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Percutaneous transcatheter pericardial interventions: Aspiration, biopsy, and pericardioplasty
EDITORIALS
Percutaneous transcatheter pericardial interventions: Aspiration, biopsy, and pericardioplasty Michael
B. Selig, MD Bethlehem,
Pa.
The pericardium has interested outstanding physicians since the biblical past. Hippocrates described the normal pericardium as a smooth mantle surrounding the heart and containing a small amount of fluid.l He did not describe pericardial disease, primarily because Hippocratic pathology was concerned with generalized disorders, but also because of the ancient belief that the heart was too noble an organ to undergo a disease process. Pericardial pathology was mostly observable on the battlefield. The incidence of pericardial inflammation detected in several autopsy series ranges from 2 % to 6 % , whereas pericarditis is diagnosed clinically in only 1 out of 1000 hospital admissions.2 This suggests that pericarditis, which often occurs with effusion, is frequently inapparent clinically, and may occur in the presence of a vast number of medical and surgical disorders. Those patients who do develop pericardial effusions or other diseases sometimes pose difficult diagnostic and management problems. Pericardial procedures to aid in these problems continue to evolve. Pericardiotomy was suggested by Riolan in 1649, but the first successful use of pericardiotomy by surgical incision was introduced in 1815 to the Faculte de Medicine de Paris by Romero. Credit for performance of the first indirect closed (blind) pericardiocentesis belonged to Frank Schuh.3 Schuh suggested in 1838 that pericardiocentesis may be justified in severe cases of hemopericardium. Modifications of Schuh’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 thera-
From Received
the Division
of Cardiology,
for publication
June
Reprint requests: Michael Bethlehem, PA 18017-7474. 4/l/42272
0002-8703/93/$1.00
+ .lO.
Muhlenberg ‘22, 1992;
B. Selig,
MD,
Hospital
accepted 2045
Center.
Aug. 1, 1992. Westgate
Drive,
Suite
202,
peutic pericardiotomy has been a controversial subject since it was introduced. Technically it has evolved through at least four stages. In its original form, the procedure involved an 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. The blind or indirect method of pericardial puncture has been the accepted approach because it is convenient, less troublesome, and less expensive, but it frequently yields erroneous and confusing diagnostic information. The obvious advantage of the direct approach to the pericardium, which allows removal of fluid, biopsy, or the creation of a window, was then emphasized. More recently, closed percutaneous catheter-based techniques for acquiring biopsy specimens and creating pericardial windows have been described. Pericardiocentesis. 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 may 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 as a result of pericardiocentesis, but the incidence of complications was not known. Reported complications are in the range of 7 7, to 55% .5-10 Pericardiocentesis is a procedure that has a greater risk of complication than cardiac catheterization and a number of other invasive procedures. Some physicians believe that pericardiocentesis should not be performed routinely unless cardiac tamponade is present.5,8l l1 Others recommend direct surgical drainage of the pericardium,s> l2 but unfortunately this procedure can also result in significant complications in 65% of patients.7 Wong et a1.i3 noted that 269
270
Se&g
there were fewer complications with pericardiocentesis when electrical alternans was present and when effusions were malignant and were greater than 200 ml. In attempts to decrease the complication rate of subxiphoid percutaneous pericardiocentesis, various techniques and adjunctive guidance modalities have been described. Electrocardiogram needle-tip guidance has been utilized for decades.” Echocardiography has been established as the diagnostic procedure of choice in pericardial effusion.14 Visualization of the pericardiocentesis needle by two-dimensional echocardiography was reported in 1978.i5 Contrast echocardiographic techniques to identify the location of the tip of the pericardial needle within the pericardial sac have been described.16 Many investigators have suggested two-dimensional echocardiography to guide the placement of the pericardiocentesis needle, biopsy forceps, or balloon catheter, recognizing the inherent safety of the technique. Despite reports, the usefulness of two-dimensional echocardiography-directed pericardiocentesis has not been appreciated. In practice, echocardiography is almost universally used to diagnose pericardial effusion, but the pericardiocentesis procedure is usually done by a blind percutaneous subxiphoid technique or by surgical pericardiotomy. Transesophageal echocardiography may