Percutaneous pericardial biopsy under echocardiographic guidance

Erief

Communications

879

neous pericardial biopsy technique under echocardiographic guidance, utilizing an Olympus bronchoscopy fenestrated biopsy forceps. (Olympus Corp., Lake Success, N.Y.). M.I. was a 76-year-old white woman who was healthy most of her life until 5 months prior to admission.At that time shewashospitalized and wasfound to have Duke’s C2 adenocarcinoma of the sigmoid colon, with subsequent colectomy and colostomy being performed. In the present hospitalization, the patient wasadmitted with new onsetof bilateral lower extremity pitting edema. Peripheral Doppler echocardiography disclosed normal femoral artery flows and signsof chronic venous insufficiency. Computed tomography of the abdomendiscIosedno femoral, iliac, or vena caval dilatation. There were enlarged periaortic lymph nodes evident. The adrenal glands measured approximately 9 cm bilaterally, thought to be a sign of metastasis.A large pericardial effusion was present. On physical examination, no inspiratory decrease in blood pressurewasnoted. The patient wasnormocardiacand had borderline arterial hypertension. Venoushypertension was also present. On electrocardiographic examination, there REFERENCES were low voltage complexes without electrical alternans. 1. Alexander JS. A pericardial effusion of “gold-paint” appearOn echocardiographic examination, a large anterior and ance due to the presence of cholesterin. Br Med J 1919;4:463. 2. Rosenbaum DL, Yu PN. Idiopathic cholesterol pericarditis posterior pericardial effusion wasnoted (Fig. 1). The heart with effusion. AM HEART J 1966;‘70:515-20. did not appear to be swinging, and there were no signsof 3. Brawiey RK, Vasko JS, Morrow AG. Cholesterol pericarditis: mechanicalalternans. There was right atria1 diastolic colconsiderations of its pathogenesis and treatment. Am J Med lapse.Also noted was a 4 cm floppy massat the interface 1966;41:235-48. 4. Hancock EW. Subacute effusive-constrictive pericarditis. Cirof the right atrium and right ventricle external to the culation 1971;43:183-92. chambers,resemblingan epicardial fat pad. Becauseof her 5. Huckell VF, Staniloff HM, Feiglin DH, Flintoft V, March JE. hoarseness,slow mentation, pericardial effusion, periphMassive pericardial e&ion due to idiopathic cholesterol eral edema, and low-normal heart rates, thyroid function pericarditis detected during gemTc-pyrophosphate imaging. tests were then acquired. The T4 level was lessthan 1.0 Clin Nucl Med 1978;3:409. 6. Miller J1, Manaour KA, Hatcher CR. Pericardiectomy: current mU/dl, and the thyroid-stimulating hormone was 59 mU/ indications, concepta and results in a university center. Ann ml. The etiology at that point for the pericardial effusion Thorac Surg 1982;34:40-5. wasthought to be either myxedematous or carcinomatous. Pericardiocentesis with pericardial biopsy and external right ventricular massbiopsy wasthen performed. Informed consent was given. A cardiothoracic surgeon was available for back-up. In the intensive care unit of a 150&d hospital, the patient wassedatedwith 1 mg intravenous diazepam. She was then placed in the 45” semiFowler’s position and prepared and draped in the usual Michael B. Selig, MD. Bethlehem, Pa. sterile fashion. Electrical alternans was present on the monitor. A 10 mm inspiratory decreasein the blood pressure was also evident. The subxiphoid area was anesthetized. A V lead of the electrocardiogram was connected to The first successfulpericardiotomy was done well over a century ago.Complication rates, while not well described, an 18-gauge,8-inch spinal needlewith an external sheath. The prepericardial puncture echocardiographic images have been as high as 55%.l Echocardiographic guidance were then attained using a modified parasternal long-axis during pericardial cannulation gives a further measureof view, indicating the prior findings. The initial pericardial safety.2Pericardiocentesisalone, however, may provide an puncture was directed to the area of maximum effusion, etiologic diagnosisin only about 25% of patients3; thereand straw-colored pericardial fluid wasobtained. The neefore tissue biopsy is also desirable to increasediagnostic dle sheathwasexchangedfor a 6F hemostasissheath. The yield. Most publications are basedon open surgical biopintrapericardial pressurewas measuredat 8 to 9 mm Hg sies.This article reports a nonsurgicalsubxiphoid percutamean. Agitated saline was then injected through the side port of the hemostasissheath, disclosingbubble-contrast Reprint requests: Michael B. S&g, MD, 2045 Westgate Dr., Suite 202, Bethlehem, PA 18017-7474. within the pericardium, visualized by echocardiography, 4/4/30428 confirming the proper location. Before fluid was drained, demonstrate a cold area around the heart, indicating fluid accumulation.5 Echocardiography remains the most accurate, safe, and rapid noninvasive means of detecting pericardial fluid. The size of effusions can be estimated and tamponade is suggestedby diastolic collapse of cardiac chambers.Cardiac catheterization confirms the findings of tamponade and can assistin planning surgical therapy. Evaluation for and treatment of underlying systemic diseaseprocessesare critical in the managementof cholesterol pericarditis. Examples of conditions predisposingto pericardial involvement include tuberculosis, myxedema, collagen vascular disease,autoimmune disorders,trauma, myocardial infarction, and carcinoma.1-3Aspiration pericardiotomy provides symptomatic relief of variable duration. Pericardiectomy or creation of a pericardial window is usually necessaryfor definitive treatment.s The patient shouldbe followed closely, especiallyif the pericardium has not been removed, since recurrence of effusion is common in those patients not treated with a pericardial window or pericardiectomy.

