Spontaneous resolution of an intrapericardial thrombus as a complication of pericardiocentesis in a neonate

We present the case of a premature neonate with pericardial effusion secondary to extravasation of total parenteral nutrition from a mispositioned/migrated umbilical venous catheter. Emergency pericardiocentesis was complicated by an intrapericardial thrombus, which was managed conservatively with spontaneous resolution within 24 hours. This case illustrates that the rare complication of an intrapericardial thrombus after pericardiocentesis can be successfully managed conservatively with close monitoring in haemodynamically stable paediatric patients.

Percutaneous image-guided management of a misplaced pericardiocentesis catheter into the inferior vena cava

Misplacement of pericardiocentesis catheter in central veins is a rare complication that can be managed with several methods. In this case, we report a percutaneous image-guided plug-assisted management of a misplaced pericardiocentesis catheter into the inferior vena cava through a transhepatic tract successfully occluded. This minimally invasive technique was not previously described in this setting and had a favorable long-term outcome.

Pericardiocentesis for COVID-19 Associated Cardiac Tamponade Using a Central Venous Catheter in Rural Australia: A Case Report

Pericardiocentesis is a high-acuity, low-occurrence procedure rarely performed by emergency and retrieval clinicians. We present a case of cardiac tamponade secondary to coronavirus disease 2019 managed with prehospital pericardiocentesis in remote Australia, 800 km from the nearest hospital. This was performed using a quadruple-lumen central venous catheter. The procedure significantly improved the patient's clinical state, enabling a safe transfer via fixed wing aircraft to a tertiary center. In this report, we highlight that the ability to diagnose cardiac tamponade in coronavirus disease 2019-positive patients and perform pericardiocentesis under point-of-care ultrasound guidance can be lifesaving.

Pericardial Effusion in Association With Periodontitis: Case Report and Review of 8 Patients in Literature

Periodontal diseases are well-known background for infective endocarditis. Here, we show that pericardial effusion or pericarditis might have origin also in periodontal diseases. An 86-year-old man with well-controlled hypertension and diabetes mellitus developed asymptomatic increase in pericardial effusion. Two weeks previously, he took oral new quinolone antibiotics for a week because he had painful periodontitis along a dental bridge in the mandibular teeth on the right side and presented cheek swelling. The sputum was positive for Streptococcus species. He was healthy and had a small volume of pericardial effusion for the previous 5 years after drug-eluting coronary stents were inserted at the left anterior descending branch 10 years previously. The differential diagnoses listed for pericardial effusion were infection including tuberculosis, autoimmune diseases, and metastatic malignancy. Thoracic to pelvic computed tomographic scan demonstrated no mass lesions, except for pericardial effusion and a small volume of pleural effusion on the left side. Fluorodeoxyglucose positron emission tomography disclosed many spotty uptakes in the pericardial effusion. The patient denied pericardiocentesis, based on his evaluation of the risk of the procedure. He was thus discharged in several days and followed at outpatient clinic. He underwent dental treatment and pericardial effusion resolved completely in a month. He was healthy in 6 years until the last follow-up at the age of 92 years. We also reviewed 8 patients with pericarditis in association with periodontal diseases in the literature to reveal that periodontal diseases would be the background for developing infective pericarditis and also mediastinitis on some occasions.

Hepatic artery branch perforation with hemoperitomeum: A rare complication of pericardiocentesis

A 58-year-old male patient presented with anterior myocardial infarction after 36 hours of symptom onset.

Management of pericardial tamponade in the electrophysiology laboratory: results from a national survey

BACKGROUND

Despite continued efforts to improve the safety of catheter ablation, pericardial tamponade remains one of its more frequent, potentially life-threatening complications. Management of cardiac tamponade is not standardized and uncertainties regarding acute treatment remain.

METHODS

This survey sought to evaluate the management of cardiac tamponade in German EP centers via a standardized postal questionnaire. All 341 identified German EP centers were invited to return a questionnaire on their standards for the management of cardiac tamponade.

RESULTS

A total of 189 German EP centers completed the questionnaire. Several precautions are followed to avoid pericardial tamponade: A minority of centers preclude very old patients (19%) or those with a high body mass index (30%) from ablation. Non-vitamin K antagonist oral anticoagulants are briefly paused in most centers (88%) before procedures, while vitamin K antagonists are continued. Pericardial tamponade is usually treated using reversal of heparin by applying protamine (86%) and pericardiocentesis under both, fluoroscopic and echocardiographic guidance (62%). A pigtail catheter is mostly inserted (97%) and autotransfusion of aspirated blood is performed in 47% of centers. The decision for surgical repair depends on different clinical and infrastructural aspects. The timing of reinitiation of anticoagulation widely differs between the centers. Approximately 1/3 of centers prescribe nonsteroidal anti-inflammatory agents, colchicine or steroids after pericardiocentesis.

