Prospective evaluation of pericardial catheter placement versus needle pericardiocentesis in the management of canine pericardial effusion.

OBJECTIVE: To compare the safety and efficacy of pericardial catheter placement with needle pericardiocentesis in dogs with pericardial effusion (PE) DESIGN: Prospective, randomized clinical trial. SETTING: University teaching hospital. ANIMALS: Thirty client-owned dogs requiring pericardiocentesis between January 2017 and August 2019. INTERVENTIONS: Dogs were randomized to undergo PE drainage via indwelling pericardial catheter placement (catheter group) followed by elective drainage every 4-6 hours or needle pericardiocentesis (needle group) repeated as necessary. MEASUREMENTS AND MAIN RESULTS: Fifteen dogs were allocated to the catheter group and 15 to the needle group. Data collected included signalment, cause of effusion, occurrence of arrhythmias pre-, during, and post-pericardiocentesis, procedural length, and details of repeated drainages. There was no significant difference between mean procedural times for pericardial catheter placement (17.7 min [±11.8]) and needle pericardiocentesis (12.1 min [±8.6]) (P = 0.192) or the rate of new arrhythmias in the catheter (36%) and needle (64%) groups (P = 0.24). Pericardial catheters were kept in situ for a median of 21 hours (range, 14-85). Three of 15 (20%) dogs in the needle group required repeated pericardiocentesis within 24 hours of initial pericardiocentesis. Pericardial catheters enabled repeated large volume PE drainage in 4 cases (median, 10.6 mL/kg; range, 8-5-10.6). CONCLUSIONS: Pericardial catheters appear to offer a safe alternative to needle pericardiocentesis. Minimal sedation is required for placement, and they can be placed quickly. Their indwelling nature and use was not associated with a higher rate of arrhythmia compared to that of needle pericardiocentesis alone, and may be beneficial in the event that clinically significant PE recurs.

[Pericardiocentesis - step by step]. / Perikardpunktion ­ Schritt für Schritt.

A pericardial effusion can be caused by malignant, infectious and autoimmune diseases or by trauma, such as a coronary artery rupture during a cath procedure. In the case of a cardiac tamponade a pericardiocentesis has to be performed immediately.Additionally, a pericardiocentesis may also be performed for diagnostic purposes. However, since histologic and microbiologic findings are rarely pointing to hitherto unsuspected results, the risk of the procedure must very carefully be weighed against its benefits. The risks of a pericardiocentesis include injuries to the lungs and liver as well as the heart itself, such as puncture of the right ventricle or the rupture of a coronary artery.This article is a step-by-step description of how to safely perform an ultrasound-guided pericardiocentesis.

Cardiac tamponade complicating thoracentesis in a patient after left pneumonectomy: A case report.

RATIONALE: Therapeutic or diagnostic thoracentesis is widely used in different clinical settings. Cardiac injury, a rare complication, could lead to fatal consequences. We describe a case of cardiac tamponade complicating thoracentesis that was recognized and rescued in a timely manner. PATIENT CONCERNS: A 42-year-old woman underwent blind thoracentesis due to excessive left pleural effusion after left pneumonectomy surgery. She suddenly lost consciousness and was in a state of shock a few minutes after needle insertion and fluid drainage. DIAGNOSIS: Bedside transthoracic echocardiography revealed pericardial effusion at a depth of 20 mm, and cardiac tamponade complicating thoracentesis was diagnosed. INTERVENTIONS: After draining 250 mL of non-coagulated blood by pericardiocentesis under transthoracic echocardiography guidance, a tube was placed for continuous drainage over the subsequent 36 hours. OUTCOMES: The patient's hemodynamic condition was stabilized hours after pericardiocentesis. The patient was discharged in good condition a few days later. LESSONS: Imaging assessment and guidance in the process of thoracentesis was indispensable, especially in a patient with altered intra-thoracic anatomy. Cardiac damage, as a life-threatening complication, should be considered once hemodynamic instability occurs during the procedure.

