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326
L. Rapoport and P. Gupta
rather the rate of accumulation of uid and pericardial compliance [1].
When making the diagnosis of pericardial
tamponade, it is important to keep the physiology
in mind: tamponade is an obstructive state where
the pressures outside the cardiac chambers inhibit
appropriate chamber lling. Thus the most
important echocardiographic signs of tamponade
include the presence of a pericardial effusion,
dilated inferior vena cava (IVC), and a left ventricle that has reduced end-diastolic and endsystolic dimensions with evidence of reduced
cardiac output (i.e., an underlled LV). Impaired
cardiac chamber lling in turn exaggerates normal interventricular dependence during a cardiac
cycle. This leads to other classic ndings such as
right ventricular diastolic chamber collapse, right
atrial systolic collapse, and the inspiratory bulge
of the interventricular septum into the left ventricle (seen bulging into the left ventricle during
spontaneous inspiration and mechanical expiration). Characteristic abnormal respirophasic
changes in Doppler ow velocity recordings
across the mitral and tricuspid valves can also be
seen and are useful ndings but not necessary to
make the diagnosis of tamponade (Table25.1).
Inferior Vena Cava Plethora
A dilated or plethoric IVC with <50% respirophasic variation in diameter is correlated with
elevated central venous pressure and decreased
venous return, seen when pericardial pressures
increase above intracardiac pressures. IVC plethora is a very sensitive sign for tamponade
(95–97%) but has poor specicity (~40%) due to
plethora potentially being due to a variety of
other causes, such as chronic pulmonary hypertension, tricuspid regurgitation, etc. [1] M-mode
can be used to track the IVC diameter across the
respiratory cycle, approximately 2–3cm from the
IVC-right atrial junction. Hepatic vein dilation
can also be used as a proxy for IVC plethora
when the IVC is difcult to visualize [4].
Right Heart Chamber Systolic/Diastolic Collapse
Right-sided chamber collapse is a critical nding
in cardiac tamponade that occurs when the pericardial pressures exceed those of the internal car-
diac chambers. The right atrial collapse in systole
is often considered the rst sonographic sign of
tamponade [5]. If the duration of right atrial collapse exceeds more than one-third of the cardiac
cycle, the sensitivity and specicity of such a
nding approach 100% for clinical cardiac tamponade [6]. Right ventricular collapse, usually
seen in early diastole, may initially only be seen
in inspiration in spontaneously breathing patients
(or during expiration in mechanically ventilated
patients) but may persist throughout the respiratory cycle as tamponade worsens [4]. Right heart
diastolic collapse may also occur in signicant
hypovolemia, in which concurrently scanning for
IVC plethora can be useful. Right heart diastolic
collapse can be seen best in the PLAX, SX, or
apical 4-chamber views (A4C). In the PLAX
view, diastole corresponds with visualization of
the opening of the mitral valve, and in the A4C
and SX views diastole corresponds with visualization of the opening of the mitral and tricuspid
valve. Keep in mind that in cases of localized
tamponade, such as post-surgical tamponade,
these classic ndings may not be seen.
Inspiratory Bulge
oftheIntraventricular Septum
Spontaneous breathing causes negative intrathoracic pressure during inspiration. During spontaneous inspiration, as right heart pressures fall, RV
lling is augmented, and a natural bowing of the
septum towards the left ventricle is expected, given
ventricular interdependence due to the shared septal wall. The opposite can be expected in mechanically ventilated patients, where bowing of the
septum towards the LV occurs in mechanical expiration. RV lling pressure in turn leads to left ventricular lling variations and subsequently
variations in LV stroke volume, with respect to
respirophasic variations. Usually, left-sided lling
changes <5% during inspiration. However, during
cardiac tamponade, ventricular interdependence
and thus left-sided lling changes are exaggerated.
This gives rise to the phenomenon of “pulsus paradoxus.” Pulsus paradoxus is generally a sign of
poor specicity, seen in a variety of conditions
whereby there are signicant heart-lung lling
pressure interactions, including COPD exacerbations and pulmonary embolism [7].
