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University Institute for Cardiovascular Diseases, Belgrade, YUUniversity Institute for Cardiovascular Diseases, Belgrade, ...
Pericardioscopy and Pericardial BiopsyPericardioscopy and Pericardial Biopsy
HISTORICAL OVERVIEWHISTORICAL OVERVIEW
♦ Init...
♦PE ofPE of unknown etiologyunknown etiology
♦PE in pts with knownPE in pts with known
malignancymalignancy
♦Verification ...
Pericardioscopy and Pericardial BiopsyPericardioscopy and Pericardial Biopsy
AIM OF THE STUDYAIM OF THE STUDY
♦ TTo assess...
Pericardioscopy and Pericardial BiopsyPericardioscopy and Pericardial Biopsy
P A T I E N T SP A T I E N T S
PATIENTS N Mal...
♦ SubxiphoidSubxiphoid
pericardiocentesispericardiocentesis andand
drainage of PEdrainage of PE
♦ Instillation of 200 ml s...
♦ SubxiphoidSubxiphoid pericardiocentesispericardiocentesis
and drainage of PEand drainage of PE
♦ LLocal anesthesiaocal a...
Flexible percutaneous pericardioscopyFlexible percutaneous pericardioscopy
BELGRADE METHODOLOGYBELGRADE METHODOLOGY
MODIFI...
MACROSCOPICMACROSCOPIC
PERICARDIOSCOPY FINDINGSPERICARDIOSCOPY FINDINGS
(Seferovic PM, et al. Herz 2000)(Seferovic PM, et ...
Olympus
FB-43ST Biopsy
Forceps
Group 1
(12 patients)
Fluoroscopy
3-6 samples
Group 2
(22 patients)
Pericardioscopy
4-6 sam...
Pericardioscopy and Pericardial BiopsyPericardioscopy and Pericardial Biopsy
SAMPLING EFFICIENCY /SAMPLING EFFICIENCY /
SE...
Pathohistology Group 1
(12 patients)
Fluoroscopy
3-6 samples
Group 2
(22 patients)
Pericardioscopy
4-6 samples
Group 3
(15...
8.3 8.3
33.3
58.3
26.3
40.9
36.4
36.440
53.3 53.3
6.7
New Dg. Etiology Clin.Dg.confirmed No useful information
0
20
40
60
...
♦ Excellent visualizationExcellent visualization but nonspecificbut nonspecific
macroscopic findingsmacroscopic findings.....
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Seferovic

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Seferovic

  1. 1. University Institute for Cardiovascular Diseases, Belgrade, YUUniversity Institute for Cardiovascular Diseases, Belgrade, YU PERICARDIOSCOPY ANDPERICARDIOSCOPY AND PERICARDIAL BIOPSYPERICARDIAL BIOPSY - Belgrade experience -- Belgrade experience - Prof. Petar M. Seferović, MD, PhD, FESC, FACC
  2. 2. Pericardioscopy and Pericardial BiopsyPericardioscopy and Pericardial Biopsy HISTORICAL OVERVIEWHISTORICAL OVERVIEW ♦ Initiated byInitiated by Santos and FraterSantos and Frater in 1977in 1977 ♦ Flexible pericardioscopy -Flexible pericardioscopy - KondosKondos et al.et al. JACCJACC 19861986 ♦ Transcutaneous approach in local anesthesia -Transcutaneous approach in local anesthesia - MaischMaisch et al.et al. Eur Heart JEur Heart J 19911991 ♦ Until nowUntil now implemented inimplemented in 16 centers16 centers ♦ OnlyOnly Marburg, Maryland and BelgradeMarburg, Maryland and Belgrade seriesseries are dealing with non-surgicalare dealing with non-surgical,, transcutaneoustranscutaneous approach in local anesthesiaapproach in local anesthesia
  3. 3. ♦PE ofPE of unknown etiologyunknown etiology ♦PE in pts with knownPE in pts with known malignancymalignancy ♦Verification ofVerification of perimyocarditisperimyocarditis ♦Verification ofVerification of tuberculoustuberculous pericarditispericarditis ♦PBPPBP window verificationwindow verification Pericardioscopy and Pericardial BiopsyPericardioscopy and Pericardial Biopsy I N D I C A T I O N SI N D I C A T I O N S
  4. 4. Pericardioscopy and Pericardial BiopsyPericardioscopy and Pericardial Biopsy AIM OF THE STUDYAIM OF THE STUDY ♦ TTo assess the feasibility and diagnostico assess the feasibility and diagnostic value of three approaches to pericardialvalue of three approaches to pericardial biopsy:biopsy: 1.1. FFluoroscopic controlluoroscopic control and standardand standard samplingsampling 2.2. PPericardioscopyericardioscopy guidance with eitherguidance with either standardstandard oror 3.3. EExtensive samplingxtensive sampling..
