Kontrastmittelechokardiographisch gesteuerte Perikarddrainage

Zusammenfassung

Die operative Perikardiotomie und die ungesteuerte perkutane Punktion weisen eine vergleichsweise hohe Letalitäts- und Komplikationsrate auf. Mit der Einführung der echokardiographisch gesteuerten Perikardpunktion konnten die Komplikationsraten entscheidend gesenkt werden.

Die durch unsere Arbeitsgruppe integrierte kontrastmittelgesteuerte echokardiographische Lagekontrolle hat sich bei 126 mit dieser Methode konsekutiv behandelten Patienten als wertvolle zusätzliche Maßnahme zur Vermeidung von Komplikationen erwiesen. Es trat keine klinisch relevante Komplikation auf. Ein intraperikardial eingebrachter Drainagekatheter (Pigtail) blieb bis zur echokardiographischen Kontrolle, jedoch nicht länger als 48 Stunden, in situ, um das Infektionsrisiko zu minimieren. Die eigenen Erfahrungen bestätigen, dass auch bedeutsame Rezidivergüsse wiederholt punktiert werden können. Allerdings kann der Katheter selbst einen serösen Reizerguss induzieren, der jedoch nach Katheterentfernung sistiert.

Die echokardiographisch mittels Kontrastmittel gesteuerte Perikardpunktion und -drainage können heute als Goldstandard gelten, da sie ein komplikationsarmes, effektive und kostengünstiges Verfahren sind.

Abstract

The most effective treatment for pericardial effusion and cardiac tamponade is removal of the pericardial fluid. Surgical pericardiotomy is associated with high mortality and morbidity. Similarly, subcostal percutaneous blind pericardiocentesis was reported to have unacceptably high mortality and complication rates. Major complications associated with blind needle punctures are right heart penetration, hemopericardium, puncture of the coronary arteries, liver and lung bleeding. Even under fluoroscopic guidance and electrocardiographic needle monitoring high complication rates persist. Pericardial drainage has been often inadequate, with frequent recurrences of significant pericardial effusions. Two-dimensional echocardiographically guided pericardiocentesis is reported to improve efficacy and safety of percutaneous puncture. Moreover, it allows immediate verification of the procedural success. We evaluated the efficacy and safety of an echocardiographically guided contrast agent controlled pericardiocentesis.

This is a retrospective, descriptive study on 126 consecutive patients who underwent percutaneous pericardiocentesis at the University Hospital Essen, Germany, from 1995 to June 2000. There were 51 women (41%) and 75 men (55%) with a mean age of 52 ± 14 years. Standard techniques for quantification of pericardial effusion were used. Depending on the localization of the pericardial effusion an apical or subxiphoidal approach was chosen. The puncture was performed under echocardiographic guidance and the position of the needle was controlled by injection of contrast agent. Over a long guidewire a pigtail catheter was inserted through a sheath for further drainage of pericardial fluid. The catheter was removed after a maximum of 48 hours to avoid infection of the pericardial cavity.

An apical approach was chosen in 98 patients (78%), a subcostal in 28 patients (22%). The procedure was successful in 99% of the attempts. No death or clinical complication occurred. The maximal pericardial diameter measured by two-dimensional echocardiography was 32 ± 16 mm before and 5,3 ± 2 mm after drainage. The calculated pericardial effusion was 657 ± 342 ml. A fluid volume of 605 ± 342 ml could be drained. In all patients a pericardial catheter was placed for 1.4 ± 0.8 days. Recurrence of pericardial effusion occurred in 18 patients (14%). Of these, 15 patients underwent repeated successful pericardiocentesis (2.5 ± 0.8), and 3 patients were referred to surgical pericardiotomy.

Pericardiocentesis under echocardiographic contrast agent guidance is a safe, successful and cost effective procedure for diagnostic and therapeutic drainage of pericardial effusion. Two-dimensional echocardiography allows localization of the optimal puncture site as well as the quantification of the effusion depth. The injection of contrast agents into the pericardial cavity improves the safety and accuracy of the procedure. Even recurrent pericardial effusions can be treated successfully.