key: cord-0078831-44m94jxh
authors: Ferro, Baldassare; Vegnuti, Lara; Santonocito, Orazio; Roncucci, Paolo
title: Ultrasound emergency lateral-to-medial parasternal pericardiocentesis with high frequency probe in Covid-19: a case report
date: 2022-05-13
journal: Eur Heart J Case Rep
DOI: 10.1093/ehjcr/ytac203
sha: 1354a515d2317081d5a72f4d42cf9eaaa77cbf67
doc_id: 78831
cord_uid: 44m94jxh

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 years old female patient with severe Covid-19 related Acute Respiratory Distress Syndrome (ARDS) 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 hemodynamic instability due to cardiac tamponade.

The pathological involvement of the heart is frequent in Sars-Coronavirus-2 infection (Covid-19) with 3 various clinical and echocardiographic manifestations during the course of the disease. 4

A 69 years old female patient with severe Covid-19 related Acute Respiratory Distress Syndrome (ARDS) 6

undergoing mechanical ventilation developed acute left ventricular dysfunction, that successfully improved 7 with vasoactive therapy. After 5 days, she suddenly developed hemodynamic instability due to acute onset of 8 pericardial effusion, which required emergency pericardiocentesis. Ultrasound guided parasternal 9

pericardiocentesis with high frequency linear probe and lateral-to-medial in-plane approach was performed 10 by inserting a central venous catheter using a Seldinger technique. 700 ml of serous fluid was 11 drained resolving the acute critical state. 12

Pericardial effusion with cardiac tamponade is a rare manifestation of Covid-19. Despite the diffusion of 14 echocardiography, emergency cardiac procedures could be particularly difficult to be performed in a 15 pandemic scenario of limited resources and the heterogeneous skills of the professional figures involved in 16 the management of Covid-19 patients. The spread of expertise in ultrasound guided vascular cannulation 17 makes this approach attractive for anesthesiologists, emergency medicine and critical care specialists too. 18

Furthermore in this pericardiocentesis' technique, the high frequency linear probe adds optimal spatial 19 resolution to maintain a close control of the needle's direction. However the need of a good parasternal view 20 and a deep ultrasound knowledge are crucial to avoid iatrogenic complications. In conclusion, ultrasound 21

guided lateral-to-medial parasternal pericardiocentesis with high frequency linear probe is an alternative to 22

treat potential lethal acute hemodynamic instability due to cardiac tamponade. 23 

Learning points 2 1) Cardiac tamponade is a rare but life-threatening manifestation of myopericarditis that should be suspected and 3 diagnosed in the acute onset of hemodynamic instability in Covid-19 patients.

2) Ultrasound guided lateral-to-medial parasternal pericardiocentesis guided by high frequency linear probe could 5 be useful in a pandemic scenario of limited resources and of heterogeneous professional skills. The pathological involvement of the heart is frequent in Sars-Coronavirus-2 infection (Covid-19) with 6

various clinical and echocardiographic manifestations during the course of the disease. 7

A 69 years old female patient with severe Covid-19 related Acute Respiratory Distress Syndrome (ARDS) 9

undergoing mechanical ventilation developed acute left ventricular dysfunction, that successfully improved 10 with vasoactive therapy. After 5 days, she suddenly developed hemodynamic instability due to acute onset of 11 pericardial effusion, which required emergency pericardiocentesis. Ultrasound guided parasternal 12 pericardiocentesis with high frequency linear probe and lateral-to-medial in-plane approach was performed 13 by inserting a central venous catheter using a Seldinger technique. 700 ml of serous fluid was 14 drained resolving the acute critical state. 15

Pericardial effusion with cardiac tamponade is a rare manifestation of Covid-19. Despite the diffusion of 17 echocardiography, emergency cardiac procedures could be particularly difficult to be performed in a 18 pandemic scenario of limited resources and the heterogeneous skills of the professional figures involved in 19

the management of Covid-19 patients. The spread of expertise in ultrasound guided vascular cannulation 20 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 22 resolution to maintain a close control of the needle's direction. However the need of a good parasternal view 23 and a deep ultrasound knowledge are crucial to avoid iatrogenic complications. In conclusion, ultrasound 24

guided lateral-to-medial parasternal pericardiocentesis with high frequency linear probe is an alternative to 25 treat potential lethal acute hemodynamic instability due to cardiac tamponade. and safety (4). We hereby report the case of a patient undergoing mechanical ventilation for severe Acute 42

Respiratory Distress Syndrome (ARDS) and cardiac manifestations of Sars Cov-2 infection, aggravated by 1 the rapid formation of pericardial effusion, in whom ultrasound guided lateral-to-medial parasternal 2 emergency pericardiocentesis with high frequency linear probe and the insertion of a central venous catheter 3 was able to resolve a near fatal cardiac tamponade 4 5 6

