Pericardiocentesis is the removal of fluid from the pericardial
space surrounding the heart. The fluid is usually aspirated with
a needle and syringe. Occasionally, a catheter is placed within
the pericardium or a surgical approach is used. This may be performed
for diagnosis, to obtain pericardial fluid; to relieve a pericardial
effusion and improve cardiac output; or as a lifesaving measure
to relieve a cardiac tamponade. The technique
is relatively simple to perform yet has a significant rate of complications.
Since humanity’s earliest times, penetrating cardiac
injuries have held a dramatic place in both romantic and medical
literature.1–8 In 1649, Riolanus first described
pericardial tamponade.3 He noted that “an abundance
of moisture is collected therein [the pericardium],
which causes suffocation, and overwhelms the heart.” In
1827, Thomas Jowett described the first use of pericardiocentesis
as an intervention for pericarditis.4 In 1829, Baron Larrey,
Napoleon’s Surgeon, is reported to have performed the first
successful pericardiocentesis.5 By 1939, Bigger had suggested
that some patients with cardiac tamponade could be managed with
pericardial tubes alone, with prompt operation for recurrence.7
The pericardium is an inverted cone-shaped sack surrounding the
heart and lying on top of the diaphragm (Figure 25-1). The inner
portion, or visceral pericardium, is a single layer of mesothelial
cells covering the epicardium. The outer layer is composed of a
dense outer fibrous tissue with an inner layer of mesothelial cells
known as the parietal pericardium. The fibrous pericardium is attached
to the central tendinous portion of the diaphragm inferiorly. Superiorly,
the outer fibrous layer blends with the sheath covering the great
vessels. Anteriorly, it attaches to the posterior surface
of the sternum. Posteriorly, it is attached to the thoracic vertebral
column, esophagus, bronchi, and aorta.
The pericardium. A. Relationship
of the pericardium to the major thoracic structures. B. Midsagittal section through the
heart and pericardium.
The heart is contained within the pericardial sac. Numerous portions
of the heart are exposed behind the anterior chest wall (Figure
25-2). This includes the right ventricle, left ventricle, right atrium,
left atrium, aorta, pulmonary artery, and inferior vena cava. These
structures are vulnerable to injury behind the anterior chest wall9,10 (Table
25-1). The surface area that each of these structures contributes
to the anterior cardiac silhouette is also listed in this table.
These numbers reflect, roughly, the anatomic incidence of injury
with cardiac trauma.11 Traumatic injury to any of these
structures can result in a pericardial effusion and cardiac tamponade.
View of the heart and great vessels, which can become
injured behind the anterior chest wall. (AO = aorta,
IVC = inferior vena cava, LA = left
atrium, LV = left ...
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