Alternative approach to pericardial effusion: EUS guided transesophageal pericardiocentesis

Introduction: Echocardiographic-guided pericardiocentesis is the preferred initial procedure for the diagnosis and treatment of pericardial effusion. Pericardial effusion is rarely located in the posterior side of pericardial sac, which makes it difficult for cardiologist to perform Echocardiographic-guided pericardiocentesis through the subxiphoid route. EUS guided-transesophageal pericardiocentesis can be an alternative method when the approach to the pericardial effusion is anatomically closer to esophagus than to subxiphoid.

Purpose: This video case is to show our experience of EUS guided-transesophageal pericardiocentesis successfully and safely.

Method: A 76-year-old male with pre-operative pancreatic cancer Stage 4a showed a large volume of pericardial effusion on chest X-rays. Chest CT scan showed effusion in the posterior pericardial sac and close to esophagus with the patient in a supine position. Therefore, it was impossible for cardiologist to do echocardiographic-guided pericardiocentesis. After consent was obtained, the patient underwent EUS guided pericardiocentesis. The procedure was preceded by sedation with midazolam and local oropharynx mucosal anesthesia with 1% lidocaine was applied. With the patient in a supine position, a safe puncture route was identified away from the cardiac pounding. The lower esophagus was punctured by a 22Fr gauge fine needle (Wilson Cook Echo-1–22; 22G) through endoscopy (Fujinon/Toshiba EUS PEF708A) into the pericardial effusion. One hundred milliliters of pericardial effusion were thereafter successfully removed.

Results: The effusion was a clear to yellowish hue with normal LDH, CEA and CA19–9, negative cytology and negative for bacterial or acid fast bacillus culture. The final diagnosis was transudate. As a result, malignancy was ruled out. The patient did not develop any complications such as infection, bleeding, arrhythmia or heart failure after the procedure. A follow-up chest X-ray revealed a smaller cardiac silhouette. The patient was finaly referred to surgery department.

Conclusion: EUS guided-transesophageal pericardiocentesis can be an alternative method when conventional approach to the pericardial effusion is anatomically difficult.