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Virk SA, Chandrakumar D, Villanueva C, Wolfenden H, Liou K, Cao C. Systematic review of percutaneous interventions for malignant pericardial effusion. Heart 2015; 101:1619-26. [PMID: 26180077 DOI: 10.1136/heartjnl-2015-307907] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2015] [Accepted: 06/24/2015] [Indexed: 11/03/2022] Open
Abstract
The present systematic review assessed the safety and efficacy of percutaneous interventions for malignant pericardial effusion (MPE), with primary endpoint of recurrence of pericardial effusion. Electronic searches of six databases identified thirty-one studies, reporting outcomes following isolated pericardiocentesis (n=305), pericardiocentesis followed by extended catheter drainage (n=486), pericardial instillation of sclerosing agents (n=392) or percutaneous balloon pericardiotomy (PBP) (n=157). Isolated pericardiocentesis demonstrated a pooled recurrence rate of 38.3%. Pooled recurrence rates for extended catheter drainage, pericardial sclerosis and PBP were 12.1%, 10.8% and 10.3%, respectively. Procedure-related mortality ranged from 0.5-1.0% across the percutaneous interventions. Although isolated pericardiocentesis can safely deliver immediate symptomatic relief, subsequent catheter drainage or sclerotherapy are required to minimize recurrence. PBP has been shown to be highly effective and may be particularly useful in managing recurrent effusions. Ultimately, the choice of intervention must be based on the clinical status of patients, their underlying malignancy and the expertise available.
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Affiliation(s)
- Sohaib A Virk
- The Systematic Review Unit, The Collaborative Research (CORE) Group, Sydney, Australia
| | - David Chandrakumar
- The Systematic Review Unit, The Collaborative Research (CORE) Group, Sydney, Australia
| | - Claudia Villanueva
- Department of Cardiothoracic Surgery, St George Hospital, Sydney, Australia
| | - Hugh Wolfenden
- Department of Cardiothoracic Surgery, Prince of Wales Hospital, Sydney, Australia
| | - Kevin Liou
- Department of Cardiology, Prince of Wales Hospital, Sydney, Australia
| | - Christopher Cao
- The Systematic Review Unit, The Collaborative Research (CORE) Group, Sydney, Australia
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Stainback RF, Hamirani YS, Cooley DA, Buja LM. Tumors of the Heart. CARDIOVASCULAR MEDICINE 2007. [DOI: 10.1007/978-1-84628-715-2_110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Klein SV, Afridi H, Agarwal D, Coughlin BF, Schielke LH. CT directed diagnostic and therapeutic pericardiocentesis: 8-year experience at a single institution. Emerg Radiol 2005; 11:353-63. [PMID: 16344977 DOI: 10.1007/s10140-004-0389-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2004] [Accepted: 11/24/2004] [Indexed: 11/28/2022]
Abstract
UNLABELLED A retrospective review of the 8-year experience at a single institution performing more than 300 CT directed pericardiocenteses was performed. The technique, results, and complications were determined. Comparative data from the literature relating to cardiology and thoracic surgery are reviewed. A CPT code data base search was performed to identify all imaging directed pericardiocenteses at a 550 bed regional medical center between 1993 and 2001. Medical records, imaging studies, and reports as well as pertinent laboratory, chemistry and hematology values were reviewed. Demographics, results, fluid analyses, techniques, systems used and complications were recorded. RESULTS Three hundred and nineteen pericardiocenteses using CT localization were attempted on 261 patients. One hundred and forty-two men were included and mean age was 61 years (range 6 months to 89 years). Mean volume aspirated was 418 cc (range 0-1,875 cc). The major complication rate was 0.3%; the minor complication rate was 6.9%. Technical success was achieved in 98.4% procedures. Emergent pericardiocentesis was performed on anticoagulated patients without significant bleeding. Seventy-nine percent of patients with echocardiographic evidence of tamponade had symptomatic improvement. Patients with marked shortness of breath without other evidence of tamponade benefited symptomatically in 78%. Pericardiocenteses with CT localization is relatively safe and many patients achieve symptomatic relief.
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Affiliation(s)
- S V Klein
- Department of Radiology, Baystate Medical Center, Springfield, MA, 01199, USA.
