European Journal of Radiology, 12 (1991)
147-149
147
Elsevier
EURRAD
00127
Percutaneous ultrasound-guided management of pericardial fluid W.H.J. Department
(Received
Key words: Heart, pericardial
Sanders and L.E.H. Lampmann
of Radiology, St. Elisabeth Hospital, Tilburg, The Netherlands
6 July 1990; accepted
fluid; Heart, pericardiocenthesis;
after revision 29 September
Pericardial fluid
1990)
fluid, US guided aspiration;
Interventional
radiology, pericardial
Abstract The use of a Rotex screw biopsy needle is advocated for percutaneous ultrasound-guided management of pericardial fluid. This procedure is performed under sonographic guidance while the needle tip is clearly visualized during introduction, thereby improving optimal placement and limiting the possibility of complications.
Introduction Compression of the heart occurs when an increasing amount of fluid in the pericardial space will become clinically evident and the cardiac output will decrease. In the case of an acute myocardial infarction or a perforating trauma, a large amount of pericardial fluid may develop very quickly. The typical clinical signs are mentioned in the socalled triad of Beck, including increased venous pressure, falling blood pressure and weak heart sounds. A paradoxical pulse is an important clue to the presence of cardiac tamponade, and the electrocardiogram may demonstrate a reduction in amplitude of the QRS complexes and an electrical alternans of the PQRS, and T waves [ 3,4,6,7,16]. Echocardiography has become the procedure of choice for the diagnosis of pericardial effusion [ 1,5,6,11,12,16]. In case of a severe cardiac tamponade, quick drainage of the pericardial fluid is obligatory. Until now blind pericardial puncture and aspiration with the help of a needle, inserted from a point directly under the xyphoid region, was the method of choice. This proceAddress for reprints: W.H.J. Sanders, M.D., Department of Radiology, St. Elisabeth Hospital, Postbox 9015 1, Hilvarenbeekseweg 60, 5000 LC Tilburg, The Netherlands. 0720-048X/91/$03.50
0 1991 Elsevier Science Publishers
dure is certainly not without danger, since incorrect positioning of the needle may be hazardous. Sonographically guided percutaneous drainage procedures are considered to be the methods of choice for treatment of most fluid collections in the abdomen. A similar approach for selected patients with pericardial fluid collections has already been widely reported in literature. The case of sonographically guided percutaneous pericardiocentesis eliminates complications. We describe our experience with the Rotex screw biopsy needle which has some advantages that will be described in this paper. Case reports Case 1 is a 65-year-old female with rheumatoid arthritis and a history of ischaemic heart disease who was admitted to our hospital for progressive pain irradiating to the neck. Ultrasonography (Aloka 650, 5 MHz transducer) demonstrated a sonolucent space around the heart with a depth of almost 1.5 cm. Diagnostic aspiration puncture was performed with a 20 G Rotex screw biopsy needle under sonographic guidance. The inner corkscrew stylet was positioned just in the tip of the outer needle in order to create good visibility of the needle. Once the needle was positioned in the sonolucent zone around the heart (Fig. l), the stylet was removed
B.V. (Biomedical
Division)
Fig. 1. Rotex needle tip well visualised within the fluid-filled pericardial sac. The three small arrows delineate the pericardial fluid collection. The larger arrow points to the tip of the needle.
and fluid was aspirated for cytology. After proper medication the patient improved and was discharged. Case 2 is a 68-year-old female referred to the hospital with progressive shortness of breath. Six years earlier she had been subjected to a mastectomy for lobular carcinoma. A high central venous and a low arterial blood pressure were measured. Cardiac rumbles and/or pericardial crepitations were not heard. Ultrasonography showed a considerable amount of free fluid in front of and lateral to the heart. Under sonographic guidance an initial puncture was performed with a 20 G Rotex screw biopsy needle. When fluid was aspirated, a 0.21 Fr J-shaped guidewire was maneuvered under fluoroscopy into the pericardial and catheter manipulations are space. Guidewire preferably performed under fluoroscopic control.
