Percutaneous pericardial catheter drainage in childhood

Pericardiocentesis in children: 20-year experience at a tertiary children's hospital

BACKGROUND

Pericardiocentesis is the invasive percutaneous procedure for acute and chronic excessive accumulation of pericardial fluid. There is a paucity of data on the effectiveness and safety of pericardiocentesis in children.

OBJECTIVES

To evaluate the effectiveness and safety of pericardiocentesis and factors associated with acute procedural failure and adverse events.

METHODS

This was a single-centered retrospective study to describe all the children aged ≤20 years who underwent pericardiocentesis. Data on demographics, etiologies of pericardial effusion, and repeat intervention at follow-up were collected.

RESULTS

A total of 127 patients underwent 153 pericardiocentesis. The median age was 6.5 years (1 day-20 years) with weight of 17 kg (0.5-125). Most common etiology was post-pericardiotomy syndrome (n = 56, 44%), followed by infectious (12%), malignant (10%), and iatrogenic (9%). Pericardiocentesis was performed more commonly in the catheterisation laboratory (n = 86, 59%). Concurrent pericardial drain placement was performed in 67 patients (53%). Acute procedural success was 92% (141/153). Repeat intervention was performed in 33 patients (22%). The incidence of adverse events was 4.6% (7/153): hemopericardium requiring emergent surgery (n = 2); hemopericardium with hypotension (n = 2); seizure with anesthesia induction (n = 1); and right ventricle puncture with needle (n = 2). Pericardiocentesis at the bedside had a higher rate of acute procedural failure than that in the catheterisation lab (17 versus 1%, p < 0.01). No identifiable risk factors were associated with adverse events.

CONCLUSIONS

Pericardiocentesis was life-saving in children with its high effectiveness and safety even in urgent situations. Although initial pericardiocentesis was effective, one of five patients required re-intervention for recurrent pericardial effusion.

Novel, Long-axis In-plane Ultrasound-Guided Pericardiocentesis for Postoperative Pericardial Effusion Drainage

Pericardial effusion can be a life-threatening complication in children after cardiac surgery. Percutaneous pericardiocentesis is associated with rare, but serious complications. This retrospective study describes our experience with a novel, long-axis in-plane real-time ultrasound (US)-guided technique for postoperative pericardial effusion drainage in small children. Ten out of sixteen procedures were performed within 14 days of cardiac surgery at a median postoperative day 12 (IQR 2, 99). Median age was 2.7 months (IQR 0.4124) and weight 4.5 kg (IQR 2.5, 41.6). All but one procedure required a single attempt. Fourteen out of sixteen procedures had subxiphoid approach, and two were apical. Median initial drainage was 9 mL/kg (IQR 4.5, 27). Fifty percent of effusions were serous, 25 % chylous, and the remainder bloody. There were no reported complications. This study demonstrates a novel, long-axis pericardiocentesis technique that allows for an easy and safe needle entry into the pericardial space for small children in the early postoperative period.

Anesthesia for children with pericardial effusion: a case series

OBJECTIVES AND AIMS

  To review the anesthetic management of children requiring surgical intervention for pericardial effusion, determine the nature and frequency of complications and define risk factors that predict perioperative risk.

BACKGROUND

Anesthesia in the presence of a pericardial effusion may be associated with significant hemodynamic compromise particularly during induction. However, the literature specifically concerning children is limited to a single-case report.

METHODS

A retrospective case review of children undergoing general anesthesia for surgical treatment for pericardial effusion between 1999 and 2008 at a single institution.

RESULTS

Sixty-five children underwent 79 general anesthetics for surgical treatment for pericardial effusion. Median age was 4 years (2 weeks-16 years), and median weight 15 kg (range, 2.5-96 kg). Fifty-five children (84%) developed effusions following cardiac surgery. The commonest induction agent was ketamine (25/65, 38%), and the majority of children (52/65, 80%) were intubated and ventilated for the procedure. Seven children (11%) suffered from eight major complications, and 14 children (22%) suffered from a minor complication. Major complications were more common in children with preoperative tachypnoea (P = 0.01) and cardiac tamponade on preoperative echocardiogram (ECHO) (P = 0.001). Preoperative hypoxia had a sensitivity of 92% and a positive likelihood ratio of 5.2 (95% CI 1.5-17.5) for predicting all complications.

