Percutaneous Epicardial Techniques



Percutaneous Epicardial Techniques


Juan F. Viles-Gonzalez, MD, FACC, FAHA, FHRS

André D’Avila, MD



Percutaneous access to the pericardial cavity (pericardiocentesis) is typically performed for drainage of pericardial effusions. In the absence of effusion, epicardial access can also be obtained during epicardial ablation of arrhythmias, certain structural heart disease procedures such as percutaneous closure of the left atrial appendage, and, more rarely, balloon pericardiotomy.1,2,3,4,5,6,7 A systematic approach to the patient evaluated for such procedures is paramount (FIGURE 25.1). The presence of adhesions (more frequent in patients with prior cardiac surgery or history of pericarditis) can complicate percutaneous access to the pericardial space.7 In this situation, surgical consultation for possible pericardial window and lysis of adhesions should be considered.

The pericardial cavity is a virtual space between the parietal and visceral layers of the serous pericardium. It is continuous with the epicardium and reflects around the roots of the great vessels and onto the visceral surface of the fibrous pericardium. The visceral surface of the pericardium is continuous with the adventitia of the great vessels superiorly, and it is related posteriorly to the bronchi, esophagus, descending thoracic aorta, and mediastinal surface of each lung. The phrenic nerves descend between the visceral pericardium and the mediastinal pleural layers that adhere to its lateral sides (FIGURE 25.2).6

The oblique sinus, a recess located behind the left atrium, is formed as the pericardium envelopes the pulmonary veins and vena cava. Within it lies the vein of Marshall, connected by the fetal remnant of the duct of Cuvier to the highest left intercostal vein and draining into the coronary sinus. The transverse sinus is located superior to the heart between the arterial mesocardium, which envelopes the ascending aorta and pulmonary trunk anteriorly, and the venous mesocardium, which covers the superior vena cava (SVC), left atrium, and pulmonary veins posteriorly and inferiorly (FIGURE 25.2).6

Although most of the pericardial cavity can be easily accessed using standard catheters, reaching the posterior wall of the left atrium (LA) can be challenging given the complex pericardial reflections that form the pulmonary vein (PV) recesses and the 2 major sinuses. On the other hand, the epicardial surfaces of both ventricles are free of reflections. In the absence of prior severe pericarditis or cardiac surgery, this allows for simple manipulation of the catheters during epicardial procedures. The inferior and anterior approach taken during percutaneous epicardial access allows for easier access to the respective surfaces of the heart (FIGURE 25.2).1,2,3,4,5

The technique for safely accessing the normal pericardial space for the purposes of epicardial interventions was first described by Sosa and colleagues using a modification of the traditional method.1,2 This approach allows free access to the entire ventricular surfaces, the right atrium, and the majority of the right and left atrium (FIGURES 25.3, 25.4, 25.5, 25.6, 25.7, 25.8, 25.9 and 25.10).

Conceptually, entering the pericardial space is simple when draining pericardial effusions. However, in the absence of an effusion, epicardial access can be challenging, as there is little room for error. The normal pericardial cavity contains only 20 to 25 cc of physiologic fluid with only virtual space. Thus, there is an increased risk of perforating the right ventricle (RV) wall and/or of damaging epicardial vessels when attempts are made to access the space percutaneously with a regular pericardiocentesis needle. In a series of 200 patients, Sosa et al reported a bleeding rate of 10% and “dry” RV puncture rate of 4.5% that decreases with experience.1,2,3,4







FIGURE 25.1 Percutaneous epicardial access: step-by-step approach.






FIGURE 25.2 A and B, The anatomy of the pericardium and its reflections along the great vessels, sinuses, and recesses are shown in an anterior view after removal of the heart. The transverse sinus is limited by a pericardial reflection between the superior pulmonary veins. The oblique sinus is confined by the pericardial reflections around the pulmonary veins and the inferior vena cava. IVC, inferior vena cava; LPA, left pulmonary artery; PCR, postcaval recess; RPA, right pulmonary artery; RPVR and LPVR, right and left pulmonary vein recesses; SVC, superior vena cava.







FIGURE 25.3 Anterior chest wall depicting the normal cardiac location within the chest. The angulation of the needle for percutaneous epicardial access should be aimed in the direction of the left scapula and/or the left shoulder. The light blue triangle represents the xiphoid process, the white lines mark the caudal border of the rib cage, and the triangle in black dotted lines marks a soft tissue area lateral to the xiphoid process typically used for initial needle puncture.






FIGURE 25.4 Anterior chest wall depicting the angle and initial puncture site for the anterior and inferior percutaneous pericardiocentesis approach. The angulation of the needle for percutaneous epicardial access should be aimed in the direction of the left scapula and/or the left shoulder as shown in FIGURE 25.3. A, The anterior approach appears to have a slightly higher rate of RV puncture and vascular structures in the anterior mediastinum including the left internal mammary artery. B, The inferior approach on the other hand is associated with inadvertent puncture of subdiaphragmatic structures including the liver and abdominal vessels. LIMA, Left internal mammary artery.






FIGURE 25.5 Sagittal cross section of the chest illustrating the relationship of the sternum with the RV, the liver, the dome of the diaphragm over the liver, and more posterior the LV and the PA. The white arrow depicts the ideal angle for an anterior percutaneous approach (landing on the anterior aspect of the apex); the light blue arrow shows the angle required for an inferior approach.







FIGURE 25.6 Sagittal cross section of a 3D reconstruction of a chest computed tomography (CT) (from a right lateral view) illustrating the relationship of the sternum and rib cage (in light brown) with the right ventricle (in blue), the right atrium (in green), the dome of the diaphragm over the liver (in gray), and more posterior the left atrium (in red) and the PA. The white arrow depicts the ideal angle for an anterior percutaneous approach (landing on the anterior aspect of the apex); the light blue arrow shows the angle required for an inferior approach. The triangular space is known as Larrey space (white dotted line).

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May 3, 2019 | Posted by in CARDIOLOGY | Comments Off on Percutaneous Epicardial Techniques

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