further aid guidance during percutaneous pericardial interventions. Hemodynamic guidance permits continuous measurement of pericardial pressure through the needle during advancement into the pericardial space. I7 Fluoroscopic techniques have also been used, but they require insertion of contrast media or air into the pericardial space to visualize the effusion. Pericardial biopsy. In the past, pericardial biopsy has been left to the direction of our surgical colleagues. Several catheter-based pericardial biopsy techniques, however, have recently been described. Acquiring biopsy specimens with routine pericardiocentesis increases the diagnostic yield. Tuberculosis is the most common source of error in determining an etiology in patients with pericardiocentesis.18, lg Pericardial fluid leads to a positive culture of Mycobacterium tuberculosis only exceptionally, and to find acid-fast bacteria in pericardial smears is almost impossible. This issue is of increasing concern with the resurgence of tuberculosis noted in the recent literature. Biopsy series have improved the diagnostic yield. 18*2o In malignant pericarditis, cytologic examination of the pericardial fluid is usually positive in 50% to 80%, but cell typing is usually poor.ls, ‘I, 22 Some centers now routinely perform pericardial biopsy in patients with large chronic pericardial ef-
American
January 1993 HeaR Journal
fusions of undetermined etiology, particularly if tuberculosis and malignancy are suspected.“(’ Nonsurgical techniques for multiple pericardial biopsies have been described. Endrys et a1.20 utilized a subxiphoid 7F catheter and a transluminal endomyocardial bioptome. Air was injected into the pericardium under fluoroscopic examination, and multiple samples were taken20 Kondos et al.” directed a flexible fiberoptic bronchoscope (Olympus BF Type 482) and bronchoscopy forceps under general anesthesia via surgical incision. Selig23 described a percutaneous subxiphoid transluminal biopsy technique using a bronchoscopy forceps under echocardiographic guidance. This technique is less cumbersome and resource-dependent and can be done without general anesthesia or surgical incision. Its safety and utility are yet to be determined. The adjunct of transcatheter biopsy would allow aspiration and biopsy to be done together as it is done in thoracentesis procedures.Z4 Guiding catheters can also be helpful to target the pericardial biopsies.25 Pericardioplasty. The optimal approach for patients with recurrent pericardial effusions continues to be debated. Symptomatic reaccumulation is an indication for a surgical procedure such as creation of a pericardial “window” or partial or complete pericardiectomy, which can be performed as an emergency procedure.“” A complete or radical pericardiectomy, which requires general anesthesia, is often too rigorous a procedure for debilitated cancer patients who most often have this problem.s7 A pericardial window is one frequently performed operation, but some surgeons have been so disappointed with their results that they have abandoned the operation in favor of total pericardiectomy.Zs! 2g Pericardial windows carry with them a lower risk and they can be done under local anesthesia. However, when there is a tumor encasement of the heart, this procedure is ineffective when adhesions develop, resulting in closure of the window and the need for repeat catheter drainage.21 Often pericardiectomy is attempted when the estimated survival is greater than 1 year. Other modalities, such as installation of interpericardial agents or radiotherapy, are suboptimal.30, “’ An indwelling pericardial pigtail catheter left in for a few days is usually enough to avoid recurrent effusions and tamponade; however, in 14”;. the need for a window procedure may arise.“2 Palacios et al.“” reported a catheter-based technique using a valvuloplasty balloon under fluoroscopic guidance. This procedure was performed successfully in all eight patients without recurrent tamponade or complications. A similar technique under echocardiographic
volume 125 Number1
guidance has been describedS3*l 35 Vora et a1.35 noted that it was possible to perform this technique under echocardiographic guidance at the bedside. Percutaneous pericardioplasty procedures appear safe and easy to perform and can allow for repeated dilations if the need arises. Conclusions. Patients with pericardial effusion may more effectively be managed by these percutaneous transcatheter techniques. These subxiphoid percutaneous procedures include pericardiocentesis followed by pericardial biopsy. If greater than 100 cm3 of fluid reaccumulation occurs over 24 hours for 3 days, then percutaneous pericardioplasty can be utilized to create a pericardial window.33 These techniques appear promising, providing a safe approach, avoiding general anesthesia, an open surgical procedure, and possible infection while maintaining a higher level of comfort to the patient.
