Pericardiocentesis

Summary

The prevalence of pericardial effusion and cardiac tamponade is growing. This may reflect increasing survival of patients with advanced malignant disease and performance of increasingly complex cardiac interventions. Thus the management of pericardial effusions and cardiac tamponade are common challenges for today’s cardiologist. Furthermore, interventional cardiology is recognising the diagnostic and therapeutic potential of percutaneously accessing the pericardial space for drug delivery, pericardial biopsy, epicardial mapping and ablation of arrhythmogenic circuits.

This chapter describes a step-by-step approach to performing pericardiocentesis and provides an overview of procedural complications and patient management ( View chapter ). We describe approaches to the prevention and management of recurrent pericardial effusion and illustrate techniques such as percutaneous balloon pericardiotomy and other novel percutaneous pericardial procedures.

Introduction

The pericardial space, which lies between the inner visceral pericardium and the outer fibrous parietal pericardium, surrounds the heart and normally contains up to 50 mls of serous fluid [11. Braunwald’s Heart Disease – A textbook of Cardiovascular Medicine Seventh Edition. Edited by Zipes DP, Libby P, Bonow RO, Braunwald E. Elsevier Saunders. 2005. p. 1757. ]. The pressure in this space varies between -5 cm and +5 cm of water and fluctuates with changes in intrathoracic pressure during respiration [22. Feigenbaum H, Armstrong WF, Ryan T. Feigenbaum’s Echocardiography, Sixth Edition. Lippincott Williams and Wilkins. 2005. p. 255-260. Reference text on echocardiography.
The first use of echo was to diagnose pericardial effusion]. The volume of fluid in the pericardial space can pathologically increase as a result of disease, traumat­­­­­ic or iatrogenic processes, with an eventual rise in intrapericardial pressure.

Rising intrapercardial volume and pressure will initially be compensated for by compliance of the pericardium, but when intra-pericardial pressure rises to meet intracardiac pressure (at around 15-20mmHg), decompensation with progressive compression of the cardiac chambers occurs, restricting ventricular filling, with an eventual decline in cardiac output and subsequent cardiac tamponade. Cardiac tamponade is a clinical diagnosis characterised by the non-specific triad of hypotension, distended neck veins, and faint (“muffled”) heart sounds- so called Beck’s triad. Patients with cardiac tamponade can present anywhere along a spectrum from early, minimal haemodynamic compromise to later, circulatory collapse. The volume of pericardial fluid that produces cardiac tamponade varies and is particularly influenced by the duration over which it accumulates. Rapidly developing pericardial effusions can be of higher intra-pericardial pressure, producing tamponade at much smaller volumes than slowly accumulating effusions.

Echocardiography and haemodynamic assessment during invasive cardiac catheterisation provide important data during the assessment of pericardial effusions. Echocardiography, in particular, can be performed quickly at the bedside in the emergency setting to confirm cardiac tamponade ( Moving image 1 and Moving image 2 ). Focus Boxes 1A and B outline the key echocardiographic and haemodynamic findings in cardiac tamponade, but are not intended as a comprehensive list of all findings. Echocardiographic findings of a “pre-tamponade’ physiology may be over-sensitive, therefore in the absence of haemodynamic compromise, echocardiographic tamponade features are not a clear indication for intervention. Cardiac tamponade is a clinical emergency that demands immediate management, usually by needle pericardiocentesis. Pericardiocentesis involves needle puncture and catheter drainage of pericardial fluid [33. Baim DS. Grossman’s Cardiac Catheterization, Angiography, and Intervention, Seventh Edition. Lippincott Williams and Wilkins. 2006. Chapter 32: Profiles in Pericardial Disease; p. 725-743.
Reference text description of standard pericardiocentesis and drainage].

Indications for pericardiocentesis

Pericardiocentesis is both therapeutic, when a pericardial effusion that impedes ventricular filling is drained, and diagnostic because it provides fluid for analysis. The timing of pericardiocentesis is dictated by the clinical status of the patient. Pericardiocentesis is indicated as an emergency procedure for patients with existing or impending cardiac tamponade. In patients with pericardial effusion not causing tamponade, pericardiocentesis may be performed electively. Table 1 outlines the indications for pericardiocentesis.

Contraindications and cautions

In the setting of cardiac tamponade pericardiocentesis is a potentially lifesaving procedure and thus there are no absolute contraindications. However, there are situations where the risk associated with pericardiocentesis may be increased and where special precautions may be necessary. Furthermore, surgery may offer a superior alternative to needle pericardiocentesis in some situations.

Diagnostic pericardiocentesis for effusions measuring less than 20mm is not recommended; The procedural risk is high given a low diagnostic yield, with pericardititic effusions usually responding well to anti-inflammatory treatment [44. C.C. De Carlini, S. Maggiolini. Pericardiocentesis in cardiac tamponade: indications and practical aspects E-journal Cardiol Pract, 15 (2017). ].

Pericardiocentesis is contraindicated in patients with tamponade or haemopericardium due to a dissection of the ascending aorta. In such circumstances, pericardiocentesis may accelerate bleeding and precipitate shock [55. Hanaki Y, Yasui K, Kamiya H, Matsunami T, Ohsugi S, Ohno M, Horiba M, Hiramatsu H. New therapeutic approach to aortic dissection complicated by cardiac tamponade. Clin Ther. 1988;10:651-5. , 66. Isselbacher EM, Cigarroa JE, Eagle KA. Cardiac tamponade complicating proximal aortic dissection. Is pericardiocentesis harmful? Circulation. 1994;90:2375-8. ]. Emergency surgical repair of the aorta and drainage of the haemopericardium is therefore advocated. However, if a patient requires stabilisation prior to transfer to the operating room, small volume pericardiocentesis removing sufficient fluid only to achieve an improvement in blood pressure can be considered [66. Isselbacher EM, Cigarroa JE, Eagle KA. Cardiac tamponade complicating proximal aortic dissection. Is pericardiocentesis harmful? Circulation. 1994;90:2375-8. ].
Similarly, haemopericardium resulting from post-infarct ventricular free wall rupture or trauma often require surgical intervention [77. Huang YK, Lu MS, Liu KS, Liu EH, Chu JJ, Tsai FC, Lin PJ. Traumatic pericardial effusion: impact of diagnostic and surgical approaches. Resuscitation. 2010;81:1682-6. ]. A bleeding diathesis as indicated by a raised international normalised ratio (INR), prothrombin time (PT), activated partial thromboplastin Time (APTT) or thrombocytopaenia is a relative contraindication to non-emergent pericardiocentesis. Haemorrhagic risk may be reduced by considering, where appropriate, the role of vitamin K and blood products such as fresh frozen plasma, solvent/detergent treated fresh frozen plasma or platelets. In some recurrent or purulent effusions surgical management may also have advantages over needle pericardiocentesis. In addition, drainage of loculated effusions, posteriorly located effusions or small effusions may be technically difficult by the percutaneous route and more amenable to surgical management. Focus Box 2 summarises the circumstances where surgical management may be advantageous.

Performing a pericardiocentesis

PREPARATION

Informed consent is obtained from the conscious patient with capacity. Possible complications of pericardiocentesis as outlined in Table 2 must be explained as part of the consenting process. The procedure may performed in the catheterisation laboratory (if fluoroscopic guidance is planned) or at the bedside under echocardiographic guidance, such as in the Emergency Department or Coronary care Unit. Monitoring of heart rate, electrocardiograph (ECG), blood pressure, and oxygen saturations is necessary. A resuscitation trolley should be near the bedside. Echocardiography should be available. The equipment necessary is outlined in Figure 1 . Nowadays much of this equipment is conveniently available in commercially prepared pericardiocentesis packs. It is important to ensure that all necessary equipment is available before starting the procedure. Ideally, a sonographer and a nurse will be available as needed throughout the procedure.

Positioning the patient

The patient is positioned at a 30º to 45º head-up angle to permit pericardial fluid to pool on the inferior surface of the heart [88. The Cardiac Catheterization Handbook Fourth Edition. Edited by Kern MJ. Mosby. 2003. p. ]. The patient’s torso should be exposed.