Fig. 2. The eight French pigtail catheter well positioned cardial space; final result.
in the peri-
Exchange for a five Fr dilator and then for a 0.38 J-shaped guidewire was followed by the introduction of a peel-away/dilator assembly. After removal of the dilator, an eight Fr pigtail catheter was placed for drainage (Fig. 2). Under antibiotic protection the drain stayed in situ for 4 days. When the complaints ceased the drain was removed. Case 3 is a 74-year-old male suffering from hypertension and ischaemic heart disease. He was admitted with progressive retrosternal pain irradiating to the back and the left arm. After 2 days he suddenly developed a bradycardia and his arterial blood pressure dropped, while the central venous blood pressure increased. The suspicion of acute pericardial tamponade was confirmed by cardiac ultrasonography. Since the clinical condition of the patient deteriorated dramatically, no further time could be lost and an instant drainage procedure was performed under sonographic guidance. Almost 300 cc blood was removed and the catheter was connected to a drainage system. The patient improved immediately and was subsequently referred to a centre for cardiosurgery where a rupture of the atrium was closed. No further complications were encountered. Discussion Clinically pericardial fluid can be divided in acute, subacute or chronic pericardial effusion, originating from infectious, non-infectious and/or auto-immune pericarditis. For the diagnosis of pericardial effusion, echocardiography is today the method of choice, since it is simple to perform and specific. In case of pericardial fluid, a relatively echo-free space between the posterior pericardium and the left ventricular epicardium can be demonstrated. The heart may swing freely within the pericardial sac, when the effusions are large. A distance of 2-3 cm between myocardium and diaphragmatic part of the pericardium is sufficient for a save puncture procedure and guidewire manipulations [ 41. Traditionally, pericardial puncture for the removal of pericardial fluid has been accomplished either as an open surgical procedure or by means of percutaneously performed blind puncture. Up to the present day, the subxyphoid approach is still a standard blind procedure, performed by either the left parastemal or the subxyphoid approach [lo]. The needle is inserted at a 45-degree angle and advanced until fluid is encounted. The initial puncture may be followed by a J-shaped wire and drainage catheter which are positioned via the so-called Seldinger technique [ 131. Gubermann re-
149
ported a 7-15x incidence of major complications and a mortality rate of 4-19% and considered the use of pericardiotomy because of the inherent risks of blind pericardiocentesis [ 71. Goldberg [ 5] was the first to report the use of sonography for guidance during pericardiocentesis. Calahan [l] reported the use of a 14 to 16 G Teflonsheeted needle. Once the needle-tip had entered the pericardial space, the Teflon sheet was advanced while withdrawing the needle itself. They described a left subcostal/subxyphoid and/or apical-intercostal approach. No complications were encountered in a patient population of 40 individuals. Jansen and Vincent [6,16] described their IO-year experience in 116 patients with pericardial effusions [6,16]. They advocated the introduction of a Redon Drain connected with a vacuum bottle through an introducer sheet, and they initiated the development of a complete pericardial puncture drainage set (PV lO.O.NLllO, Cook Denmark) that has the advantage of better drainage. The results and recurrence rates in their blind procedures, pericardiotomy method and ultrasonographically guided drainage procedures were scored. The recurrence rate for blind procedures was 92%, for subxyphoid pericardiotomy 3 1 y0 ; for antero-lateral pericardiotomy 5 %, and for medianpericardiotomy 20 %, however for the ultrasonographically guided drainage procedure it was just 7 %. Based on their experience, they advocate the ultrasonographically guided drainage puncture as the first method of choice in pericardial effusion. We share the opinion that the method of puncture and/or drainage procedure depends on the site of the procedure and the availability of equipment and personnel. The clinical history of the patient is very important and may be an indication for the planning of an aspiration puncture or, even in an acute fase, a swift and quick drainage procedure with an indwelling catheter. - The Rotex biopsy needle has some important advantages. The tip of the cork-screw stylet is just left within the outer needle, and during sonographic guidance the tip of such a needle is clearly visible, making puncture of the pericardial space very easy. - When catheter drainage is necessary after the initial puncture, sonographic guidance with a Rotex needle is followed by withdrawal of the stylet; a 0.21 Fr guidewire is introduced under further fluoroscopic control in the pericardial space. The outer Rotex needle is exchanged for a 5 Fr dilator and a 0.35 or 0.38 J-shaped guidewire. Over this guidewire an introducer set with a peel-away sheet is manipulated after withdrawal of the
dilator and a pigtail catheter can be manipulated into the pet&u-dial space. The peel-away sheet is removed and the pigtail catheter can be secured to the skin. - In an acute fase the use of so-called one-step trocar method is advised to avoid sheet and catheter manipulations. A short pigtail catheter can be mounted on an appropriate needle and the whole assembly is introduced in one step in the direction of the pericardial fluid under ultrasonographic guidance. When the tip is appreciated in the pericardial fluid the needle is secured and the catheter advanced until the curve of the pigtail sets into the pericardial space.
