Abstract: 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.
J INVASIVE CARDIOL 2016;28(10):397-402. Epub 2016 August 15.
Key words: pericardiocentesis, ultrasound
Cardiac tamponade is a life-threatening condition which, when left untreated, is associated with major morbidity and mortality.1-3 Treatment involves prompt removal of fluid from the pericardial sac to relieve pericardial pressure. This may be done surgically through the creation of a pericardial window, or percutaneously via pericardiocentesis. In many institutions, pericardiocentesis is the initial treatment modality of choice.
Despite its clinical utility, the procedure is not without risks, principally, the inadvertent puncture of either the left or right ventricle.4-6 To minimize these risks, the procedure is often performed in the cardiac catheterization laboratory under fluoroscopic and echocardiographic guidance.7-10 The standard approach relies on entering the pericardial space using an 18 gauge needle in tandem with preprocedural echocardiographic guidance, but does not allow for continuous visualization of the needle tip during initial access.11 We sought to evaluate the outcomes in patients who underwent pericardiocentesis using an ultrasound-mounted needle guide – a technique that allows continuous ultrasonographic visualization of the micropuncture needle tip as it enters the pericardial space.
Study population. We retrospectively analyzed the records of all consecutive patients who underwent pericardiocentesis between November 1, 2011 and March 3, 2016 at our institution. Patients were identified using the International Classification of Diseases - Ninth Revision - Clinical Modification (ICD-9-CM) procedure code for pericardiocentesis (37.0). Following identification, patients were stratified into two groups: group 1 comprised patients who underwent pericardiocentesis under continuous ultrasonographic visualization using an ultrasound-mounted micropuncture needle guide (needle guide group); and group 2 comprised patients who underwent pericardiocentesis using the standard ultrasound-guided approach (standard group). Both techniques are described below. Procedure and safety-related endpoints were then compared between the two groups.
Continuous ultrasonographic assessment technique (Figure 1). Prior to pericardiocentesis, a limited bedside echocardiogram was performed in the catheterization lab with specific focus on the size and location of pericardial effusion. A mark was then placed on the skin overlying the site where the pericardial fluid size was most directly accessible and closest to the ultrasound probe. Patients were chosen for either left parasternal, apical, or subxyphoid approach based upon the echocardiographic findings and operator preference. The chosen area was sterilized using a 1 mL Chloraprep applicator (CareFusion) and sterile drapes were placed around the site. The superficial skin and the deeper tissues were then locally anesthetized using a 1% lidocaine solution.
A micropuncture needle guide (Civco) was then mounted onto the ultrasound probe. After the 21 gauge, 7 cm Micropuncture needle (Cook, Inc) was placed into the needle guide (Figure 2), the ultrasound probe was positioned onto the previously marked skin site. Under continuous ultrasonographic visualization of the needle tip, the needle was advanced into the pericardial space. After the needle tip was seen entering the pericardial fluid, a 40 cm stainless-steel Micropuncture wire was inserted through the needle into the pericardial space and a 5 Fr Micropuncture dilator was introduced over the wire to dilate the tract. A 90 cm J-tipped wire was then inserted through the dilator with its position confirmed by fluoroscopy. Finally, an 8.3 Fr drainage catheter (Boston Scientific) was advanced into the pericardial space. Fluid was aspirated through the drain, which was then connected to gravity and sutured in place using Ethicon (0) silk sutures.
Standard ultrasound-guided technique. Unlike the continuous ultrasonographic technique, the standard approach to pericardiocentesis utilized preprocedural echocardiography only. Echocardiography was used to identify the site where pericardial fluid was closest to the ultrasound probe and thereby provided the roadmap for needle insertion.11 After the skin overlying the access site was marked, the ultrasound probe was released and the skin accessed with a needle attached to a syringe. An 18 gauge needle was used to access the pericardial space in the majority (92%) of these patients. In 4 of the 51 patients undergoing standard pericardiocentesis, a 7 cm Micropuncture needle was used for pericardial access.