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Brief Communication

Fig. (UFFOW).

American

September 1-1 Heart Journal

1. Parasternal long-axis view. Pericardial effusion (PE) and extracavitary right ventricular mass LV, Left ventricle; A, aorta; LA, left atrium.

Fig.

2. Modified parasternal long-axis view. A~FOW showsthe appearanceof the biopsy forceps.

keepingthe pericardial spaceseparated,an 0.038-inch, 145 cm floppy guide wire was then advanced via the hemostasis sheath and was clearly visualized in the anterior midlevel pericardial area, approximating the location of the right atrial, right ventricular mass.The guide wire was then removed and exchanged for a 6F Olympus FB18 fenestrated biopsy forceps. Under echocardiographicguidance a biopsy samplewasthen taken (Fig. 2). The biopsy forceps wasthen positioned to the free wall of the pericardium under echocardiographicguidance, and another biopsy sample was then acquired. The biopsy forceps was then exchanged for a 6F pigtail catheter loaded with the

guide wire. The pigtail waspositioned in the area of maximum effusion. The guide wire waswithdrawn, and 300cm3 of straw-colored pericardial fluid wasaspirated. At the end of the aspiration, the intrapericardial meanpressurewas3 to 4 mm Hg. There was no longer echocardiographic evidence of right atria1 inversion. The pigtail catheter and the 6F hemostasissheath remained until the following morning. There wereno complications.Electrical alternans was no longer present. The biopsy specimenwasreported asreactive mesothelial tissue. Pericardiotomy was first suggestedby Riolan in 1649, but the first successfuluse of pericardiotomy by surgical

Volume Number

122 3, Part

Brief Communications

1

incision was introduced in 1815 to the Faculte de Medicine de Paris by Romero. Credit for the performance of the first indirect (closed, blind) pericardiocentesis belongs to Frank Schuh.4 Schuh suggested in 1838 that pericardiocentesis may be justified in severe cases of hydropericardium. Modifications of &huh’s indirect pericardiotomy using a trocar and cannula without incision gradually passed into general use, and mainly favorable reports appeared before the end of the century. Diagnostic and therapeutic pericardiotomy has been a controversial subject since it was introduced. Technically, it has evolved through at least three stages. In its original form, the procedure involved incision through the chest wall and into the pericardium under direct vision. When performed in this manner, bacterial infection of the pericardial space commonly occurred, leading to the development of an indirect approach without actual incision. This blind, or indirect, method of pericardial puncture has been the accepted approach because it is convenient, less troublesome, and less expensive, but it frequently yielded erroneous and confusing diagnostic information. More recently, the obvious advantage of the direct approach to the pericardium, especially if combined with biopsy and removal of fluid under direct vision, has been emphasized. Pericardiocentesis is dramatic and lifesaving when it is performed to relieve cardiac tamponade. However, serious complications related primarily to puncture of the ventricles and coronary arteries, and subsequent arrhythmias, hemopericardium, and death can occur. There are few studies that have attempted to quantify the risk of pericardiocentesis. In 1951 Kotte and McGuire4* reported that 8 of 24 physicians had seen at least one fatality due to pericardiocentesis, but the incidence of complications was not known. Reported complications are in the range of 7% to 55% .l, 5-s Pericardiocentesis is a procedure that has a greater risk of complications than does cardiac catheterization and a number of other invasive procedures. Some physicians believe that pericardiocentesis should not be performed routinely unless cardiac tamponade is present.l* 7, lo Others recommend direct surgical drainage of the pericardium, 7,l1 but unfortunately this procedure also can result in significant complications in 65% of patients.6 In attempts to decrease the complication rate, various techniques and adjunctive guidance modalities have been described. Electrocardiograph needle-tip guidance5 has been utilized for several decades. Echocardiography has been established as the diagnostic procedure of choice in pericardial effusion. l2 Visualization of a pericardiocentesis by two-dimensional echocardiography was reported in 1978.r3 Contrast echocardiographic techniques to identify the location of the tip of the pericardial needle within the pericardial sac have been described.14 Many investigators have suggested two-dimensional echocardiography to guide the placement of the pericardiocentesis needle, recognizing the inherent safety of the method. Despite reports, the usefulness of two-dimensional echocardiographically-directed pericardiocentesis has not been appreciated. In practice, echocardiography is almost universally used to diagnose pericardial effusion, but the pericardiocentesis

