Conversations in Cardiology: Should We Use Micropuncture Technique for Pericardiocentesis?

Disclosure: Dr. Kern reports he is a consultant and speaker for St. Jude Medical and Volcano Therapeutics, and a consultant for Boston Scientific, Opsens, ACIST Medical, and Merit Medical.

The evolution of cath lab techniques is among the best demonstrations of innovative thinking. Changing technique in the cath lab is often rapidly embraced based on new data about better outcomes, cost, or safety. The use of micropuncture technique for radial access is unchallenged compared to femoral access, with many but not all operators now advocating for widespread adoption.^1,2 In this “Conversations in Cardiology”, Dr. Andrew Michaels asks whether his practice of moving to micropuncture needle technique for pericardiocentesis is also being employed across the nation.   

Dr. Michaels asks, “Over 5 years ago, I completely switched from an 18-gauge needle to a long 21-gauge micropuncture needle (with micro introducer set) for subxiphoid pericardiocentesis. In a literature search, I found nothing related to the use of the 21-gauge micropuncture kit for pericardiocentesis. I would be interested to know the following:  

1. Do you predominantly use the standard 18-gauge or 21-gauge micropuncture needle for pericardiocentesis?
2. Do you feel there is a difference in the complication rate using a smaller needle for pericardiocentesis?
3. Do you use ECG [electrocardiogram], echo, and/or fluoroscopic guidance routinely?

[For those wishing to review the technique and indications for pericardiocentesis, see Cath Lab Digest, September 2014, “When Do You Need to Do Pericardiocentesis?”]

Fred Resnick, Boston, Massachusetts: About 5 years ago, we switched exclusively to using the long micropuncture kit (with stiffened introducer sheath) with fluoroscopic guidance (no ECG) only, as the first choice for pericardial access. We always get an echo in the cath lab immediately before and after the pericardial tap. We have found that, on occasion, with chronic effusions, thick pericardium, or obese patients, we somehow cannot get into the pericardial space with the micropuncture needle. I believe it deflects off of the pericardium or bends with lots of adipose in the upper abdomen. In these cases, we revert back to the 18g needle system. When this method fails as well, we then move to the echo-guided apical approach, though that seems to be more painful for patients than the subxyphoid approach. Unfortunately, we have not collected data on whether we have fewer right ventricle perforations using the micropuncture approach, but anecdotally, it certainly seems so.   

Jeff Marshall, Gainesville, Georgia: We have switched to micropuncture, and utilize echo and fluoroscopy on almost all procedures (post-CABG [coronary artery bypass graft surgery] emergencies done at bedside with echo only). Some operators prefer an apical approach, claiming lower complication rates (from an old Mayo Clinic article); others prefer the subxyphoid location. It would be nice to compare complications with micropuncture approach versus the old 18-gauge needle method, but I suspect most have switched.

Andrew Doorey, Newark, Delaware: The 21-gauge [micropuncture needle] sounds like a good idea. I wonder if you have any issues with being unable to aspirate due to the viscosity of the pericardial effusion. We use the long 18-gauge needle in the pericardiocentesis tray. If it’s a very large circumferential effusion, we use the subxyphoid approach, since we’re so familiar with it. Otherwise, we use the parasternal/apical approach per the Mayo Clinic reports, depending on the regionality of the effusion. We always use echo guidance (and almost always in the cath lab), and fluoroscopy as well.  This seems to be helpful to make sure the wire follows a “pericardial” course after introduction, but we have been unable to routinely see the needle tip with echo. We almost always use echo to see pericardial bubbles during saline injection when the needle position is uncertain. We use hemodynamics as well with a PA [pulmonary artery] catheter in the right atrium to confirm tamponade with initial (pericardial/right atrial) pressures. We confirm resolution after draining off the fluid. 

Zoltan G. Turi, New Brunswick, New Jersey: We switched to micropuncture some years ago, pretty much for everything (arterial and venous access, pericardial access). We also learned from the Lariat experience, where initially most used the 18-gauge Pajunk upward-beveled needle and have largely switched over to micropuncture.³ In the Lariat setting, the pericardium is dry, making the procedure that much more challenging. The plus of micropuncture is lower risk of the trauma inherent in using the large needle; the minus [disadvantage] is that you lose a lot of the feel of entering the pericardial space and the risk of entering the myocardium may be higher with micropuncture. There are no randomized data, but there is an abstract. It’s not a strong evidence base for answering the question of which is safer, but it’s all I am aware of. Considering that an 18-gauge needle is about 56% larger than a 21-gauge needle, micropuncture makes a smaller hole if you do enter the right ventricle (Table 1, Figure 1). The risk of lacerating a coronary artery should be smaller. In general and somewhat ironically, the Lariat procedure has taught us to do safer pericardiocentesis, with lots of useful tips such as the benefits of a 90-degree lateral view.  

