**5. Complications of percutaneous pericardiocentesis**

Although considered a high-risk procedure, complication rates for echocardiography guided or fluoroscopy guided percutaneous pericardiocentesis are low. Multiple large scale retrospective observational studies report total complication rates of up to 4.7–6.2% [12, 27]. Importantly, procedural success rates are high. In one study involving 1127 echocardiography guided pericardiocentesis procedures over 21 years, procedural success rate was 97% and did not change over the study period [12]. However, it must be noted, these analyses were performed from patient cohorts across a timespan of decades in large tertiary level institutions with considerable expertise. As such real-life complication rates may be higher when performed for emergency indications in lower volume centres by less experienced clinicians.

In comparison, 'blind' percutaneous pericardiocentesis is associated with a lifethreatening complication rate of 20% and a mortality risk of up to 6% [19]. Consequently, imaging guided pericardiocentesis is the gold standard and a 'blind' procedure should only be performed in life-threatening emergency settings when no alternative is readily available.

Complications of percutaneous pericardiocentesis include death due to iatrogenic damage to the myocardium or adjacent structures. Myocardial or coronary artery puncture can result in haemopericardium and worsening tamponade. Haemopericardium can initially be clinically silent or present as either a tamponade refractory to drainage or worsening bloody pericardial drain output. Iatrogenic peri-procedural haemopericardium occurs in less than 1% of cases and is an indication for emergent cardiothoracic surgery [19].

Accidental puncture of surrounding structures can also have deleterious consequences. Vascular damage (including puncture of the intercostal vessels or internal mammary vessels) can lead to significant blood loss. Piercing of the lung parenchyma can result in a pneumothorax while accidental intra-peritoneal puncture (most likely with a sub-xiphoid approach) can lead to intra-abdominal organ damage. The most commonly involved intra-abdominal structure is the liver, however, cases of hollow viscus perforation and inferior vena cava perforation have been reported [28, 29].

Incidence of bacterial infection introduction into the pericardial space is low. As such there is no consensus on use of prophylactic antibiotics in the peri-procedural setting.

Arrhythmias in the peri-procedural setting is also a concern. All patients should be on continuous electrocardiographic monitoring during the procedure and during postprocedural observation in the cardiac care unit [30]. ST segment elevation during pericardiocentesis is an indicator of possible myocardial needle puncture while persistent ST segment elevation post procedure is suggestive of potential coronary artery injury leading to myocardial injury [19, 31]. Vasovagal bradycardia is common post pericardiocentesis. Although generally self-limiting, there have been documented fatalities secondary to vasovagal hypotension [32].

Pericardial decompression syndrome, although it has multiple aliases, it is broadly defined as an acute deterioration in haemodynamics that results in hypotension and pulmonary oedema post an uncomplicated pericardiocentesis procedure [33–35]. It is

#### *Percutaneous Approach to Pericardial Disease Management DOI: http://dx.doi.org/10.5772/intechopen.110635*

estimated to occur in 5% of cases [36]. Although there is some limited data to suggest it occurs more frequently in malignant effusions, there is no strong predisposition for any particular effusion aetiology [36]. The underlying pathophysiology has not been fully elucidated, however, there are multiple proposed mechanisms. One theory suggests increased right ventricular venous return post decompression results in septal bowing and a consequent drop-off in left ventricular stroke volume leading to pulmonary oedema [34, 37, 38]. Another proposed mechanism involves left ventricular myocardial stunning secondary to pericardial compression induced coronary ischaemia [36, 39]. Judicious drainage of the pericardial effusion to allow haemodynamic reequilibration is recommended to avoid the development of pericardial decompression syndrome. The European Society of Cardiology recommends rapid drainage of the fluid volume required to clinically alleviate tamponade but that subsequent fluid drainage should be no more than 1 L in 24 hours to allow haemodynamic reequilibration [5].

