Pericardiocentesis Procedure in Delhi, India

Pericardiocentesis is a procedure that removes fluid building up in the sac around the heart, an area called the pericardium. It is done using a needle and a tiny catheter to drain the excess fluid.

The fibrous sac surrounding the heart called the pericardium, is made of two thin layers. The layers are filled with fluid that reduces friction between them as they rub against each other when the heart beats. However, when too much fluid builds up between these two layers, the condition is called pericardial effusion. In these conditions, the normal functioning of the heart is affected. Pericardiocentesis is then required to drain the fluid and prevent future build-up of fluid.

When is Pericardiocentesis Surgery needed?

The build-up of fluid around the heart is a sign of many medical conditions. This fluid build-up leads to shortness of breath and chest pain that is treatable with medicine. However, it is life-threatening and needs immediate draining in most cases. Some conditions that can cause pericardial effusion include:

• Infection of the heart or pericardial sac
• Inflammation of the pericardial sac because of a heart attack
• Injury
• Cancer
• Immune system disease
• Reactions to certain drugs
• Radiation
• Metabolic causes, like kidney failure with uraemia
• Sometimes the cause of fluid build-up is unknown

Diagnosis

Before the surgery, doctors perform a thorough medical history to assess any pre-existing medical conditions that may interfere with the procedure. The tests recommended by doctors before a pericardiocentesis procedure are:

• X-ray of the chest
• Electrocardiogram - to assess the heart rhythm
• Blood tests
• Echocardiogram
• CT scan or MRI
• Heart catheterization

Treatment

There are three main approaches to performing pericardiocentesis:

• Subxiphoid or subcostal: The most common angle for needle insertion is below the breastbone.
• Parasternal: Insertion of the needle is in the fifth left intercostal space, which is the ideal space between the ribs, located close to the edge of the sternum.
• Apical: The needle is inserted approximately 1-2 cm lateral (to the side of) to the apex of the left ventricle.

A cardiologist and a surgical team perform the procedure. The most common form of pericardiocentesis is catheter-based and is performed in the following way:

• First, the patient is anaesthetized, and an IV line is inserted in the arm.
• Vital signs are closely monitored.
• An echocardiogram is taken to view the fluid around the heart, which helps determine the ideal place for needle insertion.
• A local anaesthetic is applied at the point of needle insertion, just below the breastbone.
• The needle is guided to the location of the fluid in the pericardial sac using X-ray imaging (fluoroscopy) or echocardiogram.
• Once the needle is positioned, it is removed and replaced with a catheter that drains out the fluid. In some cases, the catheter is not removed for a few days.
• The catheter is removed only when enough fluid has drained.
• Pressure is applied to prevent bleeding at the site of catheter insertion.

Who are the best candidates for surgery?

There are numerous indications for pericardiocentesis. Some include:

• Blunt or penetrating injuries may cause an accumulation of blood in the pericardial space, also known as hemopericardium and cardiac tamponade.
• Penetrating trauma to the chest from projectiles or sharp-tipped objects may injure any of the structures in the area and cause pericardial tamponade.
• Cardiac arrest.
• Pericardial effusion on the Focused Assessment with Sonography for Trauma (FAST) exam.
• Hypotension without another clear aetiology.

Who should not consider surgery?

Pericardiocentesis has no absolute contraindications. Withdrawal of even a tiny amount of fluid in a very unstable patient can immediately improve the hemodynamics of the patient.

Relative contraindications include:

• Uncorrected coagulopathy
• Low platelet count
• Lack of knowledge about the anatomy of the chest

How to prepare for surgery?

At the presurgical consultation visit, the potential risks and benefits of the surgery are discussed. In addition, a list of presurgical restrictions and other instructions to follow is given.

A proper medical history should be given to the doctors at this appointment. In general, it is recommended to follow the given instructions, such as:

• Prior consent from the physician is required to stop taking aspirin or any other blood-thinning medication before the procedure. This reduces the risk of bleeding.
• Avoid eating 8 to 12 hours before surgery, especially if general anaesthesia administration is scheduled. This prevents postoperative nausea and vomiting.
• It is crucial to take someone along for the surgery since they can provide support and assist with the postoperative instructions because it may take several hours for the effects of the anaesthesia to wear off.
• Smoking can complicate postoperative recovery. It is thus advisable to avoid smoking at least a month before the planned date of surgery.
• Discussing with the doctor about taking regular medicines with a sip of water in the morning before the procedure shall be helpful.

Possible Complications

Pericardiocentesis is a relatively safe procedure. However, all surgical procedures carry some risks, such as:

• Puncturing the heart, liver, or nearby organs that may require surgery to correct
• Excess bleeding might compress the heart and affect its normal function
• Air entrapment in the chest cavity
• Heart failure with fluid in the lungs
• Abnormal heart rhythms
• Infection
• Recurrence of fluid retention within the compartment may require a repetition of the surgery

Care after surgery

In general, after pericardiocentesis, the person may feel:

• Groggy and disoriented upon waking.
• Monitoring of vital signs, such as heart rate, breathing, blood pressure, and oxygen levels, until the condition stabilizes.
• If placed to drain the remaining fluid, the catheter will be observed and removed when necessary.
• An echocardiogram may be taken to confirm the absence of fluid re-accumulation.
• A postoperative chest X-ray helps ensure that the needle did not puncture the lung during the procedure.
• A sample of the drained fluid may be sent for testing.
• Hospitalization of a day or two may be required depending on the reason for pericardiocentesis.

After leaving the hospital:

• Avoid vigorous exercise until the doctor permits.
• Follow-up regularly.
• Resume usual activities in a few days.
• Call the doctor in case of fever, increased draining from the needle insertion site, chest pain, or severe symptoms.

Review

Reviewed by Dr. Vinay Kumar Bahl, Principal Director, Cardiac Sciences.