Selecting an optimal approach

Before the patient is draped the most appropriate access site to the pericardial space is selected. Echocardiography can identify where pericardial fluid is most superficial. The aim is to enter the pericardial space at the site where the fluid is closest to the surface of the skin, thereby minimising risk of damage to intervening structures. The traditional approach has been the subxiphoid route. However, with echocardiographic guidance for pericardiocentesis becoming standard practice alternative chest wall entry sites are increasingly used, accounting for 76% of approaches in one series of 1,127 pericardiocenteses [99. Tsang TS, Enriquez-Sarano M, Freeman WK, Barnes ME, Sinak LJ, Gersh BJ, Bailey KR, Seward JB. Consecutive 1127 therapeutic echocardiographically guided pericardiocenteses: clinical profile, practice patterns, and outcomes spanning 21 years. Mayo Clin Proc. 2002;77:429-36.
Largest observational cohort on echo-guided percicardiocentesis published]. Figure 2 outlines various pericardiocentesis access site options. Once the optimal site had been selected using echocardiographic guidance, the operator should note the distance in centimetres from probe to fluid and observe the probe orientation, which indicates the direction in which the needle should be inserted.

Aseptic technique

Strict aseptic technique is essential to avoid introducing infection into the pericardial space. The selected site and surrounding area is prepared with antiseptic solution. A sterile eye drape allows access to the proposed entry site. Additional sterile drapes placed over the lower abdomen and lower limbs reduce risk of inadvertent contamination.

Local anaesthetic

One percent lignocaine is injected into the skin at the marked site. The deeper subcutaneous tissues along the proposed trajectory of the pericardiocentesis needle are also infiltrated with local anaesthetic.

ACCESSING THE PERICARDIAL SPACE

The needle, which may be a blunt tip epicardial needle, a graduated long 18-gauge Cook needle or a Micropuncture needle [Cook, Bloomington, IN, USA] is advanced along the trajectory noted from the echo probe earlier. A graduated needle allows the depth of insertion to be gauged, while a Micropuncture technique may be used to upsize into a pericardial drain when the operator is confident of correct intra-pericardial placement. If a subxiphoid or left paraxiphoid approach is used, the needle often enters the skin at a 90º angle and is then advanced at an angle of approximately 15º-30º (to manoeuvre beneath the costal margin) towards the tip of the left shoulder [1010. Lakhter V, Aggarwal V, Bashir R, O’Murchu B, Cohen HA, O’Neill BP. Pericardiocentesis Under Continuous Ultrasonographic Guidance Using a 7 cm Micropuncture Needle. J Invasive Cardiol. 2016 Oct;28(10):397-402. Epub 2016 Aug 15. , 1111. Arvind Gireesh, Shahnaz Punjani, Joseph Hannan. Use of Micropuncture Needle in the Treatment of Pericardial Effusion by Pericardiocentesis. Cath Lab Digest Volume 24 - Issue 10 - October 2016. , 1212. Spodick DH. Acute Cardiac Tamponade. N Engl J Med. 2003;349:684-90.
Excellent review article on emergency management of tamponade] ( Figure 3 ).

Negative pressure is applied to the needle as it is advanced. If no fluid is forthcoming on aspiration, further local anaesthetic in a 10ml syringe attached to the needle can be infiltrated into the tissues during advancement. Passage of the needle through the fibrous parietal pericardium into pericardial space often produces a characteristic pop. At this time, it should be possible to aspirate fluid.

CONFIRMING ENTRY INTO PERICARDIAL SPACE

In current clinical practice, a combination of haemodynamic monitoring and echocardiographic guidance is employed in confirming entry into the pericardial space during pericardiocentesis. Other techniques such as CT guidance or the use of endoscopy have also been described – these novel techniques may have greater use in so called “dry” pericardial access (in the absence of a significant pericardial effusion) for electrophysiological or structural interventional procedures [1313. Vilela EM, Ruivo C, Guerreiro CE, Silva MP, Ladeiras-Lopes R, Caeiro D, Morais GP, Primo J, Braga P, Ferreira N, Nunes JPL, Ribeiro VG. Computed tomography-guided pericardiocentesis: a systematic review concerning contemporary evidence and future perspectives. Ther Adv Cardiovasc Dis. 2018 Nov;12(11):299-307. doi: 10. 1177/1753944718792413. Epub 2018 Aug 15. , 1414. Nakatsuma K, Yamamoto E, Watanabe S, Bao B, Watanabe H, Kawase Y, Shizuta S, Kimura T, Saito N. Ultrathin Endoscopy-Guided Pericardiocentesis: A Pilot Study in a Swine Model. J Invasive Cardiol. 2016 Mar;28(3):78-80. ]. The various commonly used techniques that may be used to confirm correct entry into the pericardial space are described below and summarized in Focus Box 3.

Echocardiographic guidance

Continuous echocardiographical guidance of the needle may be performed. The needle may be loaded onto a manifold attached to an echo transducer, allowing the needle tip to be visualized entering the pericardial space (see Figure 4). Alternatively, the procedure may be performed with non continuous echocardiography. The operator may use echocardiography before and after the puncture in order to plan and confirm correct placement of the needle tip [1515. Osman A, Wan Chuan T, Ab Rahman J, Via G, Tavazzi G. Ultrasound-guided pericardiocentesis: a novel parasternal approach. Eur J Emerg Med. 2018 Oct;25(5):322-327. doi: 10. 1097/MEJ. 0000000000000471. , 1616. Battistoni I, Marini M, Angelini L, Francioni M, Gili A, Moretti S, Costantini C, Corinaldesi C, Bordicchia M, Perna GP. Safety and efficacy of non-continuous echocardiography-guided pericardiocentesis: a single-center study of 478 patients. Minerva Cardioangiol. 2017 Oct;65(5):451-457. doi: 10.23736/S0026-4725.16. 04190-6. Epub 2016 Nov 30. ]. To confirm accurate placement, 5-10 mls of agitated saline can be injected through the needle to confirm correct position. Bubbles should be seen arriving in the pericardial space ( Figure 5 ; Moving image 3 ). Bubbles in any of the cardiac chambers alerts the operator that the needle has been advanced too far. If no bubbles are seen on echocardiography, either the needle is in an extra-cardiac location or in the case of a very large effusion, it may be necessary to re-inject agitated saline and image from an alternative echo window.

Haemodynamic pressure monitoring

The aspiration needle can be connected to a three-way tap and a 10 ml syringe and pressure tubing connected to each port respectively. Transducing the pressure tubing will facilitate examination of the intrapericardial pressure waveform, which should not resemble the right ventricular (RV) pressure waveform ( Figure 6 ). If a RV pressure waveform is observed, the needle has been advanced too far, entering the RV and should to be slowly withdrawn until the RV pressure waveform is replaced by an intrapericardial pressure waveform.

Electrocardiographic monitoring

The shaft of the aspiration needle can be attached via a sterile alligator clip to a V lead of an ECG machine. The ST segment is isoelectric in the pericardial space. However, if the needle is advanced through the pericardial space and contacts with the epicardium, ST-segment elevation (or premature ventricular complexes) is observed. Withdrawal of the needle slowly back into the pericardial space will result in resolution of the ST-segment elevation. This technique aims to reduce the risk of ventricular puncture. Similarly, PR segment elevation or premature atrial complexes are observed if the needle has been advanced into the right atrium.

Fluroscopic guidance

a) A small volume of contrast can be injected through the needle under fluoroscopy to confirm appropriate placement in the pericardial space ( Figure 76 ). Typically contrast will pool in the dependent portion of the pericardial space. b) Alternatively, a 0.035-inch J wire can be advanced through the needle under fluoroscopy. It should be seen to wrap around the heart within the mediastinal silhouette and advance easily without resistance. Guidewire position should be confirmed on two orthogonal planes (eg lateral and A-P), as pPassageassage outside of this silhouette indicates an extra-pericardial location.