REFERENCES
1. Boyd LH, Elias H. Contributions to diseases of the heart and pericardium. Historic introduction. Bull NY Med Co11 1955;18:1-37. 2. Sodeman WA, Smith RH. A re-evaluation of the diagnostic criteria for acute pericarditis. Am J Med Sci 1956235: 672-6. 3. Schuh F. Erfahrungen uber die paracentese der brust and das herzbeutels. Med Jahrbuch DKK, Oster Staates Wien (Neuste Folge 24) 1841;33:388. 4. Kotte JH, McGuire J. Pericardial uaracentesis. Mod Concepts Cardiovasc Dis 1951;20:102-3. 5. Kilpatrick ZM, Chapman CB. On pericardiocentesis. Am J Cardiol 1965;16:722-8. 6. Bishop LH, Estes EH, Macintosh HD. The electrocardiogram as a safeguard in pericardiocentesis. JAMA 1956;62:264-5. I. Fredriksen RT, Cohen LS, Mullins CB. Pericardial windows or pericardiocentesis for pericardial effusion. AM HEARTJ 1971;82:158-62. 8. Pradham JK, Ikins PM. The role of pericardiectomy in the treatment of pericarditis with effusion. Am Surg 1976;42:25761. 9. Silverberg S, Oreopalous DG, Wise DG, et al. Pericarditis in patients undergoing long-term hemodislysis and peritoneal dialysis. Am J Med 1977;63:874-80. 10. Kirkorian JK, Handcock WE. Pericardiocentesis. Am J Cardiol 1978;65:808-14. 11. Fowler NO. Diseases of the pericardium. In: Hurst JW, Logue RB, Schlant RC, Wenger ED, eds. The heart. 3rd ed. New York: McGraw-Hill, 1974:1387. 12. Santos GH, Frates RWM. The subxiphoid approach in the treatment of pericardial effusion. Ann Thorac Sum 1971;23:467-70. 13. Wong B, Murphy J, Chang JC, Hassenein K, Dunn M. The risk of pericardiocentesis. Am J Cardiol1979:44:1110-4. 14. Feigenbaum H. Echocardiographic diagnosis of pericardial effusion. Am J Cardiol 1970;26:475-9.
Percutaneous
pericardial
interventions
271
15. Martin RP, Rakowski H, French J, Popp RL. Localization of pericardial effusion with a wide-angle phased array echocardiography. Am J Cardiol1978;42:904-12. 16. Chandraratna PAN, First J, Langevin E, O’Dell R. Echocardiographic contrast studies during pericardiocentesis. Ann Intern Med 1977;87:199-200. 17. Flynn MS, Kern MJ, Aguirre F, Donohue T, Bach R. Management of a complicated pericardiocentesis. Cathet Cardiovast Diagn 1992;25:249-52. 18. Agner RCH, Gallis HA. Pericarditis. Differential diagnostic considerations. Arch Intern Med 1979;139:407-19. 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. 20. Endrys J, Simo M, Shafie MZ, et al. New nonsurgical technique for multiple pericardial biopsies. Cathet Cardiovasc Diagn 1988;15:92-4. 21. Kralstein J, Frishman W. Malignant pericardial disease; diagnosis and treatment. AMHEARTJ 1987;113:785-90. 22. Kondos GT, Rich S, Levitsky S. Flexible fiberoptic pericardioscopy for diagnosis of pericardial disease. J Am Co11 Cardiol 1986;7:432-4. 23. Selig MB. Percutaneous nericardial biopsy under echocardiographic guidance. Au HEARTJ 1991;12-2:879-82. 24. Bueno CE, Clemente MG, Castro C, Martin M, et al. Cytologic and bacteriologic analysis of fluid and pleural biopsy specimens with Cope’s needle. Arch Intern Med 1990;150:1190-4. 25. Mehan VK, Dalvi BV, Lokhandwala YY, Kale PA. Use of guiding catheters to target pericardial and endomyocardial biopsy sites. AM HEARTJ 1991;122:882-3. 26. Fowler NO. Cardiac tamponade. In: Fowler NO, ed. The pericardium in health and disease. New York: Futura Publishing Company, 198524780. 27. Guberman BA, Fowler NO, Engel PJ, Mosch LG, Allen JM. Cardiac tamponade in medical patients. Circulation