Negative back-pressure was applied to the plunger throughout the duration of needle access, until pericardial fluid was aspirated. Following successful needle access, a 90 cm J-tipped wire was introduced into the pericardial space. A dilator was then advanced over the wire to dilate the access tract. After the dilator was removed, an 8.3 Fr drainage catheter was advanced over the wire into the pericardial space with its final position confirmed by fluoroscopy.
All patients had a complete preprocedure and postprocedure echocardiographic assessment to evaluate for evidence of increased intrapericardial pressure and to estimate the pericardial fluid volume. Pericardial effusion size was defined based on two-dimensional echocardiographic parameters: small (<10 mm), moderate (10-20 mm), and large (>20 mm).12 Evidence of increased intrapericardial pressure was identified echocardiographically by the presence of right atrial collapse during ventricular systole, right ventricular diastolic collapse, and increased right-left ventricular interaction (variation in the transvalvular flow across the tricuspid valve of >40% and/or mitral valve of >25%).
Inclusion criteria. We included all patients over 18 years of age. One patient who had an unsuccessful attempt at pericardiocentesis during the active chest compression phase of a code was excluded. In the remaining cases, the procedure was performed for diagnostic and therapeutic purposes in patients who had a pericardial effusion and were symptomatic, had evidence of significant elevation of intrapericardial pressures by echocardiography, or were hemodynamically unstable or suspected to have an infectious or malignant pericardial effusion. Patients undergoing surgical pericardial window were not included.
Study endpoints. The primary endpoint of the study was procedural success, defined as the ability to successfully access and place a drainage catheter into the pericardial space. The secondary procedure-related endpoints included the ability to drain pericardial fluid, absolute amount of fluid removed, and postprocedure effusion size. The safety endpoints included procedure-related complications, in-hospital mortality, and length of hospital stay.
Statistical analysis. Continuous variables were evaluated using the two-sided t-test and expressed as means ± standard deviation. Categorical variables were evaluated using Pearson’s Chi-square test and expressed as frequencies and percentages. A test was considered to be statistically significant at a two-sided P-value <.05. SPSS version 20.0 (IBM Corporation) was used to perform the statistical analysis.
Between November 1, 2011 and March 3, 2016, a total of 72 patients underwent pericardiocentesis at our institution. Standard ultrasound-guided approach was used in 51 of these patients and was performed throughout the study period, with the remaining 21 patients undergoing pericardiocentesis under continuous ultrasonographic guidance with needle guide assistance (performed between December 2014 and March 2016). Baseline characteristics for the studied populations are listed in Table 1. There were similar rates of prior open-heart surgery, active cancer, and history of malignancy between the two groups. Patients in the standard group had higher rates of diabetes and hypertension.
Table 2 describes the various etiologies for pericardial effusion formation. The most common cause of pericardial effusion was idiopathic formation for both the needle guide (25%) and standard approach (35%) groups. Malignancy was the second most common etiology of effusion in the standard group, accounting for 30% of all effusions compared with 10% of malignant effusions in the needle guide group.
Echocardiographic characteristics of the groups are listed in Table 3. Most patients in the needle guide and standard groups had preserved left ventricular ejection fraction (63 ± 9% vs 54 ± 18%, respectively; P=.02). The effusion was moderate in size or greater in the majority of patients in both groups, with most of the effusions located circumferentially around the heart. Effusions were either partially or completely loculated in 18% of the patients in the standard approach group and in 5% of the patients undergoing pericardiocentesis under continuous ultrasonographic visualization (P=.13). Echocardiographic evidence of right ventricular diastolic collapse was present in 48% of the patients in the needle guide group and 53% of the standard group (P=.68).