### **6. Recurrent pericardial effusions**

The natural course of a pericardial effusion can be unpredictable. To prevent fluid re-accumulation and to promote adherence of the pericardial layers, the drain should not be removed until output is <30 mL in a 24-hour period. In cases at high risk of effusion recurrence, prolonged drainage is a Class IB recommendation from the European Society of Cardiology as it has been shown to reduce recurrence rates [5]. Despite this, recurrent pericardial effusion post-pericardiocentesis is common. It is particularly frequent among malignant pericardial effusions which have a recurrence rate as high as 31–62% [40, 41].

There are multiple therapeutic options for the management of recurrent pericardial effusions including repeated percutaneous pericardiocentesis, intra-pericardial administration of sclerosing agents or chemotherapeutics or creation of a pericardial 'window' - either through open cardiothoracic surgery, a video assisted thorascopic approach (VATS) approach or percutaneous balloon pericardiotomy.

There is no guideline or consensus on the approach for interventional management of recurrent effusions as there is a paucity of evidence directly comparing management strategies.

#### **6.1 Surgical pericardial window**

Although not the scope of this chapter, surgical intervention for recurrent pericardial effusion is common – either via drainage through a pericardial window or surgical pericardiectomy. Access to the pericardium can be obtained either via an open thoracotomy, an open sub-xiphoid incision or VATS approach [42].

Multiple small retrospective single institution analyses have reported that while initial success and diagnostic yield is similar between surgical and percutaneous pericardiocentesis, the complication rate and re-accumulation rates are lower with surgical intervention [43, 44]. It must be noted that these studies included first presentation and recurrent pericardial effusions and both malignant and nonmalignant aetiologies. In some studies, there may be a selection bias toward surgical intervention as the cohort also included post-operative pericardial effusions following cardiothoracic surgery. A recent published analysis of 44,637 non-surgically related pericardial effusion cases managed either surgically or percutaneously has reported

higher mortality and re-intervention rates with percutaneous intervention but increased risk of post-procedural complications and longer hospital admissions with surgery [45].

#### **6.2 Percutaneous balloon pericardiotomy**

Percutaneous balloon pericardiotomy is a less-invasive alternative for the management of recurrent pericardial effusion. It is usually reserved for patients with recurrent malignant effusions who are unfit for surgical intervention or in whom the inhospital post-operative period would significantly impact their remaining limited quality of life.

First described by *Palacios et al.*, in 1991, percutaneous balloon pericardiotomy is similar to a conventional percutaneous pericardiocentesis procedure [46]. It is performed in a cardiac catheterisation laboratory under either fluoroscopic or echocardiographic guidance. A sub-xiphoid approach is used and the area pre-infiltrated with local anaesthetic prior to incision. A stiff 0.038-inch wire with a pre-shaped broad curved tip is advanced into the pericardial space via a needle or through a preexisting pericardial drain catheter. Position is confirmed via either echocardiography or fluoroscopy. A 10French dilator is advanced over the wire to pre-dilate the skin and subcutaneous tissues and then removed. A balloon-dilating catheter is then advanced over the wire under fluoroscopic guidance until it straddles the parietal pericardium. A 3020 mm diameter balloon is used, but use of the Inoue balloon (Torray International America Inc., Houston, TX, USA) has also been described. It is essential the proximal end of the balloon is beyond the skin to prevent pericardio-cutaneous fistula formation. The position of the balloon is confirmed via insufflation with a contrast – saline mix. Insufflation is repeated until the waist formed by the parietal pericardium on the balloon visually disappears. The balloon-dilating catheter is then replaced with a pericardial drain catheter.

Post-procedural management is similar to percutaneous pericardiocentesis described above. However, intra-operative and post-operative pain is greater with balloon pericardiotomy – primarily due to purposeful stretching of the nociceptive fibre rich parietal pericardium [47]. Consequently, pre-medication with analgesics and regular pain scores is essential to the care of a balloon pericardiotomy patient.

