CONTROL OF HYPOTENSION FROM PERICARDIAL EFFUSION

1. CONTROL OF HYPOTENSION
FROM PERICARDIAL EFFUSION

2. • Pericardiocentesis is the procedure for managing Cardiac tamponade, a
life-threatening condition.
• Pericardiocentesis procedure, although life-saving, may be associated with
serious complications.
• Since the first 'blind' approach, described at the beginning of the 19th
century, the technique has evolved with a significant reduction in
complication rates.
• Nowadays, the introduction of imaging-guided procedures has significantly
improved the safety and feasibility of pericardiocentesis and has provided
the possibility of choosing the best anatomical approach among apical,
subcostal and parasternal approaches.

3. Place of Puncture Description Disadvantages Advantages
3. Subxiphoid The needle insertion site is
between the xiphisternum and
left costal margin.
Once beneath the cartilage
cage, lower the needle to a 15-
to-30-degree angle, with the
abdominal wall directed
towards the left shoulder.
A steeper angle may enter the
peritoneal cavity, and a medial
direction increases the risk of right
atrial puncture.
In some cases, the left liver lobe may
be transversed intentionally if an
alternative site is not available.
The path to reach the fluid is longer.
Lower risk of
pneumothorax.

4. A) Anatomic structures to bear in mind during pericardiocentesis procedure.
B) Three main approaches for pericardiocentesis, parasternal, substernal and apical.

5. Place of Puncture Description Disadvantages Advantages
3. Subxiphoid The needle insertion site is
between the xiphisternum and
left costal margin.
Once beneath the cartilage
cage, lower the needle to a 15-
to-30-degree angle, with the
abdominal wall directed
towards the left shoulder.
A steeper angle may enter the
peritoneal cavity, and a medial
direction increases the risk of right
atrial puncture.
In some cases, the left liver lobe may
be transversed intentionally if an
alternative site is not available.
The path to reach the fluid is longer.
Lower risk of
pneumothorax.

6. A) Anatomic structures to bear in mind during pericardiocentesis procedure.
B) Three main approaches for pericardiocentesis, parasternal, substernal and apical.

7. Place of Puncture Description Disadvantages Advantages
3. Subxiphoid The needle insertion site is
between the xiphisternum and
left costal margin.
Once beneath the cartilage
cage, lower the needle to a 15-
to-30-degree angle, with the
abdominal wall directed
towards the left shoulder.
A steeper angle may enter the
peritoneal cavity, and a medial
direction increases the risk of right
atrial puncture.
In some cases, the left liver lobe may
be transversed intentionally if an
alternative site is not available.
The path to reach the fluid is longer.
Lower risk of
pneumothorax.

8. A) Anatomic structures to bear in mind during pericardiocentesis procedure.
B) Three main approaches for pericardiocentesis, parasternal, substernal and apical.

9. • Signs of a correct catheter position include transducing a nonventricular
pressure waveform and identifying agitated saline microbubbles injected
into the pericardial space on echo (or contrast medium by fluoroscopy).
• Inadequate bubble visualization can occur in very large or loculated
effusions, warranting additional views. Bubbles observed within the heart,
liver, or pleural space indicate an incorrect catheter location.
• Generally speaking, a puncture of the relatively lower-pressure right atrium
or ventricle (caveat: severe pulmonary hypertension) should self-seal upon
removal of puncture needle/wire/catheter.
• Self-sealing of a left ventricular puncture is less certain and generally
should be attempted with the smallest caliber devices (i.e., needle and
wire only) to minimize the chances of needing surgical repair.

10. • E. Catheter or drain insertion.
• Following pericardial access confirmation, a 0.035-inch guidewire is
generously advanced into the pericardial space and observed abutting the
outer cardiac borders under fluoroscopy.
• A drainage catheter is then advanced over the wire. A more supportive
0.035-inch guidewire and predilation may be needed for scar tissue or
significant adiposity.
• If a pigtail drain is used, its tip should return to its original shape rather
than remaining unfurled under tension against the myocardium.
• Resolution of pericardial effusion and tamponade should be confirmed
after complete fluid aspiration and before patient transfer.
• The catheter is sutured in place and attached to a bag for intermittent
drainage.

11. Figure 1: A successfully
positioned guidewire courses around
the heart within the cardiac
silhouette and abuts the superior
border of the pericardial space.
Figure 2: A long 0.035-inch guidewire
is looped within the cardiac
silhouette, abutting multiple borders
of the pericardial space, over which a
pigtail drain is advanced.
Figure 3: The tip of the pigtail drain
returns to its original curved
conformation once the guidewire
is retracted.

12. Effects on prognosis
• Pericardiocentesis is a life-saving maneuver when cardiac tamponade with severe
haemodynamic impairment occurs and must be performed with urgency.
• There are no randomised studies in this setting.
• Once pericardiocentesis has been performed, the prognosis depends on the
underlying disease, being poor in case of neoplastic aetiology and excellent in
case of idiopathic/viral pericarditis.
• In patients with pericardial effusion without tamponade but suspected of
tuberculous, bacterial or neoplastic pericarditis, pericardiocentesis is mandatory
because correct diagnosis through pericardial fluid analysis allows proper therapy
and reduces the probability of an evolution towards constrictive pericarditis.
• In case of chronic large pericardial effusion, the prognosis is generally good, but
there may be a 35% risk of cardiac tamponade evolution.

13. Thank you !