1981;64:633-40. 28. Piehler JM, Pluth JR, Schaff NV, Danielson GK, Orszulak TA, Puga FJ. Surgical management of effusive pericardial disease: influence of extent of pericardial resection on clinical course. J Thorac Cardiovasc Surg 1985;90:506-16. 29. Miller 31, Mansour KA, Hatcher CR Jr. Pericardiectomy; current indications, concepts, and results in a University Center. Ann Thorac Surg 1982;34:40-5. 30. Davis S, Sharma SM, Blumberg ED, Kim CS. Intrapericardial tetracycline for the management of cardiac tamponade secondary to malignant pericardial effusion. N Engl J Med 1978;229:1113-4. 31. Gregory JR, McMurtry MJ, Mountain CF. A surgical approach to the treatment of pericardial effusion in cancer patients. Am J Clin Oncol 1985;8:319-23. 32. Koperly SL, Callahan JA, Tajik AJ, Seward JB. Percutaneous pericardisl catheter drainage; report of 42 consecutive cases. Am J Cardiol 1986;58:633-5. 33. Palacios IF, Tuzcu M, Ziskind A, Younger J, Block PE. Percutaneous balloon pericardial window for patients with malignant pericardial effusion and tamponade. Cathet Cardiovast Diagn 1991;22:244-9. 34. Selig MB. Percutaneous pericardioplasty under echocardiographic guidance. Dissertation. Institutional Review Board, Muhlenberg Hospital Center, Bethlehem, Pa: September 1991. 35. Vora AM, Lokhandwala DM, Kale PA. Echocardiographyguided creation of balloon pericardial window. Cathet Cardiovast Diagn 1992;25:164-5.
Percutaneous transcatheter pericardial interventions: Aspiration, biopsy, and pericardioplasty Michael
B. Selig, MD Bethlehem,
Pa.
The pericardium has interested outstanding physicians since the biblical past. Hippocrates described the normal pericardium as a smooth mantle surrounding the heart and containing a small amount of fluid.l He did not describe pericardial disease, primarily because Hippocratic pathology was concerned with generalized disorders, but also because of the ancient belief that the heart was too noble an organ to undergo a disease process. Pericardial pathology was mostly observable on the battlefield. The incidence of pericardial inflammation detected in several autopsy series ranges from 2 % to 6 % , whereas pericarditis is diagnosed clinically in only 1 out of 1000 hospital admissions.2 This suggests that pericarditis, which often occurs with effusion, is frequently inapparent clinically, and may occur in the presence of a vast number of medical and surgical disorders. Those patients who do develop pericardial effusions or other diseases sometimes pose difficult diagnostic and management problems. Pericardial procedures to aid in these problems continue to evolve. Pericardiotomy was suggested by Riolan in 1649, but the first successful use of pericardiotomy by surgical incision was introduced in 1815 to the Faculte de Medicine de Paris by Romero. Credit for performance of the first indirect closed (blind) pericardiocentesis belonged to Frank Schuh.3 Schuh suggested in 1838 that pericardiocentesis may be justified in severe cases of hemopericardium. Modifications of Schuh’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 thera-
From Received
the Division
of Cardiology,
for publication
June
Reprint requests: Michael Bethlehem, PA 18017-7474. 4/l/42272
0002-8703/93/$1.00
+ .lO.
Muhlenberg ‘22, 1992;
B. Selig,
MD,
Hospital
accepted 2045
Center.