Evaluation of Pericardial Effusion in Dogs and Successful Treatment Using a Hemodialysis Fistula Needle: A Retrospective Study.

The aim of this retrospective study was to assess epidemiology and echocardiographic findings of pericardial effusion in canine patients and to determine the clinical usefulness and safety of a new pericardiocentesis technique, using a "fistula needle" for hemodialysis. A database of 5304 dogs of different breeds, age, gender, type, and severity of the cardiac disease, referred for a specialist cardiology and echocardiographic examination from 2009-2016, was reviewed. All the dogs were subjected to echocardiography; when possible and required, an echo-guided pericardiocentesis was performed by mean of a 17G "fistula needle" commonly used for hemodialysis. Complete echocardiography was repeated at the end of each pericardiocentesis. Pericardial effusion was identified by echocardiography in 91 dogs (1.71%), 20 were female (21.98%) and 71 were male (78.02%). PE caused cardiac tamponade in 38/91 cases (41.76%). A clear evidence of a neoplasm was found in 33 cases (36.26%). In 32 cases (35.16%) severe degenerative mitral and tricuspid valve disease was detected as the cause of the pericardial effusion. Echo-guided pericardiocentesis was performed in 28 cases (30.77%) with cardiac tamponade. No adverse effects were found in any of the patients during the 48 hours of follow up after pericardiocentesis. This study showed the high incidence of pericardial effusion due to severe bilateral degenerative valve disease in adult to elderly dogs of different breeds. Moreover, the use of a "fistula needle" for pericardiocentesis in dogs showed no adverse effects.

Long-term peritoneal port-catheter in a patient with cardiac ascites.

A peritoneal port-catheter was inserted in a 70-year-old man because of repeated paracentesis due to cardiac ascites. Instead of frequent hospital admissions, the patient could drain his ascites at home, which dramatically improved his quality of life and enabled him to perform his daily activities.

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.

The Parable of the Errant Chest Drain in the Heart: Is There Only 1 Option?

Accidental intraventricular placement of a pericardiocentesis catheter is a rare but well-recognized complication. Failure to achieve adequate hemostasis in the ventricular wall on removal of the catheter can potentially result in fatal consequences. Here we describe a case in which a chest drain (10.2F) accidentally entered into the right ventricle while attempting to drain pleural fluid, and the entry site was sealed using an Amplatzer VSD occluder device (St. Jude Medical, St. Paul, MN).

Controlled pericardiocentesis in patients with cardiac tamponade complicating aortic dissection: experience of a centre without cardiothoracic surgery.

BACKGROUND: Cardiac tamponade has been reported in 18.7% of patients with acute type A aortic dissection and its presence is associated with worse outcomes. Emergency aortic repair together with intra-operative pericardial drainage is the recommended treatment approach. However, controversy surrounds how to manage patients with haemopericardium and cardiac tamponade who cannot survive until surgery. PURPOSE: To describe a case series of patients with critical cardiac tamponade complicating aortic dissection admitted to a hospital without cardiothoracic surgery, and in whom preoperative controlled pericardial drainage was performed. METHODS AND RESULTS: Single centre retrospective study: during a nine-year period, 21 patients with Stanford type A aortic dissection were admitted at our centre; six of them (28.6%) presented clinical and echocardiographic signs of cardiac tamponade (four males; mean age 58±17 years). In this subgroup, controlled pericardiocentesis was safely performed with no major immediate complications and it was effective in five patients, improving haemodynamic instability and allowing transfer to the operating room. CONCLUSIONS: Preoperative controlled pericardiocentesis can be lifesaving when managing patients with critical cardiac tamponade (pulseless electrical activity or refractory hypotension) complicating acute type A aortic dissection, namely when cardiac surgery is not immediately available.

The efficiency of surgical subxiphoid pericardial drainage and percutaneous pericardial drainage in pericardial effusions associated with cardiac tamponade.

