SHAPE Society

1. University Institute for Cardiovascular Diseases, Belgrade, YUUniversity Institute for Cardiovascular Diseases, Belgrade, YU
PERICARDIOSCOPY ANDPERICARDIOSCOPY AND
PERICARDIAL BIOPSYPERICARDIAL BIOPSY
- Belgrade experience -- Belgrade experience -
Prof. Petar M. Seferović, MD, PhD, FESC, FACC

2. Pericardioscopy and Pericardial BiopsyPericardioscopy and Pericardial Biopsy
HISTORICAL OVERVIEWHISTORICAL OVERVIEW
♦ Initiated byInitiated by Santos and FraterSantos and Frater in 1977in 1977
♦ Flexible pericardioscopy -Flexible pericardioscopy - KondosKondos et al.et al. JACCJACC
19861986
♦ Transcutaneous approach in local anesthesia -Transcutaneous approach in local anesthesia -
MaischMaisch et al.et al. Eur Heart JEur Heart J 19911991
♦ Until nowUntil now implemented inimplemented in 16 centers16 centers
♦ OnlyOnly Marburg, Maryland and BelgradeMarburg, Maryland and Belgrade seriesseries
are dealing with non-surgicalare dealing with non-surgical,, transcutaneoustranscutaneous
approach in local anesthesiaapproach in local anesthesia

3. ♦PE ofPE of unknown etiologyunknown etiology
♦PE in pts with knownPE in pts with known
malignancymalignancy
♦Verification ofVerification of perimyocarditisperimyocarditis
♦Verification ofVerification of tuberculoustuberculous
pericarditispericarditis
♦PBPPBP window verificationwindow verification
Pericardioscopy and Pericardial BiopsyPericardioscopy and Pericardial Biopsy
I N D I C A T I O N SI N D I C A T I O N S

4. Pericardioscopy and Pericardial BiopsyPericardioscopy and Pericardial Biopsy
AIM OF THE STUDYAIM OF THE STUDY
♦ TTo assess the feasibility and diagnostico assess the feasibility and diagnostic
value of three approaches to pericardialvalue of three approaches to pericardial
biopsy:biopsy:
1.1. FFluoroscopic controlluoroscopic control and standardand standard
samplingsampling
2.2. PPericardioscopyericardioscopy guidance with eitherguidance with either
standardstandard oror
3.3. EExtensive samplingxtensive sampling..

5. Pericardioscopy and Pericardial BiopsyPericardioscopy and Pericardial Biopsy
P A T I E N T SP A T I E N T S
PATIENTS N Males (%) Mean age
(yrs)
Evacuated PE
(ml)
Samples/pt
Group 1
(fluoroscopy)
12 66.7 46.7±12.2 775.0±171.2 3-6
Group 2
(pericardioscopy/
standard sampling)
22 50.0 50.8±10.4 769.5±185.7 4-6
Group 3
(pericardioscopy/
extensive sampling)
15 53.3 53.7±12.8 790.0±204.6 18-20

6. ♦ SubxiphoidSubxiphoid
pericardiocentesispericardiocentesis andand
drainage of PEdrainage of PE
♦ Instillation of 200 ml salineInstillation of 200 ml saline
♦ 7F7F introducer-sheath setintroducer-sheath set
♦ Position at thePosition at the upper leftupper left
laterallateral surface of thesurface of the
parietal pericardiumparietal pericardium
♦ OlympusOlympus FB-43ST forcepsFB-43ST forceps
(fenestrated, central needle)(fenestrated, central needle)
♦ 4-6 samples4-6 samples (mean 5.1)(mean 5.1)
Pericardial Biopsy Using FluoroscopyPericardial Biopsy Using Fluoroscopy
M E T H O DM E T H O D
N=12 pts (group 1)

7. ♦ SubxiphoidSubxiphoid pericardiocentesispericardiocentesis
and drainage of PEand drainage of PE
♦ LLocal anesthesiaocal anesthesia
♦ Olympus HYF-1Olympus HYF-1TT, 16F, 16F
flexible endoscopeflexible endoscope
♦ GGradual dilationradual dilation (9(9,, 12, 14F12, 14F))
up toup to 16.5F introducer-set16.5F introducer-set
♦ PericardialPericardial biopsy targeted bybiopsy targeted by
pericardioscopypericardioscopy ((OlympusOlympus
FB-43ST forceps )FB-43ST forceps )
Pericardioscopy and Pericardial BiopsyPericardioscopy and Pericardial Biopsy
M E T H O DM E T H O D
N=37 pts (groups 2 & 3)

