Subxiphoid Tube Pericardiostomy

The subxiphoid tube pericardiostomy was applied under general anesthesia (n = 30, 6.25%) or local anesthesia supported by sedation (n = 450, 93.75%). General anesthesia was preferred mostly on kids and induction was done with 1,5 mg/kg of ketamine. Also, 0.1 mg/kg of vecuronium neuromuscular block was used and anesthesia was maintained by 60% of nitrous oxide (N₂O), 40% of oxygen (O₂), and 0.5-1% of isoflurane.

As there is a hypotension risk in patients who underwent general anesthesia, they were covered and marked with paint before induction. In local anesthesia, 2% lidocaine was injected subcutaneously. Sedation was achieved by the injection of 1 mg/kg of ketamine or 1-2cc of intravenous (IV) midazolam. About 5-6 cm of incision was made from the epigastrium to the xiphoid. After the subcutaneous skin incision, 2% lidocaine was injected into the rectus muscle and the xiphoid again. By cutting the linea alba and the xiphoid and dissecting the subxiphoid tissues, the pericardium anterior face was reached. Then, some amount of liquid was aspirated by the injector; in order to determine whether the hemorrhagic liquid was defibrinated or not, its coagulation was observed. By holding and pulling the pericardium, 3-5 cm² of it was excised for pathological examination. Pericardial fluid samples were collected for cytological, biochemical, and microbiological analyses, then the liquid was poured in a controlled manner; meanwhile, IV digoxin was injected to prevent sudden cardiac dilatation.

Pericardial cavity was visually and manually checked, adhesions and mass lesions were investigated. Adhesions were removed carefully with the help of fingers. With a different incision, 2-4 cm under the former incision, the drainage tube was placed in the pericardial cavity in order to provide postoperative drainage. Making a separate incision from the drainage tube was preferred to prevent the development of postoperative wound infection and incisional hernia. The drainage tube was connected to a closed underwater drainage system, and the subxiphoid incision was closed according to the procedure.

CT-guided Catheter Drainage Method

The feasibility of performing CT-guided catheter drainage on 28 patients was determined by clinical, echocardiographic, and tomographic assessments.

All patients were assessed by helical CT. In order to determine the entry point of PE drainage, 10 mm range images were taken from the heart apex to the arcus aorta. After the assessment, the skin was marked on the determined entry point (Figure 1). To ensure that the metallic needle was in the right place, CT was performed. And to prevent complications that could occur during electrocardiogram (ECG) monitoring, an intravenous saline with IV opening was inserted, and blood pressure was monitored at frequent intervals.

Fig. 1 - Marking the entry point with computerized tomography (CT).

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Fig. 1 - Marking the entry point with computerized tomography (CT).

Having been colored and disinfected, the marked area was covered with sterile drapes. As a local anesthetic agent, 2% lidocaine was used. Then, an 18 G needle with negative puncture was entered to the pericardial cavity, the needle was fixed at the level of liquid aspiration, and the CT was taken again to reaffirm the needle's position (Figure 2). After confirming that it was in the intrapericardial space, the liquid was aspirated and evaluated. If hemorrhagic characteristics were thought to be possible after confirming that the blood defibrinated, a 0.035" guidewire was sent to the pericardial cavity through the needle (Figure 3). The needle was removed and the CT was taken; after confirming that the guidewire was in the intrapericardial cavity, an 8 or 10 F nephrostomy catheter was advanced into the pericardial cavity through a catheter guide. A three-way tap was installed in the tip of the catheter and the liquid was poured into a 50 ml syringe. The catheter was identified and it was connected to the closed underwater drainage system (Figure 4).

Fig. 2 - Demonstration of the needle in the pericardial space.

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Fig. 2 - Demonstration of the needle in the pericardial space.

Fig. 3 - Catheter in the ıntrapericardial area.

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Fig. 3 - Catheter in the ıntrapericardial area.

Fig. 4 - View of reduced intrapericardial liquid.

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Fig. 4 - View of reduced intrapericardial liquid.

ECHO-guided Pericardiocentesis/Catheter Drainage Method

Having been assessed by ECHO and under intensive care conditions, blood pressure and ECG monitoring were completed, and the patients were operated at the bedside after taking all precautions. After dyeing and disinfecting the subxiphoid area, the patients were put into a 45° tilt position, and they were covered by sterile sheets. After local anesthesia with 2% lidocaine, a small incision was made by an 11" knife. Under the xiphoid, using ECHO as a guide, an 18G needle was lifted, with a slope of 15-20° and negative pressure, aiming at the left shoulder. When the aspiration fluid came, the location of the needle tip was confirmed by ECHO, and an 0038" guidewire was sent to the pericardial space through the needle. After seeing the guidewire in the pericardia via ECHO, a 6F pigtail was sent through guidewire. During this process, the patients' heart rate and blood pressure were frequently measured. The three-way tap was installed at the catheter and fluid was aspirated into a 50 ml syringe. Pericardial liquid was aspirated slowly and intermittently in order to prevent cardiac decompression. Aspiration was done every 6 hours and the amount of liquid was checked by daily ECHO.