CONCLUSION

The present survey shows that the management of cardiac tamponade is still inhomogeneous in German ablation centers. However, multiple findings of this survey can be generalized and might guide especially less experienced operators and centers in their treatment and decision strategies.

Ellis type 4 coronary artery perforation during percutaneous coronary intervention: Case series and review

Ellis type 4 coronary artery perforation (CAP4), also referred to as Ellis type 3 cavity-spilling perforation, is a rare but life-threatening complication of percutaneous coronary intervention characterized by extravasation of blood into a cardiac chamber, anatomic cavity, or coronary sinus or vessel. CAP4 is uncommon, accounting for 1.9% to 3.0% of all CAP. Only 11 cases of CAP4 have been reported in detail; we report an additional two cases and review prior reports of this rare complication. Our first case highlights a patient with chronic anginal symptoms due to a 75% concentric stenotic lesion in the mid-LAD. Revascularization was complicated by perforation during pre-dilation with robust contrast extravasation into the left ventricle. Successful postperforation hemostasis was achieved with heparin reversal and covered stent placement. The second case demonstrates another major mechanism of CAP4: wire perforation. During intervention, the absence of blood flow distal to the lesion in the setting of an ST segment elevation myocardial infarction obscured the course of the nonhydrophilic floppy wire leading to perforation that was managed conservatively. In our scoping review, we found that the majority of CAP4 occurred in the LAD. The most frequently involved cavity was the left ventricle-other cavities involved were the right ventricle and coronary veins. Common etiologies of CAP4 included guidewire perforation (62%) and balloon dilation (31%). Perforation was managed with reversal of anticoagulation in 46% of cases, prolonged balloon inflation in 54% of cases, and covered stent deployment in 15% of cases. No patients required surgical repair or pericardiocentesis and perforations were successfully sealed in all cases. In-hospital mortality was 0%.

Minoxidil-associated pericardial effusion and impending tamponade

ABSTRACT

A patient with a large pericardial effusion and impending tamponade exhibited clinical improvement with urgent pericardiocentesis. Further workup ruled minoxidil to be the likely cause of the effusion. After discontinuation of minoxidil, the effusion did not recur.

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.

Pyopericardium presenting as pericardial tamponade in a patient with common variable immunodeficiency disorder

A male patient in his 20s with a medical history of common variable immunodeficiency disorder, non-compliant with therapy, presented to the emergency department with respiratory distress and severe hypoxaemia. Chest radiography demonstrated extensive bilateral infiltrates and an increased cardiothoracic ratio. Streptococcus pneumoniae urine antigen test was positive. ECG demonstrated diffuse ST-segment elevation. An arterial line was placed and demonstrated pulsus paradoxus. Transthoracic echocardiography revealed an extensive pericardial effusion, with echocardiographic signs of cardiac tamponade. Emergency subxiphoid pericardiocentesis was performed with an initial drainage of 750 mL of purulent fluid consistent with pyopericardium. Immediate haemodynamic improvement was observed. The patient required a second pericardiocentesis for drainage of a relapsing pericardial effusion. The course was complicated by effusive-constrictive pericarditis requiring anterior interphrenic pericardiectomy. Treatment with intravenous immunoglobulin and antibiotics led to a complete recovery.

Pericardial Effusion and Cardiac Tamponade Pathophysiology and New Approaches to Treatment

PURPOSE OF REVIEW

The objective of this manuscript is to examine up-to-date approaches to the diagnosis and treatment of pericardial effusions and cardiac tamponade.

RECENT FINDINGS

Recent recommendations from the American Society of Echocardiography and the European Society of Cardiology have improved our management of the patient with pericardial effusion and cardiac tamponade, but significant knowledge gaps remain. Novel diagnostic and triage strategies have been suggested, and recent information have improved our facility to assess the presence and size of a pericardial effusion, assess its hemodynamic impact, and determine its cause. Despite these recent findings, there is a scarcity of evidence-based data to direct the management of pericardial effusion and cardiac tamponade. While the first-line function of echocardiography in managing these disorders is undisputed, there are increasingly niche functions for multimodality imaging.