Aug. 1, 1992. Westgate
Drive,
Suite
202,
peutic pericardiotomy has been a controversial subject since it was introduced. Technically it has evolved through at least four stages. In its original form, the procedure involved an 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. The blind or indirect method of pericardial puncture has been the accepted approach because it is convenient, less troublesome, and less expensive, but it frequently yields erroneous and confusing diagnostic information. The obvious advantage of the direct approach to the pericardium, which allows removal of fluid, biopsy, or the creation of a window, was then emphasized. More recently, closed percutaneous catheter-based techniques for acquiring biopsy specimens and creating pericardial windows have been described. Pericardiocentesis. 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 may 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 as a result of pericardiocentesis, but the incidence of complications was not known. Reported complications are in the range of 7 7, to 55% .5-10 Pericardiocentesis is a procedure that has a greater risk of complication than cardiac catheterization and a number of other invasive procedures. Some physicians believe that pericardiocentesis should not be performed routinely unless cardiac tamponade is present.5,8l l1 Others recommend direct surgical drainage of the pericardium,s> l2 but unfortunately this procedure can also result in significant complications in 65% of patients.7 Wong et a1.i3 noted that 269
270
Se&g
there were fewer complications with pericardiocentesis when electrical alternans was present and when effusions were malignant and were greater than 200 ml. In attempts to decrease the complication rate of subxiphoid percutaneous pericardiocentesis, various techniques and adjunctive guidance modalities have been described. Electrocardiogram needle-tip guidance has been utilized for decades.” Echocardiography has been established as the diagnostic procedure of choice in pericardial effusion.14 Visualization of the pericardiocentesis needle by two-dimensional echocardiography was reported in 1978.i5 Contrast echocardiographic techniques to identify the location of the tip of the pericardial needle within the pericardial sac have been described.16 Many investigators have suggested two-dimensional echocardiography to guide the placement of the pericardiocentesis needle, biopsy forceps, or balloon catheter, recognizing the inherent safety of the technique. Despite reports, the usefulness of two-dimensional echocardiography-directed pericardiocentesis has not been appreciated. In practice, echocardiography is almost universally used to diagnose pericardial effusion, but the pericardiocentesis procedure is usually done by a blind percutaneous subxiphoid technique or by surgical pericardiotomy. Transesophageal echocardiography may further aid guidance during percutaneous pericardial interventions. Hemodynamic guidance permits continuous measurement of pericardial pressure through the needle during advancement into the pericardial space. I7 Fluoroscopic techniques have also been used, but they require insertion of contrast media or air into the pericardial space to visualize the effusion. Pericardial biopsy. In the past, pericardial biopsy has been left to the direction of our surgical colleagues. Several catheter-based pericardial biopsy techniques, however, have recently been described. Acquiring biopsy specimens with routine pericardiocentesis increases the diagnostic yield. Tuberculosis is the most common source of error in determining an etiology in patients with pericardiocentesis.18, lg Pericardial fluid leads to a positive culture of Mycobacterium tuberculosis only exceptionally, and to find acid-fast bacteria in pericardial smears is almost impossible. This issue is of increasing concern with the resurgence of tuberculosis noted in the recent literature. Biopsy series have improved the diagnostic yield. 18*2o In malignant pericarditis, cytologic examination of the pericardial fluid is usually positive in 50% to 80%, but cell typing is usually poor.ls, ‘I, 22 Some centers now routinely perform pericardial biopsy in patients with large chronic pericardial ef-
American
January 1993 HeaR Journal