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procedure is usually done by the blind percutaneous subxiphoid technique or by surgical pericardiotomy. The environment in which pericardiocentesis is performed also determines the incidence of complications of the indirect procedures. Wong et al.” showed that there were fewer complications when electrical alternans was present; when the effusions were malignant; and when the effusion were greater than 200 ml. Another pitfall to the technique of indirect pericardiocentesis is the need to obtain microbiologic and hi&pathologic diagnosis in patients with pericardial effusion. A definite etiologic diagnosis occurs in about 25% of patients.3 To increase diagnostic yield, pericardial biopsy oftentimes is required.15, l6 Most published reports are based on open surgical biopsies. Tuberculosis and malignancy are the most common sources of error in determining the etiology of patients with pericarditis. 16*l7 Pericardial fluid yields a positive culture of Mycobacterium tuberculosis only exceptionally, and to find acid-fast bacilli in pericardial smears is almost impossible. Biopsy series have improved diagnostic yield.16, la In malignant pericarditis, cytologic examination of the pericardial fluid is usually positive in 50 % to 80%) but cell typing is usually poor.lg Some centers now routinely perform pericardial biopsy in patients with large chronic pericardial effusions of undetermined etiology, particularly if tuberculosis or malignancy is suspected.18 Nonsurgical techniques for multiple pericardial biopsies have been described under tluoroscopic examination, requiring injection of air into the pericardium,18 as well as the use of the flexible fiberoptic pericardioscope. 2o These techniques are somewhat cumbersome compared with the technique described. In this case, an indirect subxiphoid puncture was performed with an electrocardiographically guided needle. Contrast echocardiography confirmed pericardial location. A long guide wire was advanced and visualized by echocardiography, and an Olympus bronchoscopy biopsy forceps was advanced under echocardiography with acquisition of pericardial, as well as external right ventricular mass samplings. This biopsy technique can be done with pericardiocentesis in a community, as well as in a tertiary care center, in properly selected patients while maintaining safety to the patient and increasing the diagnostic yield. REFERENCES 1.

2.

3. 4.

4a. 5. 6.

Kilpatrich ZN, Chapman CB. On pericardiocentesis. Am J Cardiol 1965;16:722-8. Callahan JA, Seward JP, Nishimura RA, et al. Two-dimensional echocardiographically-guided pericardiocentesis. Experience in 117 consecutive patients. Am J Cardiol 1985;55: 476-9. Wong B, Murphy J, Chang JC, Hassenein K, Dunn M. The risk of pericardiocentesis. Am J Cardiol 1979;44:1110-4. Schuh F. Erfahrungen uber die Paracentese der Brust und das Herzbeutels. Med Jahrb DKK, Oster Staates Wien (Neuste Folge 24) 1841;33:388. Kotte JH, M&&ire J. Pericardial paracentesis. Mod Concepts Cardiovasc Dis 1951;20:102-3. Bishop LH, Estes EH, MacIntoah HD. The electrocardiogram as a safeguard in pericardiocentesis. JAMA 1956;62:264-5. Fredriksen RT, Cohen LS, Mullins CB. Pericardial windows

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7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.

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or pericardiocentesis for pericardial effusion. AM HEART J 1971;82:158-62. Pradham JK, Ikins PM. The role of pericardiectomy in the treatment of pericarditis with effusion. Am Surg 1976;42:25761. Silverberg S, Oreopalous DG, Wise DG, et al. Pericarditis in patients undergoing long-term hemodialysis and peritoneal dialysis. Am J Med 1977;63:874-80. Kirkorian JK, Handcock WE. Pericardiocentesis. Am J Cardiol 1978;65:808-14. Fowler NO. Diseases of the pericardium. In: Hurst JW, Logue RB, Schant RC, Wenger NK, eds. The heart. 3rd ed. New York: McGraw-Hill Book Co, Inc, 19741387. Santos GH, Frates RWM. The subxiphoid approach in the treatment of pericardial effusion. Ann Thorac Surg 1977; 23:467-70. Feigenbaum H. Echocardiographic diagnosis of pericardial effusion. Am J Cardiol 1970;26:475-9. Martin RP, Rakowski H, French J, Popp RL. Localization of pericardial effusion with wide-angle phased array echocardioeranhv. Am J Cardiol 1978:42:904-12. &&&aratna PAN, First J, Langevin E, O’Dell R. Echocardiographic contrast studies during pericardiocentesis. Ann Intern-Med 1977;87:199-200. Ortbals DW. Avioli LV. Tuberculous aericarditis. Arch Intern Med 1979;139:231-4. Agner RCH, Gallis HA. Pericarditis. Differential diagnostic c&siderations. Arch Intern Med 1979;139:407-19. Little AG. Kremser PC. Wade JL. Lewett JM. DeMeester TR, skinner DB. Operation for diagnosis and treatment of pericardial effusion. Surgery 1984;96:738-44. Endrys J, Simo M, Shafie MZ, et al. New non-surgical technique for multiple pericardial biopsies. Cathet Cardiovasc Diagn 1988;15:92-4. Kralstein J, Frischman W. Malignant pericardial disease; diagnosis and treatment. AM HEART J 1987;113:785-90. Kondos GT, Rich S, Levitsky S. Flexible fiberoptic pericardioscopy for diagnosis of pericardial disease. J Am Co11 Cardiol 1986;7:432-4.