Tamponade with recurrent chylopericardium in patient with non-Hodgkin's lymphoma: chemotherapy is the key management after pericardiocentesis

Cardiac tamponade, the accumulation of fluid in the pericardial space, leads to impaired venous return, loss of left ventricular preload and haemodynamic collapse. Chylopericardium is an unusual cause of the pericardial effusion. This is often secondary to malignancy. Non-Hodgkin's Lymphoma is a primary malignancy from the lymph node. It can be produced by B lymphocytes, T lymphocytes or natural killer cells. The term chylopericardium refers to a pericardial effusion containing milky fluid within the intrapericardial space. We present a case of a 42-year-old male patient who came with dyspnoea as a result of cardiac tamponade caused by a massive milky pericardial effusion (chylopericardium) secondary to mediastinal non-Hodgkin's lymphoma.

Pericardiocentesis or surgical drainage: A national comparison of clinical outcomes and resource use

Background

While institutional series have sought to define the optimal strategy for drainage of pericardial effusions, large-scale comparisons remain lacking. Using a nationally representative sample, the present study examined clinical and financial outcomes following pericardiocentesis (PC) and surgical drainage (SD) in patients admitted for pericardial effusion and tamponade.

Methods

Adults undergoing PC or SD within 2 days of admission for non-surgically related pericardial effusion or tamponade were identified in the 2016–2019 Nationwide Readmissions Database. Multivariable logistic and linear models were developed to evaluate the association between intervention type and outcomes. The primary outcome of interest was mortality while secondary endpoints included reintervention, periprocedural complications, hospital length of stay (LOS), hospitalization costs and 30-day non-elective readmission.

Results

Of an estimated 44,637 records meeting inclusion criteria, 28,862 (64.7%) underwent PC while the remainder underwent SD for initial management of pericardial effusion or tamponade. PC was associated with significantly increased odds of in-hospital mortality, reintervention and 30-day readmission relative to SD. PC was also associated with greater odds of cardiac complications but lower odds of infection, respiratory failure and blood transfusions compared to SD. Although PC was associated with shorter index hospital length of stay and costs, the two strategies yielded similar 30-day cumulative costs.

Conclusion

Management of pericardial effusion with PC is associated with greater odds of mortality, reintervention and 30-day readmission but similar 30-day cumulative costs compared to SD. In the setting of adequate hospital capability and operator expertise, SD is a reasonable initial treatment strategy for pericardial effusion.

Successful management of life-threatening cardiac tamponade by pericardial aspiration in a boy following blunt trauma to the chest

A 7-year-old boy was presented with significant chest pain, reduced consciousness with haemodynamic instability following a minor blunt trauma to the chest. He was diagnosed to have a life-threatening pericardial effusion in FAST (Focused Assessment with Sonography for Trauma scan) ultrasound examination which was confirmed as haemopericardium causing cardiac tamponade in 2D echocardiogram. Emergency cardiac catheterisation ruled out active bleeding and prompt pericardiocentesis under fluoroscopy guidance rapidly restored patients' haemodynamic parameters. He was successfully discharged without complications after a few days. This case report highlights uncommon presentation of cardiac tamponade without major cardiac injury after a minor blunt trauma in a paediatric patient which was detected early and successfully managed without complications.

Pneumopericardium and pleural effusion: a rare complication of paediatric pericardiocentesis

Pneumopericardium is a rare complication of pericardiocentesis (PC), occurring as a result of either a direct pleuropericardial communication or a leaky drainage system. Pneumopericardium is often self-limiting; however, physicians should be aware of this complication as it may progress to tension pneumopericardium, which requires immediate recognition and management. PC has been associated with pneumothorax, pneumomediastinum or subcutaneous emphysema, but the association with pleural effusion has been less reported. The authors present the case of a 14-year-old healthy boy who developed post-PC pneumopericardium and pleural effusion, a rare association reported in the literature. The diagnosis of this potential life-threatening event was made using readily available complementary diagnostic methods, such as transthoracic echocardiography and chest X-ray.

Iatrogenic Pneumopericardium During Pericardiocentesis

Iatrogenic pneumopericardium after pericardiocentesis due to accidental leakage from the side port of the sheath has been reported in the literature. In the present case, it occurred during passage of the guidewire. Every step needs to be done meticulously. The patient should be advised not to take a deep breath during the puncture.

