Pericardiocentesis from back under echographic guidance: an approach for posterior pericardial effusions.

A 72-year-old man with degenerative aortic stenosis, coronary artery disease, hypertension, and chronic renal insufficiency presented with progressively worsening dyspnea, tachycardia, hypotension, and diuresis contraction 7 days after undergoing successful aortic valve replacement (stentless valve, 27 mm) and coronary artery revascularization. On presentation to the intensive care unit, the patient was found to have a notably bilateral pleural effusion. The blood sample revealed normal values of both troponin and creatine kinase. ECG displayed sinus rhythm with diffuse aspecific repolarization abnormalities. A transthoracic echocardiogram demonstrated normal left ventricular ejection fraction, concentric hypertrophy of the left ventricle, no valvular dysfunction, and preserved right ventricular function. A posterior-lateral echographic view showed a large left pleural effusion, a significant posterior pericardial effusion, and a prominent pericardial layer demarcating the 2 fluidfilled sacs (Figure and Movie I in the online-only Data Supplement). Pleuropericardiocentesis was urgently performed. The landmark for needle insertion corresponded to the area where the largest amount of fluid could be detected. The patient was placed in the semireclining position to enhance fluid collections in the inferior part of the chest. After appropriate disinfection of the operative field, local anesthesia of the skin was administered with 2% lidocaine. The procedure was performed by 2 physicians, 1 who performed the echocardiogram and 1 who performed the puncture and drainage. Once placement and direction of the needle were chosen, the needle was connected to a syringe for constant gentle aspiration, and it was slowly introduced through the fourth intercostal space 4 cm medially to the left posterior axillary line until there was echographic visualization of the tip. When the pleural space was reached, agitated saline bubbles confirmed that the needle tip was in the pleural space (Movie II in the onlineonly data supplement). The needle was then advanced into the pericardial cavity under echocardiographic guidance and an emulsion of 5 mL of saline solution shaken with 1 mL of air was injected through the needle to verify the intrapericardial location (Movie III in the online-only data supplement). The syringe was then removed from the needle, and a curved guide wire was advanced into the pleurapericardial sac (Movie IV in the online-only data supplement). A multiplehole, 30-cm-long catheter was subsequently introduced along the guide wire according to the Seldinger technique into the posterior pericardium. Serous-hemorrhagic fluid was drained from the pericardial cavity and, after retraction, serous fluid was aspirated from the left pleural cavity (a total of 1400 mL), with consequent hemodynamic and respiratory improvement. After the procedure, chest radiography excluded the presence of pneumothorax, and the patient underwent noninvasive mechanical ventilation to restore aeration in atelectasic-consolidate lung. Apical 4-chamber echocardiographic view showed normal biventricular function. A light residual effusion was still present without extrinsic compression of the heart chambers (Movie V in the online-only Data Supplement). Pericardial fluid analysis showed no evidence of infection or malignancy. The postoperative evolution was progressively favorable and the patient could leave the intensive care unit 2 days later.