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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 23  |  Issue : 4  |  Page : 240-243  

Echocardiography-Guided pericardiocentesis using a central venous catheter in rural area


1 Department of Emergency, Siloam Hospitals Labuan Bajo, East Nusa Tenggara, Indonesia
2 Division of Cardiology and Vascular Medicine, Siloam Hospitals Labuan Bajo, East Nusa Tenggara, Indonesia

Date of Submission01-Jul-2022
Date of Acceptance31-Oct-2022
Date of Web Publication17-Nov-2022

Correspondence Address:
Dr. Thomas Rikl
Siloam Hospitals Labuan Bajo, Gabriel Gampur Street, Gorontalo, Komodo, West Manggarai Regency, East Nusa Tenggara 86754
Indonesia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/heartviews.heartviews_59_22

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   Abstract 


Large pericardial effusion may possess potential risks of hemodynamic consequences and may progress into cardiac tamponade unexpectedly. Pericardiocentesis is advisable in asymptomatic large pericardial effusion when there are signs of hemodynamic collapse on echocardiography. However, in a limited setting, the ideal equipment is rarely available. Thus, we present a case of echocardiography-guided pericardiocentesis using a central venous catheter (CVC) in a large pericardial effusion with massive pleural effusion in a rural area.

Keywords: Central venous catheter, pericardial effusion, pericardiocentesis, rural area


How to cite this article:
Rikl T, Desandri DR. Echocardiography-Guided pericardiocentesis using a central venous catheter in rural area. Heart Views 2022;23:240-3

How to cite this URL:
Rikl T, Desandri DR. Echocardiography-Guided pericardiocentesis using a central venous catheter in rural area. Heart Views [serial online] 2022 [cited 2022 Nov 29];23:240-3. Available from: https://www.heartviews.org/text.asp?2022/23/4/240/361402




   Introduction Top


The pericardium is a double-layered membrane that encloses the heart. Between the two layers, there is a pericardial sac which normally contains 10–50 ml of pericardial fluid.[1],[2],[3] Pericardial effusion is defined as abnormal fluid accumulation in the pericardial sac.[4] A large pericardial effusion possesses a high risk of progressing into cardiac tamponade, especially when evidence of diastolic right-sided collapse is found.[2],[3] Thus, pericardiocentesis may be performed to prevent sudden progression into tamponade.[3] Here, we describe a case of large pericardial effusion that underwent a pericardiocentesis using a central venous catheter (CVC) in a rural area.


   Case Presentation Top


A 48-year-old male came to the emergency department complaining of dyspnea for 2 weeks that worsened over 2 days. He also complained of swelling in both legs and abdominal discomfort in the epigastric area, accompanied by nausea and vomiting. He was an active smoker.

His vital signs showed only slight tachycardia. The breathing sound was diminished on the left lung, accompanied by dullness on percussion. Hepatomegaly was found with bilateral pitting edema on his legs. No elevated jugular venous pressure or muffled heart sound was found. His chest radiograph showed a massive pleural effusion on the left hemithorax [Figure 1] and the ECG showed sinus tachycardia.
Figure 1: The chest radiograph on admission suggested massive pleural effusion on the left lung. The cardiac border overlapped with the pleural effusion. Hence, it was difficult to be judged

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He was sent for the water-sealed drainage (WSD) procedure. The pleural fluid was hemorrhagic exudate. He was scheduled for an acid-fast bacilli smear or GeneXpert examination. However, he did not produce any sputum and the pleural effusion was hemorrhagic, so the sample could not be used for GeneXpert testing.

On the 5th day, he underwent a noncontrast chest computed tomography scan. The result showed bilateral pleural effusions with a solid part (36–46 HU) in the left lung, which was suspected as a mass and pericardial effusion. Afterward, he was consulted by the internist for echocardiography. Massive pericardial effusion (4–7 cm surrounding the heart) was found along with right atrial and ventricular collapse on echocardiography [Figure 2]. The score of the European Society of Cardiology (ESC) 2015 scoring index was 8.5. Thus, it was decided to perform an urgent echocardiography-guided pericardiocentesis. However, there was no specific catheter for pericardiocentesis available. Therefore, a 7.5 Fr CVC was utilized. Approximately 600 ml of hemorrhagic fluid was evacuated. Subsequently, his vital signs remained stable and his echocardiographic evaluation showed a remarkable improvement [Figure 3].
Figure 2: The echocardiography showed a large PE with a marked collapse in the right ventricle and a slight collapse in the right atrium. PE: Pericardial effusion

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Figure 3: The echocardiographic evaluation after the pericardiocentesis showed a significant improvement in the PE and the right heart chambers were no longer collapsed. PE: Pericardial effusion

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Routine pericardial taps were scheduled every 5 h, with each tap accumulating 50–100 ml. To preserve the access patency, a small amount of heparinized normal saline solution was administered into the CVC after each tap was completed. Careful echocardiography-guided adjustment of the catheter's tip was performed several times. The echocardiographic evaluation showed serial improvement of the pericardial effusion (1–4 cm and 0.7–2 cm) after 2 days without right atrial and ventricular collapse. A total of 1,020 ml of pericardial effusion was drained in 3 days. The symptoms gradually improved. The WSD was removed after 8 days while the CVC was retained. On the 9th day, he was referred for further evaluation due to a possible malignancy.