Predictors, treatment, and long-term outcomes of coronary perforation during retrograde percutaneous coronary intervention via epicardial collaterals for recanalization of chronic coronary total occlusion

OBJECTIVE

To investigate predictors, treatment, and long-term outcomes associated with coronary perforation (CP) in patients who underwent retrograde percutaneous coronary intervention (PCI) through epicardial collaterals for chronic total occlusion (CTO).

BACKGROUND

Data regarding CP during retrograde PCI through epicardial collaterals for CTO are scarce.

METHODS

We included 155 patients who underwent retrograde CTO PCI through epicardial collaterals at Guangdong Cardiovascular Institute from August 2011 to December 2017. The median follow-up was 2.5 years. Major adverse cardiac events (MACEs) were analyzed using the Kaplan-Meier method, and independent predictors of long-term MACE were determined using a multivariable Cox model.

RESULTS

CP occurred in 24 (15.5%) patients, with the frequency of Ellis classes 1 or 2 and 3 being 41.7% and 58.3%, respectively. Seven (4.5%) patients had tamponade, which was effectively managed using coil embolization and pericardiocentesis. Renal dysfunction (odds ratio [OR]: 5.27; 95% confidence interval [CI]: 1.47-18.88; P = 0.011), right coronary artery (RCA) CTO (OR: 4.34; 95% CI: 1.29-14.63; P = 0.018), and Epi-CTO score ≥ 2 (OR: 3.27; 95% CI: 1.12-9.58; P = 0.030) were independent predictors of CP. At the 7-year follow-up, 17 patients had MACE. Multivariable analysis revealed that CP was not associated with worse long-term clinical outcomes (hazard ratio: 1.55; 95% CI: 0.45-5.32, P = 0.484).

CONCLUSIONS

Retrograde CTO PCI through epicardial collaterals is at increased risk of CP, which is associated with renal dysfunction, RCA CTO, and Epi-CTO score ≥ 2. Prompt and proper management of CP is important. CP is not significantly associated with adverse clinical outcomes.

Transient midventricular ballooning syndrome with thrombus post pericardiocentesis in a patient with malignant breast cancer

One day after pericardiocentesis for pericardial effusion in a patient with malignant breast cancer, the clinical and echocardiographic examination for recurrent dyspnea suggested stress cardiomyopathy with mid left ventricular ballooning and thrombus rather than pericardial decompression syndrome. Physicians should therefore pay attention to the possibility of ventricular dysfunction with thrombus post pericardiocentesis and to differences between stress cardiomyopathy and pericardial decompression syndrome. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:53-57, 2017.

Iatrogenic Pneumopericardium After Pericardiocentesis

A 65-year-old patient underwent pericardiocentesis for cardiac tamponade after radiofrequency ablation for ventricular tachycardia. Subsequent to stabilization, the patient developed pneumopericardium, which was detected in the catheterization laboratory and managed successfully by pericardial aspiration.

Pericardiocentesis Under Continuous Ultrasonographic Guidance Using a 7 cm Micropuncture Needle

OBJECTIVES

To compare procedural success and safety of pericardiocentesis using continuous ultrasonographic visualization of a long (7 cm) micropuncture needle to standard access with an 18 gauge needle without continuous ultrasound guidance.

BACKGROUND

Current approaches to pericardiocentesis commonly utilize a large-bore 18 gauge needle for access without allowing for continuous visualization of needle entry into the pericardial space.

METHODS

We included all consecutive patients at our institution who underwent pericardiocentesis between November 1, 2011 and March 3, 2016. A total of 21 patients (group 1) underwent pericardiocentesis using a 7 cm micropuncture needle inserted under continuous ultrasonographic guidance, while 51 patients (group 2) underwent pericardiocentesis, mostly with an 18 gauge needle (92%), following preprocedural echocardiography only. The primary endpoint was successful placement of a drain into the pericardial space.

RESULTS

The primary endpoint was similar between group 1 and group 2 (100% vs 94%, respectively; P=.26). Successful drainage of pericardial fluid was achieved in 95% of patients in group 1 and in 98% in group 2 (P=.88). The amount of pericardial fluid drained in each group was similar (640 mL vs 557 mL, respectively; P=.26). No procedure-related complications occurred in group 1, compared with 2 cases of right ventricular perforation that occurred in group 2. In-hospital mortality and length of stay were similar.

CONCLUSION

This study suggests that an ultrasound-mounted micropuncture needle allows for safe and effective pericardiocentesis. This technique may provide a safer alternative to the standard use of an 18 gauge needle.