DRAINAGE CATHETER PLACEMENT

Needle pericardiocentesis is a Seldinger-based technique. Once placement of the needle into the pericardial space has been confirmed, and it is possible to aspirate fluid, a 0.035-inch J wire can be advanced through the needle easily and without resistance. The J wire should not be forced against resistance. The needle is then withdrawn leaving the guidewire in the pericardial space. A 6-8 Fr dilator is advanced over the wire to prepare the path to the pericardial space for the 6-8 Fr pigtail drainage catheter (with an end hole and side holes). The dilator is removed, leaving the guidewire in situ and the catheter is then advanced over the wire into the pericardial space. To confirm correct placement of catheter in the pericardial space, the same techniques outlined above for confirming needle position can be repeated (Focus Box 3). The end of the pigtail catheter is attached to a three-way tap that has a 50 ml Luer-lock aspiration syringe attached to one port and tubing leading to a drainage bag/bottle attached to the other port. By using a three-way system, fluid can be aspirated into the 50ml syringe and then delivered into the collection bag and repeated as necessary. The drainage catheter is increasingly sutured in position for a period of extended drainage [1616. Battistoni I, Marini M, Angelini L, Francioni M, Gili A, Moretti S, Costantini C, Corinaldesi C, Bordicchia M, Perna GP. Safety and efficacy of non-continuous echocardiography-guided pericardiocentesis: a single-center study of 478 patients. Minerva Cardioangiol. 2017 Oct;65(5):451-457. doi: 10.23736/S0026-4725.16. 04190-6. Epub 2016 Nov 30. ]. The skin entry site of the drain should be covered with a clear adhesive dressing.

PERICARDIAL FLUID ANALYSIS

Aseptically obtained pericardial fluid is placed in appropriate specimen bottles and sent for microbiological (gram staining, Ziehl-Nielsen staining, culture and sensitivity), biochemical, haematological, immunological and cytological studies as deemed appropriate. Cytological analysis to assess for occult malignancy particularly influences prognosis, as in a previously undiagnosed malignancy, the presence of a pericardial effusion denotes significantly worse survival[1717. Strobbe A, Adriaenssens T, Bennett J, Dubois C, Desmet W, McCutcheon K, Van Cleemput J, Sinnaeve PR. Etiology and Long-Term Outcome of Patients Undergoing Pericardiocentesis. J Am Heart Assoc. 2017 Dec 23;6(12). pii: e007598. doi: 10.1161/JAHA. 117. 007598. ]. There are mixed reports on the yield from pericardial fluid analyses; this is particularly true for analyses other than microbiological or cytological, but it is generally accepted that routine evaluation of pericardial fluid is warranted in cases of effusions of uncertain aetiology [1818. Ben-Horin S, Bank I, Shinfeld A, Kachel E, Guetta V, Livneh A. Diagnostic value of the biochemical composition of pericardial effusions in patients undergoing pericardiocentesis. Am J Cardiol. 2007;99:1294-7.
Long observational cohort illustrating the limitations of laboratory analysis of pericardial effusions, 1919. Eroles Vega G, Rondón Fernández P, Ferreiro López D, Romero Pérez C, Salcedo Pérez S, Lacambra Calvet C, Cuesta Alvaro P, Díaz Abad R, Solís Villa J. Analysis of 73 cases of significant pericardiac effusion. [Article in Spanish] Rev Clin Esp. 2004;204:125-30. , 2020. Imazio M, Trinchero R. Clinical management of acute pericardial disease: a review of results and outcomes. Ital Heart J. 2004;5:803-17. , 2121. Karatolios K, Alter P, Maisch B. Differentiation of malignant from nonmalignant, inflammatory pericardial effusions with biomarkers. [Article in German]. i. 2009;34:624-33. , 2222. Petcu DP, Petcu C, Popescu CF, Ba˘ta˘iosu C, Alexandru D. Clinical and cytological correlations in pericardial effusions with cardiac tamponade. Rom J Morphol Embryol. 2009;50:251-6. , 2323. Ojeda W, Martínez-Toro JA. Diagnosis and management of pericardial effusions. P R Health Sci J. 2006;25:255-8. ].

Inadvertent placement of the needle/drain into a cardiac chamber is often the concern when haemorrhagic fluid is aspirated. The following features suggest haemorrhagic pericardial fluid rather than frank blood has been aspirated:
a) fluid with a lower haematocrit than intravascular blood;
b) fluid that does not clot easily when placed in a Z Serum Clot Activator tube.

However, these features whilst suggestive are not absolute. For example, pericardial fluid obtained in cases of haemopericardium from trauma or aortic dissection may well clot. Furthermore, because pericardial blood usually undergoes rapid fibrinolysis, a low haematocrit does not exclude bleeding [2424. Braunwald’s Heart Disease – A textbook of Cardiovascular Medicine Seventh Edition. Edited by Zipes DP, Libby lP, Bonow RO, Braunwald E. Elsevier Saunders 2005. p. 1769. ].

POST-PERICARDIOCENTESIS MANAGEMENT

The main aspects of managing a patient post-pericardiocentesis are listed below and summarised in Focus Box 4:
1) Record patient’s vital signs and review clinical status at appropriate intervals, observing in particular for complications of pericardiocentesis ( Table 2 ).
2) Obtain a chest radiograph immediately post procedure to exclude a complicating pneumothorax.
3) Pericardial pain may follow aspiration of a pericardial effusion. Such pain can be managed using a non-steroidal anti-inflammatory agent or a narcotic analgesia.
4) The drain can be left on free drainage, intermittent manual aspiration, or continuous/intermittent suction applied via a water-seal device.
5) Record volume of pericardial fluid draining at regular intervals.
6) Under aseptic technique the drain should be flushed with sterile heparinised saline to maintain patency every 6 to 8 hours.
7) There is no consensus on the role of antibiotic prophylaxis peri-pericardiocentesis, and there is no consistent practice pattern among hospitals. The antibiotic selected for prophylaxis should cover gram-positive bacteria, such as a first-generation cephalosporin. There is a risk of introducing infection whilst the pericardial drain remains in situ and thus, the threshold for antibiotic prophylaxis is often lower in such situations.
8) To reduce the risk of infection, a strict aseptic technique must be observed each time the drain is manipulated and the duration of catheter stay must be kept to a minimum. The clinical status of the patient, echocardiographic resolution of the effusion and volume draining will influence the timing of removing the drain. When the volume of fluid draining is less than 25-50 mls in 24 hours, the drain should be removed [99. Tsang TS, Enriquez-Sarano M, Freeman WK, Barnes ME, Sinak LJ, Gersh BJ, Bailey KR, Seward JB. Consecutive 1127 therapeutic echocardiographically guided pericardiocenteses: clinical profile, practice patterns, and outcomes spanning 21 years. Mayo Clin Proc. 2002;77:429-36.
Largest observational cohort on echo-guided percicardiocentesis published, 2525. Maisch B, Seferovic’ PM, Ristic’ AD, Erbel R, Rienmüller R, Adler Y, Tomkowski WZ, Thiene G, Yacoub MH; Task Force on the Diagnosis and Management of Pricardial Diseases of the European Society of Cardiology. Guidelines on the Diagnosis and Management of Pericardial Diseases Executive Summary. EHJ. 2004;25:587-610.
Contemporary European guidance on the management of pericardial disease]. When the volume of fluid draining after 3 days exceeds 75-100 mls/24 hours, more definitive therapy to prevent re-accumulation following drain removal should be considered. In the event of fever/sepsis, the drain should be removed immediately.
9) An echocardiogram should be performed prior to drain removal. On removing the drain, a schedule for surveillance echocardiography should be specified to screen for re-accumulation of the effusion. In the event of haemodynamic instability following drain removal, an echocardiogram should be performed immediately.

