Experience
with a Newly Developed
Pericardiocentesis
Set
Sang C. Park, MD, Elfriede Pahl, MD, Jose A. Ettedgui, MD, Donald R. Fischer, MD, Lee B. Beerman, MD, and William H. Neches, MD
ericardiocentesisis a widely used therapeutic and P diagnosticprocedure.Although a limited number of pericardiocentesissets are commercially available, none has been developedfor use in children. This report describesexperiencewith a newly developedpericardiocentesis set, specifically designedfor pediatric patients. The study group comprised 11 consecutive, unselectedpatients in whom pericardiocentesis was performed at Children’s Hospital of Pittsburgh between December 1987 and February 1990. Clinical information and characteristics of pericardial fluids are listed in Table I in order of the patient’s age. Their ages and body weights rangedfrom 1 day to 18 years (median 7 years) andfrom 3.1 to 59.7 kg (median 21.5), respectively. The presence of pericardial effusion was diagnosed by 2-dimensional echocardiography. The most common etiology of pericardial effusion was that in association with a prolonged febrile course after cardiac surgery in lpatients (nos. 3,4,6 and 11). In 3 of these the pericardial fluid culture was negative and From the University of Pittsburgh School of Medicine, Department of Pediatrics, Cardiology Division, Children’s Hospital of Pittsburgh, 3705 Fifth Avenue, Pittsburgh, Pennsylvania 15213. Manuscript receivedMay 1, 1990;revisedmanuscript received and acceptedJuly 27, 1990.
TABLE
I Clinical
Data and Findings
of Pericardial
Effusion Pericardial
Pt. No.
1 2 3 4 5 6 7 8 9
10 11
Diagnoses TGA LA perforation NEC Idiopathic PC PA, VSD, MS, PPS PA, HRV, FP, PC Abdominal injury Traumatic PE TGA, VSD. PS. BT RP, PPS Kawasaki, PC, MY0 Viral PC Viral PC Heart transplant CT, VR, PPS
the etiology was ascribed to postpericardiotomy syndrome. The remaining patient had a positive culture for staphylococcus aureus and had an associated mediastinitis. Other etiologies included viral pericarditis in 2 patients (nos. 8 and 9), idiopathicpericarditis in a newborn (patient no. 2) with necrotizing enterocolitis, and myocardial dysfunction with congestive heart failure in 2: one with Kawasaki syndrome (no. 7) and another with restrictive cardiomyopathy 3 years after orthotopic heart transplantation (no. 10). In the remaining 2 patients, the pericardial effusion was related to trauma: a 1 -day-old newborn (no. 1) with transposition of thegreat arteries developed pericardial tamponade in association with hemopericardium due to an iatrogenic perforation of the left atrium during cardiac catheterization; the other patient developed pericardial effusion after an automobile accident. Pericardiocentesis was performed in the cardiac catheterization laboratory under fluoroscopic guidance in all patients except 1 (no. 9), in whom it was performed in the intensive care unit with 2-dimensional echocardiographic guidance. All but 2 patients (nos. 1 and 9) received a combination of meperidine 2 mg/kg, promethazine 0.5 mg/kg and chlorpromazine 0.5 mg/kg intramuscularly 30 to 45 minutes before the procedure orfentanyl citrate 1 mglkg intravenously shortly before the proce-
Fluid
Catheter
Weight k)
Echo (mm)
Yield (cd
Appearance
Culture
Out/In
1 day
4.4
>lO
>5cQ*
Blood
Negative
out
5 days
3.1
a
Serousanguinous
Negative
out
9 mos.
7.7
19
133
Serousanguinous
Negative
out
Ai+
3s
2-10/12yrs.
11.5
12
120
Serousanguinous
2-10/12yrs.
14.0
18
185
Serous
Staph. aureus Negative
In out
7 yrs.
21.5
23
290
Serousanguinous
Negative
out
30.0
11
145
Viscous serous
Negative
out
19.5 29.4 46.6
59.7
20 35 25 33
170 805 610 loo+
Serousanguinous Serousanguinous Serous Serousanguinous
Negative Negative Negative Negative
out In out out
Median 21.5kg
Mean 24
7-2/12
yrs.
7-a/12 yrs. 8-3/12yrs. 15-l 1/ 12yrs.
la yrs. Median 7 yrs.
