CT-Guided Pericardial Drainage: A Safe and Viable Alternative to Ultrasound-Guided Drainage

Pericardial effusions result from a wide range of pathology, with presentations ranging from an incidental finding to a life-threatening emergency. Common causes of pericardial effusions include infection, inflammatory conditions, neoplasm, trauma, and iatrogenic.[1] The pericardium, which is a fibroelastic sac containing the heart and the proximal great vessels, normally contains 10 to 50 mL of a serous ultrafiltrate of plasma produced by the visceral pericardium.[2] The pericardium and the pericardial fluid together serve to prevent sudden dilatation of the heart and significant movement of the great vessels, minimize friction between the heart and the surrounding structures, and help prevent the spread of disease from the pleura or the lungs.

By definition, a pericardial effusion is present when the pericardial fluid exceeds 50 mL. Although the pericardium has some compliance, once enough fluid has accumulated, the pressure placed on the myocardium results in impaired filling of the heart and decreased stroke volume which may result in pericardial tamponade.[3] The amount of fluid in the pericardial space required to result in symptoms varies depending on the chronicity and the cause of the effusion. In the acute setting, only 100 to 150 mL of fluid may result in tamponade, whereas in the chronic setting, it may take up to 2 L of fluid to cause tamponade.[4] [5] Regardless of the cause, the two most common procedures performed to remove excess pericardial fluid are percutaneous pericardial drainage (PPD) and surgical pericardial window (PW). Since the first PPD series was reported by Kopecky et al in 1986, numerous studies have sought to determine the optimal treatment for pericardial effusions.[6]

Although PPD is often performed under ultrasound (US) and fluoroscopic guidance, at the authors' institution, computed tomography (CT) is the preferred imaging modality for image-guided pericardial drainage. Although US provides real-time imaging throughout the procedure, there may be artifact from ribs and limited ability to evaluate posterior and loculated effusions, as compared with CT.[7] [8] Additionally, any air that is introduced into the pericardium before or during the procedure will degrade image quality of US, whereas CT is not affected ([Fig. 1]). Pneumothorax, the most common complication of pericardial drainage, is easily assessed on postprocedure CT and can be readily treated in the same procedure room, as compared with US where postprocedure pneumothorax would not be adequately visualized.

Fig. 1 (a) Echocardiography of a postoperative patient with arrow demonstrating dirty air shadowing limiting safe percutaneous access. (b) Noncontrast axial chest CT on abdominal window and (c) lung window of the same patient demonstrating postoperative subcutaneous emphysema and small pneumothorax (arrow). (d) Safe percutaneous access into the pericardial effusion under CT guidance allowing for complete visualization of the needle (arrow) despite the postoperative air.

Publication History

Article published online:
31 August 2022

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