Video-assisted thoracoscopic pericardial window for diagnosis and management of pericardial effusions

Safety and feasibility of thoracoscopic pericardial window in recurrent pericardial effusion - A single-centre experience

BACKGROUND

This study aimed to report the surgical outcomes and also evaluating the safety and feasibility of thoracoscopic pericardial window (PW) for recurrent pericardial effusion.

MATERIALS AND METHODS

This was a retrospective analysis of eight cases of recurrent pericardial effusion, managed by thoracoscopic method in a tertiary-level thoracic surgery centre over 5 years. A detailed analysis of all perioperative variables, including complications, was carried out.

RESULTS

A total of eight patients underwent thoracoscopic PW during the study period. Males (87.5%) were predominant in the cohort. The median age was 54 years (range: 28-78 years). The median duration of symptoms was 2 months (range: 1-3 months). Tuberculosis (50%), malignancy (37.5%) and chronic kidney disease (12.5%) were the causes of recurrent effusion. All patients underwent thoracoscopic procedure with no conversions. The median operative time was 45 min (range: 40-70 min). The median effusion volume drained was 500 ± 100 ml. The median hospital stay was 3 days (range: 2-4 days) with no post-procedural complications. All the patients had complete resolution of symptoms. No recurrence was noted in the median follow-up period of 28 months (range: 6-60 months).

CONCLUSIONS

Thoracoscopic PW is a safe and feasible minimally invasive option in the management of recurrent pericardial effusion in selected patients. Surgical fitness, haemodynamic status and estimated survival (in malignant effusion) should be considered before the procedure.

Awake uniportal video-assisted thoracoscopic surgery for the management of pericardial effusion

Introduction

Pericardial drainage can be performed either with pericardiocentesis or pericardial "window" in cases with hemodynamic compromise for therapeutic and diagnostic purposes. Awake single-port video-assisted thoracoscopic surgery (VATS) is an alternative to pericardial window (PW) that has been described only in case reports in the literature. We aimed to analyse a series of patients with chronic, recurrent and/or large pericardial effusions who underwent single-port VATS-PW opening without intubation.

Patients and Methods

The PW was opened using awake single-port VATS in 20 of 23 patients referred to our clinic with recurrent, chronic and/or large pericardial effusion between December 2021 and July 2022. Demographic data, imaging modalities, treatment processes and pathological samples were analysed retrospectively.

Results

The median age of 20 patients was 68 years (52-81). The mean body mass index was 29.1 ± 6.0 kg/m2 and mean pericardial fluid measurements with pre-operative transthoracic echocardiography (TTE) was 2,8 ± 0,9 cm. The mean operation time was 44 ± 13.0 min and mean peri-operative drainage was 700 ± 307 cc. On the 1st post-operative day, control TTE revealed ≤0.5 cm effusion in 18 (90%) patients and ≥0.5 cm in 2 (10%) patients. The median day of discharge or referral to the clinic where they are followed up was 1 (1-2).

Conclusions

Awake single-port VATS could be used safely in all patient groups with pericardial effusion or tamponade as a diagnostic and therapeutic option. This technique has advantages, especially in patients with high surgical risk.

Percutaneous balloon pericardiotomy: efficacy in a series of malignant and nonmalignant cases

OBJECTIVE

In the case of malignant pericardial effusion and cardiac tamponade, balloon pericardiotomy is an established minimally invasive option to the surgical creation of a subxiphoid pericardial window. Percutaneous balloon pericardiotomy effectively drains recurrent pericardial fluid by creating a pleuro (-abdominal-) pericardial communication. Design. A series of 26 patients with underlying malignant (n = 12) and nonmalignant (n = 14) diseases underwent percutaneous balloon pericardiotomy between 2008 and 2021. All interventions were done through a subxiphoid access under local anesthesia. Results. The mean survival in the malignant and nonmalignant groups was 1.2 versus 48.0 months, respectively (p < .001). There were neither severe periinterventional complications nor in-hospital deaths. In two patients with nonmalignant disease the surgical creation of a pericardial window was necessary during follow-up. The originally described procedure was modified by the removal of all catheters at the end of the intervention. The procedure was safe. It prevented immobility and facilitated an early discharge from the hospital. Conclusion. Our experiences show that percutaneous balloon pericardiotomy is a minimally invasive approach to successfully provide palliation in the group of patients with underlying malignant disease. On the other hand, we have shown that this technique is safe and feasible in the treatment of pericardial effusion based on nonmalignant disease. We think thereby that pericardial balloon pericardiotomy can be considered as a less invasive alternative to surgery in both groups of patients.

A practical technique for subacute hemorrhagic pericarditis, a case report

Background

We used pericardioscope operation for a patient who suffered from subacute hemorrhagic pericarditis which usually have to had a sternotomy.

