Chest

Name the Hardware – Eye Test

2. Findings and Diagnosis

Did you See the Pericardia Drainage Catheter ?

Pericardial Drainage Catheter

A pericardial drainage catheter is a thin, flexible tube inserted into the pericardial space to remove excess fluid (pericardial effusion) and relieve cardiac tamponade. The procedure, known as pericardiocentesis, is most commonly performed under echocardiographic guidance, although fluoroscopic and CT guidance may also be used in select cases. Electrocardiographic (EKG) monitoring plays a role in reducing the risk of myocardial injury by detecting ST-segment elevation or ectopy, which may indicate contact with the myocardium during needle advancement.

Indications for Insertion

• Cardiac tamponade (life-threatening pericardial effusion causing hemodynamic instability)
• Large pericardial effusion (>20 mm on imaging)
• Recurrent pericardial effusions (e.g., malignancy, chronic pericarditis)
• Post-cardiac surgery pericardial effusion
• Infectious pericarditis with effusion (bacterial, tuberculous, viral)
• Hemopericardium (trauma, post-procedural, anticoagulation-related)

Type and Size of Catheter

• Pigtail catheter (most common choice)
  • Size: 6F–8F (for small effusions) or 8F–14F (for large effusions or hemopericardium)
  • Advantages: Flexible, less traumatic, allows continuous drainage
• Large-bore catheters (14F–18F) or surgical drainage
  • Used in purulent pericarditis, loculated effusions, or hemopericardium
• Percutaneous pericardial drain (6F–12F)
  • Often placed via Seldinger technique under echocardiographic guidance

How is it Done?

• Pre-procedure Preparation

  • Confirm indication and assess pericardial effusion via echocardiogram, CT, or MRI
  • Monitor vitals and correct coagulopathies if necessary
  • Position patient supine with slight head elevation
  • Apply sterile preparation and local anesthesia

• Guidance Methods

  • Echocardiographic guidance (preferred) allows real-time visualization of the effusion, needle entry, and catheter placement.
  • Fluoroscopy-guided pericardiocentesis is used when access is achieved via subxiphoid approach with contrast injection to confirm placement.
  • CT-guided pericardiocentesis may be used in complex cases or when standard approaches are not feasible.
  • EKG monitoring is used in blind or fluoroscopic approaches, where a V1 lead attached to the needle tip can detect ST-segment elevation when the needle contacts the myocardium, helping to prevent injury.

• Approaches for Insertion

  • Subxiphoid Approach (Most Common)
    • Needle inserted inferior to the xiphoid process, angled superiorly toward the left shoulder
    • Catheter advanced into the pericardial space using Seldinger technique
  • Apical Approach
    • Needle inserted at the left parasternal border (5th–6th intercostal space)
    • Used if subxiphoid access is difficult
  • Parasternal Approach
    • Needle inserted left of the sternum (3rd–5th intercostal space)
    • Used less frequently, preferred when avoiding abdominal structures

• Drain Placement and Monitoring

  • Guidewire placed, followed by catheter insertion
  • Fluid aspirated and sent for biochemical, cytologic, and microbiologic analysis
  • Continuous drainage may be maintained for 24–72 hours

Risks and Potential Complications

• Cardiac perforation → Hemopericardium, tamponade
• Arrhythmias (e.g., ventricular ectopy, atrial fibrillation due to catheter irritation)
• Pneumothorax or pneumopericardium (if pleura is inadvertently punctured)
• Coronary vessel injury → Hemopericardium
• Pericardial infection (rare but can occur with prolonged catheterization)
• Re-accumulation of fluid (especially in malignant or inflammatory effusions)

Key Points & Pearls

• Pericardiocentesis is life-saving in tamponade, and echocardiographic guidance significantly improves safety.
• Subxiphoid approach is most common, but apical and parasternal approaches are alternatives depending on effusion location.
• Pigtail catheters (6F–14F) are preferred for pericardial drainage due to lower complication rates.
• EKG monitoring can help detect myocardial contact if fluoroscopy or blind technique is used.
• Post-procedure monitoring is critical to detect recurrence or complications.