Computed Tomography-Guided Pericardiocentesis: A Practical Guide

PURPOSE OF REVIEW

The purpose of this article is to serve as a practical guide to computed tomography (CT)-guided pericardiocentesis and to discuss the role of this approach in current clinical practice. An overview of indications, technique, advantages, and limitations specific to CT-guided pericardiocentesis will be provided. The reader will have an enhanced understanding of the use of this imaging modality to guide pericardial drainage.

RECENT FINDINGS

Use of CT guidance to drain the pericardial space is safe, especially when adequate echocardiographic evaluation is precluded and when echocardiography-guided pericardiocentesis is deemed unsafe and or not feasible. Our review and experience indicate that CT-guided pericardiocentesis is technically successful in more than 94% of patients, with a low risk (<1%) of significant complications. CT-guided pericardiocentesis is therefore a viable alternative when echocardiographic guidance is insufficient and can obviate the need for surgery in most patients.

Comparing Outcomes of CT-Guided Percutaneous Pericardial Drainage with Surgical Pericardial Window in Patients with Symptomatic Pericardial Effusions

RATIONALE AND OBJECTIVES

To compare short-term outcomes of CT-guided percutaneous pericardial drainage (PPD) versus subxiphoid surgical pericardial window (PW) drainage and analyze the risk factors associated with their outcomes.

MATERIALS AND METHODS

A retrospective chart review of patients who underwent either percutaneous drainage with drainage catheter placement or PW with surgical drain placement for symptomatic pericardial effusion between January 1, 2006 and August 31, 2016 was performed after institutional review board approval (decision number 16-783). The primary objective was to test for associations between the short-term (≤30 days post procedure) complication and recurrence rates in patients with symptomatic pericardial effusions. The secondary objectives were to test for associations between short-term complications with changes in vital signs.

RESULTS

Of the 257 procedures included in the final analysis, 142 were in the percutaneous drainage group. Short-term complication rate was significantly greater (p < 0.001) in patients undergoing PW, 17% (19/114), as compared with PPD, 2% (3/142). The estimated odds of having complications in the PW cohort was 9 times greater than the percutaneous drainage cohort (OR = 9.3, 95% CI:  2.7-32.3). No significant difference was observed between whether or not a patient experienced a short-term recurrence and any of the explanatory variables (patient demographics, imaging, and vital signs).

CONCLUSION

CT-guided PPD is a safer alternative to surgical PW as it leads to fewer complications without a significant difference in recurrence rate of pericardial effusion.

Therapeutic Computed Tomography-Guided Pericardiocentesis: Lessons Learned Based on a 7-Year Single-Center Experience

OBJECTIVE

Pericardiocentesis is a well-known procedure commonly performed by either image-guided intervention or surgical approaches. Computed tomography (CT)-guided pericardiocentesis is not widely used, but provides certain advantages. In the article we will discuss our technique of CT-guided therapeutic pericardiocentesis, including advantages and disadvantages, patient selection, possible approaches, and complications.

METHODS

The retrospective study included 121 therapeutic pericardial drainages performed under CT guidance. Demographic data of the patients, entry site, and needle orientation were recorded. Procedure complications and their significance were analyzed.

RESULTS

One hundred and twenty-one pericardial drainages with catheter insertion were performed under CT guidance on 119 patients presenting with clinically significant pericardial effusion. The most common approach was at the left anterior chest wall. The rate of minor complications was 5.8%, no major complications occurred.

CONCLUSIONS

Therapeutic pericardiocentesis can be obtained under CT guidance in a safe and effective manner. Recommendations for building a patient-centered protocol with an interdisciplinary team are discussed. Patient selection, procedural guidance, and lessons to avoid complications are reviewed.

The imaging appearances of various pericardial disorders

The pericardium could be involved in a variety of clinical disorders. The imaging findings are not specific for an individual pathology in most of the cases; however, patient’s clinical history may guide radiologist to a definitive diagnosis. Congenital absence of the pericardium could be recognized with the imaging appearance of interposed lung tissue between the main pulmonary artery and aorta. Pericardial effusion is a non-specific condition that may occur due to inflammatory, infectious, and neoplastic disorders. Cardiac tamponade may occur in case of massive or rapid accumulation of fluid in the pericardial sac. Pericardial calcification is a common and easily identified entity on a computed tomography (CT) scan. Presence of calcification and/or fibrosis may result in pericardial constriction. Nevertheless, the pulsation of an adjacent coronary artery may prevent calcification formation in a focal area and consequently may result in pericardial diverticulum containing epicardial fat and coronary artery. The imaging findings encountered in patients with pericardial hydatid disease and Erdheim-Chester disease may mimic those of pericardial neoplasia. Pericardial adhesions and pedicled fat flaps may cause confusion on a CT scan in the post-surgical period following cardiac surgery. Pericardial fat necrosis can be diagnosed by CT in patients with chest pain. The radiologists should be familiar with the medical devices placed in pericardial space for certain individual indications. A pericardial patch and temporary epicardial pacemaker wires could be identified on a CT scan.

