Departments: Interventional Pulmonology in Other Journals
A New Diagnostic and Therapeutic Approach to Pericardial Effusion: Transbronchial Needle Aspiration
Chest. 2003;123:1753–1758. Ceron L, Manzato M, Mazzaro F, Bellavere F. Department of Internal medicine, Villa Salus General Hospital, Venice.
The authors describe a new approach to pericardial effusion by bronchoscopic (transbronchial) access through the left lower lobe bronchus (which allows both diagnosis and evacuation of abundant amounts of fluid) or through the distal trachea (for diagnostic purpose only, in the presence of pericardial effusions filling the aortic recess of the pericardium). The authors performed transbronchial pericardiocentesis through the bronchoscope in 3 patients. Bronchoscopy was performed under conscious sedation. The catheter containing the bronchoscopic needle was introduced into the bronchoscope channel, and the needle was completely inserted through the anterior wall of the left lower lobe bronchus to evacuate the posterior pericardial effusion or through the tracheal wall (second intercartilaginous space of the distal trachea at 12 o'clock) to reach the aortic recess of the pericardium. Suction was then applied by a 20-mL syringe connected to the proximal end of the bronchoscopic needle. The first patient was a 66-year-old woman with a large pericardial effusion following radiotherapy 3 years earlier for right lung cancer. Transbronchial pericardiocentesis was carried out by puncturing the anterior wall of the left lower lobe bronchus, and 220 mL of serosanguineous exudate was collected. The second patient was also a 66-year-old woman with bilateral metastatic pleural effusions and fluid in the aortic recess of the pericardium. Transbronchial aspiration through the second intercartilaginous space of the distal trachea at 12 o'clock yielded 10 mL of clear fluid, which showed cancer cells. The authors do not mention why thoracentesis was not performed for diagnostic purposes. The third patient was an 82-year-old man with chronic pericardial effusion in whom previous attempts at subxiphoid percutaneous evacuation had failed. Transbronchial pericardiocentesis through the left lower lobe bronchus yielded 700 mL of clear fluid. There were no complications from these procedures. Based on this experience, the authors conclude that the bronchoscopic technique is easy for operators skilled in transbronchial needle aspiration, and is safe, economical, and well tolerated. Generally, either diagnostic or therapeutic percutaneous pericardiocentesis is performed under echocardiographic guidance. Occasionally, a posterior pericardial effusion poses a problem in that it is not easy to assess by echocardiography. Such effusions can also cause difficulty in obtaining fluid for diagnostic or therapeutic purposes. In such situations, according to the authors of the study, when the size of the effusion is such that it widens the pleural fissure and brings the pericardium near or in contact with the left main stem of the bronchial tree (usually with the left lower lobe bronchus), a direct transbronchial approach could be used (with or without endobronchial ultrasound). The authors also indicate that same path can be used for access to minor pericardial effusions by passing through the anterior tracheal wall (first to third intercartilaginous space up from the carina), particularly when the effusion causes a redundancy of the aortic recess of the pericardium, which can be recognized on computed tomography as a small homogeneous, hypodense “half moon” suspended from the ascending aorta. The new and novel application of bronchoscopic approach to pericardial effusion is interesting. However, the frequency with which this technique will be applied remains doubtful.