Safety and Outcome of Percutaneous Drainage of Pericardial Effusions in Patients with Cancer

Cardiac Tamponade as an Initial Manifestation of Diffuse Large B-cell Lymphoma One Year after IgG4-related Disease in Remission

A 65-year-old man with multiple lymphadenopathies was diagnosed with IgG4-related disease (IgG4-RD) based on findings of a cervical lymph node biopsy and an elevated serum IgG4 level. Treatment was initiated after the onset of autoimmune pancreatitis, and he achieved remission. He developed diffuse large B-cell lymphoma one year later. Pericardial involvement of lymphoma resulted in cardiac tamponade, and he died before histopathological confirmation of lymphoma was made due to a lethal arrhythmia caused by massive involvement of lymphoma into the myocardium. Because patients with IgG4-RD might have an increased risk of malignant diseases, including lymphoma, histopathological examinations should be considered at any time during the course of IgG4-RD.

Pericardial effusion in oncological patients: current knowledge and principles of management

BACKGROUND

This article provides an up-to-date overview of pericardial effusion in oncological practice and a guidance on its management. Furthermore, it addresses the question of when malignancy should be suspected in case of newly diagnosed pericardial effusion.

MAIN BODY

Cancer-related pericardial effusion is commonly the result of localization of lung and breast cancer, melanoma, or lymphoma to the pericardium via direct invasion, lymphatic dissemination, or hematogenous spread. Several cancer therapies may also cause pericardial effusion, most often during or shortly after administration. Pericardial effusion following radiation therapy may instead develop after years. Other diseases, such as infections, and, rarely, primary tumors of the pericardium complete the spectrum of the possible etiologies of pericardial effusion in oncological patients. The diagnosis of cancer-related pericardial effusion is usually incidental, but cancer accounts for approximately one third of all cardiac tamponades. Drainage, which is mainly attained by pericardiocentesis, is needed when cancer or cancer treatment-related pericardial effusion leads to hemodynamic impairment. Placement of a pericardial catheter for 2-5 days is advised after pericardial fluid removal. In contrast, even a large pericardial effusion should be conservatively managed when the patient is stable, although the best frequency and timing of monitoring by echocardiography in this context are yet to be established. Pericardial effusion secondary to immune checkpoint inhibitors typically responds to corticosteroid therapy. Pericardiocentesis may also be considered to confirm the presence of neoplastic cells in the pericardial fluid, but the yield of cytological examination is low. In case of newly found pericardial effusion in individuals without active cancer and/or recent cancer treatment, a history of malignancy, unremitting or recurrent course, large effusion or presentation with cardiac tamponade, incomplete response to empirical therapy with nonsteroidal anti-inflammatory, and hemorrhagic fluid at pericardiocentesis suggest a neoplastic etiology.

Pericardiocentesis Outcomes in Patients With Pulmonary Hypertension: A Nationwide Analysis from the United States

Pericardiocentesis (PC) in patients with pulmonary hypertension (PH) and pericardial effusions has unclear benefits because it has been associated with acute hemodynamic collapse and increased mortality. Data on in-hospital outcomes in this population are limited. The National Inpatient Sample database was used to identify adult patients who underwent PC during hospitalizations between 2016 and 2020. Data were stratified by the presence or absence of PH. A multivariate regression model and case-control matching was used to estimate the association of PH with PC in-hospital outcomes. A total of 95,665 adults with a procedure diagnosis of PC were included, of whom 7,770 had PH. Patients with PH tended to be older (aged 67 ± 15.7 years) and female (56%) and less frequently presented with tamponade (44.9% vs 52.4%). Patients with PH had significantly higher rates of chronic kidney disease, coronary artery disease, heart failure, and chronic lung disease, among other co-morbidities. In the multivariate analysis, PC in PH was associated with higher all-cause mortality (adjusted odds ratio [aOR] 1.40, confidence interval [CI] 1.30 to 1.51) and higher rates of postprocedure shock (aOR 1.53, CI 1.30 to 1.81) than patients without PH. Mortality was higher in those with pulmonary arterial hypertension than other nonpulmonary arterial hypertension PH groups (aOR 2.35, 95% CI 1.46 to 3.80, p <0.001). The rates of cardiogenic shock (aOR 1.49, 95% CI 1.38 to 1.61), acute respiratory failure (aOR 1.56, 95% CI 1.48 to 1.64), and mechanical circulatory support use (aOR 1.86, 95% CI 1.63 to 2.12) were also higher in patients with PH. There was no significant volume-outcome relation between hospitals with a high per-annum pericardiocentesis volume compared with low-volume hospitals in these patients. In conclusion, PC is associated with increased in-hospital mortality and higher rates of cardiovascular complications in patients with PH, regardless of the World Health Organization PH group.