CONCLUSIONS

Anesthesia for pericardial effusion in children was associated with an adverse physiological event in one-third of children. Major complications may be predicted by preoperative tachypnoea and cardiac tamponade on preoperative ECHO, and all complications may be predicted by preoperative hypoxia. The anesthetic technique included a variety of induction agents, and we cannot recommend a particular approach.

Etiology, management, and outcome of pediatric pericardial effusions

The objective of this study was to determine the contemporary etiologies, treatment, and outcomes of moderate and large pericardial effusions in pediatric patients. We reviewed pediatric patients with moderate or large effusions diagnosed at Children's Hospital Boston. Effusion size was determined in offline review of echocardiograms. One hundred sixteen patients with moderate or large pericardial effusions were identified. The age range was 1 day to 17.8 years (median 8.6). The size of the pericardial effusions ranged from 0.5 to 4.7 cm (median 2.1). Neoplastic disease was present in 39% of patients, collagen vascular disease in 9%, renal disease in 8%, bacterial infection in 3%, and human immunodeficiency virus (HIV) in 2%; 37% were idiopathic. Pericardial drainage procedures were performed in 47 patients (41%). Of these, 29 (63%) had recurrent effusions leading to repeat drainage in 12 (41%). Pericardial effusions resolved within 3 months in 83% of patients who underwent drainage and in 91% of patients who did not. In summary, pediatric pericardial effusions were rarely caused by bacterial infections in this study population and were more frequently idiopathic or associated with neoplastic disease. Pericardial effusions often reaccumulated after drainage. The majority of both drained and undrained effusions resolved within 3 months.

Therapeutic application of intrapericardial tissue plasminogen activator in a 4-month-old child with complex fibropurulent pericarditis

OBJECTIVE

To describe a young child with complex fibropurulent pericarditis who was successfully treated with intrapericardial recombinant tissue plasminogen activator.

DESIGN

Individual case report.

SETTING

Pediatric intensive care unit of a tertiary children's hospital.

PATIENT

A 4-month-old Asian girl with Staphylococcus aureus septic shock who later developed a loculated fibropurulent pericardial effusion that was refractory to management with a subxiphoid percutaneous pericardial drainage catheter.

INTERVENTIONS

Three doses of intrapericardial tissue plasminogen activator were administered at 12-hr intervals, allowed to dwell for 2 hrs, and subsequently drained via low continuous suction.

MEASUREMENTS AND MAIN RESULTS

Immediately after intrapericardial tissue plasminogen activator was administered via a percutaneous pericardial drainage catheter, the patient had an increase in pericardial fluid drainage and resolution of a complex fibropurulent pericardial effusion. Pericardial fluid drainage ceased and then increased to 122 mL, 270 mL, and 80 mL of fluid, respectively, after each of the three doses of intrapericardial tissue plasminogen activator. Serial echocardiography confirmed the initial presence of the effusion, the subsequent loculated nature of the effusion, and ultimate resolution of the effusion after tissue plasminogen activator. The patient survived to hospital discharge without cardiac dysfunction.

CONCLUSIONS

The fibrinolytic effect of tissue plasminogen activator therapy promotes the resolution of complex fibropurulent pericardial effusions refractory to traditional pericardial drainage via percutaneous catheter and suction. Use of intrapericardial tissue plasminogen activator may preclude the need for surgical intervention in fibropurulent pericarditis.

