Br Heart J: first published as 10.1136/hrt.28.4.566 on 1 July 1966. Downloaded from Brit. Heart J7., 1966, 28, 566. A Pericardiocentesis Electrode Needle MERVYN S. GOTSMAN AND VELVA SCHRIRE From the Cardiac Clinic, Department of Medicine, Groote Schuur Hospital, the University of Cape Town and the Cardiovascular-Pulmonary Research Group,* Cape Town, South Africa Pericardial aspiration is more difficult and advanced into the pericardial cavity. If a large effusion hazardous than aspiration of other serous cavities. is present aspiration is seldom difficult, but if the If the aspirating needle is introduced too far, it effusion is small or fluid is not present the needle is into the This a may or tear the in advanced epicardium. produces injure myocardium, resulting characteristic electrocardiographic pattern with ventri- hwemopericardium, or induce ventricular fibrillation. cular premature systoles or an acute "current of injury" The dangers are increased if the effusion is small, or (Fig. 2). The tip of the needle is then withdrawn and if aspiration is performed as a diagnostic procedure the pericardial cavity explored in a different direction. to distinguish an effusion from a cardiomyopathy. The technique is also useful to assess completeness of Bishop, Estes, and McIntosh (1956), Neill, aspiration, for the needle can be manipulated until it Hurst, and Penfold (1961), and Lubell and Glass touches the epicardium. (1962) have described a procedure using a peri- Needle puncture is also performed through the fifth cardial needle as an exploring electrocardiograph right intercostal space at the border of the sternum or electrode to recognize signs of myocardial injury through the xiphisternal notch. In the former position, atrial premature systoles and an atrial current of injury during pericardiocentesis. Jacobson (1963) from occur when the needle touches the atrial wall (Fig. 3). this clinic modified the needle, and his technique Nearly a hundred pericardial effusions have been has been in routine use at Groote Schuur Hospital aspirated by this method and the following typical http://heart.bmj.com/ since 1962. The value of this method is often not examples illustrate the value of the electrode needle. appreciated. CASE REPORTS MATERIAL AND METHOD (1) Large tuberculous pericardial effusion. V.M., a The modified electrode needle is shown in Fig. 1. It Bantu man of 25 years was admitted with a six-week consists of a large bore needle (A) which is used to story of dyspncea on effort and swelling of the legs and aspirate the pericardical cavity. This is attached to a abdomen. He had the signs of a large pericardial syringe (B) to aspirate the fluid through two three-way effusion with tamponade, cedema, ascites, gross hepato- on September 27, 2021 by guest. Protected copyright. stopcocks. C is a polythene tube for emptying the megaly, raised jugular venous pressure (+ 15 cm.), syringe. D is the indifferent precordial lead of electro- tachycardia (140/minute), and pulsus paradoxus. The cardiograph attached to a specially constructed electrode diagnosis was confirmed by electrocardiogram and chest wire (E). The wire has two attachments: a soldered radiograph. junction with a male Luer-lock fitting attached to the The effusion was aspirated and 500 ml. of straw- proximal three-way stopcock, and a second screw coloured fluid withdrawn on three occasions. Although junction for attachment to the electrocardiograph lead. acid-fast bacilli were not isolated, a diagnosis of tuber- The wire, therefore, connects the aspirating needle to culous pericardial effusion is likely (Schrire, 1959). In the electrocardiograph machine so that it acts as a this patient the electrode needle was useful in assessing prwcordial lead. The electrode needle is sterilized in the completeness ofaspiration. chlorhexidine or benzalkonium chloride solution or by boiling. (2) Tuberculous pericarditis without effusion. J.B., a of 10 Aspiration is performed through an apical needle Coloured girl years, presented with cardiac failure puncture beyond the apex of the left ventricle but and a large heart on palpation and radiograph. A within the zone of cardiac dullness. An assistant loud third heart sound was heard and diffuse non- monitors the electrocardiogram while the needle is specific T wave inversion was present on the cardio- gram. Pulsus paradoxus could not be appreciated. Received September 28, 1965. She had an ESR of 100 mm. in the first hour (Wester- * Supported in the Department of Medicine by the Council gren). A diagnosis of pericardial constriction was for Scientific and Industrial Research. made at cardiac catheterization. The distance between 566 Br Heart J: first published as 10.1136/hrt.28.4.566 on 1 July 1966. Downloaded from A Pericardiocentesis Electrode Needle 567 D B E C http://heart.bmj.com/ A FIG. 1.