Severe right ventricular and tricuspid valve dysfunction after pericardiocentesis

Pericardiocentesis is performed to treat cardiac tamponade or diagnose the cause of pericardial effusion. Cardiogenic shock with right ventricular (RV) dysfunction is a rare complication after pericardiocentesis. We report a case of an 82-year-old man who suddenly suffered cardiopulmonary arrest 12 h after pericardiocentesis. A transthoracic echocardiogram showed remarkable RV dysfunction and tricuspid valve dysfunction. Tricuspid valve closure was severely impaired, and the tricuspid regurgitation signal showed laminar flow with an early peak. However, after treatment with high-dose inotropic drugs, hemodynamic parameters gradually recovered. A transthoracic echocardiogram performed 24 h later showed improved motion of the RV and the tricuspid valve, resulting in a reduction in tricuspid regurgitation. RV and tricuspid valve dysfunction after pericardiocentesis needs to be recognized as a critical complication. Physicians also need to pay attention to not only the amount of drainage but also underlying RV dysfunction.

Choice of drainage procedure in paediatric pyopericardium: a 30-year experience

Although there is general agreement on the necessity of draining pyopericardium, debate continues as to the safe and effective method of drainage. Studies describing head-to-head comparison of various drainage procedures are very few and are disadvantaged by small numbers of cases. In this observational study, we review our 30-years experience with different techniques of pericardial drainage. Between 1972 and 2003, the authors have personally treated 39 children who suffered from pyopericardium. Among the 22 children who underwent early partial pericardiectomy, 20 were alive. In contrast to this,12 out of 15 children treated with repeated pericardiocentesis or sub-xiphoid tube drainage were dead. The median hospital stay for pericardiectomy group was 18 days (range 11-32) and that for the non-thoracotomy group was 34 days (range 18-55 days).

With regard to immediate survival and early convalescence in the pyopericardium, partial pericardiectomy is superior to pericardiocentesis and sub-xiphoid tube drainage. Pericardiocentesis can be used for diagnostic or temporizing purposes, but not as the definitive drainage procedure. Partial pericardiectomy can be done even in small hospitals where heart-lung machines are not available.

Differential Impact of Constrictive Physiology after Pericardiocentesis in Malignancy Patients with Pericardial Effusion

BACKGROUND

Echocardiographic signs of constrictive physiology (CP) after pericardiocentesis are frequently observed in malignancy patients. The purpose of the current study was to explore whether features of CP after pericardiocentesis have prognostic impact in malignancy patients with pericardial effusion (PE).

METHODS

We retrospectively reviewed 467 consecutive patients who underwent pericardiocentesis at our institution from January 2006 to May 2014. Among them, 205 patients with advanced malignancy who underwent comprehensive echocardiography after the procedure comprised the study population. Co-primary end points were all-cause mortality (ACM) and repeated drainage (RD) for PE. Patients were divided into four subgroups according to cytologic result for malignant cells and CP (positive cytology with negative CP, both positive, both negative, and negative cytology with positive CP).

RESULTS

CP after pericardiocentesis was present in 106 patients (50%) at median 4 days after the procedure. During median follow-up of 208 days, ACM and RD occurred in 162 patients (79%) and 29 patients (14%), respectively. Cox regression analysis revealed that independent predictors for ACM were male gender and positive cytology (all, p < 0.05). For RD, predictors were positive cytology, the absence of cardiac tamponade, and negative CP after pericardiocentesis (all, p < 0.05). When the patients were divided into four subgroups, patients with negative cytology and positive CP demonstrated the most favorable survival (hazard ratio [HR]: 0.39, p = 0.005) and the lowest RD rates (HR: 0.07, p = 0.012).

CONCLUSION

CP after pericardiocentesis is common, but does not always imply poor survival or the need for RD in patients with advanced malignancies. On the contrary, the presence of CP in patients with negative cytology conferred the most favorable survival and the lowest rate of RD. Comprehensive echocardiographic evaluation for CP after pericardiocentesis would be helpful for predicting prognosis in patients with advanced malignancies.

Real-time cardiovascular magnetic resonance subxiphoid pericardial access and pericardiocentesis using off-the-shelf devices in swine

BACKGROUND

Needle access or drainage of pericardial effusion, especially when small, entails risk of bystander tissue injury or operator uncertainty about proposed trajectories. Cardiovascular magnetic resonance (CMR) might allow enhanced imaging guidance.

METHODS AND RESULTS

We used real-time CMR to guide subxiphoid pericardial access in naïve swine using commercial 18G titanium puncture needles, which were exchanged for pericardial catheters. To test the value of CMR needle pericardiocentesis, we also created intentional pericardial effusions of a range of volumes, via a separate transvenous-transatrial catheter. We performed these procedures in 12 animals.