Left parasternal access was used in the majority of patients in group 1 (86%) compared with the predominantly subxyphoid approach used in group 2 (84%) (Table 4). The primary endpoint of procedural success was achieved in 100% of patients in group 1 and in 94% of patients in group 2 (P=.35). The ability to remove pericardial fluid was similar between the two groups (93% vs 96%; P=.88). There were no complications in group 1 and two complications in group 2 (1 patient had a right ventricular perforation and 1 patient had right ventricular perforation and simultaneous new onset of atrial fibrillation). In both cases, right ventricular perforation was confirmed via injection of agitated saline through the drainage catheter and visualization of bubbles within the right ventricle. In both cases, a second try at pericardial access was attempted with subsequent successful access and pericardial fluid drainage. There were no deaths in either group. The amount of residual pericardial fluid and the total hospital length of stay were similar between the groups (Table 4).
In this study, we evaluated the safety and efficacy of pericardiocentesis performed using a 7 cm micropuncture needle under continuous ultrasound guidance compared with the standard technique. The major findings of our study are: (1) continuous ultrasound-guided approach was as effective as the standard approach in its ability to place a drainage catheter into the pericardial space and allow for successful fluid removal; and (2) continuous ultrasonographic guidance during pericardiocentesis had an excellent safety profile.
A drainage catheter was successfully placed into the pericardial fluid in all patients whose pericardiocentesis was performed under continuous ultrasonographic guidance compared with a 94% success rate seen in the standard group. The failure to advance the catheter to its optimal position in the standard approach group was seen in 3 patients, 2 of whom had loculated pericardial effusions. However, if successful catheter placement was achieved, the ability to remove pericardial fluid was similar between the two groups (95% vs 98%, respectively; P=.88). We did not encounter any difficulties with aspiration of the pericardial fluid through the narrow lumen of the micropuncture needle compared with the 18 gauge needle and found no significant difference in the total volume of fluid removed (640 mL vs 557 mL; P=.26, respectively). Failure to achieve fluid drainage after pericardial catheter placement was seen in 1 patient in the needle guide group who had a predominantly posterior effusion that was also loculated. Drainage was unsuccessful in 2 patients in the standard group, both of whom had loculated effusions.
Prior studies have reported lower success rates of pericardial fluid drainage in the presence of loculation.13 Therefore, it has been suggested that drainage of such effusions may require non-traditional entry sites to gain access to the pocket containing the largest amount of fluid.14,15 Kim et al described successful drainage of posterior loculated, as well as free-flowing but predominantly posterior effusions, using a transhepatic approach.14 Transhepatic access was thought to be superior to a subxyphoid approach in accessing the posterior pericardial compartment due to a more caudal orientation of the needle during access. Ceron et al successfully used transbronchial needle access in 3 patients with predominantly posterior pericardial effusions. The transbronchial access through the anterior wall of the left-lower bronchus successfully avoided myocardial puncture in these patients while achieving adequate drainage.16 In the presence of loculated malignant or purulent effusions, intrapericardial administration of thrombolytics such as tenecteplase17 and streptokinase18 has been suggested as a way to facilitate drainage. However, data on the use of thrombolytics is mostly based on case reports and small case series, and therefore necessitates confirmation with larger randomized clinical trials.17-20
Whereas there were no significant complications in the group of patients who underwent pericardiocentesis under continuous ultrasonographic visualization, 2 patients in the standard group (4%) sustained right ventricular perforation during initial access. Right ventricular perforation is a recognized complication of pericardiocentesis,7,13,14,21 with rates of procedure-related chamber perforation and resultant hemopericardium reported to occur in 0.4%-6.5% of cases. Although the perforation rate in the standard approach group was higher than previously reported in a large series,22 this is not unexpected given the relatively lower number of patients in our study (51 vs 352 cases). The smaller number of patients serves to amplify the complication rate by producing a smaller denominator (number of complications/all patients). Despite ventricular perforation, neither one of the patients in the current study developed hemodynamic compromise, required emergency surgery, or died as a result of the complication.