Pericardial Fluid Analysis in Diagnosis and Prognosis of Patients Who Underwent Pericardiocentesis

In this study, we aimed to examine the diagnostic yield of pericardial fluid biochemistry and cytology and their prognostic significance in patients with percutaneously drained pericardial effusions, with and without malignancy. This is a single-center, retrospective study of patients who underwent pericardiocentesis between 2010 and 2020. Data were extracted from electronic patient records, including procedural information, underlying diagnosis, and laboratory results. Patients were grouped into those with and without underlying malignancy. A Cox proportional hazards model was used to analyze the association of variables with mortality. The study included 179 patients; 50% had an underlying malignancy. There were no significant differences in pericardial fluid protein and lactate dehydrogenase between the 2 groups. Diagnostic yield from pericardial fluid analysis was greater in the malignant group (32% vs 11%, p = 0.002); 72% of newly diagnosed malignancies had positive fluid cytology. The 1-year survival was 86% and 33% in nonmalignant and malignant groups, respectively (p <0.001). Of 17 patients who died within the nonmalignant group, idiopathic effusions were the largest group (n = 6). In malignancy, lower pericardial fluid protein and higher serum C-reactive protein were associated with increased risk of mortality. In conclusion, pericardial fluid biochemistry has limited value in determining the etiology of pericardial effusions; fluid cytology is the most important diagnostic test. Mortality in malignant pericardial effusions may be associated with lower pericardial fluid protein levels and a higher serum C-reactive protein. Nonmalignant pericardial effusions do not have a benign prognosis and close follow-up is required.

Prevalence, characteristics and mortality of cancer patients undergoing pericardiocentesis in the United States between 2004 and 2017

BACKGROUND

Pericardiocentesis is undertaken in patients with cancer for diagnostic and therapeutic purposes. However, there are limited data on the frequency, characteristics and mortality of patients with different cancers undergoing pericardiocentesis.

METHODS

All hospitalisations of adult cancer patients (≥18 years) in the US National Inpatient Sample between January 2004 and December 2017 were included. The cohort was stratified by discharge code of pericardiocentesis and cancer, using the International Classification of Diseases. The prevalence of pericardiocentesis, patient characteristics, cancer types and in-hospital all-cause mortality were analysed between cancer patients undergoing pericardiocentesis versus not.

RESULTS

A total of 19,773,597 weighted cancer discharges were analysed, out of which 18,847 (0.1%) underwent pericardiocentesis. The most common cancer types amongst the patients receiving pericardiocentesis were lung (51.3%), haematological (15.9%), breast (5.4%), mediastinum/heart (3.2%), gastroesophageal (2.2%) and female genital cancer (1.8%), whilst 'other' cancer types were present in 20.2% patients. Patients undergoing pericardiocentesis had significantly higher mortality (15.6% vs. 4.2%, p < 0.001) compared to their counterparts. The presence of metastatic disease (aOR 2.67 95% CI 1.79-3.97), weight loss (aOR 1.48 95% CI 1.33-1.65) and coagulopathy (aOR 3.22 95% CI 1.63-6.37) were each independently associated with higher mortality in patients who underwent pericardiocentesis.