Duration (days)
1
3
3
Mean 281
* Reinfused to the venous line; 7 loculated. BT = Blalock-Taussig shunt; CT = corrected transposition; FP = Fontan procedure; HRV = hypoplastic right ventricle; Kawasaki = KavasaM syndrome; modified Etalock-Taussig shunt; MY0 = myocarditis: NEC = necrotizing enterocolitis; PA = pulmonary atresba; PC = pericarditis; PC = pericardial pericardiotomy syndrome: PS = pulmanary stenosis; RP = Rastelli procedure; Staph. = staphylococcus; TGA = transposition of the great arteries: replacement; VSD = ventricular septal defect.
THE AMERICAN
JOURNAL
OF CARDIOLOGY
DECEMBER
LA = left atrium; MS = effusion: PPS = post VR = prosthetic Valve
15, 1990
1%
dure. Most of the patients underwent the procedure in the supine position, while a few who had orthopnea were in the semi-sitting position. An electrocardiogram was monitored throughout the procedure. The set consists of (1) two 20-gauge-thin wall needles (4 cm and 7 cm in length for patients with an unusually thick chest wall); (2) a 0.025-inch J-tip Teflon@coated guidewire, 50-cm long; (3) a 3Fr Teflon introducer, 27-cm long; and (4) a 5Fr polyethylene catheter, 20-cm long with a J-shaped curve at the tip (Figure 1). The tip of the catheter is tapered to a 4Fr size. There are multiple openings (0.025 inch) on the concave as well as on the convex sides of the catheter tip. The subxyphoid area is prepped and draped to provide a sterile field. Lidocaine (1 Yo) is infiltrated at the left costoxiphoid angle extending posteriorly and slightly superiorly. Using a sharp-pointed number-l I -blade scalpel, a 2 to 3 mm stab wound is made at the site of the lidocaine infiltration (Figure 2A). The needle is attached to a 3-ml syringe containing a small amount offlushing solution and introduced into the stab wound, directed toward the left axilla with the needle advancing at an angle of 20 to 30” from the horizontal plane (Figure 2B). The operator may have a sensation of “popping” as the needle punctures the pericardium and pericardial fluid is aspirated. After confirmation of free aspiration of a small amount of pericardial fluid, the syringe is re-
63
moved. The guidewire is then advanced through the needle under biplanefluoroscopic guidance or by 2-dimensional echo imaging (Figure 2, C and 0). Ideally, the guidewire is passed around the inferior portion of the heart into the posterior aspect of the pericardial space. Once the guidewire is in a satisfactory position, the needle is removed (Figure 2E). The combined introducer and catheter set is then passed over the wire. Initially, the introducer alone is manipulated by rotating or twirling it until the tip is in the pericardial space (Figure 2F). The catheter is then advanced over the introducer by similar manipulation until the catheter reaches asfar as possible into the posterior pericardial space. The guidewire and introducer are subsequently removed while the drainage catheter remains in the pericardial space. A 3-way stopcock is attached to the catheter hub and drainage of the pericardial fluid is accomplished with a large syringe, usually of 30- or 50-ml capacity (Figure 2G). In all cases, the procedure was successful and without complication. Only 4-cm needles were used and no patient in this series, even the 2 teenagers weighing more than 45 kg, required a longer needle (7 cm). Pericardial drainage ranged from 38 ml in a J-day-old newborn to 800 ml in an 8-year-old boy with viralpericarditis (mean 281 ml). The nature of the pericardial fluid is listed in Table I. In most cases, it was either serous or serosanguinous. In the newborn infant who had left atria1 perfo-
4 cm 20
J-TIP
TEFLON
#3F
GUIDE
GAUGE
WIRE
THIN
COATED
TEFLON
INTRODUCER
WALL
NEEDLE
GUIDE
WIRE
(0.025’9
INTRODUCER
FIGURE 1. Diagramatie illustrations of each component of the pericardiocentesis set (see text).
CATHETER
FIGURE 2. Sequence of the pericardiocentesis procedure (see text).