The majority of patients in the needle guide group were accessed using the left parasternal approach as compared with the predominantly subxyphoid access that was used in most patients in the standard approach group. The decision to use left parasternal access in the needle guide group was operator dependent and therefore unrelated to technical limitation. In fact, there were 4 patients in the standard approach group whose pericardiocentesis was successfully performed using the 7 cm micropuncture needle. In addition, successful subxyphoid approach during continuous ultrasound guidance of pericardiocentesis has been previously reported.23,24 In those cases, however, a micropuncture needle was not used.
The main benefit of continuous ultrasonographic guidance is the ability to visualize the needle tip as it traverses the soft tissues and enters the pericardial space. In fact, continuous visualization of the needle during pericardial access was possible in all 21 patients in the needle guide group. Visualization of the needle tip helps to prevent the operator from advancing the micropuncture needle too far, thereby potentially avoiding perforation. Maggiolini et al described a similar benefit to the use of continuous ultrasonographic guidance during pericardiocentesis in 53 consecutive patients requiring pericardial fluid drainage.25 In their series, needle tip was visualized in all 53 patients during pericardial entry without chamber perforation in any of the patients. The advantage of our technique over Maggiolini’s is our use of a smaller 21 gauge micropuncture needle compared to their 18 gauge needle. In the event that myocardial perforation was to occur with a micropuncture needle, the extent of damage would be expected to be lower than damage caused by perforation with the larger gauge. However, since a study evaluating comparative safety of micropuncture vs standard 18 gauge needle for femoral access did not demonstrate superiority of the micropuncture approach,26 larger patient populations are needed to better define comparative safety of micropuncture needle vs the standard 18 gauge needle during pericardiocentesis.
In our study, all procedures done under continuous ultrasonographic guidance were successfully performed by a single operator. This was yet another advantage over Maggiolini’s technique, wherein a two-operator approach was usually necessary (one to hold the ultrasound probe and the other to advance the needle) to provide continuous ultrasound guidance.25 The use of the ultrasound-mounted needle guide to house the 7 cm micropuncture needle allows a single operator to hold the ultrasound probe, advance the needle, and follow the needle trajectory on the ultrasound screen. Even though only one operator is needed to perform pericardiocentesis using the standard approach, this was possible because the procedures were performed without the benefit of continuous ultrasonographic guidance.
Study limitations. Our study is a single-center retrospective analysis that did not have the element of randomization. In addition, the small number of patients in the needle guide group did not provide enough power to detect statistical differences in the safety and efficacy outcomes. Nevertheless, our study provides the foundation for future larger studies that will better evaluate comparative effectiveness of continuous ultrasound guidance of micropuncture needle approach during pericardiocentesis with the standard technique. Further studies are also needed to evaluate the role of this approach in patients with predominantly posterior as well as loculated effusions. This is of particular importance in morbidly obese patients, where a 7 cm needle may not be of sufficient length to access the pericardium. Larger studies will also be needed to further evaluate the efficacy of micropuncture needle in aspirating highly viscous effusions (such as those found in patients infected with tuberculosis).
The results of our study suggest that continuous ultrasonographic visualization of the micropuncture needle during urgent pericardiocentesis is both safe and equally as effective as the traditional approach. Continuous ultrasound guidance allows for visualization of the myocardial border during needle entry, thereby helping to avoid cardiac chamber perforation and potential hemopericardium. At the same time, the use of a 21 gauge, 7 cm micropuncture needle provides a potential safety advantage over the standard 18 gauge needle in the event of myocardial perforation. Finally, the procedure can be easily performed by a single operator, while still affording the benefit of continuous ultrasonographic guidance.
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From the Division of Cardiovascular Diseases, Temple University Hospital, Philadelphia, Pennsylvania.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.
Manuscript submitted May 16, 2016, and accepted May 23, 2016.
Address for correspondence: Brian P. O’Neill, MD, Temple University Hospital, Division of Cardiovascular Diseases, 3401 N. Broad Street (9PP), Philadelphia, PA 19140. Email: Brian.O’firstname.lastname@example.org