artery perforation was observed in the acute marginal branch of the right coronary artery. We considered that coronary artery perforation had occurred as a complication of the pericardial puncture. We therefore performed transcatheter coil embolization of the perforated branch, and angiography confirmed immediate vessel sealing and hemostasis. After the procedure, the patient made steady progress without a further increase in pericardial effusion, and was discharged on the 50th day after admission.

CONCLUSIONS

When performing pericardial drainage, it is important that the physician recognizes the correct procedure and complications of pericardiocentesis, and endeavors to minimize the occurrence of serious complications. As with the patient presented, coil embolization is an effective treatment for distal coronary artery perforation caused by pericardiocentesis.

What is the ideal approach for emergent pericardiocentesis using point-of-care ultrasound guidance?

BACKGROUND

Traditionally performed using a subxiphoid approach, the increasing use of point-of-care ultrasound in the emergency department has made other approaches (parasternal and apical) for pericardiocentesis viable. The aim of this study is to identify the ideal approach for emergency-physician-performed ultrasound-guided pericardiocentesis as determined by ultrasound image quality, distance from surface to pericardial fluid, and likely obstructions or complications.

METHODS

A retrospective review of point-of-care cardiac ultrasound examinations was performed in two urban academic emergency departments for the presence of pericardial effusions. The images were reviewed for technical quality, distance of effusion from skin surface, and predicted complications.

RESULTS

A total of 166 pericardial effusions were identified during the study period. The mean skin-to-pericardial fluid distance was 5.6 cm (95% confidence interval [95% CI] 5.2-6.0 cm) for the subxiphoid views, which was significantly greater than that for the parasternal (2.7 cm [95% CI 2.5-2.8 cm], P<0.001) and apical (2.5 cm [95% CI 2.3-2.7 cm], P<0.001) views. The subxiphoid view had the highest predicted complication rate at 79.7% (95% CI 71.5%-86.4%), which was significantly greater than the apical (31.9%; 95% CI 21.4%-44.0%, P<0.001) and parasternal (20.2%; 95% CI 12.8%-29.5%, P<0.001) views.

CONCLUSIONS

Our results suggest that complication rates with pericardiocentesis will be lower via the parasternal or apical approach compared to the subxiphoid approach. The distance from skin to fluid collection is the least in both of these views.

Therapeutic advances in cardiac targeted drug delivery: from theory to practice

The most commonly used administration methods in clinics and life are oral administration, intravenous injection, and other systemic administration methods. Targeted administration must be an essential long-term development direction due to the limited availability and a high incidence of systemic side effects. Cardiovascular diseases (CVD) are the leading cause of death all over the world. Targeted drug delivery (TDD) methods with the heart as the target organ have developed rapidly and are diversified. This article reviews the research progress of various TDD methods around the world with a heart as the target organ. It is mainly divided into two parts: the targeting vector represented by nanoparticles and various TDD methods such as intracoronary injection, ventricular wall injection, pericardial injection, and implantable medical device therapy and put forward some suggestions on the development of targeting. Different TDD methods described in this paper have not been widely used in clinical practice, and some have not even completed preclinical studies. Targeted drug delivery still requires long-term efforts by many researchers to realize the true meaning of the heart. HIGHLIGHTS Targeted administration can achieve a better therapeutic effect and effectively reduce the occurrence of adverse reactions. Parenteral administration or medical device implantation can be used for targeted drug delivery. Combined with new dosage forms or new technologies, better-targeted therapy can be achieved. Clinical trials have confirmed the safety and effectiveness of several administration methods.

Echo-Guided Pericardiocentesis: When and How Should It Be Performed?

PURPOSE OF REVIEW

Abnormal accumulation of pericardial fluid is a common cardiac condition with different etiologies. Draining of the pericardial fluid (pericardiocentesis) is often indicated for diagnostic and therapeutic purposes and is performed in an elective or emergent setting. Echocardiography is the primary imaging method for diagnosing, localizing, and quantifying pericardial effusion as well as evaluating its hemodynamic effects, including the presence of cardiac tamponade. In this manuscript, we review the indications for pericardiocentesis and provide practical step-by-step guidance for echo-guided pericardiocentesis.

RECENT FINDINGS

Echo-guidance is an effective method to improve the safety and efficacy of pericardiocentesis. In experienced hands and with a stepwise approach, procedural outcomes are excellent, and complication rates are very low. Asymptomatic small idiopathic effusions have a benign course and can be left untreated. Prolonged drainage with an indwelling pericardial catheter is key for preventing fluid re-accumulation, and the use of colchicine to prevent fluid recurrence is encouraged whenever possible. Understanding how to evaluate the significance of a pericardial effusion as well as the procedural steps in the performance of a pericardiocentesis are essential for optimal outcomes in treating patients with pericardial effusions and tamponade.