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Abstract
The pericardium envelopes the cardiac chambers and under physiological conditions exerts subtle functions, including mechanical effects that enhance normal ventricular interactions that contribute to balancing left and right cardiac outputs. Because the pericardium is non-compliant, conditions that cause intrapericardial crowding elevate intrapericardial pressure, which may be the mediator of adverse cardiac compressive effects. Elevated intrapericardial pressure may result from primary disease of the pericardium itself (tamponade or constriction) or from abrupt chamber dilatation (eg, right ventricular infarction). Regardless of the mechanism leading to increased intrapericardial pressure, the resultant pericardial constraint exerts adverse effects on cardiac filling and output. Constriction and restrictive cardiomyopathy share common pathophysiological and clinical features; their differentiation can be quite challenging. This review will consider the physiology of the normal pericardium and its dynamic interactions with the heart and review in detail the pathophysiology and clinical manifestations of cardiac tamponade, constrictive pericarditis, and restrictive cardiomyopathy.
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Affiliation(s)
- James A Goldstein
- Division of Cardiology, William Beaumont Hospital,3601 West Thirteen Mile Road, Royal Oak, MI 48073, USA,
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McDonald JM, Meyers BF, Guthrie TJ, Battafarano RJ, Cooper JD, Patterson GA. Comparison of open subxiphoid pericardial drainage with percutaneous catheter drainage for symptomatic pericardial effusion. Ann Thorac Surg 2003; 76:811-5; discussion 816. [PMID: 12963206 DOI: 10.1016/s0003-4975(03)00665-9] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The optimal therapy for symptomatic pericardial effusions remains controversial. This paper compares outcomes after the two most commonly used techniques, percutaneous catheter drainage and operative subxiphoid pericardial drainage. METHODS We performed a 5-year retrospective, single-institution study to analyze outcomes after either percutaneous catheter drainage or subxiphoid open pericardial drainage for symptomatic pericardial effusions. RESULTS Symptomatic pericardial effusions in 246 patients were treated by open pericardiotomy and tube drainage (n = 150) or percutaneous catheter drainage (n = 96). Drainage duration, total drainage volume, and duration of follow-up (2.6 years) were similar in both groups. Effusions were classified malignant in 79 (32%) patients and benign in 167 (68%) patients. No direct procedural mortality occurred, but the hospital mortality was 16 patients (10.7%) in the open group and 22 (22.9%) in the percutaneous group (p = 0.01) The 5-year survival rate was 51% in the open group versus 45% in the percutaneous group, despite a greater percentage of the open group having a preoperative malignant diagnosis (35% versus 28%). Symptomatic effusions recurred in 16.5% of the percutaneous group compared with 4.6% in the open group (p = 0.002), and sclerosis did not appear to reduce recurrence rates (10.7% with sclerosis versus 15.6% without; p > 0.05). The diagnosis of malignancy was confirmed in 16 of 27 (59%) percutaneous procedures performed on patients with known malignancy. In the open group, cytologic and pathologic evaluation of the pericardial specimen revealed malignancy in 32 of 52 (62%) patients with known malignancy. CONCLUSIONS Subxiphoid and percutaneous pericardial drainage of symptomatic pericardial effusions can be performed safely; however, death occurs from underlying disease. Open subxiphoid pericardial drainage with pericardial biopsy appears to decrease recurrence but does not improve diagnostic accuracy of malignancy over cytology alone.
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Affiliation(s)
- Jerome M McDonald
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri 63110-1013, USA
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Pericardium. Surgery 2001. [DOI: 10.1007/978-3-642-57282-1_57] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
Malignancies rarely arise from the pericardium. Mesothelioma, the most common of these, is usually unresectable and almost always incurable. Malignancies may secondarily involve the pericardium by direct extension. Carcinoma of the lung and malignant thymoma with limited direct invasion of the pericardium both can undergo complete and potentially curative resections, but adjuvant therapy is usually indicated. More frequently, malignancies involve the pericardium by a process of retrograde lymphangitic spread or hematogenous dissemination. These patients present with a symptomatic pericardial effusion and occasionally pericardial tamponade. Subxiphoid pericardiostomy and drainage is a safe procedure that provides effective and durable symptomatic relief in these terminally ill patients. More aggressive open procedures should be reserved for loculated or recurrent pericardial effusions.