  5. 5. Pericardioscopy and Pericardial BiopsyPericardioscopy and Pericardial Biopsy P A T I E N T SP A T I E N T S PATIENTS N Males (%) Mean age (yrs) Evacuated PE (ml) Samples/pt Group 1 (fluoroscopy) 12 66.7 46.7±12.2 775.0±171.2 3-6 Group 2 (pericardioscopy/ standard sampling) 22 50.0 50.8±10.4 769.5±185.7 4-6 Group 3 (pericardioscopy/ extensive sampling) 15 53.3 53.7±12.8 790.0±204.6 18-20
  6. 6. ♦ SubxiphoidSubxiphoid pericardiocentesispericardiocentesis andand drainage of PEdrainage of PE ♦ Instillation of 200 ml salineInstillation of 200 ml saline ♦ 7F7F introducer-sheath setintroducer-sheath set ♦ Position at thePosition at the upper leftupper left laterallateral surface of thesurface of the parietal pericardiumparietal pericardium ♦ OlympusOlympus FB-43ST forcepsFB-43ST forceps (fenestrated, central needle)(fenestrated, central needle) ♦ 4-6 samples4-6 samples (mean 5.1)(mean 5.1) Pericardial Biopsy Using FluoroscopyPericardial Biopsy Using Fluoroscopy M E T H O DM E T H O D N=12 pts (group 1)
  7. 7. ♦ SubxiphoidSubxiphoid pericardiocentesispericardiocentesis and drainage of PEand drainage of PE ♦ LLocal anesthesiaocal anesthesia ♦ Olympus HYF-1Olympus HYF-1TT, 16F, 16F flexible endoscopeflexible endoscope ♦ GGradual dilationradual dilation (9(9,, 12, 14F12, 14F)) up toup to 16.5F introducer-set16.5F introducer-set ♦ PericardialPericardial biopsy targeted bybiopsy targeted by pericardioscopypericardioscopy ((OlympusOlympus FB-43ST forceps )FB-43ST forceps ) Pericardioscopy and Pericardial BiopsyPericardioscopy and Pericardial Biopsy M E T H O DM E T H O D N=37 pts (groups 2 & 3)
  8. 8. Flexible percutaneous pericardioscopyFlexible percutaneous pericardioscopy BELGRADE METHODOLOGYBELGRADE METHODOLOGY MODIFICATIONSMODIFICATIONS (Seferovic PM, et al. Herz 2000)(Seferovic PM, et al. Herz 2000) ♦ Olympus HYF-1T, 16FOlympus HYF-1T, 16F flexible endoscope (flexible endoscope (biopsybiopsy channel 2.2 mmchannel 2.2 mm)) ♦ Active pericardial drainageActive pericardial drainage ♦ Intrapericardial instillationIntrapericardial instillation of 100-300 ml of airof 100-300 ml of air ♦ AIMED BIOPSYAIMED BIOPSY ♦ EXTENSIVE SAMPLINGEXTENSIVE SAMPLING (up to 20 samples/pt)(up to 20 samples/pt) ♦ Pericardioscopy after PBPPericardioscopy after PBP
  9. 9. MACROSCOPICMACROSCOPIC PERICARDIOSCOPY FINDINGSPERICARDIOSCOPY FINDINGS (Seferovic PM, et al. Herz 2000)(Seferovic PM, et al. Herz 2000) Pericardioscopy macroscopic findings Neoplastic pericardits (n=10 pts) Nonspecific inflammatory pericarditis (n=7 pts) Tuberculous pericarditis (n=3 pts) Adhesion strands 4 (40%) 2 (28.6%) 1 (33.3%) Massive adhesions 2 (20%) 0 1 (33.3%) Fibrin deposition 2 (20%) 4 (57.1%) 1 (33.3%) Vascular injections 8 (80%) 7 (100%) 2 (66.7%) Areas of hyperemia 6 (60%) 6 (85.7%) 2 (66.7%) Infiltration 7 (70%) 1 (14.3%) 1 (33.3%) Protrusions 6 (60%) 0 1 (33.3%) all p>0.05
