Pericardial Window vs Pericardiocentesis

pericardial window vs pericardiocentesis Pericardiocentesis is often performed because of cardiac tamponade, a condition that can be fatal without treatment. The non-operative approach can help relieve symptoms and avoid hemodynamic instability; however, it’s been associated with a higher risk of recurrence.

Between pericardial window vs pericardiocentesis, research generally recommends a pericardial window operation instead of pericardiocentesis. It is theoretically superior and offers reliable diagnostics.

Join experts at Hospital Procedures Consultants as we break down the applications and benefits of pericardial window vs pericardiocentesis. By the end of this article, you’ll know more about the two procedures.

Ensure Pericardiocentesis’ Patient Suitability 

Is your patient a good candidate?

Pericardiocentesis is indicated in patients with cardiac tamponade. 

There are no absolute contraindications for pericardiocentesis when cardiac tamponade and shock occur. 

However, it is not advisable for patients with aortic dissection, coagulopathy (INR of > 2.0), myocardial rupture, and thrombocytopenia (platelet count < 50,000/μL). In such cases, pericardial drainage with several cycles of intermittent volume-controlled drainage can be a temporizing measure.

For pulmonary hypertension, proceed with caution. Pericardiocentesis has been associated with significant morbidity and mortality. However, a single-center cohort study demonstrated that the risk can be lowered through echocardiographic guidance performed by a highly experienced echocardiologist.

A Step-by-Step Guide for Pericardiocentesis 

Here’s an overview of optimal techniques for pericardiocentesis:

Perform a Physical Examination 

Pericardiocentesis deals with the pericardium, a sac-like membrane that surrounds the heart. It’s thus important to conduct a thorough assessment of potential access sites to avoid injuring nearby structures. 

Prepare the Treatment Area

Pericardiocentesis is traditionally performed using anatomical landmarks via a subxiphoid approach. Use an antiseptic solution to prepare the site and apply 2% lidocaine to minimize discomfort. Advance an 18-gauge spinal needle towards the left shoulder, approximately 30° to the skin.

Perform Aspiration 

Insert a saline-filled syringe connected to the Teflon-sheathed needle until the fluid-filled cavity between the parietal and visceral layers is identified. Then, position a guide wire in the pericardial space through the sheath. Use the soft J-tipped variant. This procedure rarely causes perforation.

Next, insert a pigtail catheter via the introducer sheath. This can be kept in place for several hours in case of ongoing or recurring bleeding. 

Extended drainage until the fluid return is less than 50 mL every 24 hours for two consecutive days can prevent the recurrence of pericardial fluid. The intrapericardial administration of different agents can also be performed if needed. 

Send a Sample for Cytopathology Study 

Pericardial effusion can arise from various underlying conditions, even cancer. It’s important to send the entire initial volume of pericardial fluid for analysis.

Here are some determiners:

  • Purulent pericardial fluid ⮕ an infective etiology
  • Serous fluid ⮕ benign idiopathic or inflammatory pericarditis
  • Chylous pericardial effusions ⮕ injury to the lymphatic system
  • Sanguineous pericardial effusions ⮕ malignancy, trauma, and postoperative states

Knowing the cause and prognosis will influence the treatment strategy. 

If the fluid is bloody, measuring the hematocrit/hemoglobin in pericardial fluid against the fluid drawn from a peripheral vein can help identify the disruption or perforation of a cardiac chamber or great vessel.

Electrocardiogram Monitoring

Contact with the ventricular or atrial myocardium is indicated by elevation of the S-T or the P-R segment. If time permits, attach an alligator clip to the base of the pericardiocentesis needle. This can be connected to the V lead port of an electrocardiograph machine.

Fluoroscopy can also be used in the real-time evaluation of anatomic structures. This should be employed alongside radiographic contrast agents.

Improve the Odds With Echocardiography

Blind pericardiocentesis guided by anatomical landmarks can be performed in emergency conditions. However, it must not be used as standard treatment because it has the highest predicted complications (79.7%). In addition, its life-threatening complications exceed 20%

A better alternative is echocardiography-guided pericardiocentesis. Using it as the first line of treatment offers improved safety and efficacy.