1530
THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 66
signedto prevent inadvertent trauma to the myocardium. The number, placement and size of the side holes of this catheter are important for short- and long-term drainage.5,6There are multiple holes on the convex and concave sidesof the curved catheter tip, arranged to prevent occlusion by contact between the catheter and the pericardial or epicardial surfaces. The side holes, of 0.025 inch diameter, were large enough to drain effectively for up to 3 days in our 3 patients with serousor serosanguinous pericardial fluid. However, when purulent pericarditis is documented, open surgical drainage is recommended, even if the pericardiocentesis is successful in removing most of the fluid. The small 3Fr Teflon introducer is easily passedover the guidewire into the pericardial spacewithout the aid of Although pericardiocentesisis a relatively straight- a dilator. When the catheter is passedover this introducforward procedure, complications related to it have er, the entire system has a gentle taper from the wire been considerable,ranging from a nonproductive tap to diameter to the catheter diameter, as shown in Figure 1 death.1-3In recent years,the overall incidence of compli- (bottom), thereby eliminating the need for a separate cations hasdecreasedas accurate diagnosisand localiza- dilation procedure. This set facilitates performing perition of pericardial effusion is readily made by 2-dimen- cardiocentesisefficiently in a short period of time, particsional echocardiography and by computer tomographic ularly when emergency pericardiocentesisis needed. In conclusion, our limited clinical trial with a newly scan. Self-contained pericardiocentesissets are now com- developedpericardiocentesisset has shown its effectivemercially available; however,they are primarily aimed at nessand safety in a wide range of pediatric patients, from the adult population. The relatively large componentsare newborn infants to older teenagers.The set may help to not suitable for safeusein children. The primary purpose reduce the complications related to pericardiocentesis.It of our study wasto developa dedicatedpericardiocentesis also can be used as a short-term indwelling drainage set for the pediatric agegroup. Delicate maneuverability catheter. and precise placement of a drainage catheter into the Acknowledgment: The pericardiocentesissetsfor this limited pericardial space are of prime consideration in study were provided by Cook Incorporated (Bloomingsmaller patients with relatively smaller amounts of periton, Indiana). We gratefully acknowledgethe technical cardial fluid. assistance of Joseph Roberts of Cook Incorporated. Most commercially available pericardiocentesis sets include an alligator clip that is intended to monitor the electrocardiogram through the needle. The technique 1. Owens WC, Schaffer RA, Rahimtoola SH. Pericardiocentesis: insertion of a useselectrocardiographic changes to identify misplace- pericardial catheter. Cnrhet Cardiouasc Diag 1975;1:317-321. 2. Wong B, Murphy .I, Chang CJ, Hassenein K, Dunn M. The risk of pericardioment of the needleand direct contact with the atrium or centesis. Am J Cardiol 1979;44:1110-1114. ventricle. However, this technique is not only unreliable4 3. Kwasnik EM, Koster KM, Lazarus JM, Sloss LJ, Mee RB, Cohn LH, Collins Conservative management of uremic pericardial effusions. J Thorac Cardiobut also causesconsiderabledistraction during the deli- JJ. ua~c Surg 1978;76:629-632, cate maneuversof the procedure itself. Therefore, capa- 4. Sob01 SM, Thomas HM Jr, Evans RW. Myocardial laceration not demonbility for electrocardiographic monitoring through the strated by continuous electrocardiographic monitoring occurring during pericardiocentesis. N Engl J Med 1975;292:1222-1223. needlewas not incorporated in this set. 5. Lock JE, Bass JL, Kulik TJ, Fuhrman BP. Chronic percutaneous pericardial The drainage catheter is a relatively small, SFr-thin drainage with modified pigtail catheters in children. Am J Cardiol1984;53:1179wall polyethylene catheter, which is flexible enough to be 1182. 6. Pate1 AK, Kosolcharoen PK, Nallavivan M, Kroncke GM, Thomsen JH. usedfor a newborn, yet large enough for even the older Catheter drainage of the pericardium. Practical method to maintain long-term teenagers.The gentle J-shapedtip of the catheter is de- patency. Cht?Sl 1987;92:1018-1021.
ration during cardiac catheterization, pericardiocentesis yielded pure blood, which was reinfused through a central venous line until the surgeon repaired the perforation. The patient had an uneventful course and subsequently had a successful arterial switch procedure. In 3 patients, apericardial catheter was left inplacefor 1 to 3 days because of concern about the possibility of reaccumulation. An additional 50 to 150 ml of pericardial fluid was removed during this period. One patient had a culture-proven staphylococcal pericarditis in association with mediastinitis and required surgical intervention. The remaining 10 patients had negative bacterial cultures and did not require further surgical intervention for theirpericardial effusion. All patients recovered without sequelae.
