Safety and efficacy of inserting double-lumen catheter under echo guidance for pericardial fluid tapping
Veeresh F Manvi1, Nidhi Goel Manvi2 1 Department of Pediatric Cardiology, KLES Dr. P. K. Hospital and MRC, Belgaum, Karnataka, India 2 KLE Heart Foundation, Dr. P. K. Hospital and Research Centre, Belgaum, Karnataka, India
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Correspondence Address: Dr. Veeresh F Manvi Department of Pediatric Cardiology, KLES Dr. P. K. Hospital and MRC, Belgaum, Karnataka India
Source of Support: None, Conflict of Interest: None
Background and Objectives: The aim of the article is to determine safety and efficacy of echocardiography (ECHO) guided pericardiocentesis at a quaternary care hospital. Cardiac tamponade is a life threatening condition which requires urgent pericardiocentesis. The pericardium has the ability to stretch and accommodate fluid but when the intra pericardial pressure becomes equal to right atrial pressure, the right ventricle collapses and hypotension occurs. Echocardiography guided pericardiocentesis is a useful technique. Methodology: We describe the echo guided drainage of cardiac tamponade done on emergency basis using central venous catheter (CVC). Subxiphoid approach was done in all the cases. The approximate distance from skin to pericardial fluid was mapped. Echo guided needle insertion was done. The fluid was aspirated and guide wire was inserted. The guide wire position in pericardial space was confirmed using echocardiography. The procedure was continued as per the Seldinger technique. Results: A total of twenty two patients underwent 24 procedures in a two year period. The procedure, outcomes and complications are discussed. The central venous catheter was inserted in 12 males and 10 females.. The fluid was straw colored in 14 cases, purulent in 5 and hemorrhagic in 3 cases. The age group ranged between 2 years to 14 years while the mean age was 7 years. The mean duration of central venous catheter placement was 48 hours. The procedural success rate was 100%. Conclusion and Interpretation: It was possible to perform the entire procedure in the pediatric intensive care unit (PICU) in all the cases without the need to shift to cardiac catheterization laboratory. Pericardial catheter insertion using CVC under echo guidance is a safe and effective technique for management of pericardial effusion.
How to cite this article: Manvi VF, Manvi NG. Safety and efficacy of inserting double-lumen catheter under echo guidance for pericardial fluid tapping. Heart India 2020;8:13-6
How to cite this URL: Manvi VF, Manvi NG. Safety and efficacy of inserting double-lumen catheter under echo guidance for pericardial fluid tapping. Heart India [serial online] 2020 [cited 2022 Aug 12];8:13-6. Available from: https://www.heartindia.net/text.asp?2020/8/1/13/281881
Pericardiocentesis is the most useful therapeutic procedure for the early management and diagnosis of large, symptomatic pericardial effusion, and cardiac tamponade. In 1911, Marfan first described the subxiphoid approach, which had been used for the blind pericardiocentesis procedure for decades despite the significant morbidity and mortality rates (50% and 6%, respectively). In the subsequent years, the techniques recommended for a safe and successful pericardiocentesis have changed considerably, particularly with the introduction of fluoroscopic, electrocardiographic and finally, echocardiographic guidance. Echocardiography (ECHO)-guided pericardiocentesis is a safe alternative to fluoroscopic-guided puncture.
The objective of this study was to evaluate the efficacy and safety of echocardiography guided pericardiocentesis using double-lumen central venous catheter (CVC). A series of 22 patients underwent bedside ECHO-guided pericardiocentesis from January 2017 to December 2018, at our institute KLES Dr. Prabhakar Kore Hospital and medical research center.
The baseline characteristics of these patients are mentioned in [Table 1]. The mean age was 6.3 years, and the mean weight was 17.2 kg.
Table 1: Patient characteristics of the study population
The clinical presentation included respiratory distress, shock, hypotension, heart failure with documented pericardial effusion, and tamponade on ECHO. The majority of the patients were referred to our institute for pericardiocentesis.
A decision to perform emergency pericardial fluid tapping was done in patients with hemodynamic instability and echocardiographic evidence of cardiac tamponade.
Among 22 patients who underwent echocardiographic-guided pericardiocentesis, success was achieved in all the cases (100%).
The entire procedure was done in the pediatric intensive care unit (PICU) under hemodynamic monitoring. None of the patients were shifted to a cath lab for fluoroscopy.
The procedure was done in head end up position. Procedure was done under conscious sedation. Preprocedure mapping of the distance between the skin and pericardium was noted which would guide us in our puncture. A subxiphoid puncture technique was used in all cases [Figure 1]. ECHO was done using Sonosite micromaxx and Philips CX50. The probe used was S8-3 and S1-5.