CONCLUSIONS

CMR guided pericardiocentesis is attractive because the large field of view and soft tissue imaging depict global anatomic context in arbitrary planes, and allow the operator to plan trajectories that limit inadvertent bystander tissue injury. More important, CMR provides continuous visualization of the needle and target throughout the procedure. Using even passive needle devices, CMR enabled rapid pericardial needle access and drainage. We believe this experience supports clinical testing of real-time CMR guided needle access or drainage of the pericardial space. We suspect this would be especially helpful in "difficult" pericardial access, for example, in distorted thoracic anatomy or loculated effusion.

Cardiac tamponade likely due to candida infection, in an immunocompetent patient

Candida pericarditis is a rare disease described mainly in immunodepressed patients. Here we report the case of a 76-year-old immunocompetent woman who developed a purulent pericarditis 48 hours after pericardiocentesis. Usual etiologies such as cancer or pericardo-oesophageal fistula, were ruled out. Physical examination revealed a sub-mammary mycosis, which could have led to the infection. The early diagnosis and treatment with a combined medical and surgical approach succeeded in a favorable evolution of this case.

Comparison of surgical pericardial drainage with percutaneous catheter drainage for pericardial effusion

OBJECTIVE

We sought to investigate the outcomes for different treatments of pericardial effusions.

BACKGROUND

The optimal initial management for symptomatic pericardial effusions remains controversial.

METHODS

We performed a 3-year retrospective, single-institution study comparing open surgical drainage to percutaneous pericardiocentesis for symptomatic pericardial effusions.

RESULTS

Between 2007 and 2009, a total of 193 patients underwent an initial drainage procedure for a pericardial effusion (n = 121 [62.7%] pericardiocentesis; n = 72 [37.3%] open surgical drainage). Compared to those treated with pericardiocentesis, treatment with open surgical drainage was associated with a higher complication rate (4.9% vs 26.4%; P<.0001; odds ratio [OR], 6.9; 95% confidence interval [CI], 2.6-18.2). Treatment with pericardiocentesis was associated with a higher rate of repeat procedures to drain a recurrent effusion compared to open surgical drainage (28.9% vs 2.8%; P<.0001; OR, 14.2; 95% CI, 3.3-61.3). Thirty-day mortality (19.8% surgical group vs 18.1% pericardiocentesis group; P=.8) and long-term survival (P=.4) did not differ between the groups.

CONCLUSION

There is no significant difference in overall mortality between open surgical drainage and percutaneous pericardiocentesis for symptomatic pericardial effusions. There may be more procedural complications following surgical drainage of a pericardial effusion, and a greater need for repeat procedures if the effusion is drained using pericardiocentesis.

Pericardiocentesis in contemporary practice

OBJECTIVE

Pericardiocentesis is a life-saving procedure associated with a small, but significant, risk of major complication. An apical or subcostal approach may be used, although the relative complication rates are not reported. In modern practice, an increasing proportion of pericardial effusions occur as a result of catheter-laboratory related complications. This study examines current practice and analyzes the complications of pericardial drainage according to the route of approach.

DESIGN

Historical cohort study.

SETTING

Four Oxfordshire hospitals, including the John Radcliffe Hospital, a tertiary referral center.

PATIENTS

Local databases were searched to identify percutaneous pericardiocenteses carried out between November 2002 and October 2009.

RESULTS

A total of 188 pericardiocenteses were performed in 163 patients. Malignancy (55; 33.7%) and catheter-based cardiac procedures (45; 23.9%) were the most common causes of pericardial effusions requiring drainage. 50.0% of all pericardiocenteses were performed in patients who had received anticoagulant or antiplatelet agents the same day. This rose to 93.7% in patients whose effusions occurred as a complication of a catheter-based procedure. Nine complications occurred during the study period, giving an overall complication rate of 4.8%. Six of the complications occurred via the subcostal route and all 4 complications requiring surgery occurred via the subcostal route.

CONCLUSION

The numbers of iatrogenic pericardial effusions occurring as a complication of catheter-based procedures mean that a significant proportion of pericardiocenteses are being performed in anticoagulated patients. This may alter the risk profile. Although complication rates were low for both routes, all major complications requiring surgery occurred via the subcostal approach. These data suggest an apical approach may be preferable where practical.