25 Ultrasound-Guided Pericardiocentesis
327
(continued)
reduction in diameter during
inspiration. If IVC is difcult to assess,
dilatation of hepatic veins is a reliable
conrmatory sign
Finding Example
Dilated IVC IVC dilation (>2.1cm) with <50%
Table 25.1 Echocardiography ndings of cardiac tamponade
Two-dimensional subcostal view of the heart in a patient with tamponade showing a dilated IVC (2.0cm)
by 2D echocardiography—note also the dilation of the hepatic vein (HV). The image on the right shows the
M-mode of the IVC throughout a spontaneous respiratory cycle and is used to calculate the inspiratory
reduction in diameter
The absence of any cardiac chamber
collapse has a>90% negative
predictive value for clinical cardiac
tamponade [3]
Right heart
diastolic collapse
Two-dimensional subcostal view of the heart showing right atrial and RV indentation or “collapse” (small
arrow). In both the right atrial and RV chambers, the indentation occurs during relaxation when their
pressure is lowest and transiently falls below pericardial pressure
328
L. Rapoport and P. Gupta
An M-mode echocardiogram was obtained from a patient with pericardial effusion and cardiac tamponade.
When the RV enlarges with spontaneous inspiration (insp), the LV becomes smaller (dashed arrows).The
opposite changes are seen on expiration (exp)
Left heart lling decreases abnormally
in cardiac tamponade due to ventricular
interdependence, wherein an increase
in lling on one side of the heart is
associated with a decrease on the
opposite side
Generally, a decrease of 30% of mitral
valve E-wave inow velocity during
Finding Example
Inspiratory bulging
of interventricular
Table 25.1 (continued)
septum
Abnormal
respiratory changes
inspiration is diagnostic for
ultrasonographic cardiac tamponade.
Similarly, an increase in roughly 40%
of tricuspid valve inow velocity
during inspiration can be seen in
tamponade
in Doppler ow
velocity recordings
Pulse wave Doppler recording across the mitral valve of a patient in cardiac tamponade. The rst beat of
spontaneous inspiration should be compared to the rst beat of expiration
Adapted from the American Society of Echocardiography clinical recommendations for multimodality cardiovascular imaging of patients with pericardial disease [4]
25 Ultrasound-Guided Pericardiocentesis
329
Doppler Flow Velocity Changes
Exaggerated ventricular interdependence in tamponade physiology also causes exaggerated respirophasic ows across the tricuspid and mitral
valves in the pericardial tamponade. These can be
evaluated via Doppler ow in ultrasonography as
another tool to evaluate pericardial tamponade.
Normally, changes in peak E-wave mitral velocity during spontaneous inspiration are <5% [8],
but in tamponade, a decrease of 25–30% peak
E-wave mitral velocity is considered diagnostic
[9]. For the tricuspid valve, tamponade physiology will produce an approximately 40% increase
in in-ow velocity [7]. These velocity measurements are best achieved via the A4C view when
the pulse wave Doppler gate is in alignment with
tricuspid and mitral valve blood ow.
Approaches tothePoint-of-CareUltrasound (POCUS) Guided
Procedure
Traditionally, pericardiocentesis is performed in a
controlled, surgical setting. However, given the
life-threatening nature of cardiac tamponade and
the increasing use of point-of-care cardiac ultrasonography (POCUS), ultrasound-guided pericardiocentesis is an essential skill for any clinician
working in an emergent setting. Multiple observational studies of ultrasound-guided pericardiocentesis report improved safety and success as
compared to blind aspiration [10]. The parasternal, apical, or subxiphoid approach has all been
described, but procedure selection depends on
operator comfort or local expertise. Consideration
should be given to the approach where the largest
uid collection is visualized on ultrasound and
accessed closest to the skin surface with the safest
needle trajectory. There is no clear consensus as
to which approach is ideal, but some studies suggest the apical approach may be the safest.
Complication rates with pericardiocentesis are
reportedly lower via the parasternal or apical
compared to the subxiphoid approach, as both
minimize the distance from skin to uid collection [11–13]. In addition, observational studies of
pericardial effusion distribution suggest that left
chest access points are often superior to the traditional subxiphoid [11, 14]. However, all three
approaches (left parasternal, apical, and subxiphoid/subcostal) are described here.
• Equipment.
– Ultrasound machine with phased-array
(cardiac) and linear (vascular) probes.
– Sterile ultrasound probe cover, sterile
gown, and gloves.
– Chlorhexidine antiseptic prep.
– Pericardiocentesis kit, single-lumen central
line kit, or a pigtail thoracostomy kit and a
6F or 8F dilator if a catheter is being left in
place.
– 18-gauge needle with sheath or 18-gauge
spinal needle
– Cardiac monitor.
– Pulse oximetry.
– Specimen collection tubes (for cytology
and additional studies).
– Code cart with a debrillator.
• General Tips:
– Systematically examine the heart and look
for effusions at each imaging window (subcostal, parasternal, apical, and any additional views).