THE AMERICAN JOURNAL OF CARDIOLOGY
DECEMBER 15, 1990
with a Newly Developed
Pericardiocentesis
Set
Sang C. Park, MD, Elfriede Pahl, MD, Jose A. Ettedgui, MD, Donald R. Fischer, MD, Lee B. Beerman, MD, and William H. Neches, MD
ericardiocentesisis a widely used therapeutic and P diagnosticprocedure.Although a limited number of pericardiocentesissets are commercially available, none has been developedfor use in children. This report describesexperiencewith a newly developedpericardiocentesis set, specifically designedfor pediatric patients. The study group comprised 11 consecutive, unselectedpatients in whom pericardiocentesis was performed at Children’s Hospital of Pittsburgh between December 1987 and February 1990. Clinical information and characteristics of pericardial fluids are listed in Table I in order of the patient’s age. Their ages and body weights rangedfrom 1 day to 18 years (median 7 years) andfrom 3.1 to 59.7 kg (median 21.5), respectively. The presence of pericardial effusion was diagnosed by 2-dimensional echocardiography. The most common etiology of pericardial effusion was that in association with a prolonged febrile course after cardiac surgery in lpatients (nos. 3,4,6 and 11). In 3 of these the pericardial fluid culture was negative and From the University of Pittsburgh School of Medicine, Department of Pediatrics, Cardiology Division, Children’s Hospital of Pittsburgh, 3705 Fifth Avenue, Pittsburgh, Pennsylvania 15213. Manuscript receivedMay 1, 1990;revisedmanuscript received and acceptedJuly 27, 1990.
TABLE
I Clinical
Data and Findings
of Pericardial
Effusion Pericardial
Pt. No.
1 2 3 4 5 6 7 8 9
10 11
Diagnoses TGA LA perforation NEC Idiopathic PC PA, VSD, MS, PPS PA, HRV, FP, PC Abdominal injury Traumatic PE TGA, VSD. PS. BT RP, PPS Kawasaki, PC, MY0 Viral PC Viral PC Heart transplant CT, VR, PPS
the etiology was ascribed to postpericardiotomy syndrome. The remaining patient had a positive culture for staphylococcus aureus and had an associated mediastinitis. Other etiologies included viral pericarditis in 2 patients (nos. 8 and 9), idiopathicpericarditis in a newborn (patient no. 2) with necrotizing enterocolitis, and myocardial dysfunction with congestive heart failure in 2: one with Kawasaki syndrome (no. 7) and another with restrictive cardiomyopathy 3 years after orthotopic heart transplantation (no. 10). In the remaining 2 patients, the pericardial effusion was related to trauma: a 1 -day-old newborn (no. 1) with transposition of thegreat arteries developed pericardial tamponade in association with hemopericardium due to an iatrogenic perforation of the left atrium during cardiac catheterization; the other patient developed pericardial effusion after an automobile accident. Pericardiocentesis was performed in the cardiac catheterization laboratory under fluoroscopic guidance in all patients except 1 (no. 9), in whom it was performed in the intensive care unit with 2-dimensional echocardiographic guidance. All but 2 patients (nos. 1 and 9) received a combination of meperidine 2 mg/kg, promethazine 0.5 mg/kg and chlorpromazine 0.5 mg/kg intramuscularly 30 to 45 minutes before the procedure orfentanyl citrate 1 mglkg intravenously shortly before the proce-
Fluid
Catheter
Weight k)
Echo (mm)
Yield (cd
Appearance
Culture
Out/In
1 day
4.4
>lO
>5cQ*
Blood
Negative
out
5 days
3.1
a
Serousanguinous
Negative
out
9 mos.
7.7
19
133
Serousanguinous
Negative
out
Ai+
3s
2-10/12yrs.
11.5
12
120
Serousanguinous
2-10/12yrs.
14.0
18
185
Serous
Staph. aureus Negative
In out
7 yrs.
21.5
23
290
Serousanguinous
Negative
out
30.0
11
145
Viscous serous
Negative
out
19.5 29.4 46.6
59.7
20 35 25 33
170 805 610 loo+
Serousanguinous Serousanguinous Serous Serousanguinous
Negative Negative Negative Negative
out In out out
Median 21.5kg
Mean 24
7-2/12
yrs.
7-a/12 yrs. 8-3/12yrs. 15-l 1/ 12yrs.
la yrs. Median 7 yrs.
