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Selected Reports

Endobronchial Ultrasound
A New Technique of Pericardiocentesis in Posterior Loculated
Pericardial Effusion
Rahul K. Sharma, DM; Arjun Khanna, DM; and Deepak Talwar, DM

Diagnostic and therapeutic pericardiocentesis is traditionally carried out via the transthoracic
route under ultrasound or echocardiographic guidance. Posteriorly located loculated pericardial
effusion cannot be safely drained using the standard subxiphoid or apical, intercostal approach.
In the presence of clinically signicant loculated effusion or effusion requiring diagnostic
pericardiocentesis where an echocardiographic approach is not feasible, patients are usually
referred for surgery. We here present a novel minimally invasive endobronchial ultrasoundguided approach for the aspiration of posteriorly loculated pericardial effusion that may
obviate the need for surgery and its related complications.
KEY WORDS:

endobronchial ultrasound; loculated pericardial effusion; pericardiocentesis

Pericardiocentesis under echocardiographic

guidance is considered the procedure of
choice for etiologic diagnosis and therapeutic
evacuation of pericardial effusions. An
echocardiogram or sometimes CT-guided
subxiphoid or parasternal approach is used
for this purpose.1 However, posteriorly
loculated effusion cannot be approached this
way, often requiring surgical intervention.
Various nonconventional techniques
of pericardiocentesis including internal
transcardiac pericardiocentesis for
myocardial perforation occurring during
cardiac catheterization,2 echocardiogramguided pleuropericardial drainage by the
left axillary approach,3 and CT-guided
pericardiocentesis1 using a stereotactic
guidance device have been described in
the literature. Pericardial access through
the transatrial route has also been used safely

ABBREVIATIONS: EBUS = endobronchial ultrasound; TBNA = transbronchial needle aspiration

AFFILIATIONS: From the Metro Centre for Respiratory Diseases,
Metro Multispeciality Hospital, Noida, India.

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CHEST 2016; 150(5):e121-e123

on laboratory animals.4 We here report a

novel method of endobronchial ultrasound
(EBUS) Doppler-guided transbronchial
access for posterior loculated pericardial
effusion.

Case Report
A 59-year-old woman, reporting hypertension
and diabetes mellitus for 8 years, presented
to the ED with breathlessness accompanied
by orthopnea and paroxysmal nocturnal
dyspnea for 3 days. She also complained of a
dry cough with fever for the past 15 days and
history of signicant weight and appetite
loss for the past 8 months.
On examination, she was conscious, alert,
febrile, tachypneic, and tachycardic with
BP 100/70 mm Hg and a room air oxygen
saturation of 92%. Her jugular venous
pressure was raised and there were bilateral

CORRESPONDENCE TO: Rahul K. Sharma, DM, Metro Centre for

Respiratory Diseases, L-94, Sector 11, Noida, IN 201301; e-mail:
dr.rahulksharma@gmail.com
Copyright 2016 American College of Chest Physicians. Published by
Elsevier Inc. All rights reserved.
DOI: http://dx.doi.org/10.1016/j.chest.2016.03.013

e121

Figure 1 CT scan of the chest showing the (A) posteriorly loculated pericardial effusion and the (B) site of endobronchial ultrasound scope placement
in the left lower bronchus for localization of pericardial effusion (arrow).

crepitations and wheezing on chest examination, with

no other systemic abnormality.
Laboratory examination revealed hemoglobin 11.1
gm/dL, total leukocyte count 8,100/mm3, normal liver
and kidney function tests, and raised brain natriuretic
peptide levels (12,000 pg/mL). Workup for fever was
negative. Chest radiograph showed cardiomegaly
with increased vascular markings in parahilar region.
Echocardiogram also revealed cardiomegaly with
posteriorly located pericardial effusion, not amenable
for echocardiogram-guided diagnostic aspiration. A
CT scan of the chest conrmed the posteriorly located
pericardial effusion with pretracheal and hilar mediastinal
lymphadenopathy (Fig 1).
A diagnosis of pulmonary TB was suspected clinically, and
an EBUS-transbronchial needle aspiration (TBNA) was
done under conscious sedation with electrocardiographic

and vital monitoring after informed consent. The

subcarinal lymph node was approached from the right
main bronchus and pericardial effusion was localized by
an EBUS Doppler probe through the anterior wall of the
left lower lobe bronchus. The pericardium was identied
above the left atrium, which showed thickening and
internal septations with no vascularity.
Subsequently, an EBUS-TBNA needle was slowly
advanced into the pericardial cavity (Fig 2). Ten
milliliters of straw-colored pericardial uid was
aspirated and revealed lymphocytic exudative effusion
with an adenosine deaminase level of 92 IU/L.
The subcarinal lymph node showed necrotizing
granuloma, conrming the diagnosis of TB. The patient
tolerated the procedure well with no postprocedural
complications. She was subsequently started on anti-TB
therapy with steroids in view of pericardial involvement
being diagnosed by EBUS-guided pericardiocentesis;

Figure 2 Endobronchial ultrasound images showing a transbronchial needle aspiration needle in the pericardial space, with the left atrium (LA) below
showing widening of pericardial space during atrial contraction.

e122 Selected Reports

150#5 CHEST NOVEMBER 2016

she has improved symptomatically on follow-up at

4 weeks.

experience of EBUS-TBNA of mediastinal lymph nodes,

studies have shown that it is a safe procedure with very
low complication rate.7

Discussion

This technique is rather easy for operators skilled in

TBNA, and is safe, economical, and well-tolerated. To
the best of our knowledge, this is the rst such report
of its kind from the Indian subcontinent. Though not
adequately researched, it forms a landmark in the
management of posterior pericardial effusion and
requires further study to understand the benets and
possible hazards of this procedure.

Diagnostic pericardiocentesis is traditionally carried out

via echocardiogram-guided transthoracic route, but
most posteriorly located pericardial effusions cannot be
drained using this technique, necessitating the use of
surgery in such cases. A previous study describes a
bronchoscopic approach to pericardial effusion in three
patients by gaining needle access through the left lower
lobe bronchus or through the distal trachea based on CT
assessment.5 This was somewhat of a blind procedure,
which though uneventful in the present case series, has
potential to cause nearby vascular injury.
We describe a novel real-time, EBUS-guided approach to
drain the posteriorly located pericardial effusion. This is a
simple and safe way of sampling even minimal effusions
for diagnostic purposes. The pericardial cavity can be
safely reached with accuracy under real-time Doppler
imaging without any risk of touching the myocardium.
This approach can be used to establish an otherwise
difcult diagnosis of pericardial diseases, including the
staging of tumors in patients with a malignancy and
pericardial effusion.6 It could also represent a less
invasive alternative to surgery when evacuation cannot be
performed via either subxiphoid or parasternal puncture.
In theory, it is possible that gaining access to the
pericardium through the nonsterile bronchus could lead
to pericardial infection. No published literature is
available on this issue; nevertheless, looking into the

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Acknowledgments
Financial/nonnancial disclosure: None declared.

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