References 1 Callahan JA. Pericardiocentesis assisted by two-dimensional echocardiography. J Thorac Cardiovasc 1983; 85: 877-879. 2 Chandraratna PAN, First J, Langevin E, O’Dell R. Echocardiographic contrast studies during pericardiocentesis. Ann Intern Med 1977; 87: 199-200. 3 Cikes J. New echocardiographic possibilities in the etiological diagnosis and therapy of pericardial diseases. Cardiovascular diagnosis by ultrasound: transoesophageal, computerized, contrast, Doppler echocardiography. P. Hanrath, W. Bleifeld, J. Souquet (eds.). Boston, 1982; 188-201. 4 Ekberg 0, Nilsson PE, Aspelin P. Ultrasound guided percutaneous drainage of pericardial fluid with an indwelling catheter Forsch Rontgenstr 1986; 145: 413-416. 5 Goldberg BB, Pollach HM. Ultrasonically guided pericardiocentesis. Am J Cardiol 1983; 31: 490-493. 6 Jansen EWL, Vincent JG, Fast JH, Wielenga RP. Pericardiocentesis: een veilige drainage methode voor de subacute harttamponade. Ned Tijdschr Geneesk 1985; 129: 1190-l 192. 1 Guberman BA, Fowler ND, Engel PJ, Gueron M Allen JM. Cardiac tamponade in medical patients Circulation 1981; 64: 633-640. 8 Hayward et al. Drainage of neoplastic pericardial effusions. Lancet, 1983: 1018. 9 Kilpatrick ZM, Chapman CB. On pericardiocentesis. Am J Cardiol 1965; 16: 722-728. 10 Marfan AB. Ponction du pericarde per l’tpigastre. Ann MM Chir Inf (Paris) 1911; 15: 519-531. 11 Martin RP, Rakowski H, French J, Prop RL. Localisation of pericardial effusion with wide angle phased array echocardiography. Am J Cardiol 1978; 42: 904-912. 12 Merx W, Schweizer P, Krebs W, Effert S. Verbesserte Punktionstechnik des Perikards und Quantitizierung von Perikard ergiissen mittels Ultraschall. Dtsch Med Wochenschr 1979; 104: 19-21. catheterization of the pericar13 Nordenstrom B. Percutaneous dium. Acta Radio]. (Diagn) Stockholm 1966: 4: 622-670. 14 Redel D, Fehshe W, Meijer R. Diagnostik und Therapie des Perikardergusses mit Hilfe der zwei Dimensionalen Doppler: echokardiografle Forschr Rijntgenstr 1980; 133: 501-505. 15 Santos GH, Frater RWM. The subxiphoid approach in the treatment of pericardial effusion Ann Thorac Surg 1977; 23: 461-410. 16 Vincent JG, Jansen E, Fast J. Puncture drainage of pericardial effusions. Cook Quarterly 1989; 2: l-5.