Duration (days)
1
3
3
Mean 281
* Reinfused to the venous line; 7 loculated. BT = Blalock-Taussig shunt; CT = corrected transposition; FP = Fontan procedure; HRV = hypoplastic right ventricle; Kawasaki = KavasaM syndrome; modified Etalock-Taussig shunt; MY0 = myocarditis: NEC = necrotizing enterocolitis; PA = pulmonary atresba; PC = pericarditis; PC = pericardial pericardiotomy syndrome: PS = pulmanary stenosis; RP = Rastelli procedure; Staph. = staphylococcus; TGA = transposition of the great arteries: replacement; VSD = ventricular septal defect.
THE AMERICAN
JOURNAL
OF CARDIOLOGY
DECEMBER
LA = left atrium; MS = effusion: PPS = post VR = prosthetic Valve
15, 1990
1%
dure. Most of the patients underwent the procedure in the supine position, while a few who had orthopnea were in the semi-sitting position. An electrocardiogram was monitored throughout the procedure. The set consists of (1) two 20-gauge-thin wall needles (4 cm and 7 cm in length for patients with an unusually thick chest wall); (2) a 0.025-inch J-tip Teflon@coated guidewire, 50-cm long; (3) a 3Fr Teflon introducer, 27-cm long; and (4) a 5Fr polyethylene catheter, 20-cm long with a J-shaped curve at the tip (Figure 1). The tip of the catheter is tapered to a 4Fr size. There are multiple openings (0.025 inch) on the concave as well as on the convex sides of the catheter tip. The subxyphoid area is prepped and draped to provide a sterile field. Lidocaine (1 Yo) is infiltrated at the left costoxiphoid angle extending posteriorly and slightly superiorly. Using a sharp-pointed number-l I -blade scalpel, a 2 to 3 mm stab wound is made at the site of the lidocaine infiltration (Figure 2A). The needle is attached to a 3-ml syringe containing a small amount offlushing solution and introduced into the stab wound, directed toward the left axilla with the needle advancing at an angle of 20 to 30” from the horizontal plane (Figure 2B). The operator may have a sensation of “popping” as the needle punctures the pericardium and pericardial fluid is aspirated. After confirmation of free aspiration of a small amount of pericardial fluid, the syringe is re-
63
moved. The guidewire is then advanced through the needle under biplanefluoroscopic guidance or by 2-dimensional echo imaging (Figure 2, C and 0). Ideally, the guidewire is passed around the inferior portion of the heart into the posterior aspect of the pericardial space. Once the guidewire is in a satisfactory position, the needle is removed (Figure 2E). The combined introducer and catheter set is then passed over the wire. Initially, the introducer alone is manipulated by rotating or twirling it until the tip is in the pericardial space (Figure 2F). The catheter is then advanced over the introducer by similar manipulation until the catheter reaches asfar as possible into the posterior pericardial space. The guidewire and introducer are subsequently removed while the drainage catheter remains in the pericardial space. A 3-way stopcock is attached to the catheter hub and drainage of the pericardial fluid is accomplished with a large syringe, usually of 30- or 50-ml capacity (Figure 2G). In all cases, the procedure was successful and without complication. Only 4-cm needles were used and no patient in this series, even the 2 teenagers weighing more than 45 kg, required a longer needle (7 cm). Pericardial drainage ranged from 38 ml in a J-day-old newborn to 800 ml in an 8-year-old boy with viralpericarditis (mean 281 ml). The nature of the pericardial fluid is listed in Table I. In most cases, it was either serous or serosanguinous. In the newborn infant who had left atria1 perfo-
4 cm 20
J-TIP
TEFLON
#3F
GUIDE
GAUGE
WIRE
THIN
COATED
TEFLON
INTRODUCER
WALL
NEEDLE
GUIDE
WIRE
(0.025’9
INTRODUCER
FIGURE 1. Diagramatie illustrations of each component of the pericardiocentesis set (see text).
CATHETER
FIGURE 2. Sequence of the pericardiocentesis procedure (see text).
