Catheterization and Cardiovascular Diagnosis 27:8+88 (1992)
Letters to the Editor Echocardiography vs. Fluoroscopic Imaging TO THE EDITOR The letter to the editor by Drs. Vora, Lokhandwala, and Kale [ 11 in the February 1992 issue of Catheterization and Cardiovascular Diagnosis describes the use of echocardiography to guide
percutaneous balloon pericardial windowing. We disagree with this approach and believe that fluoroscopic imaging is required for proper balloon positioning. In a multicenter registry format, we have collected data on 57 patients treated with percutaneous balloon pericardial windowing for effusive pencardial disease [2). Those 57 cases were performed with fluoroscopic guidance in order to position the dilating balloon properly and identify a discrete waist in the balloon at the time of pericardial dilatation (Fig. 1). Identifying such a waist is particularly important since the parietal pericardium may lie directly against the chest wall. When this is occurs, chest wall tissues prevent effective dilatation of the pericardium. In addition, the balloon may be advanced too far into the pericardial space, again leading to ineffective pericardial windowing. In our experience with both transthoracic and transesophageal echocardiography during balloon pericardial windowing, the balloon can be visualized, but detail is inadequate to define whether a discrete waist in the balloon is present. When the pericardium is found to be directly apposed to the chest wall, we now use a countertraction technique in which the skin and soft tissues are Dulled toward the oatient's right side while
Fig. 1. Fluoroscopic image of percutaneous balloon pericardial windowing. The 20 mm diameter by 3 cm long dilating balloon has been advanced via a subxiphoid approach over an 0.038 inch Amplatz extra-stiff guidewire. With proper balloon positioning, a waist is seen at the perlcardial margin as the balloon is inflated. This waist will disappear as the window is created.
0 1992 Wiley-Liss, Inc.
the balloon catheter is simultaneously advanced toward the left shoulder (Fig. 2). This separates the pericardium from the chest wall permitting effective balloon windowing. Since echocardiography does not appear to provide the resolution necessary to visualize the waist in the balloon, we recommend that percutaneous balloon pencardial windowing be performed only under fluoroscopic guidance.
Andrew A. Ziskind,
MD
Director, Cardiac Catheterization Laboratory Assistant Professor of Medicine University of Maryland Steven Burstein, M D Assistant Professor of Medicine University of Southern California
REFERENCES Vora, Amit M., Lokhandwala, Yash Y.,Kale, Punhottam A.: Echocardiography guided creation of balloon pericardial window. Cathet Cardiovas Diagn 25:164-165 (1992). 2. Ziskind AA, Pearce AC. Burstein S, Hemnann HC, Gimple LW, Block PC, Waldman HM, Tuzcu EM, Lemmon C, Palacios IF: Percutaneous balloon pericardiotomy for the treatment of pericardial effusion and tamponade: Report of the registry. J Am Coll Cardiology 19:265A 1.
(1992).
Fig. 2. Schematic illustration of the countertraction technique to separate the pericardium from the adjacent chest wall. A) Initial trial inflation of the balloon demonstrates that expansion of the balloon only occurs within the pericardial space. B) After pulling on the skin and pushing with the balloon catheter, the pericardium is pushed away from the chest wall at which time proper inflation can occur.
Letters to the Editor Echocardiography vs. Fluoroscopic Imaging TO THE EDITOR The letter to the editor by Drs. Vora, Lokhandwala, and Kale [ 11 in the February 1992 issue of Catheterization and Cardiovascular Diagnosis describes the use of echocardiography to guide
percutaneous balloon pericardial windowing. We disagree with this approach and believe that fluoroscopic imaging is required for proper balloon positioning. In a multicenter registry format, we have collected data on 57 patients treated with percutaneous balloon pericardial windowing for effusive pencardial disease [2). Those 57 cases were performed with fluoroscopic guidance in order to position the dilating balloon properly and identify a discrete waist in the balloon at the time of pericardial dilatation (Fig. 1). Identifying such a waist is particularly important since the parietal pericardium may lie directly against the chest wall. When this is occurs, chest wall tissues prevent effective dilatation of the pericardium. In addition, the balloon may be advanced too far into the pericardial space, again leading to ineffective pericardial windowing. In our experience with both transthoracic and transesophageal echocardiography during balloon pericardial windowing, the balloon can be visualized, but detail is inadequate to define whether a discrete waist in the balloon is present. When the pericardium is found to be directly apposed to the chest wall, we now use a countertraction technique in which the skin and soft tissues are Dulled toward the oatient's right side while
Fig. 1. Fluoroscopic image of percutaneous balloon pericardial windowing. The 20 mm diameter by 3 cm long dilating balloon has been advanced via a subxiphoid approach over an 0.038 inch Amplatz extra-stiff guidewire. With proper balloon positioning, a waist is seen at the perlcardial margin as the balloon is inflated. This waist will disappear as the window is created.
0 1992 Wiley-Liss, Inc.
the balloon catheter is simultaneously advanced toward the left shoulder (Fig. 2). This separates the pericardium from the chest wall permitting effective balloon windowing. Since echocardiography does not appear to provide the resolution necessary to visualize the waist in the balloon, we recommend that percutaneous balloon pencardial windowing be performed only under fluoroscopic guidance.
Andrew A. Ziskind,
MD
Director, Cardiac Catheterization Laboratory Assistant Professor of Medicine University of Maryland Steven Burstein, M D Assistant Professor of Medicine University of Southern California
REFERENCES Vora, Amit M., Lokhandwala, Yash Y.,Kale, Punhottam A.: Echocardiography guided creation of balloon pericardial window. Cathet Cardiovas Diagn 25:164-165 (1992). 2. Ziskind AA, Pearce AC. Burstein S, Hemnann HC, Gimple LW, Block PC, Waldman HM, Tuzcu EM, Lemmon C, Palacios IF: Percutaneous balloon pericardiotomy for the treatment of pericardial effusion and tamponade: Report of the registry. J Am Coll Cardiology 19:265A 1.
(1992).
Fig. 2. Schematic illustration of the countertraction technique to separate the pericardium from the adjacent chest wall. A) Initial trial inflation of the balloon demonstrates that expansion of the balloon only occurs within the pericardial space. B) After pulling on the skin and pushing with the balloon catheter, the pericardium is pushed away from the chest wall at which time proper inflation can occur.