147-149
147
Elsevier
EURRAD
00127
Percutaneous ultrasound-guided management of pericardial fluid W.H.J. Department
(Received
Key words: Heart, pericardial
Sanders and L.E.H. Lampmann
of Radiology, St. Elisabeth Hospital, Tilburg, The Netherlands
6 July 1990; accepted
fluid; Heart, pericardiocenthesis;
after revision 29 September
Pericardial fluid
1990)
fluid, US guided aspiration;
Interventional
radiology, pericardial
Abstract The use of a Rotex screw biopsy needle is advocated for percutaneous ultrasound-guided management of pericardial fluid. This procedure is performed under sonographic guidance while the needle tip is clearly visualized during introduction, thereby improving optimal placement and limiting the possibility of complications.
Introduction Compression of the heart occurs when an increasing amount of fluid in the pericardial space will become clinically evident and the cardiac output will decrease. In the case of an acute myocardial infarction or a perforating trauma, a large amount of pericardial fluid may develop very quickly. The typical clinical signs are mentioned in the socalled triad of Beck, including increased venous pressure, falling blood pressure and weak heart sounds. A paradoxical pulse is an important clue to the presence of cardiac tamponade, and the electrocardiogram may demonstrate a reduction in amplitude of the QRS complexes and an electrical alternans of the PQRS, and T waves [ 3,4,6,7,16]. Echocardiography has become the procedure of choice for the diagnosis of pericardial effusion [ 1,5,6,11,12,16]. In case of a severe cardiac tamponade, quick drainage of the pericardial fluid is obligatory. Until now blind pericardial puncture and aspiration with the help of a needle, inserted from a point directly under the xyphoid region, was the method of choice. This proceAddress for reprints: W.H.J. Sanders, M.D., Department of Radiology, St. Elisabeth Hospital, Postbox 9015 1, Hilvarenbeekseweg 60, 5000 LC Tilburg, The Netherlands. 0720-048X/91/$03.50
0 1991 Elsevier Science Publishers
dure is certainly not without danger, since incorrect positioning of the needle may be hazardous. Sonographically guided percutaneous drainage procedures are considered to be the methods of choice for treatment of most fluid collections in the abdomen. A similar approach for selected patients with pericardial fluid collections has already been widely reported in literature. The case of sonographically guided percutaneous pericardiocentesis eliminates complications. We describe our experience with the Rotex screw biopsy needle which has some advantages that will be described in this paper. Case reports Case 1 is a 65-year-old female with rheumatoid arthritis and a history of ischaemic heart disease who was admitted to our hospital for progressive pain irradiating to the neck. Ultrasonography (Aloka 650, 5 MHz transducer) demonstrated a sonolucent space around the heart with a depth of almost 1.5 cm. Diagnostic aspiration puncture was performed with a 20 G Rotex screw biopsy needle under sonographic guidance. The inner corkscrew stylet was positioned just in the tip of the outer needle in order to create good visibility of the needle. Once the needle was positioned in the sonolucent zone around the heart (Fig. l), the stylet was removed
B.V. (Biomedical
Division)
Fig. 1. Rotex needle tip well visualised within the fluid-filled pericardial sac. The three small arrows delineate the pericardial fluid collection. The larger arrow points to the tip of the needle.
and fluid was aspirated for cytology. After proper medication the patient improved and was discharged. Case 2 is a 68-year-old female referred to the hospital with progressive shortness of breath. Six years earlier she had been subjected to a mastectomy for lobular carcinoma. A high central venous and a low arterial blood pressure were measured. Cardiac rumbles and/or pericardial crepitations were not heard. Ultrasonography showed a considerable amount of free fluid in front of and lateral to the heart. Under sonographic guidance an initial puncture was performed with a 20 G Rotex screw biopsy needle. When fluid was aspirated, a 0.21 Fr J-shaped guidewire was maneuvered under fluoroscopy into the pericardial and catheter manipulations are space. Guidewire preferably performed under fluoroscopic control.