fusions of undetermined etiology, particularly if tuberculosis and malignancy are suspected.“(’ Nonsurgical techniques for multiple pericardial biopsies have been described. Endrys et a1.20 utilized a subxiphoid 7F catheter and a transluminal endomyocardial bioptome. Air was injected into the pericardium under fluoroscopic examination, and multiple samples were taken20 Kondos et al.” directed a flexible fiberoptic bronchoscope (Olympus BF Type 482) and bronchoscopy forceps under general anesthesia via surgical incision. Selig23 described a percutaneous subxiphoid transluminal biopsy technique using a bronchoscopy forceps under echocardiographic guidance. This technique is less cumbersome and resource-dependent and can be done without general anesthesia or surgical incision. Its safety and utility are yet to be determined. The adjunct of transcatheter biopsy would allow aspiration and biopsy to be done together as it is done in thoracentesis procedures.Z4 Guiding catheters can also be helpful to target the pericardial biopsies.25 Pericardioplasty. The optimal approach for patients with recurrent pericardial effusions continues to be debated. Symptomatic reaccumulation is an indication for a surgical procedure such as creation of a pericardial “window” or partial or complete pericardiectomy, which can be performed as an emergency procedure.“” A complete or radical pericardiectomy, which requires general anesthesia, is often too rigorous a procedure for debilitated cancer patients who most often have this problem.s7 A pericardial window is one frequently performed operation, but some surgeons have been so disappointed with their results that they have abandoned the operation in favor of total pericardiectomy.Zs! 2g Pericardial windows carry with them a lower risk and they can be done under local anesthesia. However, when there is a tumor encasement of the heart, this procedure is ineffective when adhesions develop, resulting in closure of the window and the need for repeat catheter drainage.21 Often pericardiectomy is attempted when the estimated survival is greater than 1 year. Other modalities, such as installation of interpericardial agents or radiotherapy, are suboptimal.30, “’ An indwelling pericardial pigtail catheter left in for a few days is usually enough to avoid recurrent effusions and tamponade; however, in 14”;. the need for a window procedure may arise.“2 Palacios et al.“” reported a catheter-based technique using a valvuloplasty balloon under fluoroscopic guidance. This procedure was performed successfully in all eight patients without recurrent tamponade or complications. A similar technique under echocardiographic
volume 125 Number1
guidance has been describedS3*l 35 Vora et a1.35 noted that it was possible to perform this technique under echocardiographic guidance at the bedside. Percutaneous pericardioplasty procedures appear safe and easy to perform and can allow for repeated dilations if the need arises. Conclusions. Patients with pericardial effusion may more effectively be managed by these percutaneous transcatheter techniques. These subxiphoid percutaneous procedures include pericardiocentesis followed by pericardial biopsy. If greater than 100 cm3 of fluid reaccumulation occurs over 24 hours for 3 days, then percutaneous pericardioplasty can be utilized to create a pericardial window.33 These techniques appear promising, providing a safe approach, avoiding general anesthesia, an open surgical procedure, and possible infection while maintaining a higher level of comfort to the patient.
REFERENCES
1. Boyd LH, Elias H. Contributions to diseases of the heart and pericardium. Historic introduction. Bull NY Med Co11 1955;18:1-37. 2. Sodeman WA, Smith RH. A re-evaluation of the diagnostic criteria for acute pericarditis. Am J Med Sci 1956235: 672-6. 3. Schuh F. Erfahrungen uber die paracentese der brust and das herzbeutels. Med Jahrbuch DKK, Oster Staates Wien (Neuste Folge 24) 1841;33:388. 4. Kotte JH, McGuire J. Pericardial uaracentesis. Mod Concepts Cardiovasc Dis 1951;20:102-3. 5. Kilpatrick ZM, Chapman CB. On pericardiocentesis. Am J Cardiol 1965;16:722-8. 6. Bishop LH, Estes EH, Macintosh HD. The electrocardiogram as a safeguard in pericardiocentesis. JAMA 1956;62:264-5. I. Fredriksen RT, Cohen LS, Mullins CB. Pericardial windows or pericardiocentesis for pericardial effusion. AM HEARTJ 1971;82:158-62. 8. Pradham JK, Ikins PM. The role of pericardiectomy in the treatment of pericarditis with effusion. Am Surg 1976;42:25761. 9. Silverberg S, Oreopalous DG, Wise DG, et al. Pericarditis in patients undergoing long-term hemodislysis and peritoneal dialysis. Am J Med 1977;63:874-80. 10. Kirkorian JK, Handcock WE. Pericardiocentesis. Am J Cardiol 1978;65:808-14. 11. Fowler NO. Diseases of the pericardium. In: Hurst JW, Logue RB, Schlant RC, Wenger ED, eds. The heart. 3rd ed. New York: McGraw-Hill, 1974:1387. 12. Santos GH, Frates RWM. The subxiphoid approach in the treatment of pericardial effusion. Ann Thorac Sum 1971;23:467-70. 13. Wong B, Murphy J, Chang JC, Hassenein K, Dunn M. The risk of pericardiocentesis. Am J Cardiol1979:44:1110-4. 14. Feigenbaum H. Echocardiographic diagnosis of pericardial effusion. Am J Cardiol 1970;26:475-9.