Complications of pericardiocentesis

Serious complications are comparatively common with traditional “blind” pericardiocentesis than with echocardiographically guided pericardiocentesis, and thus “blind” pericardiocentesis should be restricted to emergency situations only [1818. Ben-Horin S, Bank I, Shinfeld A, Kachel E, Guetta V, Livneh A. Diagnostic value of the biochemical composition of pericardial effusions in patients undergoing pericardiocentesis. Am J Cardiol. 2007;99:1294-7.
Long observational cohort illustrating the limitations of laboratory analysis of pericardial effusions, 1919. Eroles Vega G, Rondón Fernández P, Ferreiro López D, Romero Pérez C, Salcedo Pérez S, Lacambra Calvet C, Cuesta Alvaro P, Díaz Abad R, Solís Villa J. Analysis of 73 cases of significant pericardiac effusion. [Article in Spanish] Rev Clin Esp. 2004;204:125-30. ]. Echocardiographically guided pericardiocentesis is effective and safe, with procedural success rates quoted as 97-100% and rates of major and minor complications reported at 0.7-3% and 2-3.5%, respectively [99. Tsang TS, Enriquez-Sarano M, Freeman WK, Barnes ME, Sinak LJ, Gersh BJ, Bailey KR, Seward JB. Consecutive 1127 therapeutic echocardiographically guided pericardiocenteses: clinical profile, practice patterns, and outcomes spanning 21 years. Mayo Clin Proc. 2002;77:429-36.
Largest observational cohort on echo-guided percicardiocentesis published, 1212. Spodick DH. Acute Cardiac Tamponade. N Engl J Med. 2003;349:684-90.
Excellent review article on emergency management of tamponade, 2828. Cho BC, Kang SM, Kim DH, Ko YG, Choi D, Ha JW, Rim SJ, Jang Y, Chung N, Shim WH, Cho SY, Kim SS. Clinical and echocardiographic characteristics of pericardial effusion in patients who underwent echocardiographically guided pericardiocentesis: Yonsei Cardiovascular Center experience, 1993-2003. Yonsei Med J. 2004;45:462-8. , 2929. Tsang TS, Freeman WK, Barnes ME, Reeder GS, Packer DL, Seward JB. Rescue echocardiographically guided pericardiocentesis for cardiac perforation complicating catheter-based procedures. The Mayo Clinic experience. J Am Coll Cardiol. 1998;32:1345-50. , 3030. Salem K, Mulji A, Lonn E. Echocardiographically guided pericardiocentesis - the gold standard for the management of pericardial effusion and cardiac tamponade. Can J Cardiol. 1999;15:1251-5. ].

Reported complications include viscus perforation, pneumothorax, bleeding (haemothorax, haemopericardiun, haemoperitoneum, liver haematoma), infection, laceration of a coronary artery/intercostal artery, perforation of the cardiac chambers, right ventricular pseudoaneurysm following puncture of the right ventricle, arrhythmia, pleuropericardial fistulae, hypotension, and rarely death ( Table 2 ) [2828. Cho BC, Kang SM, Kim DH, Ko YG, Choi D, Ha JW, Rim SJ, Jang Y, Chung N, Shim WH, Cho SY, Kim SS. Clinical and echocardiographic characteristics of pericardial effusion in patients who underwent echocardiographically guided pericardiocentesis: Yonsei Cardiovascular Center experience, 1993-2003. Yonsei Med J. 2004;45:462-8. , 2929. Tsang TS, Freeman WK, Barnes ME, Reeder GS, Packer DL, Seward JB. Rescue echocardiographically guided pericardiocentesis for cardiac perforation complicating catheter-based procedures. The Mayo Clinic experience. J Am Coll Cardiol. 1998;32:1345-50. , 3030. Salem K, Mulji A, Lonn E. Echocardiographically guided pericardiocentesis - the gold standard for the management of pericardial effusion and cardiac tamponade. Can J Cardiol. 1999;15:1251-5. , 3131. Patanè F, Sansone F, Centofanti P, Rinaldi M. Left ventricular pseudoaneurysm after pericardiocentesis. Interact Cardiovasc Thorac Surg. 2008;7:1112-3. , 3232. Petrov I, Dimitrov C. Closing of a right ventricle perforation with a vascular closure device. Catheter Cardiovasc Interv. 2009;74:247-50. ].

Acute pulmonary oedema can follow rapid drainage of pericardial effusions, particularly if the effusion is chronic [3333. Vandyke WH, Jr, Cure J, Chakko CS, Gheorghiade M. Pulmonary edema after pericardiocentesis for cardiac tamponade. N Engl J Med. 1983;309:595-6. , 3434. Bernal JM, Pradhan J, Li T, Tchokonte R, Afonso L. Acute pulmonary edema following pericardiocentesis for cardiac tamponade. Can J Cardiol. 2007;23:1155-6. , 3535. Karamichalis JM, Gursky A, Valaulikar G, Pate JW, Weiman DS. Acute pulmonary edema after pericardial drainage for cardiac tamponade. Ann Thorac Surg. 2009;88:675-7. ]. Similarly, transient acute left ventricular dysfunction and cardiogenic shock have been reported [3636. Sevimli S, Arslan S, Gündog˘du F, Senocak H. Development of left ventricular apical akinesis and thrombus during pericardiocentesis for pericardial tamponade. Turk Kardiyol Dern Ars. 2008;36:338-41. , 3737. Wolfe MW, Edelman ER. Transient systolic dysfunction after relief of cardiac tamponade. Ann Intern Med. 1993;119:42-4. , 3838. Chamoun A, Cenz R, Mager A, Rahman A, Champion C, Ahmad M, Birnbaum Y. Acute left ventricular failure after large volume pericardiocentesis. Clin Cardiol. 2003;26:588-90. , 3939. Hamaya Y, Dohi S, Ueda N, Akamatsu S. Severe circulatory collapse immediately after pericardiocentesis in a patient with chronic cardiac tamponade. Anesth Analg 1993;77:1278-81. ]. Subsequently, in the case of chronic pericardial effusions, it is advocated that once a sufficient volume of fluid has been drained to clinically alleviate cardiac tamponade, the rate at which the residual pericardial fluid is drained should be reduced to a volume not exceeding one litre per 24 hour period [3232. Petrov I, Dimitrov C. Closing of a right ventricle perforation with a vascular closure device. Catheter Cardiovasc Interv. 2009;74:247-50. , 3333. Vandyke WH, Jr, Cure J, Chakko CS, Gheorghiade M. Pulmonary edema after pericardiocentesis for cardiac tamponade. N Engl J Med. 1983;309:595-6. ]. There is some evidence to suggest that idiopathic chronic large pericardial effusions may be conservatively monitored rather than intervened upon, due to the risk of intervention [4040. Imazio M, Lazaros G, Valenti A, et al Outcomes of idiopathic chronic large pericardial effusion. Heart 2019;105:477-481. ].

The incidence of certain complications varies with the approach used for pericardiocentesis. For example, the right xiphocostal approach is associated with a higher incidence of right atrium and inferior vena cava injury; the lingula is more likely punctured during apical approaches, while puncture of the left anterior descending, internal mammary artery and intercostal arteries are more frequent with the parasternal approach [4141. Jneid H, Maree AO, Palacios IF. Pericardial Tamponade: Clinical Presentation, Diagnosis and Catheter-based Therapies. In: Parillo J, Dellinger PR, editors. Critical Care Medicine, 3rd edition. Mosby. 2008.
Comprehensive text on intervention for pericardial tamponade].

Recurrent or persistent pericardial effusions

Pericardial effusions can recur after drainage. Extended catheter drainage reduces the rate of recurrence (recurrence rate within 6 months of 14% among patients who undergo extended catheter drainage versus 27% for those who undergo simple pericardiocentesis) [99. Tsang TS, Enriquez-Sarano M, Freeman WK, Barnes ME, Sinak LJ, Gersh BJ, Bailey KR, Seward JB. Consecutive 1127 therapeutic echocardiographically guided pericardiocenteses: clinical profile, practice patterns, and outcomes spanning 21 years. Mayo Clin Proc. 2002;77:429-36.
Largest observational cohort on echo-guided percicardiocentesis published]. The incidence of recurrence is highest for effusions with a malignant aetiology, with recurrence rates as high as 40-62% without additional treatment [4242. Laham RJ, Cohen DJ, Kuntz RE, Baim DS, Lorell BH, Simons M. Pericardial effusion in patients with cancer: outcome with contemporary management strategies. Heart. 1996;75:67-71. , 4343. Lestuzzi C. Neoplastic pericardial disease: Old and current strategies for diagnosis and management. World J Cardiol. 2010;2:270-9.
Contemporary review on all aspects of malignant pericardial effusions]. The management options for symptomatic, recurrent pericardial effusions are repeat pericardiocentesis, creation of a surgical pericardial window, video-assisted thoracoscopic (VATS) pericardial fenestration, percutaneous balloon pericardiotomy, and intrapericardial injection of sclerosing agents (Focus Box 5) [4444. Palacios IF. Pericardial Effusion and Tamponade. Curr Treat Options Cardiovasc Med. 1999;1:79-89.
Overview of the techniques available to manage pericardial effusions, 4545. Geissbühler K, Leiser A, Fuhrer J, Ris HB. Video-assisted thoracoscopic pericardial fenestration for loculated or recurrent effusions. Eur J Cardiothorac Surg. 1998;14:403-8. ]. Furthermore, adjunctive treatment with local and/or systemic chemotherapy or radiation therapy (external or with intrapericardial radionuclides) for recurrent malignant effusions may be employed [4242. Laham RJ, Cohen DJ, Kuntz RE, Baim DS, Lorell BH, Simons M. Pericardial effusion in patients with cancer: outcome with contemporary management strategies. Heart. 1996;75:67-71. ]. In addition to recurrent effusions, persistent drainage of fluid (≥3 days of draining ≥ 75-100 mls/24 hours) will require similar management strategies.