[Surgical treatment of iatrogenic cardiac injury induced by pericardiocentesis; report of a case]

We reported a case of surgical treatment of iatrogenic cardiac injury. A 67-year-old man with cardiac tamponade was treated by pericardiocentesis. At night he was transferred to our hospital for emergent treatment of shock state. We found the pericardiocentesis drainage tube perforated left ventricle on computed tomography (CT). This perforation was repaired on the beating heart state using 5-0 monofilament mattress sutures reinforced by felt pledgets. Fatal complications might not occur when appropriate procedures are followed during the placement of a catheter for pericardiocentesis. Iatrogenic cardiac injury is rare but nevertheless requires caution.

Tension pneumopericardium after removal of pericardiocentesis drainage catheter

This image showed tension pneumopericardium caused by removing the pericardiocentesis catheter, which was inserted to drain malignant pericardial effusion. Tension pneumopericardium is a rare and potentially fatal event. Mortality from tension pneumopericardium can be as high as 50%. Therefore, it is important to suspect and detect early, if the patient complained of dyspnea after removing the pericardiocentesis drainage catheter.

Intracardiac shunt with hypoxemia caused by right ventricular dysfunction following pericardiocentesis

Significant hypoxemia can result from right-to-left intracardiac shunting through a patent foramen ovale, an atrial septal defect or a ventricular septal defect. Pulmonary embolus, congenital heart disease and pericardial tamponade are well-recognized causes of right-to-left shunting. However, right-to-left shunting can also follow pericardiocentesis. A case of profound hypoxemia caused by right ventricular hypokinesis precipitated by pericardial tap is reported. This under-recognized entity can be responsible for significant morbidity in the critical care setting. The clinical presentation, natural history, diagnosis and treatment of hypoxemia caused by intracardiac shunt following pericardiocentesis are discussed.

Pericardiocentesis practice in the United Kingdom

BACKGROUND

Pericardial effusions frequently present challenging clinical dilemmas. Whether or not to drain an effusion, and if so by what method, are two common decisions facing cardiologists. We performed a survey to evaluate pericardiocentesis practice in the United Kingdom (UK).

METHODS

A total of 640 questionnaires were sent to all cardiologists in the UK Directory of Cardiology in March 2003.

RESULTS

A total of 274 (43%) completed questionnaires were returned, 88% from consultants, equally distributed between tertiary referral centres and district general hospitals. More than 1500 procedures were performed, largely using a paraxiphoid approach (89%). Clinical tamponade was the commonest indication for pericardiocentesis (83%). However, the majority of respondents (69%) considered echocardiographic features alone an indication for pericardiocentesis, even in the absence of clinical tamponade. The commonest perceived indications for drainage were right ventricular diastolic collapse and right atrial collapse (69% and 33% of respondents respectively). For guidance, 82% use echocardiography, either alone or with fluoroscopy or the electrocardiogram (ECG) injury trace. 11% employ fluoroscopy alone or with the ECG injury trace. The remaining 11% stated that they would use the ECG injury trace alone or use no guidance. Using the ECG injury trace alone is said by the European Society of Cardiology (ESC) guidelines to offer an inadequate safeguard. Reported complications included ventricular puncture (n = 12, 0.8%) and hepatic damage (n = 4, 0.3%).

CONCLUSION

Pericardiocentesis practice varies substantially in the UK. Many cardiologists would perform pericardiocentesis based on echocardiographic features alone. 11% of cardiologists use guidance that is considered inadequate by the ESC guidelines.

The management of tuberculous pericardial effusion: experience in 233 consecutive patients

AIM

We report on the 30-day and one-year outcome of consecutive effusive pericarditis patients, including those with tuberculous pericarditis, over a six-year-period.

METHODS AND RESULTS

Patients with large pericardial effusions requiring pericardiocentesis were included in the study after having given written informed consent. Clinical and radiological evaluations were followed by echo-guided pericardiocentesis, and extended daily intermittent drainage via an indwelling pigtail catheter. A standard short-course anti-tuberculous regimen was initiated. A total of 233 patients was included. One hundred and sixty-two patients had pericardial tuberculosis (TB), including 118 (73%) with microbiological and/ or histological evidence of TB and 44 (27%) diagnosed on clinical and supportive laboratory data. Over the six-year period, two patients developed fibrous constrictive pericarditis after receiving adjuvant corticosteroid therapy. The 30-day mortality (8.0%) was statistically higher for HIV-positive patients (corresponding mortality 9.9%) than for HIV-negative patients (6.2%; p = 0.04). The one year all-cause mortality was 17.3%. It was also higher for HIV-positive (22.2%) than for IV-negative patients (12.3%; p = 0.03). Cardiac mortality was equal for HIV-positive and -negative patients.

