In patients with persistent pericardial effusion and/or clinical findings suggestive of infection or malignancy, echo guided pericardiocentesis is required for diagnosis and treatment.
The procedure can be used to administer chemotherapeutic agents locally in patients who have neoplastic pericardial disease.
Tamponade Rx
The only effective treatment of pericardial tamponade is prompt drainage of the fluid from the pericardial space, to relieve the compression of the cardiac chambers. The pericardial fluid can be drained via needle pericardiocentesis or surgical pericardiotomy.
When the fluid is highly viscous or loculated, pericardial drainage requires surgery. This may occur after cardiac surgery, when clotted blood may be present or when the pericarditis is due to pyogenic organisms.
Pericardiocentesis
Pericardiocentesis is the term used for needle drainage of the pericardial fluid. Echocardiography is helpful to locate and guide the pericardiocentesis needle. The ideal site for puncture is where the distance to the fluid is minimal, vascularity is minimal and no lung tissue is present.
The subxiphoid approach is usually preferred over parasternal or apical sites of entry, as the risk of pneumothorax and coronary artery laceration are lower.
Echo guided pericardiocentesis
This is an early diastolic still-frame of a two-dimensional echocardiogram in the parasternal long axis view that clearly shows a pericardiocentesis needle located anteriorly within a large pericardial effusion. The right ventricular wall is literally collapsed against the ventricular septum. The remaining right ventricular cavity is quite small.
The left ventricle, left atrium and the aortic and mitral valves are identified.
In the real-time study that follows, note the exaggerated motion of the right ventricle as it collapses in mid diastole. The needle is seen to move slightly within the pericardial fluid. The motions of the normal aortic and mitral valves identify the phases of the cardiac cycle.
Constrictive pericarditis Rx
The definitive treatment of constrictive pericarditis is pericardiectomy with complete surgical removal of the parietal, and when possible, the visceral pericardium.
When constrictive pericarditis is diagnosed, diuretics are used to reduce preload, dyspnea and edema. Long term, this is usually unsuccessful, as severe edema results and the decreased cardiac output progresses.
The mortality risk of pericardiectomy is approximately 10%, and is increased when there is heavy calcification. Pericardiectomy in patients with prior coronary artery bypass surgery carries the added risk of disruption of the grafts during the operation.
Pericardiectomy
The following surgery is presented through the courtesy of Dr. Harold Snyder, and was carried out at the Mayo Clinic, Jacksonville, Florida.
The patient is a 34-year-old woman who presented with ascites and dyspnea and was found to have constrictive pericarditis. The pathology report indicated only chronic fibrosis, thickening and calcification, presumably due to prior fungal, viral or bacterial infection.
The skin on the chest was incised, the sternum exposed and split and retractors placed exposing the mediastinum.
Although the patient was hemodynamically stable and in normal sinus rhythm, very little cardiac contractile activity is evident. In most cardiac surgeries, the heart would be contracting very vigorously at this point.
Initial dissection of the anterior pericardium reveals a whitish rind of thickened and calcified pericardium that was very adherent and entirely surrounding the heart. The cheesy looking calcified pericardium is difficult to dissect off.
After 25 minutes of dissection, the pericardium over the anterior right ventricle has been removed and the heart is contracting well. Following the institution of partial cardiopulmonary bypass in order to allow the heart to be manipulated without hypotension, a piece of thickened, diseased, calcified pericardium is being dissected off the right atrium. A second piece of thickened pericardium is dissected from the posterolateral wall of the left ventricle. When all of the thick, cheesy pericardium was removed, and the vigorous contraction of the heart muscle was freed from the pericardial constriction, the sternum was reapproximated and the fascia and the skin closed.