European Heart Journal Advance Access originally published online on April 8, 2005
European Heart Journal 2005 26(10):1046-1047; doi:10.1093/eurheartj/ehi240
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Utility and safety of diagnostic pericardiocentesis
Department of Cardiology
Ospedale San Gerardo
Monza
Italy
E-mail address: as.maggio{at}tin.it
Department of Cardiology
Ospedale Moriggia Pelascini
Gravedona
Italy
Department of Anesthesia
Ospedale San Gerardo
Monza
Italy
We read with interest the ‘Guidelines on the diagnosis and management of pericardial diseases’ by Maisch et al.1 for the Task Force on the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology.
In their paper, the authors discuss, among other topics, the indication to perform pericardiocentesis in effusions causing no haemodynamic compromise for diagnostic purposes even in small size effusions (Focus box 1).
Diagnostic pericardiocentesis is detailed in Focus box 3, which states that the analysis of pericardial effusion can establish the diagnosis of viral, bacterial, tuberculous, fungal, cholesterol, and malignant pericarditis. In support of these statements the authors quote Spodick.2 We note that the quoted paper states that pericardial drainage may be required for diagnosis only ‘occasionally’ and that pericardiocentesis by needle alone can be ‘unrewarding diagnostically’. This author relies on two studies;3,4 both studies present a low diagnostic yield of the analysis of pericardial fluid.
It is also stated that PCR analysis for cardiotropic viruses can discriminate viral from autoreactive pericarditis, on the basis of a study by Maisch et al.5 We note that the goal of this study was to verify the safety of intrapericardial steroid treatment, and that it does not provide sensibility and specificity of PCR for cardiotropic viruses. Therefore, there is no certainty, in clinical practice, that a negative viral identification can exclude a viral etiology.
The text reports that cholesterol levels are higher in bacterial and malignant pericardial fluids, suggesting the role of cholesterol dosage as a diagnostic tool, on the basis of a study by Meyers et al.4 We note that the authors of this study found a higher cholesterol level in malignant and bacterial than in normal (open heart surgery) pericardial fluid, but no discrimination between pathologies on the basis of cholesterol has been observed. The authors, therefore, do not suggest to dose cholesterol in the pericardial fluid.
We agree with these recent observations from Permanyer-Miralda,6 ‘There is not enough evidence in the literature to give hard and fast rules for the etiological diagnosis in all causes of acute pericardial disease’. We think that pericardiocentesis with a diagnostic purpose is not justified in the majority of cases for the following reasons: its low diagnostic power, the underlying pathology is often already known7 or identifiable by different non-invasive tests, viral pericarditis is usually self-limiting, and it only requires an anti-inflammatory treatment.
Since pericardiocentesis is an invasive procedure, not free from low but significant risks, we think that pericardiocentesis with only diagnostic purposes should be limited to very specific cases.6
Regarding risks of pericardiocentesis, echo-guided and fluoroscopy-guided techniques are presented to be equivalent in safety and complication rate. In reality, the quoted study of Duvernoy8 reports accidental cardiac perforations in 23 of 352 (6.5%) fluoroscopy-guided pericardiocentesis. The largest published series of echo-guided pericardiocentesis9 reports a 1.5% incidence of cardiac lacerations.
In conclusion, we believe that pericardiocentesis should be performed only on a strong clinical indication, by an experienced operator with the safest technique, which in our experience is the echo-guided approach.
References
- Maisch B, Saferovic PM, Ristic AD and the Task Force on the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology. Guidelines on the diagnosis and management of pericardial diseases. Eur Heart J 2004;25:587–610.
[Free Full Text] - Spodick DH. Pericardial diseases. In: Brunwald E, Zippes DP, Libby P, eds. Heart Disease. 6th ed. London/Toronto/Montreal/Sydney: Saunders; 2001. p1823–1876.
- Merce J, Sagrista-Sauleda J, Permanyer-Miralda G et al. Should pericardial drainage be performed routinely in patients who have a large pericardial effusion without tamponade? Am J Med 1998;105:106–109.[CrossRef][ISI][Medline]
- Meyers DG, Meyers RE, Prendergast TW. The usefulness of diagnostic tests on pericardial fluid. Chest 1997;111:1213–1221.
[Abstract/Free Full Text] - Maisch B, Ristic AD, Pankuweit S. Intrapericardial treatment of autoreactive pericardial effusion with triamcinolone: the way to avoid side effects of systemic corticosteroid therapy. Eur Heart J 2002;23:1503–1508.
[Abstract/Free Full Text] - Permanyer-Miralda G. Acute pericardial disease: approach to the aethiologic diagnosis. Heart 2004;90:252–254.
[Free Full Text] - Sagristà-Seuleda J, Mercè J, Permanyer-Miralda G et al. Clinical clues of the cause of the large pericardial effusion. Am J Med 2000;109:95–101.
- Duvernoy O, Borowiec J, Helmius G et al. Complications of percutaneous pericardiocentesis under fluoroscopic guidance. Acta Radiol 1992;33:309–313.[ISI][Medline]
- Tsang TS, Enriquez-Sarano M, Freeman WK et al. Consecutive 1127 therapeutic echocardiographically guided pericardiocentesis: clinical profile, practice patterns, and outcomes spanning 21 years. Mayo Clin Proc 2002;77:429–436.[ISI][Medline]
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