-The pericardiocentesis electrode needle. See text for description. on September 27, 2021 by guest. Protected copyright. the endocardial border of the right atrium and the The signs of tamponade disappeared and the patient free margin of the heart was greater than normal, improved. The electrode needle was useful in con- suggesting an effusion. Aspiration was attempted just firming the diagnosis, since tamponade is an uncommon lateral to the apex and again to the right of the sternum complication ofvalvotomy. in the 5th right intercostal space. No fluid was ob- (4) Malignant pericardial effusion from a carcinoma of tained, though the needle electrode touched the epi- the ovary with widespread metastases. J.E., European cardium on several occasions. The space-occupying woman of 41 years. A carcinoma of the ovary had been material, therefore, was solid and not fluid. The removed 2 years previously and the patient then re- needle electrode, therefore, excluded pericardial effusion. ceived radiotherapy. Eighteen months later pleural effusions and ascites developed: these were aspirated. (3) Acute tamponade following mitral valvotomy. The patient subsequently developed a very large left M.B., a Bantu boy of 12 years had a mitral valvotomy pleural effusion, but tachycardia, hepatomegaly, and performed for critical mitral stenosis. The signs of distended neck veins suggested additional pericardial pericardial tamponade developed on the fifth post- tamponade. She was very distressed. A litre of blood- operative day. He had pulsus paradoxus, a tender stained fluid was aspirated from the pleural cavity. liver enlarged 6 cm. below the right costal margin, peri- The pericardial aspiration electrode needle was used to pheral cedema, raised jugular venous pressure (15 cm.), explore the pericardial cavity, since the signs were and an increase in cardiac dullness. 250 ml. blood- masked by the large pleural effusion: 750 ml. of blood- stained fluid were aspirated from the pericardial cavity. stained fluid were aspirated. The patient's symptoms Br Heart J: first published as 10.1136/hrt.28.4.566 on 1 July 1966. Downloaded from 568 Gotsman and Schrire .0 I - I A A I I 1.11. .11 -.11 .11'' A I. I __O I t 4 .b..,. .: r m_-,-- miU --ii ffI , --:-- - I SQ 1%., 'M J.: 11ML.- :1 .1 I II A%%a.Lilip-1-ti +- U I http://heart.bmj.com/ w 14:11... ... II FIG. 2.-Electrocardiographic changes during aspiration of an effusion. (1) Control tracing: T wave in- version is due to the pericarditis. (2) One ventricular premature systole with an acute "current of injury" produced when the tip of the electrode needle touches the epicardium. (3A) Acute current ofinjury occurring on September 27, 2021 by guest. Protected copyright. when the needle touches the epicardium. (3 B and C) Current of injury less well marked as the needle is withdrawn from the myocardium. (4) Five ventricular premature systoles and an acute "current of in- jury" (ST segment elevation) as the needle tip touches the epicardium in a different position. The changes in 2, 3, and 4 indicate epicardial damage and irritation. Aspiration should not be attempted when these are present. FIG. 3.-Atrial premature systoles with an atrial current of injury, showing the effect of the needle electrode on right atrial muscle. Br Heart J: first published as 10.1136/hrt.28.4.566 on 1 July 1966. Downloaded from A Pericardiocentesis Electrode Needle 569 improved dramatically, and, though she died a few days Burch and Phillips (1962) discuss the pericardial later, pericardial aspiration made her more comfortable. electrode needle as a method of Once again the needle electrode was useful. In this differentiating patient the pericardial effusion was masked by the large myocardial dilatation from pericardial effusion. associated pleural effusion. In our experience this doubt can be resolved by clinical evaluation supplemented by a careful trial (5) Cardiomyopathy. B.S., a Coloured man of 45 ofaspiration whenever indicated. years, a heavy wine drinker, presented with a three- month history of congestive heart failure in which the cedema, ascites, and hepatomegaly were out of keeping SUMMARY with the degree of shortness of breath. His jugular venous pressure was raised (12 cm.), and the arterial A modified electrode needle for aspirating the pulse pressure was small. An electrocardiogram pericardial cavity is described. showed extensive T wave inversion while screening Six cases are described briefly to indicate the showed a very large heart, with a prominent left ventricle value ofthe needle in clinical practice. and reduced pulsation. A pericardial effusion with Blind pericardial aspiration is a potentially tamponade was suspected: aspiration was attempted hazardous procedure. The electrode needle pro- without success. The pericardial cavity was entered tects the patients and instils confidence in the and electrocardiographic changes were seen on several operator. occasions. A diagnosis of cardiomyopathy was made by exclusion: the electrode needle excluded a peri- cardial effusion. We are grateful to Mr. L. W. Piller for designing and constructing the needle electrode, to the medical staff (6) Cardiomyopathy with a small pericardial effusion. who referred patients for evaluation and treatment, and B.J., a Coloured boy of 9 years was admitted to hospital to the Medical Superintendent, Dr.