SURGICAL PERICARDIAL WINDOW CREATION

The two main surgical approaches to pericardial window formation are a subxiphoid pericardial window or thoracotomy and pleuropericardial window [4646. Liberman M, Labos C, Sampalis JS, Sheiner NM, Mulder DS. Ten-year surgical experience with nontraumatic pericardial effusions: a comparison between the subxyphoid and transthoracic approaches to pericardial window. Arch Surg. 2005;140:191-5. ]. Creation of a subxiphoid pericardial window is a safe technique that offers a low complication rate (1.1%) and a low recurrence rate (1.1%) and is particularly effective in the management of tuberculous and malignant pericardial processes [4747. Becit N, Ozyaziciog˘lu A, Ceviz M, Karakelleog˘lu S, Karapolat S, Koçak H. Clinical experience with subxiphoid pericardiostomy in the management of pericardial effusions: a study of 240 cases. J Int Med Res. 2003;31:312-7. , 4848. Becit N, Unlü Y, Ceviz M, Koçogullari CU, Koçak H, Gürlertop Y. Subxiphoid pericardiostomy in the management of pericardial effusions: case series analysis of 368 patients. Heart. 2005;91:785-90. , 4949. Allen KB, Faber LP, Warren WH, Shaar CJ. Pericardial effusion: subxiphoid pericardiostomy versus percutaneous catheter drainage. Ann Thorac Surg. 1999;67:437-40. , 5050. Mueller XM, Tevaearai HT, Hurni M, Ruchat P, Fischer AP, Stumpe F, von Segesser LK. Long-term results of surgical subxiphoid pericardial drainage. Thorac Cardiovasc Surg. 1997;45:65-9. ]. The more invasive surgical alternative involves thoracotomy and pericardial window creation, carries a similar low recurrence rate and similar overall complication rate but with a higher incidence of respiratory complications [4646. Liberman M, Labos C, Sampalis JS, Sheiner NM, Mulder DS. Ten-year surgical experience with nontraumatic pericardial effusions: a comparison between the subxyphoid and transthoracic approaches to pericardial window. Arch Surg. 2005;140:191-5. , 5151. Naunheim KS, Kesler KA, Fiore AC, Turrentine M, Hammell LM, Brown JW, Mohammed Y, Pennington DG. Pericardial drainage: subxiphoid vs. transthoracic approach. Eur J Cardiothorac Surg. 1991;5:99-103. ]. Horr et al demonstrated in 1,281patients undergoing either surgical pericardial window or pericardiocentesis were equally safe and efficacious in the management of pericardial effusions [5252. Horr SE, Mentias A, Houghtaling PL, Toth AJ, Blackstone EH, Johnston DR, Klein AL. Comparison of Outcomes of Pericardiocentesis Versus Surgical Pericardial Window in Patients Requiring Drainage of Pericardial Effusions. Am J Cardiol. 2017 Sep 1;120(5):883-890. doi: 10.1016/j.amjcard.2017.06. 003. Epub 2017 Jun 15. ].

VIDEO ASSISTED THORASCOPIC PERICARDIAL WINDOW

This technique offers a minimally-invasive, effective surgical alternative for pericardial drainage, particularly if the effusion is loculated, if pericardial biopsy is necessary, or if there is concomitant pleural disease [5353. Muhammad MI. Pericardial window: is video-assisted thoracoscopy approach better than surgical approach. Interact Cardiovasc Thorac Surg. 2010;12:174-8. ].