Successful Repair of a Diaphragmatic Hernia Through a Pericardial Window with Acellular Dermal Matrix

A successful placement of a transabdominal pericardial window is associated with diaphragmatic hernia. In this paper, we present the case of a 5-month-old ex-31-weeks-premature baby who developed a symptomatic diaphragmatic hernia following a chronic pericardial effusion who was treated successfully with a laparoscopic transabdominal pericardial window. Laparoscopy and a pericardial window were used to manage the symptomatic effusion that developed following a bilateral thoracotomy and median sternotomy for the patient's massive hygroma. The patient was followed before and after pericardial drainage with a serial examination, chest radiography, and echocardiography. In addition, computerized tomography was also used for long-term follow-up following the repair of the hernia. An acellular dermal matrix was utilized for patching the hernia with a laparotomy. The abdominal approach in both operations offered direct access to the pericardial space and hernia, thereby avoiding previously operated thoraces. A subsequent follow-up at 9 months following the creation of the window suggested a recurrent tamponade physiology. Plain radiographs and an echocardiogram showed herniation into the pericardial sac. The hernia was operatively reduced and repaired with an acellular dermal matrix. Recovery and subsequent followup at 1 year revealed no hernia, full symptom resolution, and no recurrence of the pericardial effusion. A pericardial window is an effective approach for the management of chronic pericardial effusion. Diaphragmatic herniation through a pericardial window can be successfully repaired with an acellular dermal matrix.

Large pericardial effusions of inflammatory origin in childhood

OBJECTIVES

Our aim was to review the clinical records from children with large pericardial effusions of inflammatory origin presenting to a tertiary referral centre over the last 21 years, with emphasis on their clinical presentation, management and outcome.

BACKGROUND

The common identifiable causes of pericardial effusion in children include prior cardiac surgery, bacterial pericarditis, malignancy, and connective tissue disorders. In a significant number of children, however, despite extensive investigation, it is not possible to identify a clear aetiology. A viral cause is often considered, though rarely confirmed. The clinical course of such large idiopathic pericardial effusions in children has not been extensively reported.

METHODS AND RESULTS

We reviewed retrospectively the records of all patients seen between 1981 and 2001 with large pericardial effusions of inflammatory origin requiring drainage, excluding the effusions related to cardiac surgery or malignancy. We found 31 patients fulfilling our criterions for study. They could be divided into three groups, with 15 patients having no specific identifiable aetiology despite extensive investigation, 12 patients having evidence of bacterial pericarditis, and four with a probable immunologic disorder. Fever was present in only eight patients (53%) in the idiopathic group. All patients in the other groups had fever. Except for fever and the resultant tachycardia, it was not possible to distinguish on clinical grounds, nor on the presence or otherwise of cardiac tamponade, between those with idiopathic aetiology and those with bacterial infection. Of the patients with presumed bacterial pericarditis, five (42%) had both positive blood and pericardial fluid cultures, three (25%) had positive blood cultures, while a further three patients (25%) had only positive pericardial fluid cultures. All patients required drainage of the pericardial effusion, either under echocardiographic guidance or surgically. None of the patients died. The hospital stay was significantly shorter for those with idiopathic as opposed to bacterial pericarditis. Of those with an idiopathic aetiology, six required readmission due to recurrence of the pericardial effusion, with four patients requiring further surgical drainage. No patients required readmission with a bacterial or immunologic aetiology. No patient developed constrictive pericarditis after a median follow-up of 22 months.

CONCLUSION

Patients with large idiopathic pericardial effusion had relatively few constitutional symptoms as compared with their gross echocardiographic findings. Those with bacterial pericarditis had more urgent need for treatment. Patients with pericardial effusion of inflammatory origin, when treated appropriately, had an excellent outcome with no mortality or development of constrictive pericarditis.

Chylopericardium after cardiac operations in children

BACKGROUND

Chylopericardium is a rare complication after operation for congenital heart disease. The incidence and clinical outcomes in a large cohort of surgical patients are unknown.

METHODS

We retrospectively reviewed the clinical records spanning more than 12 years in a single institution of 16 children with chylopericardium after cardiac operation.

RESULTS

We identified 16 patients with chylopericardium between 1985 and 1997. Chylopericardium was isolated in 7 patients. Twelve patients required pericardial drainage. Patients with isolated chylopericardium presented late and were treated initially as having postpericardiotomy syndrome. Three patients underwent thoracic duct ligation. There were two late deaths unrelated to the chylothorax. Associated diagnoses were internal jugular vein thrombosis and recurrent pulmonary vein obstruction (1 of 16 patients), an associated syndrome but not Turner or Noonan (10 of 16), superior cavopulmonary or total cavopulmonary anastomosis (7 of 16), atrioventricular septal defect repair (5 of 16), and repair of tetralogy of Fallot (2 of 16).