– The optimal site contains the largest peri-
cardial uid that is closest to the chest wall
and can be entered without puncturing an
adjacent vital organ.
– Select a target uid layer (distance from
pericardium to epicardium) of at least 1cm
to avoid cardiac puncture.
– Real-time ultrasound visualization of the
needle passage is optimal, but continuous
visualization of needle tip may be
difcult.
– If available, two clinicians scrubbed in
sterile attire may be superior to one, with
one clinician as the designated ultrasonographer and the other clinician as the
proceduralist.
– Agitated saline injected through the peri-
cardial catheter should create an artifact
easily visualized in the pericardial space,
330
L. Rapoport and P. Gupta
and this is a tenet to conrm the proper
placement of the drain with any approach.
– Ultrasound can also be used to monitor for
complications post-procedurally, such as
pneumothorax, drain malfunction, and
potentially drain malposition.
• Parasternal Approach:
Adapted from Osman etal. [15]
– With the patient in the supine position,
obtain a parasternal view using a linear
probe. Patient repositioning (i.e., reverse
Trendelenburg), may redistribute pericardial uid and affect the target window.
– Prep the skin overlying the left chest and
drape the patient in a sterile manner. Place
a sterile sheath over the ultrasound
transducer.
– Identify a transverse view of the sternum
bone.
– Move the transducer laterally to identify
the internal thoracic artery vessel and pleural line (with lung sliding), just lateral to
the sternum.
25 Ultrasound-Guided Pericardiocentesis
331
– Optimize the depth settings so that only the
pericardial effusion and right ventricle are
visible.
– Advance the needle tip via an in-plane
medial-to- lateral approach with respect to
the ultrasound probe at a 45-degree angle to
pericardial tissue until the needle tip is in
the pericardial cavity. The point of needle
entry should be along the superior border of
the rib to prevent inadvertent injury to the
intercostal vessels that run along the inferior rib border.
penetrate the skin, intercostal muscle, and
ab
– Once within the pericardial sac, one should
be able to aspirate pericardial uid easily.
Even the drainage of a small amount of
uid may have a dramatic effect on the
patient’s hemodynamics.
– To conrm placement, connect two 10mL
syringes via a three-way stopcock, one
empty and one with 9mL of normal saline.
Rapidly agitate the saline between the two
syringes with the stopcock turned off to the
patient, and then open the stopcock to the
patient and ush the agitated saline under
continued ultrasound monitoring. This
should create a “rocket are” appearance
and conrm the needle tip is in the pericardial space.
332
ab c
L. Rapoport and P. Gupta
– Agitated saline within the intracardiac
areas or rapid washout of the saline may
indicate an accidental myocardial puncture
[16].
– Another form of conrmation is to deploy
the guidewire and visualize the guidewire
within the pericardial sac under ultrasound
guidance.
– Place the guide wire under real-time visu-
alization after properly conrming the
placement of the needle tip as above via
agitated saline. You can use the standard
Seldinger technique to dilate the subcutaneous space after the needle is removed.
Place a single-lumen catheter or pigtail
catheter into the pericardial space.
– After pericardial drainage, you can leave
the catheter in place and then use ultrasound at serial intervals to monitor the
clinical condition, effusion size, hemodynamics, and complications.
• Apical:
– The apical approach takes advantage of a
thicker left ventricle and small apical coronaries but theoretically has a higher risk of
pneumothorax given the proximity to the
left pleural space [17].
– The ultrasound probe should be placed
over the cardiac apex, usually found
between the fth, sixth, and seventh intercostal spaces, between the mid-clavicular
and mid-axillary lines, to nd the largest
effusion, closest to the skin [12].
– Prep the skin overlying the left chest and
drape the patient in a sterile manner. Place
a sterile sheath over the ultrasound
transducer.
– Advance the needle tip via a transverse
approach with respect to the ultrasound
probe at a 45-degree angle towards the
right shoulder to penetrate the skin, intercostal muscle, and pericardial tissue until
the needle tip is in the pericardial cavity.
The point of needle entry should be along
the superior border of the rib to prevent
inadvertent injury to the intercostal vessels
that run along the inferior rib border.
– Follow similar steps as above regarding
conrmation of needle placement and catheter placement.
• Subxiphoid Approach:
– The subxiphoid approach is traditionally
done as a blind technique but can be
achieved via ultrasound guidance as well.
– With the patient in the supine position,
obtain a subxiphoid cardiac view using the
phased array probe. Patient repositioning
(i.e., reverse Trendelenburg), may redistribute pericardial uid and affect the target
window.