Statistical Analysis

Statistical analyses of the results were done using the Statistical Packet for Social Science (SPSS) 11.0 software and x² and post-hoc tests were applied to the data. In this study, recurrent effusion ratios obtained from the groups, the number of cases developing constriction, complication rates, and 1-month mortality were determined by x² tests, 3x2 contingency table, or 2x2 Fisher's exact test. For the length of in-hospital stay and duration of the catheter or drainage tube stay, a two-way analysis of variance (ANOVA) was used. In bilateral comparisons, P-values were obtained by applying the least square difference (LSD) method and interpreted; P values < 0.05 were considered significant.

Subxiphoid Tube Pericardiostomy

Data belonging to 480 patients who underwent subxiphoid tube pericardiostomy - ages ranging from 6 months to 84 years (mean 35.7 years), 261 of whom being men (55%) and 219 being women (45%) - were examined. ECHO detected mild PE in 16 patients (3%), medium PE in 193 patients (40%), and severe PE in 271 patients (57%). All of the patients with traumatic PE had tamponade symptoms (n = 25). Some patients also underwent invasive procedures like blunt thoracic trauma, coronary angioplasty, stent implantation, and temporary endocardial pacemaker implantation (n = 20).

In all patients with symptomatic PE, relief was provided by subxiphoid tube pericardiostomy. Intraoperative myocardial injury (MI) occurred in five patients (1%). In these cases, upon failing to control bleeding with subxiphoid approach, urgent median sternotomy was done. In two patients, bleeding occurred during the removal of adhesions connected to the tuberculous pericarditis; in other three cases, bleeding occurred during the placement of the tube connected to the traumatic rupture of the right atrium. None of the patients were lost.

The reasons for the subxiphoid tube pericardiostomy in the patients were: uremic pericarditis (n = 208, 43.3%), idiopathic and unidentified pericarditis (n = 92, 19.1%), malignancies (n = 65, 13.5%), tuberculous pericarditis (n = 50, 10.4%), nontuberculous bacterial pericarditis (n = 24.5%), trauma (n = 25, 5.2%), rheumatoid arthritis (five), systemic lupus erythematosus (SLE) (five), hypothyroid (four), and polyarteritis nodosa (PAN) (two) (Table 2).

Table 2 - Causes of pericardial effusion.

During the operation, the amount of drainage was 50-4500 ml (average 1258±720) and the average amount of drainage during the postoperative periods was 980 ± 255 ml. The approximate duration of postoperative drainage was 4.3 ± 1.6 days. The maximum drainage was from a uremic pericarditis patient, and the minimum drainage was from a 6-month-old baby with bacterial pericarditis. The fluid was transudate in 228 cases (47.5%), hemorrhagic in 138 cases (28.7%), and exudate in 85 cases (6%).

Forty-seven (72%) of the 65 PE patients had malignancies, and malignancy cells were positive in the investigation of pericardial material and/or liquid. Twenty-eight of the 65 patients had lung cancer (Ca), 16 had lymphoma, 12 had breast Ca, seven had leukemia, and two had malignant thymoma.

Twenty-two of the 50 patients with tuberculous pericarditis had positive preoperative purified protein derivative (PPD) and microbiological laboratory test results. Through cytological examination of pericardial fluid taken during surgery, 45 (90%) patients were diagnosed with tuberculous pericarditis. Five of eight patients having negative polymerase chain reaction (PCR) were diagnosed with tuberculous pericarditis in cytological examination of pericardial fluid. Preoperative diagnosis of tuberculosis in three patients could not be confirmed in the received materials and examinations; however, they continued their treatment as they were accepted as tuberculosis patients.

The microorganisms obtained from fluid sample cultures of patients with pericarditis were Mycobacterium tuberculosis (n = 40), Pneumococcus (n = 11), Viridans streptococci (n = 7), Haemophilus influenzae (n = 4), and Staphylococcus (n = 3).

Patients stayed at the hospital between three and 30 days (average 3 ± 27 days). Wound infection was seen in 27 (5.6%) patients. Most of these patients were female and obese. There was not any intraoperative mortality. During the hospital stay, seven of 480 patients (1.4%) died. Four of those patients had a diagnosis of congestive heart failure, and despite inotropic therapy in the postoperative period, they died because of low cardiac output and multiorgan failure.

Within the first postoperative 30 days, there was a need of additional surgery for PE in 45 patients (9.3%). Twenty-four of the recurrent PE patients had uremic pericarditis, 15 had tuberculous pericarditis, three had idiopathic pericarditis, and three were sticked to malignancy. Recurrence rate in patients with tuberculosis was found to be 30% in 15 patients.

In all of the patients with effusion recurrence, incision was made from the epigastrium, left to the sternocostal junction and a pericardiopleural window was opened. None of the patients with pericardiopleural window developed recurrence at one-year follow-up. All patients were followed up for one year. After 6-12 months follow-up due to the development of malignant effusion, three patients had the pericardiapleural window opened through a left anterior mini-thoracotomy. Two of these patients had tuberculous pericarditis, and one had uremic pericarditis due to effusion. After the operation, no recurrence happened during the follow-up (Tables 2 and 3).

