Flexible percutaneous pericardioscopy: Inherent drawbacks and recent advances

Pericardioscopy enables endoscopic inspection and aimed biopsy of the parie tal and visceral pericardium. To elucidate possible technical modifications contributing to the feasibility diagnostic value and safety of the procedu re, pericardioscopy with an Olympus HYF-1T flexible endoscope was performed in 32 patients (53.1% males, mean age 46.2 +/- 13.1 years) with pericardia l effusions. In all patients, the initial step of the procedure was subxiphoid fluorosco pically controlled pericardiocentesis and drainage of the pericardial effus ion. An Olympus FB-41ST biopsy forceps was applied for endoscopically guide d pericardial biopsies. Standard sampling was used in 22/32 patients (3 to 6 samples/patient) and extensive sampling in 10/32 patients (18 to 20 sampl es/patient). In additional 12 patients pericardial biopsy was performed wit hout pericardioscopy, under fluoroscopic control. Endoscopic visualization was clearly superior when pericardial effusion was partially replaced with 100 to 300 ml of air (29/32 procedures) in compari son to 3/32 procedures in which the pericardial effusion was replaced with warm normal saline (37 degreesC). In patients with hemorrhagic effusion (12 /32), we either repeatedly injected and removed 100 to 150 ml volumes of no rmal saline (37 degreesC), or postponed pericardioscopy for 2 to 3 days of active drainage. The specificity of endoscopic findings is low and not deci sive for the diagnosis. However, pericardioscopy is significantly contribut ing to the diagnostic value of pericardial biopsy, especially regarding est ablishing the new diagnosis and eitology of the pericardial disease. Sampli ng efficiency was also significantly higher for procedures using aimed peri cardial biopsy with standard and extensive sampling compared to procedures performed under fluoroscopy: 86.2%, 87.3%, and 43.7%, respectively. No majo r complications directly related to the procedure were encountered. Minor c omplications included: short-run ventricular tachycardia (6.3%), pain at th e sheath entry site (75%) and transient fever (37.5%). In conclusion, pericardioscopy with Olympus HYF-1T, after air instillation, is a technically complex, but safe procedure that enables excellent visual ization and extensive pericardial sampling with improved diagnostic value o f pericardial biopsies.