PERCUTANEOUS BALLOON PERICARDIOTOMY

Palacios et al were the first to describe the technique of percutaneous balloon pericardiotomy (PBP) (percutaneous pericardial window creation) as an effective alternative to surgery in the management of patients with malignant pericardial effusions and tamponade in 1991 [5454. Palacios IF, Tuzcu EM, Ziskind AA, Younger J, Block PC. Percutaneous balloon pericardial window for patients with malignant pericardial effusion and tamponade. Cathet Cardiovasc Diagn. 1991;22:244-9. ]. From 1991 through 2010, this technique was described in the literature in the management of over 333 adult patients with high procedural success rates, low re-accumulation rates and low complication rates [5555. Ziskind AA, Pearce AC, Lemmon CC, Burstein S, Gimple LW, Herrmann HC, McKay R, Block PC, Waldman H, Palacios IF. Percutaneous balloon pericardiotomy for the treatment of cardiac tamponade and large pericardial effusions: description of technique and report of the first 50 cases. J Am Coll Cardiol. 1993;21:1-5.
Original description of percutaneous balloon pericardiotomy, 5656. Deb B, Crean P, Graham I. Percutaneous balloon pericardiotomy in the treatment of malignant pericardial effusion. Ir J Med Sci. 1993;162:456-7. , 5757. Sharma A, Kamble R, Kumar L, Bhargava B, Biswal BM, Kochupillai V. Palliative treatment of malignant pericardial effusion: report of two cases and a review of the literature. Support Care Cancer. 1996;4(4):317-9. , 5858. Bahl VK, Chandra S, Goel A, Goswami KC, Wasir HS. Versatility of Inoue balloon catheter. Int J Cardiol. 1997;59:75-83. , 5959. Law DA, Haque R, Jain A. Percutaneous balloon pericardiotomy: non-surgical treatment for patients with cardiac tamponade. W V Med J. 1997;93:310-2. , 6060. Galli M, Politi A, Jemoli R, Zerboni S. Transcatheter management of cardiac and pericardial metastatic involvement. G Ital Cardiol. 1998;28:687-90. , 6161. Grumbach IM, Werner GS, Figulla HR. [Percutaneous balloon pericardiotomy for the treatment of a malignant pericardial tamponade] [Article in German] Dtsch Med Wochenschr. 1998;123:726-9. , 6262. Ohke M, Bessho A, Haraoka K, Ohgou T, Ozaki S, Kishimoto T. Percutaneous balloon pericardiotomy by the use of Inoue balloon for the management of recurrent cardiac tamponade in a patient with lung cancer. Intern Med. 2000;39:1071-4. , 6363. Ovünç K, Aytemir K, Ozer N, Atalar E, Aksöyek S, Nazli N, Gürsel G, Kes S. Percutaneous balloon pericardiotomy for patients with malignant pericardial effusion including three malignant pleural mesotheliomas. Angiology. 2001;52:323-9. , 6464. Navarro Del Amo LF, Córdoba Polo M, Orejas Orejas M, López Fernández T, Mohandes M, Iñíguez Romo A. [Percutaneous balloon pericardiotomy in patients with recurrent pericardial effusion]. [Article in Spanish]. Rev Esp Cardiol. 2002;55:25-8. , 6565. del Barrio LG, Morales JH, Delgado C, Benito A, Larrache J, Martinez-Cuesta A, Bilbao JI. Percutaneous balloon pericardial window for patients with symptomatic pericardial effusion. Cardiovasc Intervent Radiol. 2002;25:360-4. , 6666. Jalisi FM, Morise AP, Haque R, Jain AC. Primary percutaneous balloon pericardiotomy. W V Med J. 2004;100:102-5. , 6767. Aqel R, Mehta D, Zoghbi GJ. Percutaneous balloon pericardiotomy for the treatment of infected pericardial effusion with tamponade. J Invasive Cardiol. 2006;18:E194-7. , 6868. Aqel RA, Aljaroudi W, Hage FG, Tallaj J, Rayburn B, Nanda NC. Left ventricular collapse secondary to pericardial effusion treated with pericardicentesis and percutaneous pericardiotomy in severe pulmonary hypertension. Echocardiography. 2008;25:658-61. , 6969. Ashraf T, Pathan A, Memon A, Rasool I, Kundi A. Percutaneous balloon pericardiotomy in a patient with advanced case of malignant pericardial effusion and tamponade. J Pak Med Assoc. 2008;58:334-6. , 7070. Chouhan NS, Mukharjee S, Chandra P. Percutaneous balloon pericardiotomy in a patient with end stage renal disease with recurrent pericardial effusion & pericardial tamponade. Indian Heart J. 2010;62:87-9. , 7171. Velchev V, Finkov B. Case report: Percutaneous balloon pericardiotomy using Inoue balloon for patients with massive pericardial effusion. Int J Cardiol. 2010;138:314-6. , 7272. Swanson N, Mirza I, Wijesinghe N, Devlin G. Primary percutaneous balloon pericardiotomy for malignant pericardial effusion. Catheter Cardiovasc Interv. 2008;71:504-7. , 7373. Fakiolas CN, Beldekos DI, Foussas SG, Olympios CD, Pissimissis EG, Alexopoulos D, Cokkinos DV. Percutaneous balloon pericardiotomy as a therapeutic alternative for cardiac tamponade and recurrent pericardial effusion. Acta Cardiol. 1995;50:65-70. , 7474. Wang HJ, Hsu KL, Chiang FT, Tseng CD,Tseng YZ, Liau CS. Technical and Prognostic Outcomes of Double-Balloon Pericardiotomy for Large Malignancy-Related Pericardial Effusions. Chest. 2002;122;893-9. , 7575. Ziskind A, Lemmon C, Rodriguez S. Final report of the percutaneous balloon pericardiotomy registry for the treatment of effusive pericardial disease. Circulation. 1994;90:I -121. ]. It is now generally considered a safe, effective alternative to the more invasive surgical pericardial window creation in the management of patients with recurrent effusions, in particular if such patients are poor surgical candidates. It is also a cheaper alternative to surgery [5858. Bahl VK, Chandra S, Goel A, Goswami KC, Wasir HS. Versatility of Inoue balloon catheter. Int J Cardiol. 1997;59:75-83. ]. Percutaneous balloon pericardiotomy allows pericardial fluid to drain through a communication created by the procedure into the better resorbing pleural space (usual) or peritoneal space [7676. Bertrand O, Legrand V, Kulbertus H. Percutaneous balloon pericardiotomy: a case report and analysis of mechanism of action. Cathet Cardiovasc Diagn. 1996;38:180-2. , 7777. Galli M, Politi A, Pedretti F, Castiglioni B, Zerboni S. Percutaneous balloon pericardiotomy for malignant pericardial tamponade. Chest. 1995;108:1499-501. ]. Thus, a transient left pleural effusion is common post-PBP and occasionally may necessitate thoracocentesis [4444. Palacios IF. Pericardial Effusion and Tamponade. Curr Treat Options Cardiovasc Med. 1999;1:79-89.
Overview of the techniques available to manage pericardial effusions, 5656. Deb B, Crean P, Graham I. Percutaneous balloon pericardiotomy in the treatment of malignant pericardial effusion. Ir J Med Sci. 1993;162:456-7. ]. For this reason, respiratory reserve should be assessment in all patients proposed for percutaneous balloon pericardiotomy to identify those who may be significantly compromised by a post-procedural pleural effusion. Large pericardial effusions should be allowed to drain to smaller volumes at an appropriate rate before percutaneous balloon pericardiotomy is performed in order to minimise the size of any pleural effusion that may follow. All complications of needle pericardiocentesis via the subxiphoid approach listed above can also occur during percutaneous balloon pericardiotomy. The rate of minor complications among the series of 50 patients undergoing percutaneous balloon pericardiotomy described by Palacio et al was 13% [4444. Palacios IF. Pericardial Effusion and Tamponade. Curr Treat Options Cardiovasc Med. 1999;1:79-89.
Overview of the techniques available to manage pericardial effusions]. The cautions and contraindications for pericardiocentesis also apply to percutaneous balloon pericardiotomy.

The procedure is performed in the cardiac catheterisation labarotory. Preparation and patient positioning is the same as for pericardiocentesis performed via the subxiphoid approach described above. The patient may experience considerable discomfort as a result of mechanical disruption of the parietal pericardium during balloon inflation thus adequate administration of analgesia and sedation is essential. The subxiphoid area is infiltrated with local anaesthetic as before. A stiff 0.038-inch wire with a pre-shaped broad curved tip is advanced into the pericardial space via a needle advanced into the pericardial space or via a pre-existing subxiphoid-placed drainage catheter. The needle or catheter is then removed leaving the wire in place. A 10French dilator is advanced over the wire to pre-dilate the skin and subcutaneous tissues and then removed. A balloon-dilating catheter is then advanced over the wire under fluoroscopic guidance until it straddles the parietal pericardium. Typically a 3.0cm long x 20mm diameter balloon is used, but use of the Inoue balloon (Torray International America Inc., Houston, TX, USA) has also been described [4949. Allen KB, Faber LP, Warren WH, Shaar CJ. Pericardial effusion: subxiphoid pericardiostomy versus percutaneous catheter drainage. Ann Thorac Surg. 1999;67:437-40. , 5454. Palacios IF, Tuzcu EM, Ziskind AA, Younger J, Block PC. Percutaneous balloon pericardial window for patients with malignant pericardial effusion and tamponade. Cathet Cardiovasc Diagn. 1991;22:244-9. , 6363. Ovünç K, Aytemir K, Ozer N, Atalar E, Aksöyek S, Nazli N, Gürsel G, Kes S. Percutaneous balloon pericardiotomy for patients with malignant pericardial effusion including three malignant pleural mesotheliomas. Angiology. 2001;52:323-9. ]. It is essential that the proximal end of the balloon is inserted beyond the skin and subcutaneous tissues to avoid creating a pericardiocutaneous fistula. Once the trans-parietal pericardial position of the balloon is satisfactory, the balloon is inflated with a contrast/saline mix under fluoroscopy. Inflation is continued and/or repeated (two to three inflations) until the waist formed on the balloon by the parietal pericardium is eliminated ( Figure 8 ). The balloon-dilating catheter is then exchanged for a pigtail drainage catheter, which remains in situ for a short period of extended drainage as described earlier. Variations of this technique have been described including double balloon techniques [6767. Aqel R, Mehta D, Zoghbi GJ. Percutaneous balloon pericardiotomy for the treatment of infected pericardial effusion with tamponade. J Invasive Cardiol. 2006;18:E194-7. , 7878. Hsu KL, Tsai CH, Chiang FT, Lo HM, Tseng CD, Ho SG, Tseng YZ. Percutaneous balloon pericardiotomy for patients with recurrent pericardial effusion: using a novel double-balloon technique with one long and one short balloon. Am J Cardiol. 1997;80:1635-7. , 7979. Iaffaldano RA, Jones P, Lewis BE, Eleftheriades EG, Johnson SA, McKiernan TL. Percutaneous balloon pericardiotomy: a double-balloon technique. Cathet Cardiovasc Diagn. 1995;36:79-81. ]. Post-procedural patient care is similar to management following pericardiocentesis described above and summarised in Focus Box 4.