Fig. 2. The eight French pigtail catheter well positioned cardial space; final result.
in the peri-
Exchange for a five Fr dilator and then for a 0.38 J-shaped guidewire was followed by the introduction of a peel-away/dilator assembly. After removal of the dilator, an eight Fr pigtail catheter was placed for drainage (Fig. 2). Under antibiotic protection the drain stayed in situ for 4 days. When the complaints ceased the drain was removed. Case 3 is a 74-year-old male suffering from hypertension and ischaemic heart disease. He was admitted with progressive retrosternal pain irradiating to the back and the left arm. After 2 days he suddenly developed a bradycardia and his arterial blood pressure dropped, while the central venous blood pressure increased. The suspicion of acute pericardial tamponade was confirmed by cardiac ultrasonography. Since the clinical condition of the patient deteriorated dramatically, no further time could be lost and an instant drainage procedure was performed under sonographic guidance. Almost 300 cc blood was removed and the catheter was connected to a drainage system. The patient improved immediately and was subsequently referred to a centre for cardiosurgery where a rupture of the atrium was closed. No further complications were encountered. Discussion Clinically pericardial fluid can be divided in acute, subacute or chronic pericardial effusion, originating from infectious, non-infectious and/or auto-immune pericarditis. For the diagnosis of pericardial effusion, echocardiography is today the method of choice, since it is simple to perform and specific. In case of pericardial fluid, a relatively echo-free space between the posterior pericardium and the left ventricular epicardium can be demonstrated. The heart may swing freely within the pericardial sac, when the effusions are large. A distance of 2-3 cm between myocardium and diaphragmatic part of the pericardium is sufficient for a save puncture procedure and guidewire manipulations [ 41. Traditionally, pericardial puncture for the removal of pericardial fluid has been accomplished either as an open surgical procedure or by means of percutaneously performed blind puncture. Up to the present day, the subxyphoid approach is still a standard blind procedure, performed by either the left parastemal or the subxyphoid approach [lo]. The needle is inserted at a 45-degree angle and advanced until fluid is encounted. The initial puncture may be followed by a J-shaped wire and drainage catheter which are positioned via the so-called Seldinger technique [ 131. Gubermann re-
149
ported a 7-15x incidence of major complications and a mortality rate of 4-19% and considered the use of pericardiotomy because of the inherent risks of blind pericardiocentesis [ 71. Goldberg [ 5] was the first to report the use of sonography for guidance during pericardiocentesis. Calahan [l] reported the use of a 14 to 16 G Teflonsheeted needle. Once the needle-tip had entered the pericardial space, the Teflon sheet was advanced while withdrawing the needle itself. They described a left subcostal/subxyphoid and/or apical-intercostal approach. No complications were encountered in a patient population of 40 individuals. Jansen and Vincent [6,16] described their IO-year experience in 116 patients with pericardial effusions [6,16]. They advocated the introduction of a Redon Drain connected with a vacuum bottle through an introducer sheet, and they initiated the development of a complete pericardial puncture drainage set (PV lO.O.NLllO, Cook Denmark) that has the advantage of better drainage. The results and recurrence rates in their blind procedures, pericardiotomy method and ultrasonographically guided drainage procedures were scored. The recurrence rate for blind procedures was 92%, for subxyphoid pericardiotomy 3 1 y0 ; for antero-lateral pericardiotomy 5 %, and for medianpericardiotomy 20 %, however for the ultrasonographically guided drainage procedure it was just 7 %. Based on their experience, they advocate the ultrasonographically guided drainage puncture as the first method of choice in pericardial effusion. We share the opinion that the method of puncture and/or drainage procedure depends on the site of the procedure and the availability of equipment and personnel. The clinical history of the patient is very important and may be an indication for the planning of an aspiration puncture or, even in an acute fase, a swift and quick drainage procedure with an indwelling catheter. - The Rotex biopsy needle has some important advantages. The tip of the cork-screw stylet is just left within the outer needle, and during sonographic guidance the tip of such a needle is clearly visible, making puncture of the pericardial space very easy. - When catheter drainage is necessary after the initial puncture, sonographic guidance with a Rotex needle is followed by withdrawal of the stylet; a 0.21 Fr guidewire is introduced under further fluoroscopic control in the pericardial space. The outer Rotex needle is exchanged for a 5 Fr dilator and a 0.35 or 0.38 J-shaped guidewire. Over this guidewire an introducer set with a peel-away sheet is manipulated after withdrawal of the
dilator and a pigtail catheter can be manipulated into the pet&u-dial space. The peel-away sheet is removed and the pigtail catheter can be secured to the skin. - In an acute fase the use of so-called one-step trocar method is advised to avoid sheet and catheter manipulations. A short pigtail catheter can be mounted on an appropriate needle and the whole assembly is introduced in one step in the direction of the pericardial fluid under ultrasonographic guidance. When the tip is appreciated in the pericardial fluid the needle is secured and the catheter advanced until the curve of the pigtail sets into the pericardial space.
