Real-time cardiovascular magnetic resonance subxiphoid pericardial access and pericardiocentesis using off-the-shelf devices in swine

Abstract

BackgroundNeedle access or drainage of pericardial effusion, especially when small, entails risk of bystander tissue injury or operator uncertainty about proposed trajectories. Cardiovascular magnetic resonance (CMR) might allow enhanced imaging guidance.Methods and resultsWe used real-time CMR to guide subxiphoid pericardial access in naïve swine using commercial 18G titanium puncture needles, which were exchanged for pericardial catheters. To test the value of CMR needle pericardiocentesis, we also created intentional pericardial effusions of a range of volumes, via a separate transvenous-transatrial catheter. We performed these procedures in 12 animals.Pericardiocentesis was performed in 2:47 ± 1:43 minutes; pericardial access was performed in 1:40 ± 4:34 minutes. The procedure was successful in all animals. Moderate and large effusions required only one needle pass. There were no complications, including pleural, hepatic or myocardial transit.ConclusionsCMR guided pericardiocentesis is attractive because the large field of view and soft tissue imaging depict global anatomic context in arbitrary planes, and allow the operator to plan trajectories that limit inadvertent bystander tissue injury. More important, CMR provides continuous visualization of the needle and target throughout the procedure. Using even passive needle devices, CMR enabled rapid pericardial needle access and drainage. We believe this experience supports clinical testing of real-time CMR guided needle access or drainage of the pericardial space. We suspect this would be especially helpful in “difficult” pericardial access, for example, in distorted thoracic anatomy or loculated effusion.

Interventional Cardiac Magnetic Resonance Imaging in Electrophysiology

“…39,40 A comparison between these needles demonstrates favorable results for active tracking. Active needles needed shorter access time (88 versus 244 s; P=0.022) and required significantly fewer needle passes (4.5 versus 9.1; P=0.028).…”

“…In addition, a recent animal study demonstrated the feasibility of performing pericardiocentesis inside the scanner room using commercially available needles. 39 In total, 12 successful procedures (no complications) were performed using a realtime imaging approach and passive tracking of the needle. This development increases the practicability of complex ablative therapy in the scanner and significantly expands the emergency solving capacity of iCMR.…”

Magnetic Resonance Sequences and Rapid Acquisition for MR-Guided Interventions

“…Passive visualization uses the intrinsic material properties. For example, metallic devices (e.g., biopsy needles, guidewires, stents, occluders) create a signal void on real-time MR images because they distort the local magnetic field, leading to local signal dephasing 56 . Signal voids can be emphasized using long TE gradient echo sequences.…”

MRI Catheterization in Cardiopulmonary Disease

“…In patients with pulmonary hypertension, a lack of right ventricular functional augmentation and pulmonary vascular resistance reduction neous transthoracic left ventricular access for delivery of large devices, 45 direct transthoracic ventricular septal defect closure, 46 atrial septal puncture and balloon septostomy, 47 aortic coarctation stenting, 48 and MRIguided pericardiocentesis. 49 The great advantage of MRI over radiographic fl uoroscopy is the ability to view the interaction of devices with the surrounding tissue in real time. For example, while deploying stents or stent grafts or cardiac implants, the operator can watch for and address iatrogenic rupture, dissection, or pericardial tamponade.…”