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Affiliation(s)
- W H Warren
- Department of Cardiovascular-Thoracic Surgery, Rush-Presbyterian-St. Luke's Medical Center, Chicago, IL 60612, USA
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Allen KB, Faber LP, Warren WH, Shaar CJ. Pericardial effusion: subxiphoid pericardiostomy versus percutaneous catheter drainage. Ann Thorac Surg 1999; 67:437-40. [PMID: 10197666 DOI: 10.1016/s0003-4975(98)01192-8] [Citation(s) in RCA: 113] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Optimal management of cardiac tamponade resulting from pericardial effusion remains controversial. METHODS Cardiac tamponade in 117 patients was treated with either subxiphoid pericardiostomy (n = 94) or percutaneous catheter drainage (n = 23). Percutaneous catheter drainage was used for patients with hemodynamic instability that precluded subxiphoid pericardiostomy. Effusions were malignant in 75 (64%) of 117 patients and benign in 42 (36%) of 117. RESULTS Subxiphoid pericardiostomy had no operative deaths and a complication rate of 1.1% (1 of 94). In contrast, percutaneous drainage had significantly (p < 0.05) higher mortality and complication rates of 4% (1 of 23) and 17% (4 of 23), respectively. Patients with an underlying malignancy had a median survival of 2.2 months, with a 1-year actuarial survival rate of 13.8%. In comparison, patients with benign disease had a median survival of 42.8 months and a 1-, 2-, and 4-year actuarial survival rate of 79%, 73%, and 49%, respectively (p < 0.05). Effusions recurred in 1 (1.1%) of 94 patients after subxiphoid pericardiostomy compared with 7 (30.4%) of 23 patients with percutaneous drainage (p < 0.0001). CONCLUSIONS Benign and malignant pericardial tamponade can be safely and effectively managed with subxiphoid pericardiostomy. Percutaneous catheter drainage should be reserved for patients with hemodynamic instability.
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Affiliation(s)
- K B Allen
- Department of Cardiovascular and Thoracic Surgery, Rush-Presbyterian-St. Lukes Medical Center, Chicago, Illinois, USA
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Maher EA, Shepherd FA, Todd TJ. Pericardial sclerosis as the primary management of malignant pericardial effusion and cardiac tamponade. J Thorac Cardiovasc Surg 1996; 112:637-43. [PMID: 8800150 DOI: 10.1016/s0022-5223(96)70046-6] [Citation(s) in RCA: 96] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The management of malignant pericardial effusion remains controversial. We present our experience with 93 patients referred for drainage and sclerosing procedures between 1979 and 1994. METHODS With continuous electrocardiographic monitoring, a Kifa catheter was inserted percutaneously into the pericardial sac and allowed to drain. A 100 mg dose of lidocaine hydrochloride was instilled intrapericardially, followed by 500 to 1000 mg tetracycline or doxycycline hydrochloride in 20 to 50 ml normal saline solution. The catheter was clamped for 1 to 2 hours and then reopened, and the procedure was repeated daily until the net drainage was less than 25 ml in 24 hours. RESULTS Subjects included 53 women and 40 men (median age 58 years). Eight patients could not undergo sclerosis because of technical failure. Eighty-five patients underwent sclerosis and required a median dose of 1500 mg of the sclerosing agent (range 500 to 700 mg), given in a median of three injections (range one to eight). Complications included pain (17 patients), atrial arrhythmias (eight patients), fever with temperature greater than 38.5 degrees C (seven patients), and infection (one patient). Two patients had cardiac arrest before sclerosis could be attempted. Sixty-eight patients (73%) had the effusion controlled for longer than 30 days, for an overall control rate of 81%. Seven other patients had control of the effusion but died of progressive malignant disease in less than 30 days. The overall median survival was 98 days (range 1 to 1724 days). Comparison of these results with outcomes reported for patients with malignant pericardial effusion who underwent surgical drainage indicates that drainage and sclerosis provide similar survivals but sclerosis carries lower morbidity, mortality, and recurrence rates. CONCLUSION Percutaneous drainage and sclerosis constitutes a safe and effective treatment for malignant pericardial effusion. Surgical management should be reserved for the small percentage of cases that cannot be controlled by this method.