A 69 years old female patient was admitted to the Emergency Department after 5 days from onset of 8 symptoms related to Sars Cov -2 infection. She referred worsening dyspnea, extreme fatigue, and 9

palpitations. She was tachycardic (120 beats/min) and tachypneic ( 42 breaths/min) with no fever on 10 physical examination. Her past medical history was negligible for cardiac or any other pathology The 11

arterial blood gas analysis revealed severe hypoxemia (paO2/fiO2 87) and respiratory alkalosis (pH 7.51, The ward cardiologist was called but he couldn't be on the scene before 30 minutes. 34

The need of emergency pericardiocentesis was established due to deterioration of the hemodynamic 35 condition in the context of a difficult setting and the absence of a dedicated kit. A modified off-axis 36

parasternal echocardiographic view at fifth intercostal space with high frequency linear probe was 37 performed (fig 1) , evidencing the point of intersection between lung and pericardium, the pericardial fluid 38 over the right ventricle and the intercostal vessels (video 3). This view was obtained with a gently clockwise 39 rotation of the high frequency linear probe until the ribs were displayed on a trasversal plane, ensuring a 40 solid support surface away from lung sliding. The depth of the image was adjusted to enhance needle's 41 visualization and the movement of the right ventricle wall. This approach let to insert a central venous 42

catheter with an in-plane ultrasound guided Seldinger technique (video 4). Small horizontal movements 43 under the probe were essential to monitor the tip of the needle, its pathway and guidewire's progression in 44 the pericardial sac (video 4). Color doppler avoided accidental puncture of the intercostal vessels. The 45

procedure was uneventful and the drainage of 700 ml of serous fluid resolved the critical condition (fig 2) . 46

The patient needed tracheostomy and a slow ventilator weaning of another 15 days prior to discharge to 47

rehabilitation center. Ct scan showed near complete resolution of infiltrates and echocardiography was 1 normal at discharge. 2

Despite its rare incidence (5), we described a modified ultrasound guided lateral to medial parasternal 4 pericardiocentesis to resolve a rare but life-threatening condition of cardiac tamponade in a Covid-19 patient 5

und. Clinical presentation of pericardial effusion depends on the rapidity of production and accumulation of 6 fluid in the pericardial sac. Even small amount of effusion can produce dramatic increase of intrapericardial 7 pressure, when the pericardial sac has not the time to increase its compliance lowering its stiffness (6). 8

A position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial 9

Diseases advocates the use of a stepwise scoring system to triage patients with cardiac tamponade. A score > 10 6 ( recent viral infection= 1 point, systolic blood pressure < 95 mmHg = 2 points, sinus tachycardia =1 points 11 rapid worsening of symptoms= 2 points, circumferential pericardial effusion >2 cm in diastole = 3 points, showing the advantages of the procedure in terms of time and practical considerations (9). In this report the 23 lateral-to-medial parasternal approach with an off-axis view, guided by the linear probe let us to perform a 24 safe pericardiocentesis with a perfect view of all surround structures (intercostal vessels, the lung and the 25 right ventricle). This approach could be useful when subxiphoid image is difficult to obtain as in obese 26

patients. Furthermore the use of high frequency probe guarantees an optimal spatial resolution for the 27 complete in-plane visualization of the needle and of the guidewire during the procedure. 28

This technique has an important limitation: the need of a good parasternal view is crucial, but it could be 29 absent in ventilated or emphysematous patients. A short expiratory pause or disconnection from mechanical 30 ventilator could increase the rate of visualization, also reducing the risk of pneumothorax. 31

The spread of expertise in ultrasound guided vascular cannulation makes this approach attractive to different 32 professional emergency figures, but it must be accompanied by a deep ultrasound knowledge to reduce 33 possible iatrogenic fatal complications as right ventricle perforation or pneumothorax. 34

Despite the diffusion of echocardiography in intensive care units, the ability of performing urgent cardiac 36 procedures can be lacking, especially in a pandemic scenario of limited resources and the involvement of 37 various professional figures in the management of Covid-19 patients. 38

The lateral-to-medial parasternal pericardiocentesis technique is of interest, because it can be spread to 39

specialists with skills in ultrasound guided vascular cannulation using a high frequency linear probe, as 40 critical care or emergency doctors and anesthesiologists. 

Consent: The author/s confirm that written consent for submission and publication of this case report 18

including image(s) and associated text has been obtained from the patient in line with COPE guidance. 19

Conflict of interest: none declared. 

COVID-19 myopericarditis: it should be kept in mind in today's conditions

Potential effects of coronaviruses on the cardiovascular system

Cardiac Involvement in a Patient With Coronavirus 7 Disease 2019 (COVID-19)

Echocardiographically-guided pericardiocentesis: evolution and 9 state-of-the-art technique

Pericardial effusion in patients with COVID-19: case series

Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management 14 of Pericardial Diseases of the European Society of Cardiology (ESC)Endorsed by: The European Association for Cardio-15

Thoracic Surgery (EACTS)

Triage strategy for urgent management of 17 cardiac tamponade: a position statement of the European Society of

Pericardial Diseases

Pericardiocentesis: ultrasound guidance is essential

Ultrasound-guided pericardiocentesis: a novel parasternal