Ann Thorac Surg 1996;61:741-742
© 1996 The Society of Thoracic Surgeons
How To Do It
Echocardiography-Guided Pericardiocentesis With a Needle Attached to a Probe
Shigefumi Suehiro, MD, PhD,
Koji Hattori, MD,
Toshihiko Shibata, MD,
Yasuyuki Sasaki, MD,
Hirokazu Minamimura, MD, PhD,
Hiroaki Kinoshita, MD, PhD
Second Department of Surgery, Osaka City University Medical School, Osaka, Japan
Accepted for publication September 20, 1995.
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Abstract
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Pericardiocentesis with a needle attached to a probe was performed under two-dimensional echocardiographic guidance in 9 patients with pericardial effusion after cardiac operations. The first 5 mm of the tip of a puncture needle for percutaneous transhepatic cholangiodrainage is scratched with a scalpel to give the tip high echo intensity. When the probe is placed on the skin, the direction of puncture at that probe angle appears automatically on the monitor.
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Introduction
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Pericardial effusion (PE) after cardiac operations may progress to cardiac tamponade and other problems. Pericardiocentesis under echocardiographic guidance, in which the probe is placed several centimeters from the site to be punctured, can be done for drainage [1–3]. We used instead a needle mounted on a probe. The technique is reported here.
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Technique
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A 3.5-MHz echocardiographic probe was used for percutaneous transhepatic cholangiodrainage (UST-944B; for the most recent 3 patients, UST-5223, Aloka, Tokyo, Japan) (Fig 1
). The skin below the xiphoid process is anesthetized locally before the probe is positioned on the skin. The monitor immediately displays a line of dots showing where the puncture would be at that patient-probe angle (Fig 2). The needle is set at an unchangeable angle to the probe, so the path of the puncture is chosen by adjustment of the patient-probe angle. We use a metal percutaneous transhepatic cholangiodrainage puncture needle (17 gauge, 15 cm long), which we scratched as described in the legend of Figure 2 so that the needle tip can be monitored by its high echo intensity. Once a suitable direction for the puncture is decided, the puncture can be made by advancing the needle with the probe held firmly in place. After the tip of the needle is seen on the monitor as entering the pericardial space, the location of the tip is confirmed if bloody fluid can be withdrawn with little resistance through the needle. A J-shaped guidewire is then inserted through the needle until its tip enters the pericardial space. The needle is removed and a straight angiographic catheter (7.2F, 35 cm long) is inserted. (A pigtail catheter can be used instead.) After the PE is syringed off as completely as possible, the catheter is connected to an extension tube for continuous siphon drainage.
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Fig 1. . Echocardiographic probe (UST-944B) with needle attached. The needle is held at an invariable angle with respect to the probe. The echocardiographic instrument was an Aloka model SSD 500 or SSD 830 (Tokyo, Japan).
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Fig 2. . Two-dimensional echocardiographic image obtained during pericardiocentesis before introduction of the guidewire. The line of dots shows the direction of the puncture. The needle point is seen as an area with a higher echo intensity (arrow) than the rest of the needle, because the first 5 mm of the tip was scratched with a scalpel. (LV = left ventricle; PE = pericardial effusion.)
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Results
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Between October 1990 and March 1995, 359 patients underwent open heart operations at our department, 9 (2.5%) of whom experienced moderate to severe PE 7 days postoperatively or later. Our technique was used to treat these patients, who had undergone valvular heart operations (4 patients), modified Bentall operations (2), coronary artery bypass grafting (2), or closure of an atrial septal defect (1). Except for the patient with atrial septal defect, all patients were given postoperative warfarin and antiplatelet therapy. The causes of PE could not be identified, but were probably related to postoperative anticoagulation or postpericardiotomy syndrome. In 1 patient, cardiac tamponade developed as a complication of the cardiac operation. The 8 other patients had symptoms suggesting PE, including weight gain, malaise, and dyspnea. Four patients also had fever.
Pericardial drainage was performed between 11 and 55 days (mean, 19 days) after operation. Only 1 patient had PE surrounding the heart. In the other patients, PE was limited to a region from the apex to the posterior portion of the heart, and in each case, an echo-free space of 1.5 cm or wider was seen at end diastole. Pericardiocentesis was successful in all patients. The catheter was left in place for 1 to 3 days; no patient had prolonged PE discharge. The total volume drained was 330 to 700 mL (mean, 470 mL). Clinical symptoms disappeared in all patients, and fever resolved within 3 days of the start of drainage in 3 of the 4 patients with fever. Antibiotics were given prophylactically to all patients for 2 or 3 days. No drainage-associated infection occurred. Anticoagulant therapy was continued during drainage, without recurrence of PE.
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Comment
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Our technique is advantageous because it can be done at the bedside by one operator without the risk of injuring the myocardium or the coronary arteries. The procedure is straightforward once the angle of the probe is selected, and the location of the needle tip is known at all times. Only 5 to 10 minutes is needed. The risk of complications seems low, and much experience is not essential.
Most postoperative PE is found in the space behind the heart [3, 4], as in our patients. We used a subxiphoid approach in all patients because in this approach, the inferoposterior wall of the left ventricle is seen to be parallel with the diaphragm. There were no vital organs, such as a lung, between the puncture site and the echo-free space. If the operator advances the needle so that it is in parallel with the diaphragm, the pericardial space can be reached without danger of injuring the heart. In our technique, the operator pushes the needle in the direction of the dashed line shown in Figure 2
. This approach is suitable for the loculated posterior PE because the heart is not in the region where the needle passes. Even if the puncture is deep, the risk of complications is low. About 1 cm of echo-free space seems to be the least required for safe pericardial puncture using this technique. Thus, the method should be usable if there is a small amount of PE or loculated PE. Patients with medical, not surgical, causes of cardiac tamponade can be treated with this technique as well.
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Footnotes
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Address reprint requests to Dr Suehiro, Second Department of Surgery, Osaka City University Medical School, 1-5-7 Asahimachi Abeno-ku, Osaka 545, Japan.
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References
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- Callahan JA, Seward JB, Tajik AJ, et al. Pericardiocentesis assisted by two-dimensional echocardiography. J Thorac Cardiovasc Surg 1983;85:877–9.[Abstract]
- Chandraratna PAN, Reid CL, Nimalasuriya A, Kawanishi D, Rahimtoola SH. Application of 2-dimensional contrast studies during pericardiocentesis. Am J Cardiol 1983;52:1120–2.[Medline]
- Pandian NG, Brockway B, Simonetti J, Rosenfield K, Bojar RM, Cleveland RJ. Pericardiocentesis under two-dimensional echocardiographic guidance in loculated pericardial effusion. Ann Thorac Surg 1988;45:99–100.[Abstract/Free Full Text]
- Borkon AM, Schaff HV, Gardner TJ, et al. Diagnosis and management of postoperative pericardial effusions and late cardiac tamponade following open-heart surgery. Ann Thorac Surg 1981;31:512–9.[Abstract/Free Full Text]
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Abstract
Introduction