Ajay Kirtane, New York City, New York:  There are some minor differences due to operator preference, but most are using the long micropuncture kit with echo done in-room for guidance (which also sometimes allows a more apical approach). We definitely feel more comfortable (less potential trepidation) with this approach than with the standard large needle in the tray. I agree with the issue of [needle] length though in obese patients, regarding the potential for the needle to bend (or theoretically snap with too much manipulation) in these larger patients. We will confirm position with combination of fluoro/echo with agitated saline. We never use EKG guidance. Sometimes we will use a pressure transducer to confirm position, especially if we are doing the full hemodynamic assessment. 

Navin Kapur, Boston, Massachusetts:  We use the long micropuncture and echo/fluoro for all perciardiocenteses unless it’s an emergency outside the cath lab. No data on complication rates. It seems to be a matter of comfort. We try to always document an opening pericardial pressure (unless emergent) and a final pericardial pressure before leaving a drain in place. If a complication occurs at any point, it can be helpful to know that it was necessary, we were in the right place, and it was hemodynamically beneficial to perform the pericardiocentesis. We do not routinely use an ECG lead. Of note, while right ventricle perforation is a concern for the subxyphoid approach, coronary puncture is a rare, but potential concern with the anterior or apical approaches for puncture location depends on where the fluid depth is the greatest.

Arnold Seto, Long Beach, Virginia:  I believe that micropuncture access of the pericardium is pretty quickly becoming the standard of care, albeit with minimal literature on the topic. It is impressive that so many quietly came to the same conclusion to switch to micropuncture when the typical pericardiocentesis kit includes only the 18-gauge needle. I have personally had one too many effusions where the echo suggested “early tamponade” but the pericardial pressure was low, at least until I punctured the right ventricle. The micropuncture needle has a lower profile and is more likely to penetrate rather than deflect the pericardium (especially an inflamed or calcified one) against the myocardium in low-pressure states, based on how it much more easily punctures collapsible veins under ultrasound. It may be difficult to consent patients prospectively to compare 18-gauge with 21-gauge access.  A pre/post protocol change is likely the best someone could write up and would be welcome. Perhaps it is time for manufacturers to include a long micropuncture needle and sheath with the pericardial tray, ideally one longer than 7 cm, if this can be manufactured safely. Reports of the needle breaking are disturbing and suggest that a stronger material than stainless steel (i.e., titanium) might be helpful.

Gus Pichard, Washington, D.C.:  We use the micropuncture needle, then place a 5-6 French Terumo sheath and a 5-6 French pigtail. We do not use the tools or catheters in the kit (too stiff). Echo guidance in the cath lab or in the ICU. Some operators do an agitated saline check. Some just look at the wire on fluoroscopy. By the way, we use micropuncture for all vascular access (cath, PCI [percutaneous coronary intervention], TAVR [transcatheter aortic valve replacement], etc.). 

The bottom line

Mort Kern, Long Beach, California: The uptake of micropuncture needles for almost all arterial work has become well known and standard in some labs. It is a logical extension to use it for pericardial access.  The limitations of the thin needle should be recognized as a more fragile needle and greater potential to clog with viscous material on aspiration. For tamponade due to large effusions, the approach (subxyphoid vs apical or parasternal or needle size) probably makes little difference and is a function of operator experience. For moderate or small effusions, the micropuncture technique offers a theoretical advantage. For monitoring and confirming intrapericardial location of the needle, pressure and echo contrast is routinely used. There remains a question about micropuncture needle use in routine femoral artery catheterization regarding potential reduction of complications. In a 2012 study, Ben-Dor et al showed higher rates of vascular complications, perforation requiring intervention, and retroperitoneal bleeding with the use of a micropuncture vs 18-gauge needle.² This will be a discussion for the future.

I hope this conversation was helpful and I thank my colleagues for their thoughtful contributions to our cath lab experience.

References

1. Cilingiroglu M, Feldman T, Salinger MH, Levisay J, Turi ZG. Fluoroscopically-guided micropuncture femoral artery access for large-caliber sheath insertion. J Invasive Cardiol. 2011; 23(4): 157-161.
2. Ben-Dor I, Maluenda G, Mahmoudi M, Torguson R, Xue Z, Bernardo N, Lindsay J, Satler LF, Pichard AD, Waksman R. A novel, minimally invasive access technique versus standard 18-gauge needle set for femoral access. Cathet Cardiovasc Intervent. 2012; 79: 1180-1185.
3. Martin AR, Crimmons E, Martin S, Bajwa H, Korpas D, Rooney S, Nagaraj H. Pericardial access with micropuncture needle for Lariat: is it safe and effective? J Am Coll Cardiol. 2015: 10S: A432.