Percutaneous Approach to Pericardial Disease Management

*Jack Hartnett, Richard Armstrong, Lisa Brandon, Hani Jneid, Igor F. Palacios and Andrew O. Maree*

### **Abstract**

Percutaneous access of the pericardial space is increasingly sought. This is not only due to growing prevalence of pericardial effusions and cardiac tamponade, but also the emerging diagnostic and therapeutic potential of the pericardial space for mapping and ablation of arrhythmogenic circuits, biopsy, and drug delivery. Although increasingly performed, percutaneous pericardiocentesis remains a technically challenging procedure with potentially life-threatening complications. Consequently, management of patients with pericardial disease is highly complex. In this chapter we outline a step-by-step approach to percutaneous pericardiocentesis and the required specialised management of pericardial disease patients. Procedural complications are discussed along with their alleviating therapeutic strategies. Furthermore, we describe approaches to the prevention and management of recurrent pericardial effusion including diagnostic and therapeutic procedures such as percutaneous balloon pericardiotomy and intra-pericardial delivery of chemotherapeutics and sclerosing agents.

**Keywords:** pericardial effusion, cardiac tamponade, pericardiocentesis, percutaneous balloon pericardiotomy, pericardial disease management

#### **1. Introduction**

The pericardial space is a potential space contained between the inner visceral pericardium and the outer fibrous pericardium. In normal physiological states it contains up to 50 mL of serous fluid, which acts as a lubricant for the enclosed heart [1]. Similar to the pleural space, the pressure within the pericardial space varies with respiration driven changes in intra-thoracic pressure – ranging from – 5 cm of water during inspiration to +5 cm water during expiration. However, in certain pathological states, both the volume and pressure within the pericardial space can increase giving rise to haemodynamic compromise.

An increase in intra-pericardial volume and pressure is initially compensated for by the compliance of the pericardium [2]. However, when intra-pericardial pressure rises to equilibrate with or surpass intra-cardiac pressures (at approximately 15–20 mm Hg), right heart haemodynamic function is compromised. The underlying pathophysiology centres on excessive intra-pericardial pressures that cause

compression of right heart chambers. Consequently, right ventricular filling is restricted and results in a reduction in cardiac output, increased systemic venous pressures and ultimately cardiac tamponade.

Cardiac tamponade is a clinical diagnosis characterised by the concurrent presence of three non-specific clinical signs known as Beck's Triad. This comprises hypotension, distended neck veins and 'distant muffled' heart sounds on auscultation [3]. Although cardiac tamponade is classically taught as a potentially fatal medical emergency requiring immediate intervention, in practice, the presentation is a spectrum ranging from more subtle asymptomatic persistent hypotension (often refractory to intravenous fluid resuscitation) to life-threatening circulatory collapse.

Clinical severity is not only determined by the volume of fluid within the pericardial space, but also the rate at which it accumulates. Rapidly developing pericardial effusions are more likely to cause cardiac tamponade at smaller fluid volumes than slowly accumulating effusions [2]. In rapidly accumulating pericardial effusions, the pericardium remains relatively stiff resulting in a rapid rise in intra-pericardial pressure. In comparison, slow progressive effusions allow for adaptive stretching of the pericardium over time and thus result in lower intra-pericardial pressures for longer.

Echocardiography is crucial to the assessment of any patient with suspected pericardial effusion and/or cardiac tamponade [4]. It can be performed quickly at the bedside to confirm cardiac tamponade in an emergency setting. Although less convenient, haemodynamic assessment during invasive catheterisation can also provide important diagnostic information. **Boxes 1** and **2** outline key echocardiographic and haemodynamic findings in cardiac tamponade.

Definitive management is drainage of the excess pericardial fluid. This is most commonly performed via percutaneous pericardiocentesis which involves insertion of a needle through the skin into the pericardial sac to drain the effusion and relieve haemodynamic compromise on the heart. In this chapter we outline a step-by-step guide to percutaneous pericardiocentesis along with the peri-procedural management of pericardial patients. Novel techniques to prevent and alleviate recurrent pericardial effusions – such as percutaneous balloon pericardiotomy and intra-pericardial chemotherapeutics – are also discussed.


#### **Box 1.** *Key echocardiographic findings in cardiac tamponade.*


**Box 2.** *Key haemodynamic findings in cardiac tamponade.*

### **2. Percutaneous pericardiocentesis**

#### **2.1 Indications**

The clinical utility of percutaneous pericardiocentesis cannot be understated. It is both diagnostic – providing pericardial fluid for analysis of cell counts, cytology, culture etc. – as well as therapeutic – reducing intra-pericardial pressures and improving right ventricular filling and cardiac output. However, as subsequently outlined, it is a technically challenging procedure with potential life-threatening complications. As such, there are a narrow range of indications for percutaneous pericardiocentesis (**Box 3**) [5].

Timing of percutaneous pericardiocentesis depends on the degree of haemodynamic deterioration and the rapidity with which compromise has developed. Echocardiographic features, aetiology of the underlying effusion and risk–benefit ratio of the procedure (e.g. presence of concurrent coagulopathy) must be considered.

Among patients with life-threatening circulatory collapse, immediate intervention is required. However, the clinical scenario is more complex when haemodynamic compromise is progressive. Percutaneous pericardiocentesis may be deferred to facilitate appropriate planning but these patients remain at high risk of clinical deterioration. Numerous scoring systems have been developed to aid clinicians in determining the timing of intervention. *Halpern et al.,* developed a pericardial effusion scoring


#### **Box 3.** *Indications for percutaneous pericardiocentesis.*

index to predict need for pericardiocentesis among patients with haemodynamically stable moderate-to-large pericardial effusions [6]. More recently, the ESC Working Group on Myocardial and Pericardial Diseases published a novel triage system based on aetiology, clinical presentation and diagnostic imaging findings [7]. A combined score of six or greater requires urgent pericardiocentesis. In cases of a score less than six, intervention can be delayed for up to 12–24 hours to facilitate planning. Of note, these recommendations are not based on a body of published data but rather on expert opinion. As such randomised studies are required to validate this triage system.

In the absence of clinical haemodynamic compromise, echocardiographic evidence of cardiac tamponade is not a clear indication for intervention as recent evidence suggests echocardiographic findings of 'pre-tamponade physiology' may be oversensitive [4]. Consequently, despite near ubiquity of echocardiographic assessment, the decision to proceed with pericardiocentesis is primarily a clinical one.