1530
THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 66
signedto prevent inadvertent trauma to the myocardium. The number, placement and size of the side holes of this catheter are important for short- and long-term drainage.5,6There are multiple holes on the convex and concave sidesof the curved catheter tip, arranged to prevent occlusion by contact between the catheter and the pericardial or epicardial surfaces. The side holes, of 0.025 inch diameter, were large enough to drain effectively for up to 3 days in our 3 patients with serousor serosanguinous pericardial fluid. However, when purulent pericarditis is documented, open surgical drainage is recommended, even if the pericardiocentesis is successful in removing most of the fluid. The small 3Fr Teflon introducer is easily passedover the guidewire into the pericardial spacewithout the aid of Although pericardiocentesisis a relatively straight- a dilator. When the catheter is passedover this introducforward procedure, complications related to it have er, the entire system has a gentle taper from the wire been considerable,ranging from a nonproductive tap to diameter to the catheter diameter, as shown in Figure 1 death.1-3In recent years,the overall incidence of compli- (bottom), thereby eliminating the need for a separate cations hasdecreasedas accurate diagnosisand localiza- dilation procedure. This set facilitates performing perition of pericardial effusion is readily made by 2-dimen- cardiocentesisefficiently in a short period of time, particsional echocardiography and by computer tomographic ularly when emergency pericardiocentesisis needed. In conclusion, our limited clinical trial with a newly scan. Self-contained pericardiocentesissets are now com- developedpericardiocentesisset has shown its effectivemercially available; however,they are primarily aimed at nessand safety in a wide range of pediatric patients, from the adult population. The relatively large componentsare newborn infants to older teenagers.The set may help to not suitable for safeusein children. The primary purpose reduce the complications related to pericardiocentesis.It of our study wasto developa dedicatedpericardiocentesis also can be used as a short-term indwelling drainage set for the pediatric agegroup. Delicate maneuverability catheter. and precise placement of a drainage catheter into the Acknowledgment: The pericardiocentesissetsfor this limited pericardial space are of prime consideration in study were provided by Cook Incorporated (Bloomingsmaller patients with relatively smaller amounts of periton, Indiana). We gratefully acknowledgethe technical cardial fluid. assistance of Joseph Roberts of Cook Incorporated. Most commercially available pericardiocentesis sets include an alligator clip that is intended to monitor the electrocardiogram through the needle. The technique 1. Owens WC, Schaffer RA, Rahimtoola SH. Pericardiocentesis: insertion of a useselectrocardiographic changes to identify misplace- pericardial catheter. Cnrhet Cardiouasc Diag 1975;1:317-321. 2. Wong B, Murphy .I, Chang CJ, Hassenein K, Dunn M. The risk of pericardioment of the needleand direct contact with the atrium or centesis. Am J Cardiol 1979;44:1110-1114. ventricle. However, this technique is not only unreliable4 3. Kwasnik EM, Koster KM, Lazarus JM, Sloss LJ, Mee RB, Cohn LH, Collins Conservative management of uremic pericardial effusions. J Thorac Cardiobut also causesconsiderabledistraction during the deli- JJ. ua~c Surg 1978;76:629-632, cate maneuversof the procedure itself. Therefore, capa- 4. Sob01 SM, Thomas HM Jr, Evans RW. Myocardial laceration not demonbility for electrocardiographic monitoring through the strated by continuous electrocardiographic monitoring occurring during pericardiocentesis. N Engl J Med 1975;292:1222-1223. needlewas not incorporated in this set. 5. Lock JE, Bass JL, Kulik TJ, Fuhrman BP. Chronic percutaneous pericardial The drainage catheter is a relatively small, SFr-thin drainage with modified pigtail catheters in children. Am J Cardiol1984;53:1179wall polyethylene catheter, which is flexible enough to be 1182. 6. Pate1 AK, Kosolcharoen PK, Nallavivan M, Kroncke GM, Thomsen JH. usedfor a newborn, yet large enough for even the older Catheter drainage of the pericardium. Practical method to maintain long-term teenagers.The gentle J-shapedtip of the catheter is de- patency. Cht?Sl 1987;92:1018-1021.
ration during cardiac catheterization, pericardiocentesis yielded pure blood, which was reinfused through a central venous line until the surgeon repaired the perforation. The patient had an uneventful course and subsequently had a successful arterial switch procedure. In 3 patients, apericardial catheter was left inplacefor 1 to 3 days because of concern about the possibility of reaccumulation. An additional 50 to 150 ml of pericardial fluid was removed during this period. One patient had a culture-proven staphylococcal pericarditis in association with mediastinitis and required surgical intervention. The remaining 10 patients had negative bacterial cultures and did not require further surgical intervention for theirpericardial effusion. All patients recovered without sequelae.
THE AMERICAN JOURNAL OF CARDIOLOGY
DECEMBER 15, 1990