   Discussion Top


Pericardial effusion is a challenging condition that may portend a disastrous outcome due to its progression to life-threatening cardiac tamponade.[4] The clinical spectrum varies from asymptomatic pericardial effusion to critical cardiac tamponade.[4],[5] Transthoracic echocardiography is the gold standard to diagnose pericardial effusions and identify their effect on hemodynamics. Pericardial effusions with the largest end-diastolic echo-free space >20 mm are considered as large (>500 ml).[1],[3],[4] However, it should be noted that large pericardial effusion is not equivalent to cardiac tamponade.[4]

Due to their lower pressure, the earliest sign of hemodynamically significant pericardial effusion is abnormal right heart filling.[2] The presence of right atrial and right ventricular collapse was more specific to detecting clinical tamponade. However, it is not rare that echocardiography suggests hemodynamic compromises, such as right-sided collapse, in patients with large pericardial effusion that surprisingly do not exhibit any clinical sign of tamponade. Therefore, it is believed that echocardiography can identify patients with elevated intrapericardial pressure before hemodynamic consequences develop.[6] Ultimately, the compression by pressurized pericardial effusion results in a decrease in cardiac output, and if it is left untreated, it can be fatal.[2]

Pericardiocentesis is recommended in asymptomatic large pericardial effusion along with evidence of hemodynamic disturbance, such as diastolic right-sided collapse, due to the risk of developing unexpected tamponade.[3],[6] In 2015, ESC proposed a scoring index to guide the appropriate timing for pericardiocentesis. A total score ≥6 favors urgent pericardiocentesis. For safety reasons, it is emphasized that pericardiocentesis should always be guided by echocardiography and performed by an experienced operator.[1] Nevertheless, the treatment of large pericardial effusion is still controversial since several deaths have been reported after pericardiocentesis.[4]

Although asymptomatic and the vital signs were still normal, it was decided to perform pericardiocentesis concerning the risk of progressing into tamponade. The right-sided collapses indicated that the intrapericardial pressure had surpassed the right heart chambers pressure.

The CVC was used as indwelling pericardial drainage because the pigtail catheter was not available. Compared to the pigtail catheter, the CVC has some limitations when used for pericardiocentesis. First, the CVC is an end-hole catheter, while the pigtail catheter is a side-hole catheter. Therefore, the CVC depth should be frequently adjusted based on the size of the effusion to prevent obstruction when the tip touches the heart's surface. Second, the length of a CVC is shorter. Thus, adjusting its depth should be carried out very carefully because of the higher risk of dislodging. For these reasons, the adjustment should be done under echocardiographic guidance.

A similar case of pericardiocentesis using CVC was described in a limited setting in South Africa.[7] In our case, the patient's condition was getting better after several pericardial taps using the CVC so that he could be referred for further management. Therefore, despite its limitations, such as frequent and careful adjustment of its tip, the CVC may provide safe access that is readily available for pericardiocentesis in a limited setting area. However, further studies should be advocated to evaluate the technique.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Adler Y, Charron P, Imazio M, Badano L, Barón-Esquivias G, Bogaert J, et al. 2015 ESC guidelines for the diagnosis and management of pericardial diseases: The task force for the diagnosis and management of pericardial diseases of the European Society of Cardiology (ESC) endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2015;36:2921-64.  Back to cited text no. 1
    
2.
Little WC, Freeman GL. Pericardial disease. Circulation 2006;113:1622-32.  Back to cited text no. 2
    
3.
Manea M, Gabriel Bratu O, Bacalbasa N, Cristina Diaconu C, Gabriel O, Cristina C, et al. Diagnosis and management of pericardial effusion. J Mind Med Sci 2020;7:148-55.  Back to cited text no. 3
    
4.
Lazaros G, Vlachopoulos C, Lazarou E, Tsioufis K. New approaches to management of pericardial effusions. Curr Cardiol Rep 2021;23:106.  Back to cited text no. 4
    
5.
Huang YS, Zhang JX, Sun Y. Chronic massive pericardial effusion: A case report and literature review. J Int Med Res 2020;48:300060520973091.  Back to cited text no. 5
    
6.
Sagristà-Sauleda J, Mercé AS, Soler-Soler J. Diagnosis and management of pericardial effusion. World J Cardiol 2011;3:135-43.  Back to cited text no. 6
    
7.
Loughborough W. Emergency pericardiocentesis under dynamic ultrasound guidance in the resource limited setting. Afr J Emerg Med 2014;4:127-9.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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