OBJECTIVES: The optimal management for pericardial effusions with cardiac tamponade remains controversial. This study compares the results after two commonly performed techniques: subxiphoid surgical pericardial drainage (DPSS) and percutaneous catheter drainage (DPPK). MATERIAL AND METHODS: We conducted a 5-year retrospective study to analyse the outcome after DPSS and DPPK in patients with non-traumatic pericardial effusions with cardiac tamponade. OUTCOMES: Patients with non-traumatic cardiac tamponade were treated with DPSS (N=138) and DPPK (N=54). There were no statistical differences between groups regarding: age, drainage volume and duration of drainage. The etiology was malignant in 72 patients and benign in 120 patients. The 2-year survival was statistically non-significant: 55,1% in the surgical group and 44,4% in the percutaneous group, but there was a slight prevalence of malignant diagnosis in the first group (38% versus 35%). The 1-year survival in patients with proved cyto- hystological malignancy was statistically poorer than in patients with malignant diagnosis and with both negative cytology and hystology (7% versus 33%). The 1-year freedom of re-intervention for recurrence of pericardial effusion was statistically better in the surgical group as in the percutaneous one (92.8% versus 79,6%). CONCLUSIONS: DPSS and DPPK can be both safely performed. DPSS appears to decrease intervention-necessitating recurrence, but it brings a minimal advantage for the malignant diagnosis over cytology alone.

Impact of controlled pericardial drainage on critical cardiac tamponade with acute type A aortic dissection.

BACKGROUND: Cardiac tamponade is associated with fatal outcomes for patients with acute type A aortic dissection, and the presence of cardiac tamponade should prompt urgent aortic repair. However, treatment of the patient with critical cardiac tamponade who cannot survive until surgery remains unclear. We analyzed our experience of controlled pericardial drainage (CPD) managing critical cardiac tamponade. METHODS AND RESULTS: Between September 2003 and May 2011, 175 patients with acute type A aortic dissection were treated surgically, including 43 (24.6%) who presented with cardiac tamponade on arrival. Eighteen patients, who did not respond to intravenous volume resuscitation, underwent CPD in the emergency department. An 8F pigtail drainage catheter was inserted percutaneously, and drainage volume was controlled by means of several cycles of intermittent drainage to maintain blood pressure at ≈90 mm Hg. After CPD, all of the patients were transferred to the operating room, and immediate aortic repair was performed. Systolic blood pressure before CPD was 64.3 ± 8.2 mm Hg and elevated significantly in all of the cases after CPD. Systolic blood pressure after CPD was 94.8 ± 10.5 mm Hg, and increase in systolic pressure was 30.5 ± 11.7 mm Hg. Total volume of aspirated pericardial effusion was 40.1 ± 30.6 mL, and 10 patients required only ≤30-mL aspiration volume. All of the patients underwent aortic repair successfully. In-hospital mortality was 16.7%; however, there was no complications or mortality related to CPD. CONCLUSIONS: Preoperative pericardial drainage with control of volume is a safe and effective procedure for acute type A aortic dissection complicated by critical cardiac tamponade. In our patient population, timely controlled pericardial drainage is warranted.

[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.

Highly controlled vascular syringes for pericardiocentesis.

OBJECTIVES: The present study determined the utility and needle control characteristics of highly controlled vascular syringes for image-guided pericardiocentesis. BACKGROUND: Vascular syringes have been integrated into invasive cardiovascular procedures with improved patient safety, but to date have not been used in pericardiocentesis. To address this issue, we determined the method of use of vascular syringes for pericardiocentesis. METHODS: A vascular syringe with reciprocating plungers, the reciprocating procedure device (RPD syringe), replaced the corresponding 10 ml and 20 ml conventional syringes in a standard pericardiocentesis tray. The vascular syringe is controlled with one hand, and can either aspirate or inject by pushing the corresponding aspiration or injection plunger. Four hundred and thirty seven subjects underwent vascular syringe procedures. The linear displacement method was used to precisely measure control of the needle tip in millimeters (mm) in vascular syringes compared to conventional syringes in 20 individual operators. RESULTS: Relative to the corresponding 10 ml and 20 ml conventional syringes, vascular syringes significantly reduced unintended forward penetration of the needle tip by 44% (7.0 ± 4.3 mm; p < 0.0001) and 53% (10.1 ± 5.5 mm; p < 0.0001), respectively, and reduced unintended retraction of the needle by 56% (2.7 ± 2.2 mm; p < 0.001) and 60% (3.5 ± 2.5 mm; p < 0.001), respectively. During pericardiocentesis, the mechanical syringe permitted facile one-handed aspiration and maintained the operator's ability to clear the needle. In the 437 vascular syringe procedures, there were no complications, with an estimated cost savings of $10-65 per procedure. CONCLUSION: Vascular syringes improve needle control in pericardiocentesis, promote patient safety and permit one-handed aspiration and injection.