8. Flexible percutaneous pericardioscopyFlexible percutaneous pericardioscopy
BELGRADE METHODOLOGYBELGRADE METHODOLOGY
MODIFICATIONSMODIFICATIONS
(Seferovic PM, et al. Herz 2000)(Seferovic PM, et al. Herz 2000)
♦ Olympus HYF-1T, 16FOlympus HYF-1T, 16F
flexible endoscope (flexible endoscope (biopsybiopsy
channel 2.2 mmchannel 2.2 mm))
♦ Active pericardial drainageActive pericardial drainage
♦ Intrapericardial instillationIntrapericardial instillation
of 100-300 ml of airof 100-300 ml of air
♦ AIMED BIOPSYAIMED BIOPSY
♦ EXTENSIVE SAMPLINGEXTENSIVE SAMPLING
(up to 20 samples/pt)(up to 20 samples/pt)
♦ Pericardioscopy after PBPPericardioscopy after PBP

9. MACROSCOPICMACROSCOPIC
PERICARDIOSCOPY FINDINGSPERICARDIOSCOPY FINDINGS
(Seferovic PM, et al. Herz 2000)(Seferovic PM, et al. Herz 2000)
Pericardioscopy
macroscopic
findings
Neoplastic
pericardits
(n=10 pts)
Nonspecific
inflammatory
pericarditis
(n=7 pts)
Tuberculous
pericarditis
(n=3 pts)
Adhesion strands 4 (40%) 2 (28.6%) 1 (33.3%)
Massive adhesions 2 (20%) 0 1 (33.3%)
Fibrin deposition 2 (20%) 4 (57.1%) 1 (33.3%)
Vascular injections 8 (80%) 7 (100%) 2 (66.7%)
Areas of hyperemia 6 (60%) 6 (85.7%) 2 (66.7%)
Infiltration 7 (70%) 1 (14.3%) 1 (33.3%)
Protrusions 6 (60%) 0 1 (33.3%)
all p>0.05

10. Olympus
FB-43ST Biopsy
Forceps
Group 1
(12 patients)
Fluoroscopy
3-6 samples
Group 2
(22 patients)
Pericardioscopy
4-6 samples
Group 3
(15 patients)
Pericardioscopy
18-20 samples
Feasibility of
pericardial access
92.8% 96.2% 100%
Feasibility of sheath
introduction
92.3% 96.0% 100%
Adequate pericardial
visualization
Not applicable 90.9% 93.3%
Sampling efficiency 43.7% 84.9%** 84.2%**
Pericardioscopy and Pericardial BiopsyPericardioscopy and Pericardial Biopsy
FEASIBILITY AND SAMPLINGFEASIBILITY AND SAMPLING
EFFICIENCYEFFICIENCY

11. Pericardioscopy and Pericardial BiopsyPericardioscopy and Pericardial Biopsy
SAMPLING EFFICIENCY /SAMPLING EFFICIENCY /
SENSITIVITYSENSITIVITY
43.7
84.9
84.2
41.7
63.6
93.3
Group 1 (fluoroscopy, 12 pts, 3-6 samples/pt)
Group 2 (pericardioscopy, 22 pts, 4-6 samples/pt)
Group 3 (pericardioscopy, 15 pts, 18-20 samples/pt
0 20 40 60 80Sampling efficiency Sensitivity
**
**
**
(%)

12. Pathohistology Group 1
(12 patients)
Fluoroscopy
3-6 samples
Group 2
(22 patients)
Pericardioscopy
4-6 samples
Group 3
(15 patients)
Pericardioscopy
18-20 samples
Planocellular Ca 1 (8.3%) 3 (13.6%) 13.3 %
Adenocarcinoma 0 3 (13.6%) 6.7%
Mesothelioma 0 0 6.7%
Plasmocytoma 0 1 (4.5%) 0
Hodgkin’s disease 0 1 (4.5%) 6.7%
Tuberculosis 0 1 (4.5%) 20 %
Nonspecific
inflammation
4 (33.3%) 5 (22.7%) 40 %
False negative 58.3 36.4 6.7**
Pericardioscopy and Pericardial BiopsyPericardioscopy and Pericardial Biopsy
HISTOLOGYHISTOLOGY

13. 8.3 8.3
33.3
58.3
26.3
40.9
36.4
36.440
53.3 53.3
6.7
New Dg. Etiology Clin.Dg.confirmed No useful information
0
20
40
60
80
100
%
Fluoroscopic biopsy (3-6 samples)
Pericardioscopy (3-6 samples)
Pericardioscopy (18-20 samples)
* *
* *
DIAGNOSTIC VALUE OFDIAGNOSTIC VALUE OF
PERICARDIOSCOPYPERICARDIOSCOPY ANDAND
PERICARDIAL BIOPSYPERICARDIAL BIOPSY

14. ♦ Excellent visualizationExcellent visualization but nonspecificbut nonspecific
macroscopic findingsmacroscopic findings..
♦ Pericardioscopic guidancePericardioscopic guidance enhancedenhanced
pericardial sampling efficiency.pericardial sampling efficiency.
♦ TheThe diagnostic value of pericardial biopsydiagnostic value of pericardial biopsy
was significantly improved by extensivewas significantly improved by extensive
samplingsampling made possible by pericardioscopy.made possible by pericardioscopy.
Pericardioscopy and Pericardial BiopsyPericardioscopy and Pericardial Biopsy
CONCLUSIONSCONCLUSIONS