Figure 1: Subxiphoid puncture technique for pericardial tapping
Apical four-chamber view and subxiphoid view were used for needle-guided aspiration of pericardial effusion. 7F double-lumen or triple-lumen catheter was used. Using negative pressure, the puncture needle was inserted until the fluid was aspirated. At this stage, the guidewire was inserted in the needle without moving the needle. The guidewire position in the pericardial cavity was confirmed by quick bedside ECHO [Figure 2]. Apical four-chamber view and parasternal short-axis view at the papillary muscle level helped in demonstrating the presence of guidewire in the pericardial cavity [Video 1]. In majority of the cases, it was possible to confirm the guidewire position in the apical four-chamber view. However, in few cases, parasternal short-axis and long-axis view was used. The dilator was advanced over the guidewire. It was followed by the placement of the central venous catheter over the wire [Figure 3] and Video 2]. The pericardial fluid was tapped. The mean duration of the catheter in situ was 48 h. In 14 out of 22 cases, the fluid was straw colored, in 5 cases, it was purulent, and in three cases, it was hemorrhagic. One of the patients developed recurrent pericardial fluid collection and was tapped three times. On follow-up, he developed the features of superior vena cava (SVC) obstruction. Computerized tomography of the chest was done which revealed mediastinal lymphoma compressing the SVC. In another case, a sick child developed bradycardia and shock soon after administering sedation. The child was resuscitated, and emergency pericardiocentesis was performed along with cardiopulmonary resuscitation. The child stabilized after the procedure. On an average, 140 ml of fluid was tapped (range 80–320 ml). Three out of 22 cases had undergone cardiac surgery and developed pericardial fluid collection as a complication.
Figure 2: Visualization of guidewire in bedside echocardiography
The echo-guided pericardial tapping technique is less invasive, does not require general anesthesia, improves visibility, markedly improves safety, and significantly reduces the need for surgical drainage. ECHO imaging guided the needle advancement to assess the depth and plane of the pericardial cavity.
The rate of major complications for echo-guided pericardiocentesis is 0.3%–3%. They include cardiac perforation, puncture of the coronary artery, ventricular arrhythmia, pneumothorax, and puncture of abdominal viscera. In our series, we had a complication of apnea and bradycardia which was successfully managed. There were no procedure-related deaths. When an effusion is large or hemodynamically significant, the definitive treatment is prompt evacuation of the pericardial fluid. Blind pericardiocentesis has complication rates ranging in the incidence from 7% to 50%, and it was associated with mortality rates up to 6%. As many patients had ascites, bleeding into the abdomen could easily go undetected clinically. Surgical procedures are effective in relieving pericardial effusions, but they are not ideal because of perioperative risks and complications. Pericardiocentesis under echocardiographic guidance is the therapy of choice in the treatment of pericardial effusion. CVCs are readily available in all PICUs, whereas pigtail catheter is available only in centers with cath laboratory facility. It is more convenient to use CVC due to the short length of the catheter and wire in comparison to the pigtail catheter and Medtronic Teflon wire. There are distinct diagnostic and therapeutic advantages. ECHO detects even small pericardial effusions thus facilitating earlier diagnosis. Doppler assessment permits the evaluation of the hemodynamic significance of the effusion. Fluid obtained during the procedure can be used to determine effusion etiology. Pericardiocentesis can be performed rapidly under emergency circumstances. As general anesthesia is unnecessary, the technique is safe even in very sick and unstable patients. In selected stable and ambulatory patients, this procedure can be performed on an outpatient basis, thus minimizing hospitalization. A pericardiocentesis tray can be assembled from standard medical supplies found in most hospitals. Although ECHO-guided pericardiocentesis is simple, safe, and effective in removing pericardial fluid, improving hemodynamics, and relieving symptoms initially, it has not been considered definitive. A high incidence of recurrence has been demonstrated when pericardiocentesis alone was used as the initial strategy. In this series, the use of a pericardial catheter for extended drainage has been associated with a very low incidence of recurrence. Procedural success rates are high in most series, generally more than 95% and complication rates are low (approximately 4%)., In our series, this was confirmed with a major complication rate of <2%. Special considerations are warranted in some conditions. Malignant pericardial effusions are generally associated with a poor prognosis. A patient with lymphoma who had recurrent pericardial effusions eventually died of SVC obstruction and complications. In these patients, more invasive or surgical techniques have not been demonstrated to provide additional therapeutic or survival benefits over simple ECHO-guided pericardiocentesis with catheter drainage. The treatment goal in these patients should focus on relieving symptoms and enhancing the quality of life. The CVC provides a useful access route for intrapericardial therapy, such as steroids as an adjunct to oral anti-tuberculous (TB) therapy in TB pericarditis.
Pericardiocentesis is an emergency, life-saving procedure. Echocardiographic guidance improves the accuracy of procedure and reduces complication. In none of our patients, there was a need to shift to cardiac cath laboratory. All the procedures were done using a double-lumen or triple-lumen catheter. This is the first case series using central venous catheters for pericardiocentesis and extended drainage instead of the conventional pigtail catheter.