Pericardial effusion, the collection of fluid around the heart, typically occurs in patients following heart surgery and when symptomatic, is usually treated by surgeons, using an invasive surgical drainage technique.

Recently, researchers have discovered that a minimally invasive procedure called CT-guided tube pericardiostomy is just as effective and requires no recovery time. What's more, the procedure costs 89 percent less than the standard surgical drainage technique, according to a study published in the October issue of the American Journal of Roentgenology (AJR).

The study performed by Suzanne L. Palmer, M.D. at the University of Southern California Keck School of Medicine, included 39 CT-guided tube pericardiostomy procedures, all performed successfully.

"The purpose of this paper was to show the simplicity of using a technique familiar to most radiologists for a [cardiac) procedure that is daunting to those same radiologists," Dr. Palmer tells DOTmed News.

Regarding the cost-savings of the radiological approach, Dr. Palmer says the charges are much lower for some very simple reasons: The CT procedure is done in the imaging department in the CT scanner room with minimum personnel, she says. Typically, only a radiologist and the CT tech are present. The procedure lasts about 30 minutes from start to finish and there is no pre-op or post-op recovery needed.

In comparison, surgical drainage requires the use of an operating suite and general anesthesia. The personnel that are required include a surgeon, anesthesiologist, scrub nurse and OR nurse at minimum. Although, the drainage procedure is very quick, at least one hour of OR time is used. And then the patient needs to be sent to the post-op recovery room, which results in additional charges, Dr. Palmer says.

Cardiac Surgeons May Balk

She notes that because the CT procedure is safe, effective and less costly than surgical drainage, it is a "small but key measure of health care reform." However, she fears cardiac surgeons may balk at letting radiologists take over what is now their work, as it would hurt their pocketbooks.

She tells DOTmed, "I had no problem getting this procedure accepted by my cardiothoracic colleagues at USC because we have an excellent working relationship and we want to do what is best for the patient, regardless of potential loss of income. But I can see how this may be different at other institutions."

Refresher Course at RSNA

Dr. Palmer says her study is an attempt to promote the CT-pericardial procedure. To this end, she has been moderating a refresher course on
thoracic procedures at the Radiological Society of North America for the past two years, presenting CT tube pericardiostomy as part of the course.

"I will be doing it again this year," she tells DOTmed. "I clearly need more venues to get this information out to our surgical colleagues. Radiologists are capable of and willing to do the procedure but without the cardiothoracic surgeons' support we will not get the patient referrals."

How CT-Guided Tube Pericardiostomy Works

Patients are brought to the radiology department, to CT, and placed on the table just as if they were getting a routine CT examination. Images of
the chest are taken without any contrast injection.

When conducting the procedure herself, Dr. Palmer says that first she decides whether the fluid around the heart is accessible and if it is, she chooses the safest route for the needle and tube to traverse, to avoid injuring the lung, the heart and the major vessels in the chest.

"All of these structures are very well seen on CT," she says. "When I have decided on the path, we can begin. There is no patient preparation needed. I clean the patient's chest and use a generous amount of lidocaine for local anesthesia. No general anesthesia is used and conscious sedation is necessary only when the patient is very anxious. Only one patient has needed anything more than local anesthesia."

She continues, "I then use a small sheathed needle to get through the skin and though the tough, fibrous covering around the heart (pericardium). I check on the location of the needle/catheter intermittently with CT scanning, in order to make sure that I am going in the correct direction and confirming that I am not near any vital structures.

"When I 'hit' fluid, I know that I am in the space around the heart. After I have reached the fluid, I take out the center needle from the catheter, and feed a wire through the catheter and into the fluid. After dilating the tract, I place the final catheter into the fluid over the wire, remove the wire and sew the catheter to the skin with one suture. I then remove all of the fluid from around the heart manually with a syringe, and the procedure is done. The catheter is small, almost the same size as IV tubing," Dr. Palmer says.

Awake and Alert

Throughout the procedure, Dr. Palmer talks to patients, telling them what she is doing and making sure that they are feeling okay. Even though she is working right in front of them, most patients have no problem with being awake and alert for this procedure, she says.

Source: ARRS