CONCLUSIONS

Percutaneous drainage to relieve tamponade together with a low-fat or medium-chain triglyceride diet results in resolution in most cases of postoperative chylopericardium. If a pericardial effusion enlarges, fails to clear on aspirin therapy, or presents late after hospital discharge, diagnostic pericardial tap and a low-fat diet are indicated.

Clinical and echocardiographic characteristics of significant pericardial effusions following cardiothoracic surgery and outcomes of echo-guided pericardiocentesis for management: Mayo Clinic experience, 1979-1998

STUDY OBJECTIVES

This study assessed the clinical features, timing of presentation, and echocardiographic characteristics associated with clinically significant pericardial effusions after cardiothoracic surgery. The outcomes of echocardiographically (echo-) guided pericardiocentesis for the management of these effusions were evaluated.

DESIGN

From the prospective Mayo Clinic Registry of Echo-guided Pericardiocentesis (February 1979 to June 1998), 245 procedures performed for clinically significant postoperative effusions were identified. Clinical features, effusion causes, echocardiographic findings, and management outcomes were studied and analyzed. Cross-referencing the registry with the Mayo Clinic surgical database provided an estimate of the incidence of significant postoperative effusions and the number of cases in which primary surgical management was chosen instead of pericardiocentesis.

RESULTS

Use of anticoagulant therapy was considered a significant contributing factor in 86% and 65% of early effusions (< or =7 days after surgery) and late effusions (>7 days after surgery), respectively. Postpericardiotomy syndrome was an important factor in the development of late effusions (34%). Common presenting symptoms included malaise (90%), dyspnea (65%), and chest pain (33%). Tachycardia, fever, elevated jugular venous pressure, hypotension, and pulsus paradoxus were found in 53%, 40%, 39%, 27%, and 17% of cases, respectively. Transthoracic echocardiography permitted rapid diagnosis and hemodynamic assessment of all effusions except for three cases that required transesophageal echocardiography for confirmation. Echo-guided pericardiocentesis was successful in 97% of all cases and in 96% of all loculated effusions. Major complications (2%), including chamber lacerations (n = 2) and pneumothoraces (n = 3), were successfully treated by surgical repair and chest tube reexpansion, respectively. Median follow-up duration for the study population was 3.8 years (range, 190 days to 16.4 years). The use of extended catheter drainage was associated with reduction in recurrence for early and late postoperative effusions by 46% and 50%, respectively.

CONCLUSIONS

The symptoms and physical findings of clinically significant postoperative pericardial effusions are frequently nonspecific and may be inadequate for a decision regarding intervention. Echocardiography can quickly confirm the presence of an effusion, and pericardiocentesis under echocardiographic guidance is safe and effective. The use of a pericardial catheter for extended drainage is associated with lower recurrence rates, and the majority of patients so treated do not require further intervention.

Percutaneous echocardiographically guided pericardiocentesis in pediatric patients: evaluation of safety and efficacy

The purpose of this study was to evaluate the safety and efficacy of echocardiographically (echo) guided pericardiocentesis in pediatric patients. Echo-guided pericardiocenteses performed in pediatric patients (age >/=16 years) at the Mayo Clinic between 1980 and 1997 were identified. Presentation, cause and characteristics of the effusion, details of the pericardiocentesis procedure, and outcome were determined by comprehensive chart review supplemented by telephone interviews when necessary. Seventy-three pediatric patients, median age 6.7 years (range 1 day to 16 years), underwent 94 consecutive echo-guided pericardiocenteses for effusions of various causes. Twenty-one (22%) procedures were performed in children younger than 2 years. All but 1 procedure were successful (99%). A mean fluid volume of 237 mL (range 4 to 970 mL) was withdrawn. Only a single attempt was needed for entry into the pericardial space in 87 (93%) procedures. No deaths were associated with the pericardiocentesis procedure. Only 1 major complication occurred (1%), a pneumothorax requiring chest tube reexpansion. Three (3%) minor complications-2 instances of right ventricular puncture and a small pneumothorax-did not require treatment. Extended catheter drainage for a mean of 5.2 +/- 4.5 days (range 1 to 19 days) was used with 30 (32%) of the 94 procedures. For the 52 patients who underwent pericardiocentesis without catheter drainage as the initial management strategy, 18 required 21 repeat pericardiocenteses for recurrence of effusion. In contrast, for the 21 patients who had pericardial catheterization as the initial management strategy, none had recurrences necessitating a repeat procedure (P <.001). Increased utilization of a pericardial catheter was associated with a concomitant decrease in the number of surgical pericardial procedures over the study period. Echo-guided pericardiocentesis was the only therapeutic modality for the management of effusion in 73% of all patients. Echo-guided pericardiocentesis is safe and effective in pediatric patients, including children younger than 2 years. The increasing use of pericardial catheterization in conjunction with this technique was associated with significant reduction of recurrence and decreased frequency of surgical interventions for treatment of pericardial effusion. Echo-guided pericardiocentesis with extended catheter drainage should be considered as primary management strategy for clinically significant pericardial effusions in pediatric patients.

