A Novel Ultrasound-guided With Needle Visualization Pericardiocentesis Via Subcostal Approach

Osman Adi (  osman.adi@gmail.com ) Hospital Raja Permaisuri Bainun https://orcid.org/0000-0003-4932-8907 Nurul Shaliza Shamsudin Hospital Raja Permaisuri Bainun, Kementerian Kesihatan Malaysia Chan Pei Fong Hospital Raja Permaisuri Bainun, Kementerian Kesihatan Malaysia Muhammad Faiz Baherin Hospital Raja Permaisuri Bainun, Kementerian Kesihatan Malaysia Azma Haryaty Ahmad Hospital Raja Permaisuri Bainun, Kementerian Kesihatan Malaysia


Introduction
Cardiac tamponade is a life-threatening clinical condition caused by rapid accumulation of pericardial uid, resulting in impaired ventricular lling, decreased cardiac output, and hemodynamic instability [1].
Prompt recognition and urgent intervention to treat of cardiac tamponade is lifesaving.
Ultrasound-guided pericardiocentesis is currently considered the gold-standard for pericardial uid aspiration. This technique was introduced in 1979 and has become the preferred technique for cardiac tamponade management [2]. This technique has been proven to be safe and effective and has lower risks and complications compared to blind or surgical techniques [2,3].
Since its rst introduction, ultrasound-guided pericardiocentesis procedure has been re ned and shaped into better techniques with different approaches [4]. The older practice used echocardiography to diagnose pericardial effusion and locate the best site for puncture [5]. This method, known as echocardiography-assisted pericardiocentesis, does not provide continuous ultrasound visualization of needle trajectory. The newer approach is a true echocardiography-guided procedure that uses ultrasound transducer to guide the needle, allowing the clinician to avoid injury to surrounding structures [5,6]. This is a case report of our experience with a novel subcostal in-plane ultrasound-guided pericardiocentesis using linear transducer for a patient with cardiac tamponade in the emergency department (ED).

Case Report
A 50-year-old man with underlying hypertension presented to ED with shortness of breath for 1 week. His vital signs revealed a blood pressure of 85/45 mmHg, heart rate of 120 per minute, respiratory rate of 28 per minute, temperature of 37 C, and oxygen saturation (SPO2) of 82% with oxygen 12 L/min. Physical examination revealed he was in respiratory distress and he was diaphoretic. His jugular venous pressure was not raised and his cardiorespiratory system did not reveal any signi cant ndings. He was intubated and mechanically ventilated. Electrocardiogram showed sinus tachycardia and chest radiograph revealed

Discussion
This case illustrated a successful pericardiocentesis procedure using subcostal approach with real-time ultrasound guidance. The contemporary use of ultrasound has allowed pericardiocentesis to be performed at any position surrounding the pericardium [4,5]. In this case the subcostal site was chosen because this was where the image was clearest, and the pericardial collection was largest.
Traditionally, pericardiocentesis which was performed blindly using the subxiphoid approach, the older term used interchangeably with subcostal approach, had a high complication rate of 5-20% [7,8]. Vayre et al performed ultrasound-guided subcostal pericardiocentesis with contrast study to detect accidental cardiac puncture [9]. However, a 10% rate of right ventricular puncture was still observed because the procedure was not completely done under real-time ultrasound guidance [10].
Recently, Law et al demonstrated that this technique could still be a safe procedure. He con rmed this by using long axis in-plane approach at subcostal area for pericardiocentesis. The procedure was carried out on 14 post-operative pediatric patients and no complications were observed [11]. In adult patients, the increase of depth of surrounding tissues and structures may affect angulation of the needle and it will be more challenging. In this case, we demonstrated that in-plane subcostal approach using high frequency linear probe safe and feasible in adult patients.
Before the era of ultrasound, subxiphoid or subcostal approach was the most widely accepted method due to its high success rate to locate anatomical landmark at Larrey's triangle [12,9]. After the introduction of ultrasound, the practice had tremendously changed and anatomical location for pericardiocentesis varies. Para-apical is the most common site (63%), followed by subcostal (15%) and parasternal (14%) [10]. The para-apical approach is preferred because it is usually where the pericardial space is closest to the probe and the uid accumulation is maximal [5,13]. Osman et al. demonstrated the left parasternal with medial to lateral approach which provided excellent visualization of needle trajectory. This practice avoids injury to surrounding structures making the procedure practically free from any complications [14]. Apical approach is less commonly preferred due to the risk of left ventricular perforation and left pneumothorax [15].

Conclusion
The in-plane subcostal pericardiocentesis is a safe and simple approach that can be performed in ED for patients with cardiac tamponade. We recommend this new technique as an alternative when cardiac window for other approaches cannot be visualized.

Declarations
Authors' contribution OA and CPF , NSS , and MFB was involved in the initial conception and drafting of the manuscript. All authors contributed to the image interpretation, writing and revision of the manuscript.
Written informed consent was obtained from the patient for publication of this case report and accompanying images.

Availability of data and materials
The material are available from the corresponding author on reasonable request Funding Authors received no funding for this clinical trial from any institution/ individual.

Figure 1
A high frequency linear ultrasound transducer was placed horizontally at subcostal area with the marker pointing caudally Figure 2