References 1 Callahan JA. Pericardiocentesis assisted by two-dimensional echocardiography. J Thorac Cardiovasc 1983; 85: 877-879. 2 Chandraratna PAN, First J, Langevin E, O’Dell R. Echocardiographic contrast studies during pericardiocentesis. Ann Intern Med 1977; 87: 199-200. 3 Cikes J. New echocardiographic possibilities in the etiological diagnosis and therapy of pericardial diseases. Cardiovascular diagnosis by ultrasound: transoesophageal, computerized, contrast, Doppler echocardiography. P. Hanrath, W. Bleifeld, J. Souquet (eds.). Boston, 1982; 188-201. 4 Ekberg 0, Nilsson PE, Aspelin P. Ultrasound guided percutaneous drainage of pericardial fluid with an indwelling catheter Forsch Rontgenstr 1986; 145: 413-416. 5 Goldberg BB, Pollach HM. Ultrasonically guided pericardiocentesis. Am J Cardiol 1983; 31: 490-493. 6 Jansen EWL, Vincent JG, Fast JH, Wielenga RP. Pericardiocentesis: een veilige drainage methode voor de subacute harttamponade. Ned Tijdschr Geneesk 1985; 129: 1190-l 192. 1 Guberman BA, Fowler ND, Engel PJ, Gueron M Allen JM. Cardiac tamponade in medical patients Circulation 1981; 64: 633-640. 8 Hayward et al. Drainage of neoplastic pericardial effusions. Lancet, 1983: 1018. 9 Kilpatrick ZM, Chapman CB. On pericardiocentesis. Am J Cardiol 1965; 16: 722-728. 10 Marfan AB. Ponction du pericarde per l’tpigastre. Ann MM Chir Inf (Paris) 1911; 15: 519-531. 11 Martin RP, Rakowski H, French J, Prop RL. Localisation of pericardial effusion with wide angle phased array echocardiography. Am J Cardiol 1978; 42: 904-912. 12 Merx W, Schweizer P, Krebs W, Effert S. Verbesserte Punktionstechnik des Perikards und Quantitizierung von Perikard ergiissen mittels Ultraschall. Dtsch Med Wochenschr 1979; 104: 19-21. catheterization of the pericar13 Nordenstrom B. Percutaneous dium. Acta Radio]. (Diagn) Stockholm 1966: 4: 622-670. 14 Redel D, Fehshe W, Meijer R. Diagnostik und Therapie des Perikardergusses mit Hilfe der zwei Dimensionalen Doppler: echokardiografle Forschr Rijntgenstr 1980; 133: 501-505. 15 Santos GH, Frater RWM. The subxiphoid approach in the treatment of pericardial effusion Ann Thorac Surg 1977; 23: 461-410. 16 Vincent JG, Jansen E, Fast J. Puncture drainage of pericardial effusions. Cook Quarterly 1989; 2: l-5.