CONCLUSION

Pericardiocentesis is an infrequent procedure in cancer patients and is most commonly performed in patients with lung, haematological and breast cancer. Cancer patients undergoing pericardiocentesis have increased mortality, irrespective of the underlying cancer type.

Outcomes of Patients with and without Malignancy Undergoing Percutaneous Pericardiocentesis for Pericardial Effusion

(1) Background: This study aimed to evaluate the etiologies and clinical outcomes of patients with pericardial effusion (PE) treated with echo-guided percutaneous pericardiocentesis. (2) Methods: Between July 2010 and December 2020, a total of 502 patients underwent echo-guided percutaneous pericardiocentesis for PE at our hospital. The reasons for PE were malignancy (N = 277), and non-malignancy (N = 225). The comorbidities, complications, and all-cause mortality were compared between the malignancy and non-malignancy groups. (3) Results: In multivariable Cox regression analyses for 1-year mortality, malignancy related PE, nasopharyngeal and oropharyngeal cancer, and metastatic status were positive predictors. A higher incidence of in-hospital and 1-year mortality were observed in patients with malignancy-related PE than with non-malignancy-related PE. In patients with malignancy-related PE, the Kaplan-Meier curve of 1-year all-cause mortality significantly differed between patients with or without metastasis; however, PE with or without malignant cells did not influence the prognosis. (4) Conclusions: In the patients with large PE requiring percutaneous pericardiocentesis, malignancy-related PE, nasopharyngeal and oropharyngeal cancer, and metastatic status were positive predictors of 1-year mortality. In patients with malignancy, a higher incidence of all-cause mortality was noted in patients with metastasis but did not differ between the groups with and without malignant cells in PE.

High frequency ultrasound-guided pericardiocentesis performed in the sitting position: A novel apical approach

Background

So far, few approaches have been described to reduce inadvertent injury to structure of the heart and nearby organs in percutaneous pericardiocentesis.

Hypothesis

We hypothesized that an in‐plane high frequency ultrasound‐guided apical approach, performed in the sitting position, would provide additional benefits in terms of feasibility and safety for draining malignant pericardial effusion (MPE).

Methods

The authors selected 53 consecutive patients with moderate or large symptomatic MPE who underwent high frequency ultrasound‐guided pericardiocentesis. After the procedure, all patients were followed for 90 days with the main purpose of detecting procedure success, procedure‐related complications, and recurrent PE.

Results

Procedure success rate for pericardiocentesis was 100%. All patients were placed in the sitting position with their left hands extended above the heads. An apical puncture approach was performed in all cases (100%). The mean duration of catheter drainage was 8.1 ± 3.2 days. The mean initial amount of pericardial fluid drained was 956.3 ± 687.5 ml. Overall, six patients (11%) had recurrent PE; 3 (6%) had repeated percutaneous pericardiocentesis. There was no major complication and minor complications occurred in four patients (8%).

Conclusion

This novel in‐plane high frequency US‐guided apical approach has several advantages for percutaneous pericardiocentesis of MPE: performed in the sitting position; a benefit for patients with orthopnea; a maximum inserted wide angle to prevent damage to the myocardium; local enlargement of the PE region; high procedure success rate of pericardiocentesis; and excellent clinical outcomes.

Case study-based systematic review of literature on lymphoma-associated cardiac tamponade

This study aimed to compile all the relevant studies of patients presenting with pericardial tamponade before or after diagnosis of lymphoma, describe the clinical presentations of patients with lymphoma and cardiac tamponade, and assess the difference in overall survival based on the timing of cardiac tamponade diagnosis.

