Step 4: ultrasound setting optimization
Depth of the sector on the screen and focus position was adjusted so that only the pericardial effusion and the right ventricle were visible.
Step 5: needle insertion
An in-plane medial-to-lateral approach with a 45° angle was used to visualize the needle trajectory and its entrance into the pericardial space (Fig. 4, Video 1, Supplemental digital content 1, http://links.lww.com/EJEM/A165).
Step 6: microbubble test confirmation and hemodynamic stabilization
Using the same parasternal view with a high-frequency linear probe, a normal saline–air microbubble was systematically injected through the needle while its position was monitored by ultrasonography, creating a ‘rocket flare’ appearance. (Fig. 5, Video 1, Supplemental digital content 1, http://links.lww.com/EJEM/A165). The first amount of fluid was drained with a syringe connected to the catheter by a three-way stopcock until hemodynamic stabilization occurred.
Step 7: wire and catheter position
A guide wire was placed under real-time visualization and a standard Seldinger technique was used to dilate the subcutaneous space after the needle removal. Then, a single lumen catheter was placed into the pericardial space (Video 2, Supplemental digital content 2, http://links.lww.com/EJEM/A166).
Step 8: pericardial drainage and monitoring
After pericardial drainage, the catheter was left in place and ultrasound was repeated every 24 h, or as dictated by clinical conditions, to ensure the absence of effusion and other postprocedural complications. Skin to pericardium distance, maximum effusion diameter, time to needle in, time to catheter in, and the first and total amount of fluid drained were recorded.
A descriptive statistical analysis was carried out with IBM SPSS Statistics for Windows, version 23 (IBM Corp., Armonk, New York, USA). Numerical measures were checked for normality. Measures with normal distribution were described using mean and SD, and those not normally distributed were described using median and interquartile range (IQR). Categorical measures were reported as numbers and percentages. Differences in blood pressures before and after the procedure were tested using the Wilcoxon-signed rank test and differences in the heart rate were tested using a paired t-test. Significance was considered at P less than 0.05.
All pericardiocentesis were performed successfully in the emergency room without complications, relieving the hemodynamic instability. Patients’ demographics and clinical features are summarized in Table 1.
Four patients had pericardial effusion related to malignancy; two out of 11 as a complication of myocardial infarction, one was a victim of traumatic injury, and the other patient’s effusion was related to inflammatory diseases or complication of uremic status.
The in-hospital 30-days mortality was 18%. One died because of septic shock secondary to pneumonia and another died because of septic shock with multiorgan failure. Seven (63%) patients required inotropes or vasopressors, which were reduced and subsequently discontinued after the procedure. The mean time to perform the eight-step procedure was 309±76.4 s.
Patients’ median blood pressures before and after the procedure were 53 mmHg (median; IQR: 4) and 90 mmHg (median; IQR: 19), respectively (Z=−2.803, P=0.005). Patients’ heart rates before and after the procedure were 120 bpm (median IQR: 54) and 98 bpm (median; IQR: 25), respectively (t=8.643, P<0.001). The maximum effusion diameter was 20 mm [median; IQR: 6, Q1 (first quartiles): 17, Q3 (third quartiles): 22] and the skin to parietal pericardium distance was 15 mm (median; IQR: 4, Q1: 12, Q3: 17). Fluid removed during the procedure and the total amount of fluid drained during hospital stay were 580 ml (median; IQR: 510) and 1030 ml (median; IQR: 840), respectively.
We report our preliminary experience on a novel ultrasound-guided pericardiocentesis technique with a medial-to-lateral approach, performed in the emergency context of tamponade, which led to the 100% success rate of the procedure without complications.
The main advantages of this medial-to-lateral approach are as follows: (i) safety, as all the surrounding structures are visualized and thus avoided, including the lungs and thoracic vessels; (ii) The high-frequency probe enables a more detailed visualization of the needle and the wire during their insertion; and (iii) fast procedural time.