  10. 10. Olympus FB-43ST Biopsy Forceps Group 1 (12 patients) Fluoroscopy 3-6 samples Group 2 (22 patients) Pericardioscopy 4-6 samples Group 3 (15 patients) Pericardioscopy 18-20 samples Feasibility of pericardial access 92.8% 96.2% 100% Feasibility of sheath introduction 92.3% 96.0% 100% Adequate pericardial visualization Not applicable 90.9% 93.3% Sampling efficiency 43.7% 84.9%** 84.2%** Pericardioscopy and Pericardial BiopsyPericardioscopy and Pericardial Biopsy FEASIBILITY AND SAMPLINGFEASIBILITY AND SAMPLING EFFICIENCYEFFICIENCY
  11. 11. Pericardioscopy and Pericardial BiopsyPericardioscopy and Pericardial Biopsy SAMPLING EFFICIENCY /SAMPLING EFFICIENCY / SENSITIVITYSENSITIVITY 43.7 84.9 84.2 41.7 63.6 93.3 Group 1 (fluoroscopy, 12 pts, 3-6 samples/pt) Group 2 (pericardioscopy, 22 pts, 4-6 samples/pt) Group 3 (pericardioscopy, 15 pts, 18-20 samples/pt 0 20 40 60 80Sampling efficiency Sensitivity ** ** ** (%)
  12. 12. Pathohistology Group 1 (12 patients) Fluoroscopy 3-6 samples Group 2 (22 patients) Pericardioscopy 4-6 samples Group 3 (15 patients) Pericardioscopy 18-20 samples Planocellular Ca 1 (8.3%) 3 (13.6%) 13.3 % Adenocarcinoma 0 3 (13.6%) 6.7% Mesothelioma 0 0 6.7% Plasmocytoma 0 1 (4.5%) 0 Hodgkin’s disease 0 1 (4.5%) 6.7% Tuberculosis 0 1 (4.5%) 20 % Nonspecific inflammation 4 (33.3%) 5 (22.7%) 40 % False negative 58.3 36.4 6.7** Pericardioscopy and Pericardial BiopsyPericardioscopy and Pericardial Biopsy HISTOLOGYHISTOLOGY
  13. 13. 8.3 8.3 33.3 58.3 26.3 40.9 36.4 36.440 53.3 53.3 6.7 New Dg. Etiology Clin.Dg.confirmed No useful information 0 20 40 60 80 100 % Fluoroscopic biopsy (3-6 samples) Pericardioscopy (3-6 samples) Pericardioscopy (18-20 samples) * * * * DIAGNOSTIC VALUE OFDIAGNOSTIC VALUE OF PERICARDIOSCOPYPERICARDIOSCOPY ANDAND PERICARDIAL BIOPSYPERICARDIAL BIOPSY
  14. 14. ♦ Excellent visualizationExcellent visualization but nonspecificbut nonspecific macroscopic findingsmacroscopic findings.. ♦ Pericardioscopic guidancePericardioscopic guidance enhancedenhanced pericardial sampling efficiency.pericardial sampling efficiency. ♦ TheThe diagnostic value of pericardial biopsydiagnostic value of pericardial biopsy was significantly improved by extensivewas significantly improved by extensive samplingsampling made possible by pericardioscopy.made possible by pericardioscopy. Pericardioscopy and Pericardial BiopsyPericardioscopy and Pericardial Biopsy CONCLUSIONSCONCLUSIONS

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