B.6. Describe the procedures for treating cardiac tamponade. What are the clinical indications for each approach?
Answer:
Pericardial decompression can be performed percutaneously or surgically. Percutaneous echocardiographically guided catheter decompression is the treatment of choice in patients with nonloculated, free-flowing pericardial fluid. Subxiphoid, parasternal, and apical approaches each have advantages and disadvantages (Table 12.6). Existing literature and guidelines advocate taking the approach with the maximal effusion depth on ultrasound to minimize the risk of cardiac puncture. Percutaneous options are more likely to be appropriate in delayed cardiac tamponade, several days or weeks after cardiac surgery when pericardial blood has liquefied. It is unlikely to be appropriate for this patient because there is a high likelihood of compression from clotted blood on imaging.
Table 12.6: Approaches to Pericardiocentesis
| Approach | Insertion Site | Approach-Specific Complications |
|---|---|---|
| Subxiphoid | Between xiphoid process and left costal margin | Peritoneal injury |
| Apical | Near apex beat, at fifth to seventh intercostal space in the anterior axillary line | Left pneumothorax |
| Parasternal | Fifth intercostal space, left sternal margin | Pneumothorax |
| Internal mammary artery injury |
Adapted from De Carlini CC, Maggiolini S. Pericardiocentesis in cardiac tamponade: indications and practical aspects. e-J Cardiol Pract. 2017;15. https://www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-15/Pericardiocentesis-in-cardiac-tamponade-indications-and-practical-aspects
In patients with an intact pericardium and free-flowing pericardial fluid, surgical decompression can be performed in conjunction with a limited pericardiectomy, opening a drainage "window" to the pleural space to prevent recurrence. Minor pericardial adhesions can be manually divided and loculated effusions drained. Subxiphoid, transthoracic via anterior mini-thoracotomy, and thoracoscopic approaches have been described. The subxiphoid approach does not technically create a "pericardial window"; rather, it provokes inflammatory fusion of the pericardium to the epicardium, thereby obliterating the potential space for recurrence. In unstable patients, only subxiphoid and anterior thoracotomy approaches are suitable. An important advantage of the subxiphoid approach is that it can be performed under local anesthesia and conscious sedation in anatomically suitable patients (eg, not obese, absence of ascites) who are otherwise too unstable for induction of general anesthesia. Local anesthesia for the anterior thoracotomy approach has also been described but might be poorly tolerated because it requires dissection through the pectoralis muscles and intercostal spaces. After cardiac surgery, a limited sternal reopening under local anesthesia and conscious sedation might be tolerated and can confer some physiologic benefit prior to definitive exploration. However, most patients within this population are typically not candidates for limited rescue techniques and will require full sternotomy to evacuate clotted blood, drain residual fluid, and identify the source of ongoing bleeding.
References
- Adler Y, Charron P, Imazio M, 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;36:2921-2964.
- De Carlini CC, Maggiolini S. Pericardiocentesis in cardiac tamponade: indications and practical aspects. e-J Cardiol Pract. 2017;15.
- Langdon SE, Seery K, Kulik A. Contemporary outcomes after pericardial window surgery: impact of operative technique. J Cardiothorac Surg. 2016;11:73.
- Sugimoto JT, Little AG, Ferguson MK, et al. Pericardial window: mechanisms of efficacy. Ann Thorac Surg. 1990;50:442-445.