Echocardiography-guided pericardiocentesis was developed in the 1970s and it has been adopted as the gold standard because of a significant reduction in complications in comparison with the blind technique, including liver, myocardium, arteries, and lungs perforation 6.
The standard technique involves identifying the location and distribution of pericardial fluid and insertion of the needle at the point where the largest amount of fluid is closest to the skin using the ‘bubble test’ to verify the correct position of the needle. This technique accounts for the low incidence of minor and major complications (3.5 and 1.2%, respectively) 5. A number of alternative but similar techniques, including the probe-mounted needle, have been proposed, with similar complication rates 16.
The technique described above differ on the site of the puncture (subxiphoid, apical, or parasternal) 6–8, whereas they shared the use of low-frequency probes and absence of real-time needle visualization and complete control of needle trajectory. This might increase the risk of puncture to other vital organs.
The apical approach was transpleural, with the possibility of pneumothorax or spread of infection to the pleura and lung. The subxiphoid approach had a higher risk of injury to the liver, heart, and inferior vena cava. Vayre et al. 8 chose the subxiphoid approach for most of his case series and reported a complication rate of 21% (0.9% major and 20.1% minor). Akyuz et al. 9 reported the use of the subcostal (85%) and apical approach (15%) under echocardiographic guidance, and reported a complication rate of 1.3% for all minor and major complications.
The parasternal approach relies on the identification of the cardiac notch, where the pericardium is exposed, enabling direct and safe access to pericardium. The cardiac notch can be identified sonographically by the absence of lung tissue overlying the pericardial sac. A parasternal, in-plane, and real-time technique has only been described anecdotally 12,13, but never with a medial-to-lateral approach.
Several observational studies showed that the left chest approach was superior to the traditional subxiphoid approach 5,10,13,17.
Traditional echo-guided pericardiocentesis without a probe-mounted needle did not enable continuous visualization of the needle in 56–75% of cases 16,18–20.
Our preliminary experience suggested that real-time visualization of the needle and the catheter by the left parasternal approach, avoiding the lung and other organs, and the preprocedural ultrasonography mapping of the thoracic vessels 11 make the procedure theoretically free of any complications.
Furthermore, our preliminary experience showed good timeliness and feasibility of this technique as shown by our average time to needle (Table 1).
No studies have been published to date addressing complete control of needle trajectory and real-time needle visualization in ultrasound-guided pericardiocentesis without an additional probe-mounted needle.
There are a few main limitations of this technique. It requires two probes as the initial assessment of pericardial effusion has to be performed with a cardiac probe while the procedure is performed using a linear high-frequency probe. It cannot be performed if the pericardial effusion is only posterior, but these kinds of effusions are usually more solid following cardiac surgery and the percutaneous approach is not efficient. In case of severe subcutaneous emphysema, the parasternal approach is unfeasible.
The preliminary description, although effective and promising, requires further validation in a larger population.
The in-plane parasternal medial-to-lateral approach using a high-frequency probe offers potential advantages in terms of feasibility and safety as it abolishes the risk of liver injury, enables real-time visualization of the needle trajectory, and avoids the internal thoracic vessels, lung, and heart perforation.
The authors would like to thank the Society of Critical Care and Emergency Sonography (SUCCES) Malaysia, Ipoh Emergency Medicine Society and Clinical Research Centre (CRC) HRPB, Ipoh, for their support and assistance.
Adi Osman and Tan Wan Chuan were involved in the initial conception, data acquisition, and drafting of the manuscript. Gabriele Via and Guido Tavazzi are senior authors who equally contributed toward the statistical analysis and data interpretation of the study, drafting, and revising of the manuscript. Jamalludin Ab Rahman was involved in biostatistics interpretation and advice.
Conflicts of interest
There are no conflicts of interest.
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cardiac tamponade; focused cardiac ultrasound; pericardiocentesis; point of care ultrasound; procedural guidance; ultrasound-guided pericardiocentesis
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