– Prep the skin overlying the left chest and
drape the patient in a sterile manner. Place
a sterile sheath over the ultrasound
transducer.
– Once an appropriate pocket of uid is iden-
tied, insert the nder needle 1cm inferior
to the left xiphocostal angle at a 30-degree
angle to the skin [12]. As mentioned above,
this technique can be done blind, aiming
towards the left shoulder and advancing
25 Ultrasound-Guided Pericardiocentesis
333
while aspirating. If using ultrasound, a
transverse out-of-plane needle approach
will allow the visualization of the needle
tip into the pericardial sac.
– If approaching blind and unable to aspirate
uid, attempt a redirected trajectory initially deeper posteriorly and then slowly
from the patient’s left to the right until
aimed at the patient’s right shoulder [12].
Complications
Major complications of pericardiocentesis
include injury of cardiac chambers, coronary
arteries, intercostal or internal thoracic vessels,
abdominal viscera, pneumothorax, pneumopericardium, ventricular arrhythmias, and death.
Minor complications include transient vasovagal
hypotension and bradycardia, supraventricular
arrhythmias, and pleuropericardial stulas [10].
Although an immediate chest x-ray should be
ordered to evaluate for pneumothorax, and if possible, an upright abdominal x-ray to evaluate for
free air under the diaphragm, ultrasound can be
utilized to quickly evaluate for complications at
the bedside.
Some studies show bedside ultrasonography,
although dependent on the skill of the operator,
shows higher sensitivity and similar specicity
when compared to chest radiographs in the diagnosis of pneumothorax [18–20].
Summary Points
• Pericardiocentesis is indicated for cardiac
tamponade or in symptomatic pericardial
effusions, clinical situations often found in
intensive care units (ICU).
• Key features on bedside echocardiogram that
may suggest clinical tamponade include infe-
rior vena cava plethora, right heart collapse in
diastole, bulging of the interventricular sep-
tum during inspiration, and changes in mitral
and tricuspid inow velocity on Doppler
ultrasound.
• The use of ultrasound reduces complications
in pericardiocentesis and may assist in identi-
fying immediate complications.
References
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Pericarditis andConstriction
SarahBain andBrooksOhlson
26
Learning Objectives
1. Identify the three most common etiologies of
constrictive pericarditis.
2. Describe the unique pathophysiology of constrictive pericarditis in terms of increased
interventricular dependence and dissociation
of intrathoracic-intracardiac pressures.
3. Identify specic variables that should be
included in an echocardiographic examination in the setting of suspected pericardial
disease.
4. Identify the three echocardiographic principles that were found by the Mayo Clinic study
to be independently associated with constrictive pericarditis.
Pro Tips
• Utilize extended clips of up to ten beats.
• Record respiration with a respirometer when
assessing mitral inow velocities, ventricular
septal shift, and hepatic vein ow.
Supplementary Information The online version contains supplementary material available at https://doi.
org/10.1007/978- 3- 031- 80038- 2_26.
S. Bain (*) · B. Ohlson
Virginia Mason Franciscan Health, Seattle, WA, USA
e-mail: sarah.bain@commonspirit.org;
brooks.ohlson@commonspirit.org
Causes ofConstrictive Pericarditis
The epidemiology of constrictive pericarditis
(CP) in the modern, developed world is nebulous.
Likely owing to a relatively low prevalence [1]
and changing disease burden, much of our knowledge of CP in the twenty-rst century stems from
single-center surgical databases. In the late
1950s, tuberculosis was estimated to represent
nearly half of all cases of CP with an increasing
incidence of presumed viral causes [2]. Presently,
the most common etiologies of constrictive
pericarditis cited are idiopathic, postoperative, and post-radiation [3]. While an
exhaustive analysis of the causes of CP is beyond
the scope of this text, any disease process that
leads to inammatory, brous scarring of the
pericardium should be considered.
Pathophysiology
In normal circumstances, the basic mechanical
functions of the pericardium promote ventricular
elasticity and a low-friction structural sac for the
heart [4]. Variations in ventricular lling during
respiration are compensated for by pericardial
stretch, minimizing the effects of ventricular
interdependence. Recall that during spontaneous
respiration, intrathoracic pressures inuence lling pressure gradients on the left and right sides
of the heart. With inspiration, negative intratho-
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. J. Lanspa, A. T. Levinson (eds.), Echocardiography and Ultrasonography in the ICU,
Respiratory Medicine, https://doi.org/10.1007/978-3-031-80038-2_26
335