Pericardial approach for cardiac therapies: old practice with new ideas

Abstract

Treatment of cardiac disease via the epicardium fell under the domain of cardiac surgery due to the need for an open thoracotomy. Since an open thoracotomy is invasive in nature and has the potential for complications, a minimally invasive and percutaneous approach would be more attractive for suitable patients. The recent success of epicardial ablation of refractory arrhythmia via the percutaneous pericardial approach has increased the potential for delivery of epicardial therapies. Epicardial ablation has increased the success and safety since anti-coagulation and transseptal catheterization for left atrial arrhythmias is not required. The pericardial space has also been used to deliver therapy for several cardiac diseases. There are reports on successful delivery of drugs and their efficacy. Even though there was a wide range of efficacies reported in those studies, the reported complication rates are strikingly low, which suggests that direct delivery of drugs to the epicardium via the pericardial space is safe. Furthermore, recent animal studies have supported the feasibility of epicardial delivery of biological agents, including genes, cells, and even genetically engineered tissue for therapeutic purposes. In conclusion, percutaneous pericardial cannulation of closed pericardial space can play a significant role in providing non-surgical therapy for cardiovascular diseases. However, it requires skills and operator experiences. Therefore, there is need to further develop new tools, safer techniques, and effective procedure environment before generalizing this procedure.

Keywords: Administration routes, drug; Cannulation; Pericardium.

Fig. 1

A: the anatomy of the pericardium and its reflections along the great vessels, sinuses, and recesses are shown in an anterior view after removing the heart. The superior sinus (superior aortic recess) lies anterior to the upper ascending aorta and the main pulmonary artery. The transverse sinus is limited by the pericardial reflection between the superior pulmonary veins, and contains the RPA. The oblique sinus is confined by the pericardial reflections around the pulmonary veins and the IVC. The PCR lies behind the SVC, RPA, and right superior pulmonary vein. The RPVR, LPVR extend between their respective superior and inferior pulmonary veins. The white areas indicate the bare regions between the reflections of the serous pericardium. B: the transverse sinus and its right inferior extension (anterior view). The inferior aortic recess allows access to the epicardial portion of the ascending aorta related to the non-coronary cusp and the inferior aspect of the right coronary cusp. RPA: right pulmonary artery, IVC: inferior vena cava, PCR: postcaval recess, SVC: superior vena cava, RPVR: right pulmonary vein recesses, LPVR: left pulmonary vein recesses, LPA: left pulmonary artery, IAR: inferior aortic recess.

Fig. 2

Variations in the pulmonary venous pericardial recesses (posterior view). The white areas indicate uncovered areas between the reflections of the serous pericardium. The most common anatomic variant is the presence of both right and left pulmonary venous pericardial recesses. A, B-type was seen in more than half of the patients studied. IVC: inferior vena cava, OS: oblique sinus, SVC: superior vena cava.

Fig. 3

Congenital absence of the left pericardium and pericardial varices. A: an anteroposterior tomogram of the chest documenting the interposition of the lungs between the aorta and pulmonary artery (arrow). B and C: a magnified CT scan through the great vessels (B) showing the rotation of the main pulmonary artery segment out of the mediastinal fat, with resulting interposition of air between the aorta and prominent pulmonary artery (arrow). Compare this appearance to the normal anatomy in another patient (C). D: a magnified CT scan at the level of the heart demonstrates the abrupt termination of the right pericardium at the site of the indentation of the cardiac contour (arrow) where the heart bulges into the left chest. E: CT scan of a patient with a superior vena cava obstruction. An axial volume-rendered maximum-intensity-projection CT scan through the lower heart and liver showing a left-to-right pericardiophrenic arcade. A continuous arcade is seen going counterclockwise from the left pericardiophrenic vein (open white arrow) to the left inferior phrenic vein (thick arrow), to the inferior vena cava (i), thence anteriorly via intrahepatic collaterals (open black arrows) to create a blush of contrast material in the quadrate lobe (solid black arrow), and thence to the right inferior phrenic (short white arrow) and pericardiophrenic veins (long white arrow).

Fig. 4

The components of a standard pericardial cannulation tray. A: scalpel. B: 10 cc syringe with 1% lidocaine. C: 10 cc syringe with a contrast agent. D: Tuohy Point Epidural Needle with a stylet. E: J shaped guide wires. F: short sheath for the initial access. G: dilator for a long sheath. H: long sheath. I: magnified view of the tip of the Tuohy needle.

Fig. 5

Puncture technique 1. A: the junction of the xyphoid process and left lower costal margin is a good site for the pericardial puncture. B: the angle of skin puncture should be narrow to advance the needle under the rib-cage. C: if the angle is wide, there is risk of injuring the abdominal organs. D: once the needle is placed under the rib cage, the direction can be redirected depending on the target chamber.

Fig. 6

Puncture technique 2. A: the left anterior oblique view is helpful to confirm the anterior versus posterior orientation of the needle (right and left cardiac chambers). B: the right anterior oblique view helps to confirm the superior and inferior orientation (atria and ventricles). C: if the penetration of the parietal pericardium is felt, a small volume (<1 mL) of contrast is injected into the pericardial space to confirm a successful puncture. D: a long soft "J" tip guide wire is advanced far enough to silhouette the pericardial space.

Fig. 7

Puncture technique 3. A and B: after removing the puncture needle, an 8F dilator is advanced over the guide wire under fluoroscopy to achieve pre-dilatation. C and D: the long sheath with the dilator is advanced or manipulated with the guide wire to reach the target area and then the dilator is removed.

Fig. 8

Right anterior oblique projection of a pericardiogram used to guide the epicardial mapping. A: groove between the aorta and superior vena cava. B: pulmonary artery. C: left atrial appendage. D: right atrial appendage. E: inferior wall of the left ventricle. F: anterior wall of the left ventricle.

Fig. 9

The location of possible epicardial mapping. The mapping catheter (duodecapolar) is located in the crux of the heart (A), sulcus terminalis (B), sinus node (C), junction of the superior vena cava and right atrium (D), superior sinus at the 3rd fat pad (E), and ligament of Marshall (F).