INTRAPERICARDIAL DELIVERY OF SCLEROSING AGENTS, LOCAL CHEMOTHERAPY AND LOCAL RADIOTHERAPy for malignant disease

Sclerosing agents, chemotherapy and radiotherapy can be delivered locally into the pericardial space to reduce risk of effusion recurrence. Intrapericardial sclerotherapy involves instilling a sclerosing agent into the pericardial space that will induce inflammation, irritation and subsequent fibrosis thereby producing adhesion of the parietal to the visceral pericardium [4242. Laham RJ, Cohen DJ, Kuntz RE, Baim DS, Lorell BH, Simons M. Pericardial effusion in patients with cancer: outcome with contemporary management strategies. Heart. 1996;75:67-71. ]. Agents with sclerosing properties only (e.g., tetracycline, doxycycline, minocycline) and agents with both sclerosing and antineoplastic properties for malignant effusions (e.g., bleomycin, thiotepa, cisplatin) have been used effectively [8080. Bischiniotis TS, Lafaras CT, Platogiannis DN, Moldovan L, Barbetakis NG, Katseas GP. Intrapericardial cisplatin administration after pericardiocentesis in patients with lung adenocarcinoma and malignant cardiac tamponade. Hellenic J Cardiol. 2005;46:324-9. , 8181. Martinoni A, Cipolla CM, Cardinale D, Civelli M, Lamantia G, Colleoni M, Fiorentini C. Long-term results of intrapericardial chemotherapeutic treatment of malignant pericardial effusions with thiotepa. Chest. 2004;126:1412-6. , 8282. Martinoni A, Cipolla CM, Civelli M, Cardinale D, Lamantia G, Colleoni M, DeBraud F, Susini G, Martinelli G, Goldhirsh A, Fiorentini C. Intrapericardial treatment of neoplastic pericardial effusions. Herz. 2000;25:787-93. , 8383. Liu G, Crump M, Goss PE, Dancey J, Shepherd FA. Prospective comparison of the sclerosing agents doxycycline and bleomycin for the primary management of malignant pericardial effusion and cardiac tamponade. J Clin Oncol. 1996;14:3141-7. , 8484. Lashevsky I, Ben Yosef R, Rinkevich D, Reisner S, Markiewicz W. Intrapericardial minocycline sclerosis for malignant pericardial effusion. Chest. 1996;109:1452-4. , 8585. Davis S, Rambotti P, Grignani F. Intrapericardial tetracycline sclerosis in the treatment of malignant pericardial effusion: an analysis of thirty-three cases. J Clin Oncol. 1984;2:631-6. ]. Employing such adjuncts at the time of simple pericardiocentesis in the management of neoplastic effusions can achieve freedom from recurrence at 30 days of up to 90%, without significant side effects (other than chest pain associated with tetracycline instillation) [8383. Liu G, Crump M, Goss PE, Dancey J, Shepherd FA. Prospective comparison of the sclerosing agents doxycycline and bleomycin for the primary management of malignant pericardial effusion and cardiac tamponade. J Clin Oncol. 1996;14:3141-7. , 8686. Martinoni A. [Treatment of neoplastic pericardial effusions]. [Article in Italian] Recenti Prog Med. 2006;97:206-10. ]. Radioactive agents (e.g., phosphorus-32-colloidal chromic phosphate) have been instilled successfully into the intrapericardial space to achieve local radiotherapy to reduce recurrence of malignant effusions [8787. Dempke W, Firusian N. Treatment of malignant pericardial effusion with 32P-colloid. Br J Cancer. 1999;80:1955-7. , 8888. Martini N, Freiman AH, Watson RC, Hilaris BS. Intrapericardial installation of radioactive chromic phosphate in malignant effusion. AJR Am J Roentgenol. 1977;128:639-41. ]. The recurrence and chronicity of malignant pericardial effusions requires further research in regards to determining the best course of treatment [8989. El Haddad D, Iliescu C, Yusuf SW, William WN Jr, Khair TH, Song J, Mouhayar EN. Outcomes of Cancer Patients Undergoing Percutaneous Pericardiocentesis for Pericardial Effusion. J Am Coll Cardiol. 2015 Sep 8;66(10):1119-28. doi: 10.1016/j.jacc.2015. 06. 1332. ].

Novel percutaneous pericardial techniques

PERCUTANEOUS PERICARDIAL BIOPSY

Case series suggest that percutaneous pericardial biopsy offers a surgical alternative and adjunctive technique in the diagnosis of pericardial disease [9090. Selig MB. Percutaneous transcatheter pericardial interventions: aspiration, biopsy, and pericardioplasty. Am Heart J. 1993;125:269-71. , 9191. Ziskind AA, Rodriguez S, Lemmon C, Burstein S. Percutaneous pericardial biopsy as an adjunctive technique for the diagnosis of pericardial disease. Am J Cardiol. 1994;74:288-91. , 9292. Seferovic PM, Ristic’ AD, Maksimovic R, Ostojic M, Simeunovic D, Petrovic P, Maisch B. Flexible percutaneous pericardioscopy: inherent drawbacks and recent advances. Herz. 2000;25:741-7. , 9393. Maisch B, Bethge C, Drude L, Hufnagel G, Herzum M, Schönian U. Pericardioscopy and epicardial biopsy –new diagnostic tools in pericardial and perimyocardial disease. Eur Heart J. 1994;15:68-73. , 9494. Endrys J, Simo M, Shafie MZ, Uthaman B, Kiwan Y, Chugh T, Ali SM, Spacek K, Yousef AM, Cherian G. New nonsurgical technique for multiple pericardial biopsies. Cathet Cardiovasc Diagn. 1988;15:92-4. , 9595. Uthaman B, Endrys J, Abushaban L, Khan S, Anim JT. Percutaneous pericardial biopsy: technique, efficacy, safety, and value in the management of pericardial effusion in children and adolescents. Pediatr Cardiol. 1997;18:414-8. , 9696. Margey RJ, Suh WM, Sahkuja R, Seto A, Witzke C, Palacios IF. Percutaneous pericardial biopsy-A novel interventional technique to aid diagnosis and management of pericardial disease. J. Am. Coll. Cardiol. 2010;56; B109-B110. ]. Biopsy material obtained by this technique can help establish pericardial disease aetiology, particular in cases of tuberculous or malignant disease [8484. Lashevsky I, Ben Yosef R, Rinkevich D, Reisner S, Markiewicz W. Intrapericardial minocycline sclerosis for malignant pericardial effusion. Chest. 1996;109:1452-4. , 8585. Davis S, Rambotti P, Grignani F. Intrapericardial tetracycline sclerosis in the treatment of malignant pericardial effusion: an analysis of thirty-three cases. J Clin Oncol. 1984;2:631-6. ]. This procedure can be performed at the same time as pericardiocentesis. The pericardial space is accessed and a pigtail drainage catheter placed as described above. Once all the pericardial fluid is drained, a 0.035-inch guidewire is reintroduced through the pigtail catheter maintaining intrapericardial position. This catheter is then exchanged for a curved sheath. The guidewire is removed, leaving the curved sheath in the pericardial space. A bioptome is advanced through the sheath under fluoroscopic guidance, away from the cardiac shadow to the lateral pericardial wall ( Figure 9 ).

The bioptome is then used to obtain multiple biopsy specimens from the parietal pericardium at this position. Once biopsy specimens have been collected, the bioptome is removed, the guidewire re-advanced through the sheath and exchanged for the pigtail drainage catheter. Percutaneous pericardial biopsy may be performed using fluoroscopic guidance alone or directed by endoscopic visualisation i.e., pericardioscopy.

PERICARDIOSCOPY

Pericardioscopy enables endoscopic inspection and targeted biopsy of the parietal and visceral pericardium [8282. Martinoni A, Cipolla CM, Civelli M, Cardinale D, Lamantia G, Colleoni M, DeBraud F, Susini G, Martinelli G, Goldhirsh A, Fiorentini C. Intrapericardial treatment of neoplastic pericardial effusions. Herz. 2000;25:787-93. ]. The efficiency and diagnostic value of pericardial biopsy is reportedly enhanced by pericardioscopic guidance [9797. Seferovic’ PM, Ristic’ AD, Maksimovic’ R, Tatic’ V, Ostojic’ M, Kanjuh V. Diagnostic value of pericardial biopsy: improvement with extensive sampling enabled by pericardioscopy. Circulation. 2003;107:978-83. , 9898. Levy PY, Habib G, Collart F, Lepidi H, Raoult D. Etiological diagnosis of pericardial effusion. Future Microbiol. 2006;1:229-39. ]. Endoscopic visualisation during flexible percutaneous pericardioscopy is facilitated by partial replacement of the pericardial effusion with a volume of warmed normal saline or with air [8282. Martinoni A, Cipolla CM, Civelli M, Cardinale D, Lamantia G, Colleoni M, DeBraud F, Susini G, Martinelli G, Goldhirsh A, Fiorentini C. Intrapericardial treatment of neoplastic pericardial effusions. Herz. 2000;25:787-93. , 9999. Maisch B, Drude L. Pericardioscopy –a new diagnostic tool in inflammatory diseases of the pericardium. Eur Heart J. 1991;12 Suppl D:2-6. , 100100. Maisch B, Bethge C, Drude L, Hufnagel G, Herzum M, Schönian U. Pericardioscopy and epicardial biopsy -new diagnostic tools in pericardial and perimyocardial disease. Eur Heart J. 1994;15 Suppl C:68-73. ].