CONCLUSION

Tuberculous pericardial effusions responded well to closed pericardiocentesis and a six-month treatment of antituberculous chemotherapy. The former was effective and safe irrespective of HIV status.

Echocardiographically guided pericardiocentesis for treatment of clinically significant pericardial effusion in rheumatoid arthritis

OBJECTIVE

To assess the safety and efficacy of echocardiographically guided pericardiocentesis for patients with rheumatoid arthritis (RA) and hemodynamically significant pericardial effusion.

METHODS

We identified 16 patients with RA who underwent 18 echocardiographically guided pericardiocentesis procedures at our institution over a 20-year period. Clinical and laboratory characteristics of the patients, response to treatment, complications, and need for future pericardial surgery were abstracted from the echocardiography database.

RESULTS

Ten patients were men and 6 were women (mean age, 62 yrs; range, 36-75 yrs). On average, patients were diagnosed with RA 11 years before pericardial disease developed. Twelve of 15 patients were seropositive for rheumatoid factor, 10 patients had radiographic evidence of erosions, and 7 patients had rheumatoid nodules. Cardiac tamponade was present in 11 of the 18 cases. Mean volume drained on the first pericardiocentesis was 504 +/- 264 ml (range 120-1000 ml). The fluid was an exudate with a mean protein concentration of 5 g/dl (range 3.3-51.1 g/dl). All cultures and cytologic findings were negative for bacteria and neoplastic cells. No serious complications resulted from echocardiographically guided pericardiocentesis. For 11 patients, a catheter was placed for intermittent drainage over an average of 3 days. Seven patients ultimately required a more definitive surgical procedure.

CONCLUSION

Echocardiographically guided pericardiocentesis is a safe and effective treatment for this uncommon but serious complication of RA.

A cadaveric study of complications associated with the subxiphoid and transthoracic approaches to emergency pericardiocentesis

OBJECTIVES

The aim of this cadaveric study was to compare three commonly used approaches for emergency pericardiocentesis and to determine the safest approach.

METHODS

Thirteen cadavers were injected at three sites with three different coloured dyes, one for each of the three different recommended approaches. The approaches used were (1) ATIP: anterior transthoracic in the fifth left intercostal space (Advanced Cardiac Life Support protocol), (2) SXP1: immediately subxiphoid and (3) SXP2: subxiphoid approach 1.5 cm inferior to SXP1 (Advanced Trauma Life Support protocol). The needles were left in the chest cavity to confirm their course on the way into the pericardial sac. Once the chest plate was removed, the location of the needle and the presence of dye enabled the identification of structures damaged and cavities entered by the needle. The associated complications from the three approaches were then recorded and compared.

RESULTS

The anterior transthoracic intercostal pericardiocentesis approach to pericardiocentesis (2/39) and an immediately subxiphoid approach SXP1 (1/39) produced fewer potential complications than SXP2 (4/39).

CONCLUSIONS

The SXP1 approach appeared to be the safest, followed by anterior transthoracic intercostal pericardiocentesis. The SXP2 approach caused the highest amount of complications, resulting from the needle entering the abdominal cavity. The presence of intra-abdominal pathology and the possibility of post-mortem changes in the position of the diaphragm, however, might have been a causative factor in this finding.

Chronic Expanding Intrapericardial Hematoma After Pericardial Paracentesis

Chronic expanding intrapericardial hematoma (CEIH) is rare. A thorough search of literature revealed a few cases after open heart surgery, chest trauma, or epicardial injury. We report the case of a 72-year-old man presenting with a large CEIH and constrictive pericarditis, who had no past history of the above conditions but had undergone pericardiocentesis four years earlier. The cause of the initial hemorrhage of the hematoma might be due to a scratch by a needle during pericardial paracentesis. The hematoma had expanded during a course of four years. The hematoma was removed surgically, and there has been no sign of recurrence 17 months after the operation.

Transient biventricular dysfunction following pericardiocentesis

We report the case of a 41-year-old woman admitted to the hospital due to cardiac tamponade as the first manifestation of a pulmonary neoplasm. The patient developed an early biventricular dysfunction and pulmonary edema after removal of the pericardial effusion, with complete recovery within ten days. Since transient ventricular dysfunction after pericardiocentesis is a very unusual complication, we present a review of the different mechanisms suggested in the literature to explain the pathophysiology of this rare phenomenon.