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.

Prognosis of large, symptomatic pericardial effusion treated by echo-guided percutaneous pericardiocentesis.

BACKGROUNDS: The causes and prognosis of pericardial effusion (PE) may be different according to time, region, economy, and hospital. This study was performed to evaluate the etiology, clinical outcome, and prognosis of patients with large, symptomatic PE treated by echo-guided pericardiocentesis at Kangnam St. Mary's Hospital (the Catholic University of Korea, Seoul, Korea). HYPOTHESIS: According to etiologies of large, symptomatic PE, the prognosis of patients may be different. METHODS: We reviewed 116 consecutive patients who underwent echo-guided pericardiocentesis due to large, symptomatic PE over the last 12 y. The Kaplan-Meier survival curve with log-rank method was applied for the survival analysis. RESULTS: Procedural success rate of echo-guided pericardiocentesis was 99.1%. Common causes of PE requiring pericardiocentesis were lung cancer (27.6%), tuberculosis (TB) (13.8%), and uremia (6.9%). The mortality rate of 6 mo after the pericardiocentesis was 80.3% in malignant PE, whereas the over-all mortality rate was 18.2% in nonmalignant PE (p < 0.0001). Among the malignant PE, lung cancer (27.6%) and breast cancers (6.9%) were the most common causes. The mean cytologic detection rate and mean life expectancy of malignant PE were 44% and 5-7 mo. Patients with breast cancer and lymphoma had relatively better life expectancy (11.4 and 7.7 mo), whereas those with stomach cancer and metastases of unknown origin (MUO) had poorer prognosis (1.2 and 2.3 mo). The most common causes of nonmalignant PE were TB, uremia, and iatrogenic, and their mean life expectancy was approximately 54 mo. CONCLUSIONS: Malignancy, especially lung cancer and TB, were the most common causes of large symptomatic PE. The prognosis of large symptomatic PE was related to the underlying disease. Malignant PE was associated with the poorest prognosis.

Pericardial exploration by pericardioscopy during a surgical sub xyphoid approach.

This clinical feasibility study was planned to evaluate pericardioscopy as a means of control of the pericardial cavity during drainage for pericardial effusion by a surgical sub xyphoid approach. Seventeen patients who underwent an operation for surgical drainage of the pericardium (11 medical and 6 postoperative pericardial effusions) benefited from a pericardial exploration with a mediastinoscope or rigid thoracoscope (Karl Storz, Germany). In 7 of the 11 medical cases, a severe inflammation of the pericardium associated with false membranes was visualized; in 3 cases, the pericardium was considered as normal; and in 1 case, pericardial metastases were visualized. In the 6 postoperative cases, clots were visualized with a venous bypass graft and the pulmonary cannula of a right ventricular assist device (Thoratec, USA) was also perfectly controlled. The cause of bleeding was reported in one case and suspected in another, but required total sternotomy for repair in both cases. No mortality or morbidity was reported to be directly due to the technique. The peroperative assessment of pericardial cavity is possible by use of pericardioscopy with a satisfactory resolution, but visualization of the left lateral part of the heart remains difficult. The possibility exists to partially remove clots and false membranes, obtain various samples, and control the position of the drains. Improvement in the optic device with the possibility of a flexible device that has a tip protector for optimal visualization, may improve both the technique and results.