1) Pericardiocentesis is performed to drain fluid from the pericardial sac surrounding the heart. It was first done in 1840 by Franz Schuh in Vienna on a patient with a mediastinal tumor. 2) There are several potential access sites for the procedure including sub-xiphoid, left and right parasternal, and apical approaches. Ultrasound is typically used to guide needle placement and confirm proper positioning within the pericardial sac. 3) After fluid is drained, samples are obtained for analysis. The drainage catheter is then sutured in place and connected to a drainage system. Complications can include laceration of nearby organs or vessels,

1. Ahmed Elborae
How to ?
series
How to perform pericardiocentesis ?

2. Here we begin…
Vienna
Paris

3. Franz Schuh 1840, Vienna
First percutaneous pericardiocentesis in human
24-year-old lady with
mediastinal tumor
Done via “Trocar” introduced
in the left 3rd intercostal space

4. Antoine Marfan 1911, Paris
First percutaneous sub-xiphoid approach

5. Indications?

6. Settings:
-Emergency
-Semi-urgent
-Elective

7. Two layers : Visceral and outer fibrous parietal
Normally:
Volume: 25 ml
Pressure: < 5 mmHg

8. Signs of tamponade
Beck’s triad
Electrical alternans
Pulsus paradoxus
> 10 mmHg drop Volume: Variable
Pressure: “15-20 mmHg”

9. Rate dependent not volume dependent
Cardiac tamponade
as little as 50 cc can
cause tamponade
May exceed 1000 cc
without tamponade

10. Measure at end diastole
Grading effusion severity:
-Mild (< 1 cm)
-Moderate (1-2 cm)
-Severe (> 2 cm)

11. Late diastole Inspiration Early diastole Inspiration
A4 view A4 view+ PWD
Hemodynamic significance is what really matter

12. Contraindications?

13. All are relative
because tamponade itself is life threatening
• -Bleeding diathesis:
- Platelets< 50,000
- High INR (Modifiable)
- Anticoagulation
• -Surgical candidates:
- Rupture LV free wall
- Ruptured aortic aneurysm
- Posterior effusion
- Loculated effusion

14. How?

15. Ideally  Prepared kit
4- Tubes for cytology, chemistry, C/S
2- Puncture needle, dilator/sheath, 0.035 J-wire, Pigtail catheter
3- I.V line, 3-way,Urine bag, 20 cc syringes
1- Sterile drape, local anesthesia

16. Six Possible drainage site
• Xiphoid: Sub-xiphoid (1), Left para-
xiphoid (2), Right para-xiphoid (3)
• Apical (4)
• Parasternal: left parasternal(5) , right
parasternal (6)

17. Step by step
1- Informed consent, check platelets count and coagulation status
2-Patient is positioned supine at (30º- 45º), monitored
3- Sterilization and local anesthesia, sterile probe cover
Gravity !
Skin
Liver
*
(30º- 45º)
Head
Leg

18. Step by step (sub-xiphoid approach)
4- Echo: Distance from probe to fluid & orientation *
Skin
Liver
X *
Either:
Echo assisted: Memorise position and go
Echo guided: Continuous monitoring

19. Step by step (sub-xiphoid approach)
5- Advance needle slowly at 30º angle to pass
beneath the costal margin and directed towards tip
of left shoulder (on negative pressure, feel
characteristic pop once pass through the fibrous
parietal pericardium ,stop once get fluid)

20. Step by step (sub-xiphoid approach)
6- Check position:
-Echo method: Inject (5 cc ) of agitated saline
and check in echo (Should seen in pericardial sac
not RV)
The most critical step

21. Step by step (sub-xiphoid approach)
6- Check position:
-Pressure method :
Just connect it to transducer using
three-way
Pericardial pressure wave
RV pressure wave
X
The most critical step

22. Step by step (sub-xiphoid approach)
6- Check position:
-Dye method: inject few cc of dye and check shadow by fluoroscopy
The most critical step

23. Step by step (sub-xiphoid approach)
6- Check position:
-ECG method: connect to v
electrode using sterile alligator
Pericardium
“Isoelectric”
Touching RV
“ST elevation or PVCS”
X
The most critical step

24. Step by step (sub-xiphoid approach)
7- Advance 0.035- inch soft J shaped wire under
fluoroscopy , then remove needle
-J-Wire course: around heart shadow, check in 2 views ( AP& lateral)
Don't advance if any
resistance

25. Step by step (sub-xiphoid approach)
8- Advance sheath, then pigtail over the J-wire
(Monitor course by fluoroscopy)
Alternative sheathless technique (Safer) : Direct pigtail on J wire after using 6F dilator only without sheath

26. Step by step (sub-xiphoid approach)
9- Get your samples for analysis first:
1- Cytology
2-Histopathology
3- Chemistry (LDH, Glucose, protein),
ADA for TB
4- Gram stain, Z/N stain, bacterial
culture and sensitivity, TB C/S & PCR
(Usually three 20 cc sterile syringes)

27. This end = close, so when face I.V set =suck from pigtail, when face pigtail =evacuate to I.V set
10- Use the “3-way connection” ,
aspirate fluid through the pigtail
and inject into urine bag via I.V set
Aspirate Inject

28. Is it blood or hemorrhagic effusion ?
More likely hemorrhagic effusion if :
1- Lower hematocrit value than blood
2-Does not clot easily

29. Post procedure
• Reading of intra-pericardial pressure “Post-drainage” > Especially If
effusive-constrictive suspected (Remains elevated)
• Fix catheter by suture, and cover with sterile dressing
• No consensus about prophylactic antibiotics “preferred anti-staph if drain
left”
• Do CXR post procedure to exclude lung complications
• Remove drain if less than 30 ml / 24 hours & no residual by echo
• Echo FU before and after removal of drainage
• If after 72 hours and still high output > 100 ml, consider further steps to
prevent recurrence

30. Complications?
“If you didn’t have complications, then you did not perform the number needed to get one”

31. “Expect the unexpected, then you will be ready”
The PCR-EAPCI Textbook – Percutaneous interventional cardiovascular medicine
John D. Groarke, Andrew O. Maree, Igor F. Palacios
Liver laceration
“Left lobe”
LAD injury
RV/RA/LV
perforation
Pericardial decompression If large amount drained

32. Special situations?

33. Daniel A Jones.Journal of thoracic oncology.2011
Percutaneous balloon pericardiotomy
Intra-pericardial instillation of sclerosing agent
Or

34. Thank You