A comprehensive search strategy was conducted in the following databases: PubMed and Cochrane Library, using the following keywords: Lymphoma AND Cardiac Tamponade. The criteria for eligibility included cases with a confirmed diagnosis of lymphoma and cardiac tamponade, human studies, and publications in English language. The statistical analysis was performed using IBM Statistical Package for Social Sciences (SPSS) version 20. We included 48 research articles (n = 52 cases) with adequate reporting of measured outcomes. The median age of the patients was 52 (9–94) years. Only 6 patients were noted to have primary cardiac lymphoma, while the majority of cases were considered to have secondary cardiac lymphoma (88.5%). According to the data on the type of lymphoma reported through cytology and immunohistochemistry, 49 patients were diagnosed with non-Hodgkin lymphoma, and of these cases the most common subtype was large B-cell lymphoma (42.9%). Overall, the average duration of illness was 14 ± 23 days. A total of 13 patients had distant heart sounds, 12 cases were noted to be hypotensive, and 13 subjects were found to have increased jugular venous pressure.

Our retrospective study demonstrated that most patients presented with pericardial tamponade after lymphoma diagnosis, and those were mostly secondary cardiac lymphoma of the non-Hodgkin type with large B-cell as the most common subtype. Dyspnoea, oedema, and constitutional symptoms were the most common presenting signs. The median overall survival of patients with lymphoma and cardiac tamponade is 4 months, with no significant difference in mortality in the presentation timing before and after the diagnosis of lymphoma.

Oncologic Emergencies: Traditional and Contemporary

The recognition and management of oncologic emergencies are becoming increasingly relevant in the intensive care unit, particularly in the era of novel biologic therapies. Early recognition and multidisciplinary collaboration are essential to improving patient outcomes. This article discusses aspects of diagnosis and management for important malignancy-associated emergencies.

Impending Cardiac Tamponade as the Initial Manifestation of BCR-ABL Positive Chronic Myeloid Leukemia

Leukemia involves all organs and tissues of the body. Leukemic infiltration of the pericardium has been documented frequently at post-mortem examinations. Clinically, however, pericardial effusion with cardiac tamponade is rare, and only isolated case reports have been described. In all the reported cases, therapeutic pericardiocentesis was required for the relief of cardiac tamponade with the risk of bleeding since these patients often had deranged hemostasis. We are reporting a rare case of hemorrhagic pericardial effusion in chronic myeloid leukemia before starting the tyrosine kinase inhibitors. The patient required therapeutic pericardiocentesis and hydroxyurea treatment.

Overview of Optimal Techniques for Pericardiocentesis in Contemporary Practice

PURPOSE OF REVIEW

This review summarizes the optimal techniques for the performance of pericardiocentesis in contemporary practice, highlighting the indications, contraindications, and techniques used. Routine pericardial catheter management and the diagnostic role of pericardial fluid analysis are described.

RECENT FINDINGS

Echocardiographic-guided pericardiocentesis should be considered the therapy of choice in current clinical practice and may be performed safely despite the presence of coagulopathy and thrombocytopenia in the hands of expert operators. Computed tomography (CT)-guided techniques may provide a useful adjunctive tool in patients with poor acoustic windows or complex loculated effusions. Conservative management utilizing pericardiocentesis may be considered in select patients with device lead and interventional-related pericardial effusions. Echocardiographic-guided pericardiocentesis with extended pericardial drainage (goal output < 50 mL/24 h) should be considered the standard of care in contemporary practice. Pericardial fluid analysis should be tailored based on the clinical history and appearances of the pericardial fluid.

Cardiac Interventional Procedures in Cardio-Oncology Patients

Comorbidities specific to the cardio-oncology population contribute to the challenges in the interventional management of patients with cancer and cardiovascular disease (CVD). Patients with cancer have generally been excluded from cardiovascular randomized clinical trials. Endovascular procedures may represent a valid option in patients with cancer with a range of CVDs because of their minimally invasive nature. Patients with cancer are less likely to be treated according to societal guidelines because of perceived high risk. This article presents the specific challenges that interventional cardiologists face when caring for patients with cancer and the modern tools to optimize care.