PERCUTANEOUS PERICARDIAL ACCESS FOR EPICARDIAL ARRHYTHMIA MAPPING AND ABLATION

Arrhythmogenic substrate can be epicardial in location. Thus, electrophysiologists are percutaneously accessing the pericardial space to perform transepicardial mapping and ablation in the treatment of arrhythmias. Epicardial mapping and ablation can be an alternative technique following an unsuccessful endocardial approach or an adjunctive technique utilised in addition to the traditional endocardial approach [101101. Pokushalov E, Romanov A, Turov A, Artyomenko S, Shirokova N, Karaskov A. Percutaneous epicardial ablation of ventricular tachycardia after failure of endocardial approach in the pediatric population with arrhythmogenic right ventricular dysplasia. Heart Rhythm. 2010;7:1406-10. , 102102. Cesario DA, Vaseghi M, Boyle NG, Fishbein MC, Valderrábano M, Narasimhan C, Wiener I, Shivkumar K. Value of high-density endocardial and epicardial mapping for catheter ablation of hemodynamically unstable ventricular tachycardia. Heart Rhythm. 2006;3:1-10. ]. Epicardial fat can mimic scar tissue, which is important during epicardial mapping and ablation [103103. Desjardins B, Morady F, Bogun F. Effect of epicardial fat on electroanatomical mapping and epicardial catheter ablation. J Am Coll Cardiol. 2010;56:1320-7. , 104104. Abbara S, Desai JC, Cury RC, Butler J, Nieman K, Reddy V. Mapping epicardial fat with multi-detector computed tomography to facilitate percutaneous transepicardial arrhythmia ablation. Eur J Radiol. 2006;57:417-22. ].

Left atrial appendage ligation

The left atrial appendage has long been identified as a source of thrombus formation in patients with Atrial Fibrillation. This is primarily due to the shape and trabeculated structure of the area leading to thrombus formation. In a proportion of patients anticoagulation proves unfavourable and recent advances with left atrial appendage occluder devices and novel pericardial techniques have become of increasing interest and benefit.

Percutaneous left atrial appendage ligation is a novel technique where the left atrial appendage is snared ‘externally’ after pericardial entry. Recent studies have shown good outcomes in a small cohort of patients. The procedure itself is carried out under general anaesthesia in the Cath Lab setting with surgical back- up. Preoperative work up using Cardiac CT is utilised to define the left atrial appendage anatomy prior to the procedure. The patient is laid supine on the table and pericardial access is obtained under fluoroscopic guidance in a manner similar to a pericardiocentesis. Concomitant femoral venous access provides a transseptal cathether approach under transoesophageal guidance. A left atrial appendogram is taken to clearly visualise the left atrial appendage and its ostium. A pericardial sheath is advanced into the pericardial cavity and allows for introduction of a snare device to obliterate the ostium of the left atrial appendage. A post-procedural pericardial drain is typically left in situ for 24 hours with echocardiographic follow up to rule out any complications [105105. Bartus K, Han FT, Bednarek J, Myc J, Kapelak B, Sadowski J, Lelakowski J, Bartus S, Yakubov SJ, Lee RJ. Percutaneous left atrial appendage suture ligation using the LARIAT device in patients with atrial fibrillation: initial clinical experience. J Am Coll Cardiol. 2013 9;62:108-18. , 106106. Shetty R, Leitner JP, Zhang M. Percutaneous catheter-based left atrial appendage ligation and management of periprocedural left atrial appendage perforation with the LARIAT suture delivery system. J Invasive Cardiol. 2012 24:E289-93. , 107107. Patel MB, Rasekh A, Shuraih M, Chelu MG, Bartlett T, Mathuria N, Naeini P, Strickland J, Massumi A, Razavi M, Cheng Safety and effectiveness of compassionate use of LARIAT® device for epicardial ligation of anatomically complex left atrial appendages. J. Circulation: J Interv Card Electrophysiol. 2015 42:11-9. , 108108. Kimura T, Takatsuki S, Miyoshi S, Katsumata Y, Nishiyama T, Nishiyama N, Tanimoto Y, Aizawa Y, Jinzaki M, Fukuda K. Pericardial endoscopy-guided left atrial appendage ligation: a pilot study in a canine model. Circ Cardiovasc Interv. 2014;7:844-50. ].

This remains a novel technique and further studies to determine the long-term end results are still required [109109. Miller MA, Gangireddy SR, Doshi SK, Aryana A, Koruth JS, Sennhauser S, d’Avila A, Dukkipati SR, Neuzil P, Reddy VY. Multicenter study on acute and long-term safety and efficacy of percutaneous left atrial appendage closure using an epicardial suture snaring device. Heart Rhythm. 2014;11:1853-9. ].

Intrapericardial Infusions for recurrent pericarditis

Incessant or recurrent pericarditis is an uncommon complication associated with pericardial disease. Most recent studies look at timing and duration of anti-inflammatory or colchicine therapy [110110. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC)Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS). Authors/Task Force Members, Adler Y, Charron P, Imazio M, Badano L, Barón-Esquivias G, Bogaert J, Brucato A, Gueret P, Klingel K, Lionis C, Maisch B, Mayosi B, Pavie A, Ristić AD, Sabaté Tenas M, Seferovic P, Swedberg K, Tomkowski W; Document Reviewers, Achenbach S, Agewall S, Al-Attar N, Angel Ferrer J, Arad M, Asteggiano R, Bueno H, Caforio AL, Carerj S, Ceconi C, Evangelista A, Flachskampf F, Giannakoulas G, Gielen S, Habib G, Kolh P, Lambrinou E, Lancellotti P, Lazaros G, Linhart A, Meurin P, Nieman K, Piepoli MF, Price S, Roos-Hesselink J, Roubille F, Ruschitzka F, Sagristà Sauleda J, Sousa-Uva M, Uwe Voigt J, Luis Zamorano J. Eur Heart J. 2015 36:2921-64. ]. Research into the use of intrapericardial infusion of corticosteroids locally such as Triamcinolone have shown benefit. Maisch et all demonstrated good symptomatic resolution and reduction in recurrence. In their cohort 84 patients where stratified to receive varying doses of Triamcinolone infusion and outcomes measured [111111. Maisch B, Ristić AD, Pankuweit S. Intrapericardial treatment of autoreactive pericardial effusion with triamcinolone; the way to avoid side effects of systemic corticosteroid therapy. Eur Heart J. 2002 ;23:1503-8. ]. Although the data since then has been limited further studies are ongoing [112112. Ramer SA, Sapp JL. Percutaneous intrapericardial injection of triamcinolone in a patient with incessant pericarditis: a novel technique. Can J Cardiol. 2013;29:751. , 113113. Maxwell CB, Crouch MA. Intrapericardial triamcinolone for acute pericarditis after electrophysiologic procedures. Am J Health Syst Pharm. 2010 ;67:269-73. ].

Conclusions

Needle pericardiocentesis is an effective and potentially lifesaving technique in the management of cardiac tamponade. The safety of this technique had been greatly enhanced by use of echocardiographic and/or fluoroscopic guidance. Competence in this technique is a pre-requisite for cardiologists given the increasing prevalence of cardiac tamponade. The field of percutaneous pericardial interventions has expanded beyond simple pericardiocentesis with exciting developments including percutaneous balloon pericardiotomy and pericardial biopsy. Such procedures are increasingly performed with a growing body of literature and evidence to support their practice.

Personal perspective - Andrew Maree

Pericardiocentesis techniques have evolved in line with refinements in cardiac imaging. Echo and CT guided taps are gradually superseding the fluoroscopic guided approach. The technique has been further refined by Electrophysiologists who frequently access the pericardium in the absence of an effusion. However determining when to access the pericardium and weighing risk versus benefit to the patient is an enduring clinical skill.

ESC Guidelines 2015

http://www.escardio.org/Guidelines-&-Education/Clinical-Practice-Guidelines/Pericardial-Diseases-Guidelines-on-the-Diagnosis-and-Management-of