Table 3 - Comparison of the length of in-hospital stay and duration of the drainage tube stay between the  groups.

CT-guided Catheter Drainage Method

Among the 28 patients who underwent PE drainage with CT-guided catheter drainage method, 15 were female (53.5%) and 13 were male (46.5%). Their ages varied between 1 and 80 years (mean 41.3 years). The most important symptom in these patients was dyspnea. Relief was observed in the symptoms of 25 patients who were successfully operated. ECHO detected moderate effusion in ten of these patients (35.7%) and severe effusion in 18 (64.3%). Thirteen of these patients (46.4%) had previously undergone open-heart surgery. These patients had effusions, two of them due to malignancy, one due to bacterial infection, and two due to uremia. Other ten patients (35.7%) had idiopathic PE (Table 2).

The effusion localization was in the left ventricular lateral in 14 patients, left ventricular posterior in eight patients, right atrium posterolateral in five patients, and right ventricular posterior in one patient. In the patients whose daily amount of drainage were followed, it was applied three-way tap for the aspiration of liquid when necessary. When the daily amount of drainage was < 50 ml, catheters were taken guided by ECHO on the lack of intrapericardial liquid.

As for complications, upon development of hemopericardium, depending on the pericardial laceration, subxiphoid tube pericardiostomy was performed under local anesthesia in one patient. Although the needle entered the intrapericardial space in one patient, the liquid was not aspirated. So, considering that there could be organized hematoma under general anesthesia, the hematoma was evacuated by opening a pericardial window through anterior mini-thoracotomy.

In one case in which was applied CT-guided catheter drainage method due to uremic PE, ECHO and CT detected the existence of fluid and the presence of catheter in the thorax; because it was a right pleural effusion in severe level, pericardiopleural window was opened with right mini-thoracotomy.

About 1000 ml of liquid was evacuated from thorax and 1000 ml was from the pericardial cavity. In the remaining 25 patients (93%), the desired results were obtained from the operations performed.

In 11 patients (39%), it was aspirated serous fluid; in 10 patients (38%), hemorrhagic fluid; in seven patients (25%), transudate fluid; and in one patient, purulent fluid. The amount of aspirated fluid was 50-1500 ml (mean 920 ± 225). The minimum drainage was from chronic renal failure (CRF) patients; the maximum drainage was from an idiopathic pericarditis patient.

In two (7.1%) of the patients who underwent CT-guided catheter drainage, there was recurrence; again, the catheter drainage was applied with the same method and no recurrence was observed. There were no mortalities due to the process. One patient died three days after the surgery because of fulminant hepatitis. After being discharged from hospital, one patient who had a mitral valve replacement (MVR) died in the intensive care unit because of overdose of coumadin due to cerebral hemorrhage (Tables 3 and 4).

Table 4 - Comparison of the results between the groups.

ECHO-guided Pericardiocentesis/Catheter Drainage Method

ECHO-guided pericardiocentesis was performed in 45 patients; 28 of them were males (62.2%) and 17 were females (37.8%). Their ages ranged from 19 to 76 years (mean 42.7 years). In these patients, the most common symptom was dyspnea. In ten patients (22.2%), there was overt tamponade.

Fifteen patients (33.3%) had moderate effusion, and 30 (66.7%) had severe effusion. Ten of these patients (22.2%) had CRF, seven (15.5%) had tuberculous pericarditis, 13 (28.8%) had malignancy, four (9%) had iatrogenic complications of angiography, eight (17.7%) had infection, and three (6.6%) had effusion related to acute MI. Pericardiocentesis was performed successfully in all patients. The average number of punctions were 1.3 ± 0.6. In all patients, clinical relief was observed after the procedure and their symptoms decreased. In one patient, acute left heart failure developed after the procedure and it was cured by medical treatment.

No major complication occurred during the procedure, except for one patient in whom subcutaneous hematoma occurred by puncture to subcutaneous vascular structure; the hematoma was regressed by applying ice. In this patient, hematocrit fall did not occur.

200-1500 ml (average 1278 ± 620) of liquid were discharged from the patients. Hemorrhagic fluid was aspirated from 18 (40%) patients, serous fluid from 27 (60%) patients. Six of the seven patients with tuberculous pericarditis were identified as PCR positive. In one patient, the adequate identification could not be done by liquid cytology and microbiology. Then, subxiphoid tube pericardiostomy was performed in four of these patients. In the culture of infective pericarditis of eight patients, Streptococcus viridans and Staphylococcus were detected.

The average hospital stay of these patients was 7-30 days. No mortality occurred during this period. The catheter was extracted in an average of 5.9 ± 2.6 days. In seven patients (15.5%), after the catheter was extracted, subxiphoid pericardiostomy was needed due to recurrence of PE; no re-recurrences were observed in these patients later. Four of these patients had tuberculous pericarditis, two had uremic pericarditis, and one had PE due to malignancy. During the one-year follow-up, seven patients died from infarction: five malignancy patients, due to malignancy; one patient with CRF, due to the primary disease; and one patient with MI. On the development of constrictive pericarditis in one patient with tuberculous pericarditis, surgical pericardiectomy was performed (Tables 3 and 4).