under fluoroscopic control. The pericardial fluid is aspirated and air is introduced into the pericardial cavity to outline the parietal pericardium. A bioptome is then introducedthrough the sheath, which is usedto direct the bioptome to the right and left pericardial walls for biopsy.2 However, becauseof the floppy nature of the bioptome, we experienced difficulty in directing it to the desired biopsy sites, especially on the right pericardial wall, since the bioptome had a tendency to go toward the left pericardial wall and the sheath too would lose its curve on our attempting to steer the bioptome. ways to overcome this problem.

sought

A 9F coronary guiding catheter wascut 40cm from its tip. The distal segment was introduced through a 9F Teflon sheath with a backbleed valve and a side arm flush mechanism (Hemaquet, USCI, Galway, Ireland) placed in the pericardial cavity by the technique described above. A bioptome with a 1.8 mm jaw diameter (Byceps, Mansfield Scientific, Mansfield, Mass.) wasthen passedthrough this guiding catheter (Fig. l), and the guiding catheter wasused to direct the bioptome to the desiredsite for biopsy. Useof differently shaped guiding catheters (both right and left coronary) allowed easy accessto all parts of the pericardium, sincethesecatheters, being more rigid than the Teflon sheath recommended by Endrys et aL2 had a greatly increasedmaneuverability. Pericardial biopsieswere performed in this manner in 25 patients agedbetween 16 and 56 years. An averageof six biopsy specimens(rangefour to nine) were obtained from different sites in each patient, placed in 10% formalin solution, and subjected to histopathologic examination. A histologic diagnosisof tuberculous pericarditis was obtained in 11 patients, that of pyogenic pericarditis wasobtained in two, and that of nonspecific inflammatory changes was obtained in 12 with

matomain one patient. Sincethe biopsy samplesrepresent such a minute portion of the vast area of the pericardial surface,and sincemany of the lesionsaffecting the serosal membranes(chiefly granulomasand tumor implants) tend to be focally distributed, the chance of missingdiagnostic

Vivek K. Mehan, MD, Bharat V. Dalvi, DM, Yash Y. Lokhandwala, MD, and Purshottam A. Kale, MD. Bombay, India

tissue is great. The yield can be increased

by multiple

bi-

opsies.This has already been shown to be true for closed pleural biopsies,3,4 and we proposethat obtaining multiple pericardial

Pericardial biopsy is conventionally performed by an open surgical technique, or with the use of a flexible fiberoptic pericardioscope.’ Endrys et al2 have recently described a nonsurgical technique for multiple pericardial biopsiesin the presenceof pericardial effusion. An 8F Teflon sheath with a curved tip is introduced into the pericardial cavity by the Seldinger technique via the subxiphoid approach

4/4/30433

We therefore

presumed viral pericarditis. There were no complications of this procedure apart from occasionalventricular premature beats in 10 patients and a small subcutaneous he-

Use of guiding catheters to target pericardial and endomyocardial biopsy sites

From the Department of Cardiology, K.E.M. Hospital, Parel. Reprint requests: Vivek K. Mehan, MD, Dept. of Cardiology, K.E.M. pital, Parel, Bombay 400 012, India.

September 1991 Heart Journal

Hos-

biopsies

also would

increase

the diagnostic

yield. The procedure usinga curved sheathasdescribedby Endrys et al2 took us an average of 1 hour, with 300 seconds of fluoroscopy time, in our initial six cases.However,

using the modified technique describedabove, the procedure took an average of 45 minutes, with an average fluoroscopytime of 260 seconds(a difference of 10% to 15%) in the subsequent25 patients. We later extended this technique to endomyocardial biopsy. This is classically done by the internal jugular approach, with a bioptome passedthrough a long Teflon sheath into the right ventricle followed by biopsy from the interventricular

septum

at the right

ventricular

apical