Türk Kardiyol Dern Arfl - Arch Turk Soc Cardiol 2009;37(3):177-181 177 Echocardiography-guided pericardiocentesis with the apical approach Ekokardiyografi rehberli¤inde apikal yaklafl›mla perikardiyosentez Hasan Orhan Ozer, M.D., Vedat Davutoglu, M.D., Musa Cakici, M.D., Adnan Dogan, M.D., Ibrahim Sari, M.D., Mustafa Oylumlu, M.D., Mehmet Aksoy, M.D. Gaziantep University Faculty of Medicine, Department of Cardiology, Gaziantep Objectives: We aimed to evaluate our experience with echo- Amaç: Bu çal›flmada perikart efüzyonu nedeniyle ekokar- cardiography-guided pericardiocentesis with the apical appro- diyografi rehberli¤inde apikal yaklafl›mla perikardiyosentez ach for pericardial effusions. uygulamalar›m›z›n de¤erlendirilmesi amaçland›. Study design: We evaluated 32 pericardiocentesis perfor- Çal›flma plan›: Çal›flmaya, tan› amac›yla veya perikardiyal med under echocardiography guidance and with the apical tamponad ya da semptomatik perikart efüzyonu nedeniyle approach in 29 patients (15 men, 14 women; mean age of 49 ekokardiyografi rehberli¤inde apikal perikardiyosentez ya- years; range of 18 to 72 years). Indications were diagnostic p›lan ard›fl›k 29 hasta (15 erkek, 14 kad›n; ort. yafl 49; da- purpose, pericardial tamponade or symptomatic pericardial ¤›l›m 18-72) al›nd›. Toplam 32 perikardiyosentez uygula- effusion. Procedural success, the amount of drainage, and mas›, ifllem baflar›s›, boflalt›lan s›v› miktar› ve komplikas- complications were assessed. yonlar yönünden de¤erlendirildi. Results: Common causes of pericardial effusion were malig- Bulgular: Perikart s›v›s›n›n s›k nedenleri malignite (n=6), nancy (n=6), postpericardiotomy syndrome (n=5), idiopathic postperikardiyotomi sendromu (n=5), idiyopatik (n=5), kro- (n=5), chronic renal disease (n=4), and myocardial infarction nik renal yetersizlik (n=4) ve akut miyokard enfarktüsü (n=3). The amount of drainage was 120 ml to 2,200 ml and (n=3) idi. Boflalt›lan s›v› miktar› 120 ile 2200 ml aras›nda the duration of pericardial catheter placement in the pericardi- de¤iflmekte idi. Kateterin perikartta kalma süresi 24 ile 144 al space was 24 to 144 hours. Death did not occur. Echocar- saat aras›ndayd›. ‹flleme ba¤l› mortalite olmad›. Bir hasta- diographic control showed residual effusion in the lateral wall da ekokardiyografik kontrolde lateral duvarda efüzyon kal- in one case, which required repositioning of the pericardial d›¤› görüldü ve kateterin floroskopi alt›nda buraya yönlendi- catheter for complete removal. The procedure failed in one rilerek kalan s›v›n›n tamam›n›n boflalmas› sa¤land›. Bir patient due to insufficient drainage caused by multiple septa- hastada perikart bofllu¤undan afl›r› septasyon ve fibrinöz tions and fibrinous fluid in the pericardial space. The success s›v› içeri¤ine ba¤l› olarak yeterli s›v› boflalt›lamad›¤›ndan rate of the procedures was 96.9%. Four cases developed he- ifllem baflar›s›z kabul edildi. Uygulanan apikal perikardiyo- mopneumothorax requiring tube drainage, vasovagal reacti- sentez ifllemlerinde baflar› oran› %96.9 idi. Birer hastada on, nonsustained ventricular tachycardia, and frequent ventri- s›ras›yla tüp drenaj› gerektiren hemopnömotoraks, vazova- cular extrasystoles, respectively. Apical puncture was repea- gal reaksiyon, devaml› olmayan ventrikül taflikardisi ve s›k ted in two cases due to erroneous left ventricular puncture ventrikül erken at›mlar› izlendi. Bir hastada sol ventrikül and pleural catheter placement, respectively. ponksiyonu, bir hastada kateterin plevraya yerlefltirilmesi Conclusion: Echocardiography-guided pericardiocentesis nedeniyle ponksiyon tekrarland›. with the apical approach is readily performed at the bedside Sonuç: Ekokardiyografi rehberli¤inde perikardiyosentezde without the need for catheterization laboratory, with a high apikal yaklafl›m, kateter laboratuvar›na ihtiyaç duymadan success rate and low complication rate. It should be conside- yatakbafl›nda rahatl›kla yap›labilmesi, ifllem baflar›s›n›n red especially in cases in which anterior pericardial collection yüksek, komplikasyonlar›n düflük olmas› nedeniyle ve özel- is more prominent where it will reduce unnecessary surgical likle s›v›n›n kalbin anteriyorunda birikti¤i olgularda gereksiz interventions. cerrahi giriflimi azaltaca¤›ndan mutlaka düflünülmelidir. Key words: Echocardiography; heart catheterization; Anahtar sözcükler: Ekokardiyografi; kalp kateterizasyonu; pericardial effusion/therapy; pericardiocentesis/methods. perikart efüzyonu/tedavi; perikardiyosentez/yöntem. Received: 19.10.2008 Accepted: 26.02.2009 Corresponding address: Hasan Orhan Özer, M.D., Gaziantep Üniversitesi, T›p Fakültesi, fiahinbey Uygulama Hastanesi, Kardiyoloji Anabilim Dal›, 27310 fiahinbey, Gaziantep, Turkey Tel: +90 - 342 - 360 60 60 e-mail: [email protected] The English version of this article is prepared for online access only. 178 Arch Turk Soc Cardiol Echocardiography-guided percutaneous pericardi- Horteni Norway) was performed under local anesthesi- ocentesis, as an alternative to electrocardiography or a on all patients in the coronary intensive care unit. fluoroscopy-guided procedures was first developed at With the assistance of two-dimensional echocardiog- the Mayo-Clinic in 1979.