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Affiliation(s)
- E A Maher
- Department of Medicine, Toronto Hospital, Ontario, Canada
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Figueroa W, Alankar S, Pai N, Dave M. Subxiphoid pericardial window for pericardial effusion in end-stage renal disease. Am J Kidney Dis 1996; 27:664-7. [PMID: 8629625 DOI: 10.1016/s0272-6386(96)90100-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Fifty-seven patients with end-stage renal disease who were on maintenance dialysis underwent pericardial fluid drainage surgically between January 1980 and December 1991. All patients had echocardiographically proven pericardial effusion of more than 300 to 500 mL. Seven patients had pericardiectomy by left thoracotomy under general anesthesia in the first 2 years. Subsequently, 50 patients underwent a subxiphoid pericardial window by a left subcostal incision. A pericardial drainage tube was inserted at surgery and removed after 4 to 5 days. All but five patients undergoing subxiphoid pericardial window surgery received local anesthesia. The xiphoid process was not resected during surgery and steroids were not instilled in the pericardial cavity. There were minimal complications, no surgery-related deaths, and no recurrence of fluid in patients after pericardial window surgery. With our present experience, we advise a subxiphoid pericardial window with pericardial drainage under local anesthesia for all end-stage renal disease patients on dialysis who have a symptomatic or large pericardial effusion of more than 300 to 500 mL. Steroid instillation is not necessary for the prevention of recurrence of effusion.
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Affiliation(s)
- W Figueroa
- Department of Medicine and Surgery, The Bronx-Lebanon Hospital Center, NY 10457, USA
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Abstract
BACKGROUND Malignancy-related pericardial effusions may represent a terminal event in patients with therapeutically unresponsive disease. However, select patients with malignancies sensitive to available therapies may achieve significant improvement in palliation and long term survival with prompt recognition and appropriate intervention. METHODS From 1968 to 1994, 150 invasive procedures were performed for the treatment or diagnosis of pericardial effusion in 127 patients with underlying malignancies. These cases were reviewed retrospectively to best identify the clinical features, appropriate diagnostic workup, and optimal therapy for this complication of malignancy. RESULTS Dyspnea (81%) and an abnormal pulsus paradoxus (32%) were the most common symptoms. Echocardiography had a 96% diagnostic accuracy. Cytology and pericardial biopsy had sensitivities of 90% and 56%, respectively. Fifty-five percent of all effusions were malignant comprising 71% of adenocarcinomas of the lung, breast, esophagus, and unknown primary site. In 57 patients, a malignant effusion could not be determined, and no definitive etiology could be established for 74% of these effusions. Radiation-induced, infectious, and hemorrhagic pericarditis each were identified in fewer than 5% of cases. CONCLUSIONS Subxyphoid pericardiotomy proved to be a safe and effective intervention that successfully relieved pericardial effusions in 99% of cases with recurrence and reoperation rates of 9% and 7%, respectively. Survival most closely was related to the extent of disease and its inherent chemo-/radiosensitivity, with 72% of the patients who survived longer than 1 year having breast cancer, leukemia, or lymphoma.
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Affiliation(s)
- J D Wilkes
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, New York, USA
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Abstract
Pericardial effusion can be treated effectively by the technique of subxiphoid pericardial window. We present a case in which the Cooper retractor designed for transcervical thymectomy facilitated this operation. When available, the Cooper retractor can be useful in selected patients.
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Affiliation(s)
- B K Temeck
- Thoracic Oncology Section, National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892
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Schultz MZ, Murren JR. Critical Care of Intrathoracic Complications of Lung Cancer. J Intensive Care Med 1994. [DOI: 10.1177/088506669400900206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Lung cancer is the most common underlying malignancy in cancer patients admitted to intensive care units. Because of the proximity to vital organs in the mediastinum, lung cancer frequently causes complications requiring critical care, including cardiac tamponade, central airway obstruction, massive hemopytsis, and superior vena cava syndrome. In addition, radiation and chemotherapeutic agents used to treat lung cancer may cause life-threatening pneumonitis in a minority of patients. There are several management options available for each complication. Educated decisions must be made based on individual patient circumstances. Technological advances have allowed for successful treatment of the majority of patients with such complications. For example, photoresection with the NdYAG laser can relieve dyspnea in 18% of patients with airway obstruction; hemorrhage can be controlled 80% of the time with bronchial artery embolization; and symptoms of superior vena cava syndrome may be relieved in more than 90% of patients. Although the median survival of cancer patients admitted to the intensive care unit is relatively short, such interventions can effectively palliate symptoms and may prolong survival.
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Affiliation(s)
- Michelle Z. Schultz
- Department of Medical Oncology, Yale University School of Medicine, New Haven, CT
| | - John R. Murren
- Department of Medical Oncology, Yale University School of Medicine, New Haven, CT
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