Pericardiocentesis is routinely employed in clinical practice for the relief of cardiac tamponade and to define pericardial effusion etiology where indicated. Whilst historically performed using blind or fluoroscopic techniques, imaging-guided pericardiocentesis should be considered the standard of care in routine clinical practice. Performance of concurrent imaging to guide the proceduralist increases the margin of procedural safety by allowing the operator to identify and hence avoid injury to adjacent and intervening structures.

Ultrasound technology is widely and readily available, especially in the current era where handheld and bedside units are ubiquitous in the outpatient, emergency room and inpatient settings. Hence, echocardiographic guidance of pericardiocentesis should be considered routine in current clinical practice. This technique has been well described in previous publications such as that by Flint and Siegel.^1-3 Pericardial access is most frequently obtained from the para-apical (63%) and parasternal (14%)  approaches, rather than the subxiphoid (15%) approach routinely employed in blind or fluoroscopically guided techniques, minimizing the risk of injury to liver and other subcostal structures.⁴ A standard transthoracic echocardiographic transducer is used to identify and mark the site of puncture, where the pericardial effusion is closest to the skin and the largest accumulation of fluid is present, to minimize risk of cardiac perforation and injury to other structures. In most instances, the echocardiographic transducer is used to define needle trajectory prior to needle puncture rather than directly visualize needle position during the procedure. Pericardial access can be obtained using a 16G intravenous catheter with length based on the skin to pericardial effusion distance by echocardiography, as its lumen is sufficient to allow subsequent introduction of a J-tipped 0.035" wire. Upon obtaining pericardial access, the plastic cannula should be advanced into the pericardial space and needle withdrawn, with intrapericardial position subsequently confirmed by agitated saline contrast injection through the cannula, prior to dilatation of the tract using a larger sheath via the Seldinger technique. Where techniques utilizing a needle without a plastic cannula are chosen for pericardial access, great caution should be taken when performing agitated saline injection due to the increased risk of inadvertent cardiac perforation. If real-time imaging to visualize intraprocedural needle position is desired, linear ultrasound probes with a multiangle bracket should be utilized as described by Maggiolini et al.² It should be noted that curvilinear ultrasound transducers routinely used in echocardiography are unable to accurately identify the needle tip and should not be utilized for this purpose. Complication rates for echocardiographic-guided pericardiocenteses are low (4.7%), including major complications in 1.2% and minor complications not requiring additional intervention in 3.5%.⁴ Echocardiographic-guided pericardiocenteses provide an increased margin of safety when compared with blind and fluoroscopic guided techniques allowing it to be employed with caution amongst patients with thrombocytopenia, therapeutic anticoagulation and pulmonary hypertension when performed by experienced operators. Amongst 221 echocardiography-guided pericardiocenteses in patients with an INR ≥2.0, major bleeding was described in 0.5% with total bleeding rates of 0.9%, suggesting that the procedure can be performed safely despite therapeutic anticoagulation, particularly at the hands of expert proceduralists.⁵ The same series described no bleeding complications amongst 81 thrombocytopenic patients with platelet counts <100x10⁹/L including 18 of whom had platelet counts <50×109/L.⁵ Due to the potential catastrophic risks associated with procedural complications in patients with severe pulmonary hypertension, echocardiography-guidance improves the margin of safety with no complications reported in one series of 14 patients.⁶

Despite the advantages of echocardiography over non-imaging guided techniques, technical challenges including inadequate acoustic windows, pericardial loculations and posterior effusions may preclude use of echocardiography in certain circumstances. In such instances, computed tomography (CT)-guided techniques provide a valuable alternative to surgical drainage. CT-guided pericardiocentesis has predominantly been described in patients undergoing therapeutic pericardiocentesis, particularly in the post-surgical setting.⁷ Procedural techniques involve preliminary thoracic CT imaging to define the ideal entry site and needle orientation for the procedure. Imaging is repeated following superficial needle puncture to ensure correct orientation. The pericardiocentesis needle is then advanced and aspirated, with serial imaging performed to define needle position and adjust trajectory. Pericardial access may be confirmed by direct visualization of the needle tip entering the pericardial space. Iodinated contrast injection can also be considered to confirm needle position.⁸ As with echo-guided procedures, following confirmation of pericardial access, a guidewire is inserted through the pericardiocentesis needle with subsequent insertion of a pericardial catheter using the Seldinger technique. CT-guided pericardiocentesis has been associated with high procedural success (98%),⁹ even when performed in patients in whom echocardiography-guided pericardiocentesis was deemed unfeasible.^10,11 CT-guided pericardiocentesis is also associated with a low procedural complication rate with a large single center study of 319 CT-guided pericardiocentesis identifying major complications (defined as events adversely affecting hemodynamic status or acuity of care) in just 0.3%.⁹ Minor complications (defined as events not requiring intervention or prolonging length of hospital stay) were seen amongst 6.9%, including pleural puncture with or without pneumothorax and myocardial puncture.⁹ Limitations to utilization of CT-guided pericardiocentesis include extended procedure times (median time 65 minutes in one series);⁸ lack of availability and proceduralist experience; need to transport patient to the CT scanner; and need for ionizing radiation and/or iodinated contrast.