Cardiac tamponade

Cardiac tamponade is a cardiological emergency requiring prompt treatment in order to avoid a fatal outcome. It can complicate a number of medical conditions and it is important, therefore, that all practitioners are aware of its presentation, diagnosis and management. These are outlined. We suggest that, with certain specific and important exceptions, percutaneous catheter pericardiocentesis is to be recommended in the management of cardiac tamponade. We include a review of 51 consecutive cases treated at our own institution. Catheter pericardiocentesis was successful in 49 (96%) cases and 36 (80%) patients did not require any further intervention. There were no major and only two minor complications which required no additional treatment. We review previous literature concerning percutaneous pericardiocentesis. Using recommended procedures, pericardiocentesis is successful in 90-100% of cases and major complications are rare.

Cardiac tamponade in the pediatric oncology population: treatment by percutaneous catheter drainage

PURPOSE

The treatment of pericardial effusion resulting in cardiac tamponade has undergone an evolution in recent years, with the use of less invasive drainage methods in selected cases. To determine optimal therapy for pediatric oncology patients with pericardial effusion and tamponade, the authors reviewed their institutional experience with percutaneous catheter drainage.

METHODS

Patient records and operative reports were reviewed, and nine patients were identified who met clinical and echocardiographic criteria of cardiac tamponade and were treated with percutaneous pericardial catheter drainage.

RESULTS

The median age at time of diagnosis was 14 years (range, 5 months to 19 years), and the male:female ratio was 7:3. Underlying malignancies included acute myeloblastic leukemia in three, acute lymphoblastic leukemia in one, and Hodgkin's disease, B-cell lymphoma, medulloblastoma, desmoplastic small round cell tumor, and rhabdomyosarcoma in one each. EIght patients (89%) were receiving granulocyte colony-stimulating factor (GCSF) during the period when tamponade developed. All patients had a large or moderate-to-large pericardial effusion and right ventricular collapse with hemodynamic compromise on echocardiography, and two patients (22%) also had pericardial thickening. In nine patients, percutaneous catheter drainage was performed intraoperatively and under fluoroscopic or echocardiographic guidance. A median of 300 mL (range, 82 to 500 mL) of fluid was removed from the pericardial sac during the initial drainage, and cytology was positive in one (6%). Complete echocardiographic resolution was observed in eight patients (89%); a small posterior component persisted in one patient but was not significant hemodynamically. The catheters remained in place for a median of 5 days (range, 1 to 35 days) while repeat aspirations were performed. Tamponade resolved in all patients, and one died of overwhelming systemic sepsis. The survival period was 10 to 22 months, and tamponade or the drainage procedure did not contribute to death. Four patients remain alive after 4 month to 7 years of follow-up.

CONCLUSION

Cardiac tamponade was effectively treated in all patients and did not recur with percutaneous catheter drainage alone. THere was no evidence of pericardial loculation or infection despite pancytopenia being prevalent with underlying illness and chemotherapy. Percutaneous catheter drainage is an effective treatment for pediatric oncology patients with pericardial tamponade. Because of its simplicity in comparison to move invasive techniques, initial treatment with percutaneous drainage should be considered in this patient population.