Emergency electrocardiography-guided pericardiocentesis in cardiac tamponade

Introduction

Pericardiocentesis (PC) and pericardial fluid drainage is the method of choice in cardiac tamponade (CT). It is usually performed under echocardiography control. The objective of the study was the description of CT etiology, symptoms and clinical findings and the evaluation of the electrocardiography (ECG)-guided PC procedure.

Methods

Thirty-nine consecutive patients (nine females) with CT, mean age 56 years, underwent 41 emergency PC between November 1998 and November 2006. There was full data registry for 31 patients and 33 PC. We used a subxiphoidal approach in 31 and an apical approach in two cases. Catheters used were Cordigan (Braun) and C-PCS-830-LOCK (Cook). A full transthoracic echocardiography (TTE) study preceded and PC was performed under ECG monitoring (intrapericardial ECG recording).

Results

Patients with CT had the following symptoms or clinical findings: dyspnea (77%), pleural effusion (68%), chest pain (48%), weight loss (29%), fever (23%), cough (19%), peripheral edema (12%), abdominal pain (12%), hoarseness (12%), jugular vein distension (6%). Forty-five percent of patients were hemo-dynamically stable, while 26% had high BP. The mean heart rate on admission was 94/minute. Seventy-one percent of patients exhibited hypoxemia (half of them mild). Deep heart sounds were recognized in 39% and pulsus paradoxus was present in 29% of cases. Only 12% had pericardial knock and pericardial friction rub was absent in all patients. On ECG there was sinus rhythm in 71%, the rest being atrial fibrillation. Sixty-five percent of patients showed repolarization changes, and only 16% had low voltage. On TTE, 3/4 of patients had right atrium/right ventricle collapse and the intapericardial space measured 1.8–3.8 cm. Only 39% of patients exhibited cardiac enzyme increase (cardiac troponin I, CK-MB), while the majority had elevated CRP. The underlying diagnosis for CT in 35% of cases was lung adenocarcinoma/nonsmall cell carcinoma or breast carcinoma. In 35% the final diagnosis was that of idiopathic pericarditis. Seventy percent of pericardial fluid samples were exudates and 74% were sanguineous/serosanguineous. Four patients had pericardial fluid under pressure. The mean volume drained was 1,540 ml (850–3,010), the mean period of drainage was 56 hours (3 hours-14 days). No major complications occurred; 23% patients had nonmalignant arrhythmias (AF, NSVT).

Conclusion

'Classical' symptoms and signs (low BP, pulsus paradoxus, deep heart sounds or low voltage) can be absent in CT. Emergency PC with ECG intrapericardial ECG recording, after meticulous TTE, can be safe. Appearance of nonmalignant arrhythmias could be a rare complication.