Table 1: Summary of echocardiography versus computed tomography (CT) guided pericardiocentesis.

	Echocardiography guided pericardiocentesis	Computed tomography (CT) guided pericardiocentesis
Indications	Preferred as first-line	Suggested as second-line where echocardiography-guided pericardiocentesis is not feasible
Advantages	High feasibility Widespread availability Excellent visualization in most patients Can be performed at bedside and in catheterization and electrophysiology laboratories	High feasibility Excellent visualization of adjacent structures Access site not limited by acoustic windows
Limitations	Inadequate acoustic windows (e.g. pneumopericardium) Loculated posterior pericardial effusions	Availability and operator experience Procedural duration Requires transportation to CT scanner Ionizing radiation use Potential use of iodinated contrast in selected cases

Recurrent pericardial effusions have been described in some patients undergoing pericardiocentesis regardless of the presence or absence of image guidance. Hence, pericardial catheter management, rather than the mode of imaging guidance, likely plays a more significant role in reducing recurrence risk. Simple pericardial aspiration is associated with an increased risk of recurrence when compared to extended pericardial catheter drainage-time (27% vs. 14%). Hence, extended pericardial catheter drainage-time should be favored in all patients undergoing pericardiocentesis. In order to facilitate this, the pericardial catheter should remain in place with periodic aspiration and flushing of the catheter until net pericardial drainage decreases to <50mL over a 24 hour period. Ongoing pericardial inflammation due either to inflammatory pericarditis as the initial inciting etiology of pericardial effusion or inflammation resulting from the procedure may also be associated with risk of recurrent effusion. Hence, anti-inflammatory therapy including colchicine and non-steroidal anti-inflammatories should strongly be considered in patients undergoing pericardiocentesis.

Imaging-guided pericardiocentesis should be considered the standard of care in current clinical practice. Both echocardiography and CT provide excellent imaging options to guide the proceduralist during pericardiocentesis. These techniques offer better safety by allowing visualization of adjacent structures, and improved feasibility by allowing utilization of non-subxiphoid access sites, when compared with blind or fluoroscopic guided pericardiocentesis. Given both imaging techniques offer excellent procedural guidance, the choice of echocardiography versus CT-guided pericardiocentesis techniques should first be guided by institutional experience and proceduralist expertise in each technique. For example, at our institution >99% of pericardiocentesis procedures are performed under echocardiographic guidance. Where both techniques are feasible based on institutional expertise, one may consider echocardiography-guided pericardiocentesis first-line due to its availability and portability, with CT-guided pericardiocentesis reserved for those patients with contraindications to an echocardiographically-guided approach.

References

1. Flint N, Siegel RJ. Echo-guided pericardiocentesis: when and how should it be performed? Curr Cardiol Rep 2020;22:71.
2. Maggiolini S, Gentile G, Farina A, et al. Safety, efficacy, and complications of pericardiocentesis by real-time echo-monitored procedure. Am J Cardiol 2016;117:1369-74.
3. Luis SA, Kane GC, Luis CR, Oh JK, Sinak LJ. Overview of optimal techniques for pericardiocentesis in contemporary practice. Curr Cardiol Rep 2020;22:60.
4. Tsang TSM, Enriquez-Sarano M, Freeman WK, et al. Consecutive 1127 therapeutic echocardiographically guided pericardiocenteses: clinical profile, practice patterns, and outcomes spanning 21 years. Mayo Clin Proc 2002;77:429-36.
5. Ryu AJ, Kane GC, Pislaru SV, et al. Bleeding complications of ultrasound-guided pericardiocentesis in the presence of coagulopathy or thrombocytopenia. J Am Soc Echocardiogr 2020;33:399-401.
6. Fenstad ER, Le RJ, Sinak LJ, et al. Pericardial effusions in pulmonary arterial hypertension: characteristics, prognosis, and role of drainage. Chest 2013;144:1530-8.
7. Vilela EM, Ruivo C, Guerreiro CE, et al. Computed tomography-guided pericardiocentesis: a systematic review concerning contemporary evidence and future perspectives. Ther Adv Cardiovasc Dis 2018;12:299-307.
8. Neves D, Silva G, Morais G, et al. Computed tomography-guided pericardiocentesis - a single-center experience. Rev Port Cardiol 2016;35:285-90.
9. Klein SV, Afridi H, Agarwal D, Coughlin BF, Schielke LH. CT directed diagnostic and therapeutic pericardiocentesis: 8-year experience at a single institution. Emerg Radiol 2005;11:353-63.
10. Eichler K, Zangos S, Thalhammer A, et al. CT-guided pericardiocenteses: clinical profile, practice patterns and clinical outcome. Eur J Radiol 2010;75:28-31.
11. Palmer SL, Kelly PD, Schenkel FA, Barr ML. CT-guided tube pericardiostomy: a safe and effective technique in the management of postsurgical pericardial effusion. AJR Am J Roentgenol 2009;193:W314-20.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Pericardial Disease

Keywords: Pericardiocentesis, Pericardial Effusion, Cardiac Tamponade, Pneumopericardium, Platelet Count, Pneumothorax, Colchicine, Length of Stay, Dilatation, Outpatients, Inpatients, Feasibility Studies, International Normalized Ratio

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