Evolution of the pericardiocentesis technique

: Pericardiocentesis is a valuable technique for the diagnosis and treatment of patients with pericardial effusion and cardiac tamponade, although it may be associated with potentially serious complications. Through the years, many different imaging approaches have been described to reduce the complication rate of the procedure. This systematic review provides a focused overview of the different techniques developed in recent years to reduce the procedural complications and to increase the related success rate.

Computed tomography-guided pericardiocentesis: a systematic review concerning contemporary evidence and future perspectives

BACKGROUND

Pericardial effusion (PE) can develop in several pathological scenarios, and is often initially evaluated by means of echocardiography. Computed tomography (CT) has been used as an aid in the management of patients presenting with PE, in selected cases. The role of CT-guided pericardiocentesis in contemporary practice, however, remains not fully ascertained. We aimed at presenting a systematic review concerning the state-of-the-art of this technique.

METHODS

A systematic review of published data on the use of CT for guiding pericardiocentesis was carried out (search performed on PubMed, ISI Web of Knowledge and Scopus databases).

RESULTS

From title and abstract analysis, 14 articles were included that met the prespecified criteria. After full-text analysis, six articles were excluded. The eight articles under analysis included a total of 635 procedures performed in 571 patients. CT guidance was mostly used in a postoperative setting (364 procedures). Most procedures were done mainly for therapeutic purposes (528 procedures). Success rates ranged from 94% to 100%. Complications ranged from 0% to 7.8%.

CONCLUSION

CT-guided pericardiocentesis is a useful technique in the approach to PE, in several clinical scenarios. Its use can be especially relevant in the postoperative period, as well as in individuals with suboptimal image quality (as assessed by echocardiography, for the moment the first choice in the approach to most cases of PE).

Interventional procedures in the chest

Many thoracic conditions will require an interventional procedure for diagnosis and/or treatment. For this reason, radiologists need to know the indications and the technique for each procedure. In this article, we review the various interventional procedures that radiologists should know and the indications for each procedure. We place special emphasis on the potential differences in the diagnostic results and complications between fine-needle aspiration and biopsy. We also discuss the indications for radiofrequency ablation of lung tumors and review the concepts related to the drainage of pulmonary abscesses. We devote special attention to the management of pleural effusion, covering the indications for thoracocentesis and when to use imaging guidance, and to the protocol for pleural drainage. We also discuss the indications for percutaneous treatment of pericardial effusion and the possible complications of this treatment. Finally, we discuss the interventional management of mediastinal lesions and provide practical advice about how to approach these lesions to avoid serious complications.

Colchicine for postoperative pericardial effusion: a multicentre, double-blind, randomised controlled trial

OBJECTIVES

Pericardial effusion is common after cardiac surgery. Growing evidence suggests that colchicine may be useful for acute pericarditis, but its efficacy in reducing pericardial effusion volume postoperatively has not been assessed.

METHODS

This randomised, double-blind, placebo-controlled study conducted in 10 centres in France included 197 patients at high risk of tamponade (ie, with moderate to large-sized persistent effusion (echocardiography grades 2, 3 or 4 on a scale of 0-4)) at 7-30 days after cardiac surgery. Patients were randomly assigned to receive colchicine, 1 mg daily (n=98), or a matching placebo (n=99). The main end point was change in pericardial effusion grade after 14-day treatment. Secondary end points included frequency of late cardiac tamponade.

RESULTS

The placebo and the colchicine groups showed a similar mean baseline pericardial effusion grade (2.9±0.8 vs 3.0±0.8) and similar mean decrease from baseline after treatment (-1.1±1.3 vs -1.3±1.3 grades). The mean difference in grade decrease between groups was -0.19 (95% CI -0.55 to 0.16, p=0.23). In total, 13 cases of cardiac tamponade occurred during the 14-day treatment (7 and 6 in the placebo and colchicine groups, respectively; p=0.80). At 6-month follow-up, all patients were alive and had undergone a total of 22 (11%) drainages: 14 in the placebo group and 8 in the colchicine group (p=0.20).

CONCLUSIONS

In patients with pericardial effusion after cardiac surgery, colchicine administration does not reduce the effusion volume or prevent late cardiac tamponade.

CLINICAL TRIAL REG NO

NCT01266694.