| CHAPTER | ||
| 43 | Hemopericardium | |
| Jalaj Garg, MD; Jacob S. Koruth, MD |
INTRODUCTION
Although percutaneous epicardial access has been demonstrated to be to be safe and feasible, it is not without serious and potentially fatal complications. One such complication is hemopericardium, the occurrence of which is understandable, as percutaneous epicardial access is often performed in patients who have no significant pericardial fluid, which automatically increases the risk of inadvertent myocardial puncture. Hemopericardium related to this procedure is best understood by classifying it according to when it occurs in relation to percutaneous epicardial access: (1) early after epicardial access, (2) during the course of the procedure, (3) toward the end of procedure, and (4) late after the procedure (Table 43.1). Several clinical and procedural factors have been identified as having the potential to predispose the patient to hemopericardium. These include the most obvious factor, that is, direct cardiac chamber perforation by the percutaneous epicardial access needle. Other factors include the presence of prior cardiac surgery that results in pericardial adhesions, the use of systemic anticoagulation, and faster VT cycle lengths (likely due to increased interaction of ventricle with the epicardial sheath and the ablation catheter).1
In addition to its occurrence as an acute intraprocedural complication, delayed-onset hemopericardium can also occur.2 Given the relative complexity of the percutaneous epicardial access procedure and the severity of illness in patients undergoing this procedure, it is imperative that appropriate preprocedural planning occurs and early diagnosis of hemopericardium is made to ensure effective management and successful outcome of this often serious complication.
Table 43.1 Etiologies of Hemopericardium
| Early after epicardial access | Inadvertent right ventricular puncture |
| Injury to epicardial vessel (artery/vein) with the sheath or ablation catheter | |
| Disruption to prior pericardial adhesions | |
| During the procedure | Minimal fluid aspirate: 10–30 cc, usually self-limiting, related to mapping/ablation |
| Thrombus disruption from sealed-off bleeding site (injury during epicardial access) from either the catheter or heparin initiation | |
| Epicardial bleb/pop during ablation | |
| At the end of procedure | Double RV puncture (separate entry and exit sites in the RV free wall during epicardial access) |
| Disruption of subcutaneous vessels during sheath removal | |
| Late after the procedure | Postprocedure pericarditis |
| Resumption of systemic anticoagulation |
Adapted from Koruth JS, d’Avila A. Management of hemopericardium related to percutaneous epicardial access, mapping, and ablation. Heart Rhythm. 2011 Oct;8(10):1652–1657.
PREPROCEDURAL PLANNING AND EPICARDIAL ACCESS
Preprocedural planning for percutaneous epicardial access procedures plays a critical role in reducing both the occurrence as well as impact of hemopericardium on the patient. The use of intracardiac echocardiography (ICE) to assess for presence or absence of any pericardial fluid (loculated or diffuse) is important, as it allows the operator to establish a baseline. This can prevent confusion that may even result in unwarranted intervention, if a “new” effusion is found unexpectedly during or after percutaneous epicardial access. Systemic anticoagulation for endocardial ablation is initiated only after epicardial access is obtained (and therefore patients must be off oral anticoagulants prior to access). Ideally, systemic anticoagulants should be withheld until the epicardial map is completed to potentially reduce the impact of any trauma that may have occurred during epicardial access. This step is even more important if the initial pericardial aspirate is hemorrhagic or if it is evident that inadvertent puncture occurred. Recognizing patients with a history of prior pericarditis (or even prior pericardial access) is another important step, as these factors may increase the risk of myocardial puncture. In such cases, if myocardial puncture occurs, the operator may readily abandon percutaneous access altogether. Although previously popular, attempts at percutaneous epicardial access in patients with prior cardiac surgery have gradually fallen out of favor.
The diagnosis of hemopericardium itself is often made during or immediately after percutaneous epicardial access, when either blood is seen in the needle aspirate during puncture or there is evidence of a new pericardial effusion noted on echocardiogram imaging (intracardiac or other approaches; Figure 43.1
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