Percutaneous
pericardial
interventions
271
15. Martin RP, Rakowski H, French J, Popp RL. Localization of pericardial effusion with a wide-angle phased array echocardiography. Am J Cardiol1978;42:904-12. 16. Chandraratna PAN, First J, Langevin E, O’Dell R. Echocardiographic contrast studies during pericardiocentesis. Ann Intern Med 1977;87:199-200. 17. Flynn MS, Kern MJ, Aguirre F, Donohue T, Bach R. Management of a complicated pericardiocentesis. Cathet Cardiovast Diagn 1992;25:249-52. 18. Agner RCH, Gallis HA. Pericarditis. Differential diagnostic considerations. Arch Intern Med 1979;139:407-19. 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. 20. Endrys J, Simo M, Shafie MZ, et al. New nonsurgical technique for multiple pericardial biopsies. Cathet Cardiovasc Diagn 1988;15:92-4. 21. Kralstein J, Frishman W. Malignant pericardial disease; diagnosis and treatment. AMHEARTJ 1987;113:785-90. 22. Kondos GT, Rich S, Levitsky S. Flexible fiberoptic pericardioscopy for diagnosis of pericardial disease. J Am Co11 Cardiol 1986;7:432-4. 23. Selig MB. Percutaneous nericardial biopsy under echocardiographic guidance. Au HEARTJ 1991;12-2:879-82. 24. Bueno CE, Clemente MG, Castro C, Martin M, et al. Cytologic and bacteriologic analysis of fluid and pleural biopsy specimens with Cope’s needle. Arch Intern Med 1990;150:1190-4. 25. Mehan VK, Dalvi BV, Lokhandwala YY, Kale PA. Use of guiding catheters to target pericardial and endomyocardial biopsy sites. AM HEARTJ 1991;122:882-3. 26. Fowler NO. Cardiac tamponade. In: Fowler NO, ed. The pericardium in health and disease. New York: Futura Publishing Company, 198524780. 27. Guberman BA, Fowler NO, Engel PJ, Mosch LG, Allen JM. Cardiac tamponade in medical patients. Circulation
1981;64:633-40. 28. Piehler JM, Pluth JR, Schaff NV, Danielson GK, Orszulak TA, Puga FJ. Surgical management of effusive pericardial disease: influence of extent of pericardial resection on clinical course. J Thorac Cardiovasc Surg 1985;90:506-16. 29. Miller 31, Mansour KA, Hatcher CR Jr. Pericardiectomy; current indications, concepts, and results in a University Center. Ann Thorac Surg 1982;34:40-5. 30. Davis S, Sharma SM, Blumberg ED, Kim CS. Intrapericardial tetracycline for the management of cardiac tamponade secondary to malignant pericardial effusion. N Engl J Med 1978;229:1113-4. 31. Gregory JR, McMurtry MJ, Mountain CF. A surgical approach to the treatment of pericardial effusion in cancer patients. Am J Clin Oncol 1985;8:319-23. 32. Koperly SL, Callahan JA, Tajik AJ, Seward JB. Percutaneous pericardisl catheter drainage; report of 42 consecutive cases. Am J Cardiol 1986;58:633-5. 33. Palacios IF, Tuzcu M, Ziskind A, Younger J, Block PE. Percutaneous balloon pericardial window for patients with malignant pericardial effusion and tamponade. Cathet Cardiovast Diagn 1991;22:244-9. 34. Selig MB. Percutaneous pericardioplasty under echocardiographic guidance. Dissertation. Institutional Review Board, Muhlenberg Hospital Center, Bethlehem, Pa: September 1991. 35. Vora AM, Lokhandwala DM, Kale PA. Echocardiographyguided creation of balloon pericardial window. Cathet Cardiovast Diagn 1992;25:164-5.