The previously listed complications of percutaneous pericardiocentesis can also be seen with percutaneous balloon pericardiotomy. However, post-procedural left sided pleural effusion is more common following balloon pericardiotomy. This is believed to be due to balloon insufflation induced creation of a pericardiopleural window which allows the recurrent effusion to drain into the more resorptive pleural space. In one retrospective analysis by *Ziskind et al.* involving 50 cases of balloon pericardiotomy, a post-procedural pleural effusion was seen in all cases and eight required thoracocentesis mediated drainage [47]. Post-operative pneumothorax also appears to occur more commonly with balloon pericardiotomy.

Although usually reserved for oncology patients with poor operative fitness, percutaneous balloon pericardiotomy is an effective alternative to surgical intervention with procedural success rates of 85–100% documented in retrospective studies [48, 49]. However, patient prognosis is poor. Median survival post procedure in these patients is reported up to 3.3 months [47]. The poor survival was primarily driven by underlying malignancy since peri-procedural mortality rates were low (approximately 0–1%) [48].

Overall, there remains a paucity of evidence surrounding percutaneous balloon pericardiotomy. The 2015 ESC guidelines for the diagnosis and management of pericardial diseases do not recommend balloon pericardiotomy for neoplastic effusions but rather "in rare cases of recurrent effusion" [5].

#### **6.3 Intra-pericardial delivery of therapeutics**

Intra-pericardial administration of therapeutics is a potential percutaneous intervention which can be performed once percutaneous access has been obtained and the effusion has been drained.

The most common indication is for delivery of sclerosing agents, which drive inflammation and fibrosis of the visceral and parietal layers – thus eliminating the potential space for fluid to re-accumulate. A variety of chemotherapeutic or sclerosing agents have been employed in the past. These include tetracyclines [50], bleomycin [51], cisplatin [52, 53] and thiotepa [54, 55].

Intra-pericardial instillation of sclerosing agents such as talc has no proven recurrence reduction benefit over other approaches including balloon pericardiotomy and surgical intervention. Although it has lower peri-procedural risks, specific complications include severe retrosternal chest pain (likely due to the induction of constrictive pericarditis), atrial arrhythmias or electrocardiographic changes on monitoring suggestive of sub-pericardial or epicardial injury [56, 57].

The 2015 ESC guidelines on the diagnosis and management of pericardial disease recommend intra-pericardial instillation of chemotherapeutics as part of the management of large neoplastic pericardial effusions [5]. It has been shown to reduce recurrence for lung and breast malignancy associated pericardial effusions [52–54]. Chemotherapy choice should be tailored to the specific malignancy – cisplatin is more effective for lung malignancy [52, 53] and thiotepa more beneficial in breast cancer [54].

#### **7. Pericardial complications of Catheter Ablation**

Catheter ablation of atrial fibrillation is an established therapy however pericardial effusion is a common complication that occurs in up to 14% of cases [58]. The majority of effusions are mild and asymptomatic and resolve spontaneously within a month. However pericardial tamponade may occur in up to 1% of cases and is usually related to traumatic transseptal puncture [59].

Ischaemic and non-ischaemic cardiomyopathy and infiltrative myocardial disease may be complicated by ventricular tachycardia. Treatment with catheter ablation is increasingly employed with improved outcome. While an endocardial approach is most common, presence of epicardial re-entrant circuits can result in treatment failure and necessitate an epicardial approach. This approach can be percutaneous or surgical and improves procedural success but major complication rates in certain sub-groups, such as post infarct patients, may be as high as 14%. Complications include haemopericardium, right ventricular puncture and may necessitate emergent cardiac surgery [60].

## **8. Conclusions**

Incidence of cardiac tamponade is rising due to the increasing prevalence of pericardial access for electrophysiological intervention and cardiothoracic surgery. Fortunately, percutaneous pericardiocentesis is a safe and effective intervention for the management of this potentially life-threatening clinical syndrome. However, the field of percutaneous pericardial intervention has significantly expanded beyond pericardiocentesis alone. More complex interventional techniques including balloon pericardiotomy and intra-pericardial instillation of chemotherapeutic agents have emerged, particularly in the management of recurrent malignant pericardial effusions.
