Ultrasound emergency lateral-to-medial parasternal pericardiocentesis with high frequency probe in COVID-19: a case report

Abstract

Background: The pathological involvement of the heart is frequent in SARS-Coronavirus-2 infection (COVID-19) with various clinical and echocardiographic manifestations during the course of the disease.

Case summary: A 69-year-old female patient with severe COVID-19-related acute respiratory distress syndrome undergoing mechanical ventilation developed acute left ventricular dysfunction, that successfully improved with vasoactive therapy. After 5 days, she suddenly developed hemodynamic instability due to acute onset of pericardial effusion, which required emergency pericardiocentesis. Ultrasound-guided parasternal pericardiocentesis with high-frequency linear probe and lateral-to-medial in-plane approach was performed by inserting a central venous catheter using a Seldinger technique. 700 mL of serous fluid was drained resolving the acute critical state.

Discussion: Pericardial effusion with cardiac tamponade is a rare manifestation of Covid-19. Despite the diffusion of echocardiography, emergency cardiac procedures could be particularly difficult to be performed in a pandemic scenario of limited resources and the heterogeneous skills of the professional figures involved in the management of COVID-19 patients. The spread of expertise in ultrasound-guided vascular cannulation makes this approach attractive for anesthesiologists, emergency medicine and critical care specialists too. Furthermore in this pericardiocentesis' technique, the high-frequency linear probe adds optimal spatial resolution to maintain a close control of the needle's direction. However the need of a good parasternal view and a deep ultrasound knowledge are crucial to avoid iatrogenic complications. In conclusion, ultrasound-guided lateral-to-medial parasternal pericardiocentesis with high-frequency linear probe is an alternative to treat potential lethal acute haemodynamic instability due to cardiac tamponade.

Keywords: COVID-19; Cardiac tamponade; Case report; Pericardial effusion; Ultrasound-guided pericardiocentesis.

Figure 1

High-frequency linear probe’s position on the chest and lateral-to-medial needle’s direction to perform pericardiocentesis. Modified with permission from Dr T Cruise MD (https://lagynecomastia.org/gynecomastia-overview/ideal-male-chest/)

Figure 2

Central venous catheter position and drainage of pericardial serous effusion (A). Absence of pericardial fluid on echocardiographic control (B) with no fluctuation of diastolic filling (C).