CASE 2585 Published on 01.09.2008

Percutaneous balloon pericardiotomy

Section

Interventional radiology

Case Type

Clinical Cases

Authors

Marcy PY, Bondiau PY, Benezery K, Peyrade F

Patient

16 years, male

Categories
No Area of Interest ; Imaging Technique Digital radiography, Digital radiography, Digital radiography, CT
Clinical History
A 16-year-old patient presented with malignant tamponade. A successful percutaneous drainage was performed under fluoroscopy and US guidance.
Imaging Findings
The patient presented with malignant cardiac tamponade. An ultrasound examination done showed massive pericardial effusion, evidence of paradoxical interventricular septal motion, dilated inferior vena cava and jugular veins without significant respiratory variations. Pericardiocentesis utilizing the apical approach revealed an epithelioid sarcoma. Two thousand milliliters of blood-stained fluid was drained off slowly. Three weeks later, the patient was admitted because of the recurrence of severe dyspnea caused by recurrent pericardial effusion. Percutaneous balloon pericardiotomy was performed under combined ultrasound and fluoroscopy guidance in the interventional suite. The patient was placed supine on the fluoroscopy table, in a 45° head-up position. A large-bore intravenous catheter line was established, with continuous electrocardiographic and blood pressure monitoring. The apical area was infiltrated with 20 mL of 1% Lidocaine (xylocaine). The entry in to the pericardial cavity was made using a 22G needle under US guidance and a 0.018 inch guide wire with an angled tip was advanced under fluoroscopy guidance. The needle was removed, leaving the guide wire in the pericardial cavity. An exchanger was then passed to allow placement of a 0.038-inch J wire (Fig.1). The skin and the underlying tissue were dilated with a 14F dilator. A 18 mm x 40 mm high pressure balloon was advanced over the guide wire and placed in the pericardial cavity under fluoroscopy guidance (Fig.2). Care was taken to advance the proximal tip of the balloon beyond the skin and the subcutaneous tissue. The distal portion was inflated first, and the catheter was pulled back gently until resistance was felt when the distal balloon anchored itself at the parietal pericardium. The balloon catheter was then rapidly inflated manually to its fullest extent (Figs.3a,b). Three inflations were performed to ensure that there was an adequate opening of the parietal pericardium (Fig.3c). The balloon catheter was later removed, leaving the guide wire in the pericardial cavity. A 5F pigtail catheter was advanced over the guide wire and was left in place for subsequent drainage. An injection of 5 mL of contrast material failed to depict any pleural opacification. Three days later, after 900 mL of blood stained fluid was drained, a pigtail catheter was clamped. After 48 hours, the thoracic CT scanner showed the disappearance of the pericardial effusion, and the catheter was removed. The patient remained free of cardiac tamponade but died four months later under poor conditions.
Discussion
Pericardial metastases occur frequently in patients having an advanced stage of a disease, in 5%–10% of all patients with cancer, at a time when the overall lifespan is already short. Primary tumors include melanomas (30%–65%), bronchogenic carcinomas (21%–37%), lymphomas (13%–35%), breast cancer (25%–33%), and sarcomas (25%) (1). Cardiac tamponade is caused by an accumulation of the pericardial fluid under pressure. Its diagnosis is suspected when an elevation of systemic venous pressure, a decline in systemic arterial pressure and a clinical context of recent acute pericarditis or neoplasia are associated. The effect is mainly due to the nature of effusion (blood clots), the poor right ventricular reserve, and the rapidity to develop effusion. Numerous surgical approaches have been described for the drainage of the pericardial sac. Initially described by Larrey in 1829, the epigastric surgical inferior approach allows the best access to the pericardial sac. More recently, US-guided percutaneous epigastric pericardiocentesis as an alternative to surgery has been used for immediate alleviation of symptoms and for therapy (2). A complete evacuation by an intrapericardial suction catheter permits complete apposition of the visceral and parietal pericardium, symphysis of the two layers, thus preventing a further fluid accumulation in more than 50% of the cases. Park et al. compared surgical pericardial windowing and pericardiectomy and concluded that creation of a pericardial window was recommended in cancer patients because of a far lower morbidity (10% vs 67%, respectively) (3). Percutaneous balloon pericardiotomy (4) as well as pericardial instillation of sclerosing agents are mandatory in patients who continue to get more than 100 mL/24 h three days after doing a standard US-guided catheter drainage, or in the case of recurrence of pericardial effusion. Single- or double-balloon inflation (4,5) results in the localized tearing of the parietal pericardium leading to a communication of the pericardial space with the peritoneal and/or pleural cavity, and appears to be less invasive than the surgical technique. The reported recurrence rate is 4% (4). Complications include fever (12%), left pleural effusion and/or asymptomatic pneumothorax (8%), bleeding (from a pericardial vessel) requiring surgery (2%), and persistent catheter drainage requiring surgery (2%) (4). Percutaneous balloon pericardiotomy has limitations when performed in obese patients, patients with Morgagni hernia, or in those who have had a prior thoracic surgery, patients presenting with bowel obstruction or severe ascites. Advantages of the percutaneous procedure include minimal discomfort, a low morbidity rate and an efficiency similar to that of surgical pericardiotomy without sedation.
Differential Diagnosis List
Successful percutaneous balloon pericardiotomy in a patient with recurrent malignant tamponade.
Final Diagnosis
Successful percutaneous balloon pericardiotomy in a patient with recurrent malignant tamponade.
Case information
URL: https://eurorad.org/case/2585
DOI: 10.1594/EURORAD/CASE.2585
ISSN: 1563-4086