[1] Echocardiography-guided raphy, the puncture site was designated as the site in pericardiocentesis had several advantages in diagnosis which pericardial fluid mostly accumulated and which and treatment of pericardial effusion owing to its ease was proximal to the skin.[10] The direction of puncture of use and significantly lower complication rates.[1-5] needle and echocardiographic probe was parallel du- Most of the procedures are performed through anterior ring the procedure. The area of the chest wall with pe- chest wall, mostly from apical region.[4,5] ak heart beat and its surrounding was described as the apical and para-apical region. The procedure was per- Despite its ease of use and lower complication ra- formed through the upper margin of ribs in the inter- tes, the apical approach is not generally preferred com- costals space. Puncture was not performed to prevent pared to the subxiphoid approach. In addition, api- any damage to the left internal mammary artery located cal/anterior approach is often neglected although peri- 4-5 cm to the left side of sternum.[1,10] cardial effusion is mostly seen anteriorly rather than in- feriorly.[6-9] Patients were instructed to lie supine, with the up- per body elevated to a 45 degree angle. The puncture In this study, we aimed to evaluate our experience site was cleaned with povidone-iodine, covered with a of the past 2 years with echocardiography-guided peri- sterile cloth and local anesthesia with 2% lidocaine was cardiocentesis with the apical approach for pericardial applied. An 18-gauge needle was placed into a 10-mm effusions. syringe filling with a 3-mL saline solution and the flu- PATIENTS and METHODS id was aspirated continuously. Simultaneously, punctu- re was performed under negative pressure. When peri- We evaluated 29 consecutive patients (15 men, 14 cardial fluid was aspirated, the puncture needle was ret- women, mean age 49 years; range 18 to 72 years) ret- rieved after replacing a 0.038-inch J-tip guidewire. rospectively who underwent echocardiography-guided Agitated saline contrast was injected to confirm correct apical pericardiocentesis in cardiology clinic between guidewire position in suspected cases. A 6- or 7-F Cor- March 2006 and September 2008. Indications were; di- dis sheath (Figure 1a) or multi-orifice pleural catheter agnostic purpose (cases with asymptomatic and diasto- (Pleuracan®, B. Braun Melsungen AG, Germany) (Fi- lic >10 mm pericardial fluid), pericardial tamponade gure 1b) was placed into the pericardial space over the (consistent with echocardiographic and/or clinical cri- guidewire and the guidewire was retrieved. Following teria) or symptomatic pericardial effusion (cases witho- insertion of the sheath, drainage was done via a pigtail ut clinical or echocardiographic findings of cardiac catheter which was advanced into the pericardial space tamponade). A total of 32 pericardiocentesis were eva- through the sheath. A closed system was used to drain luated with respect to procedural success, the amount the fluid. Samples from the drained fluid were obtained of drainage, mortality and complications. for biochemical, microbiological and cytological Bedside surface echocardiography-guided apical analyses. Samples from effusions which developed iat- pericardiocentesis (Vivid 3, GE Vingmed Ultrasound, rogenically or following the procedure were not collec- Figure 1. Sheath containing a pigtail catheter (A) and pleural catheter (B) in the apical region. The English version of this article is prepared for online access only. Echocardiography-guided pericardiocentesis with the apical approach 179 ted for analysis. Initially, fluid >1000 mL was not drai- Mortality did not occur due to the procedure. One ned to prevent hypotensive shock due to acute right patient each developed hemopneumothorax requiring ventricular dilatation which could result from rapid flu- tube drainage, vasovagal reaction, nonsustained ven- id drainage.[11] Following the procedure, the inside of tricular tachycardia, and frequent ventricular extrasy- the catheter was washed using saline to prevent possib- stoles. Left ventricular puncture was performed in one le occlusions associated with protein content of the flu- patient. Following echocardiographic evaluation of id. Drainage was repeated every 4-6 hours. The success the puncture site after removal