The addition of echocardiography provides a detailed evaluation of the size and location of the effusion while allowing clinicians to assess the progression of cardiac tamponade. Studies show that it can also offer visualizations of the effusion and surrounding structures. This helps decrease the likelihood of accidental chamber and organ punctures.

Echocardiography-guided pericardiocentesis is widely available to General Practitioners (GP).

Direct visualization of the needle tip—once it is introduced to the skin for pericardiocentesis—should not be attempted using echocardiography probes. They offer poor visibility and variabilities exist in the echogenicity of the needles and image processing.

Understanding the Application of Pericardial Window

Pericardiocentesis can be considered in cases of symptomatic moderate or large pericardial effusions that have a 29% risk of progressing to cardiac tamponade. 

Since recurrence is common, a pericardial window is an excellent alternative. It has been shown to lower the incidence of malignant pericardial effusion in patients with cancer.

Surgical pericardial windows allow ongoing drainage of any effusion to the pleural space, preventing the occurrence of the tamponading effect.

It can be done in two ways:

  • Subxiphoid method
  • Thoracotomy technique

The former technique generally requires less narcotics within 48 hours after surgery, indicating reduced pain after an operation. It is also characterized by earlier extubation. In contrast, the thoracostomy window technique is associated with preventing the recurrence of moderate or large pericardial effusions and possibly the need for repeat operations thereafter.

However, perioperative the mortality rates and hospital lengths of stay were similar for the two procedures.

There is a Better Alternative….

Complex conditions with poor sonographic windows and posteriorly located pericardial effusions need additional imaging modalities like computed tomography (CT). 

It’s a common diagnostic and screening imaging tool. CT’s application is currently limited to pericardiocentesis because the median duration of the procedure is lengthy at 65 minutes. It also has a tendency to exaggerate the size of pericardial effusions

Take Home Message

Pericardial window vs pericardiocentesis: which one is superior?

Both procedures are safe and effective. Pericardiocentesis is much less intrusive for patients with cardiac tamponade while a pericardial window is preferred for patients with longer life expectancies. Using imaging modalities like ultrasound can further improve patient outcomes.

Learn the finer details by taking our pericardiocentesis course. The program uses an advanced stimulator to help students become more familiar with the optimal insertion sites, indications and contraindications, and complications. Ultimately, this allows them to make better decisions for their patients.

Resources 

Lee, J. Kim, K. Gwak, S.-Y. Lee, H.-J. Cho, I. Hong, G.-R. Ha, J.-W. Shim, C. Y. Pericardiocentesis versus window formation in malignant pericardial effusion: trends and outcomes. Comparative Study Heart. 2024 May 23;110(12):863-871. doi: 10.1136
Stashko, E. Meer, J. M. Cardiac Tamponade. StatPearls 2023.07
Willner, D. A. Grossman, S. A. Pericardiocentesis. 2023.19
Dwivedi, S. Siddiqui, F. Patel, M. Cardozo, S. Guide Wire Induced Cardiac Tamponade: The Soft J Tip Is Not So Benign. Case Rep Crit Care. 2016; 2016: 1436924. Published online 2016 Aug 11
Fenstad, E. R. Le, R. J. Sinak, L. J. Maradit-Kremers, H. Ammash, N. M. Ayalew, A. M. Villarraga, H. R. Oh, J. K. Frantz, R. P. McCully, R. B. McGoon, M. D. Kane, G. C. Pericardial effusions in pulmonary arterial hypertension: characteristics, prognosis, and role of drainage. Comparative Study Chest. 2013 Nov;144(5):1530-1538. doi: 10.1378
Hayashi, T. Tsukube, T. Yamashita, T. Haraguchi, T. Matsukawa, R. Kozawa, S. Ogawa, K. Okita, Y. Impact of controlled pericardial drainage on critical cardiac tamponade with acute type A aortic dissection. Clinical Trial Circulation. 2012 Sep 11;126(11 Suppl 1):S97-S101. doi: 10.1161
Blanco, P. Figueroa, L. Menéndez, M. F. Berrueta, B. Pericardiocentesis: ultrasound guidance is essential. Ultrasound J. 2022 Dec; 14: 9.Published online 2022 Feb 14. doi: 10.1186

Read all articles in Featured Procedure, Pericardiocentesis

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