Case presentation

A pericardioscope was used in the operation rather than sternotomy on a 66-year-old male who was diagnosed with subacute hemorrhagic pericarditis after PCI(Percutaneous Coronary Intervention). He was discharged 7 days after the operation with an uneventfull postoperative course.

Conclusions

We believe that this technique is a safe procedure without any major complications.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-021-01499-7.

Landmark Trials in the Surgical Management of Mesothelioma

The treatment of mesothelioma has evolved slowly over the last 20 years. While surgery as a standalone treatment has fallen out of favor, the importance of multimodality treatment consisting of combinations of chemotherapy, radiotherapy, and surgery have become more common in operable, fit patients. In this review, we discuss trials in surgery, chemotherapy, and radiation that have shaped contemporary multimodality treatment of this difficult malignancy, and we touch on the new and emerging immunotherapeutic and targeted agents that may change the future treatment of this disease. We also review the multimodality treatment regimens, with particular attention to trimodality therapy and neoadjuvant hemithoracic radiation strategies.

Supravalvular pulmonary stenosis 9 years after surgically created pleuro-pericardial window

Supravalvular pulmonary stenosis acquired as a postoperative cardiac procedure complication is relatively common. However, that occurring after a surgically created pleuro-pericardial window has not been described until now, to the best of our knowledge. We present a case of acquired supravalvular pulmonary stenosis that developed 9 years after the pleuro-pericardial window creation for pyopericardium due to a constricting pericardial band. The child underwent successful surgical relief of the stenosis along with repair of the atrial and ventricular septal defects.

Mid-Term Efficacy of Subxiphoid Versus Transpleural Pericardial Window for Pericardial Effusion

BACKGROUND

The optimal surgical technique for drainage of pericardial effusions is frequently debated. Transpleural drainage via thoracotomy or thoracoscopy is hypothesized to provide more durable freedom from recurrent pericardial effusion than a subxiphoid pericardial window. We sought to compare operative outcomes and mid-term freedom from recurrent effusion between both approaches in patients with nontraumatic pericardial effusions.

METHODS

All patients at our institution who underwent a pericardial window from 2001 to 2018 were identified. After excluding those who underwent recent cardiothoracic surgery or trauma, patients (n = 46) were stratified by surgical approach and presence of malignancy. Primary outcome was freedom from recurrent moderate or greater pericardial effusion. Secondary outcomes included operative mortality and morbidity and mid-term survival. Follow-up was determined by medical record review, with a follow-up of 67 patient-years. Fisher's exact test and Wilcoxon rank-sum test were used to compare groups. Mid-term survival and freedom from effusion recurrence were determined using Kaplan-Meier method.

RESULTS

Subxiphoid windows (n = 31; 67%) were more frequently performed than transpleural windows (n = 15; 33%) and baseline characteristics were similar. Effusion etiologies included malignancy (n = 22; 48%), idiopathic (n = 12; 26%), uremia (n = 8; 17%), and collagen vascular disease (n = 4; 9%). Perioperative outcomes were comparable between the two surgical approaches, except for longer drain duration (7 versus 4 d, P = 0.029) in the subxiphoid group. Operative mortality was 19.6% overall and 36.4% in patients with malignancy. Mid-term survival and freedom from moderate or greater pericardial effusion recurrence was 37% (95% confidence interval [CI]: 19%-54%) and 69% (95% CI: 52%-86%) at 5 y, respectively. There was no difference in mid-term survival (P = 0.90) or freedom from pericardial effusion recurrence (P = 0.70) between surgical approaches. Although malignant etiology had worse late survival (P < 0.01), freedom from effusion recurrence was similar to nonmalignant etiology (P = 0.70).

CONCLUSIONS

Pericardial window provides effective mid-term relief of pericardial effusion. Subxiphoid and transpleural windows are equivalent in mid-term efficacy and both surgical approaches can be considered. Patients with malignancy have acceptable operative mortality with low incidence of recurrent effusion, supporting palliative indications.

Single-trocar thoracoscopic pericardio-pleural fenestration under local anesthesia for malignant pleural effusion: a case report

Background

Pericardio-pleural fenestration by video-assisted thoracoscopic surgery is an efficient procedure for malignant pericardial effusion, but requires general anesthesia with single-lung ventilation.

Case presentation

A 43-year-old woman was referred with complaints of deteriorating dyspnea and orthopnea. Chest computed tomography revealed right massive pleural effusion and pericardial effusion. Echocardiography demonstrated collapse of both the right atrium and right ventricle due to cardiac tamponade. Semi-rigid thoracoscopic pleural biopsy and pericardio-pleural fenestration were successfully performed under local anesthesia via a single trocar, because surgical procedures under general anesthesia with single-lung ventilation might have been intolerable for the patient. Adequate biopsy specimens of pleura and pericardium and immediate relief of serious symptoms were obtained without perioperative complications. No recurrence of pleural or pericardial effusion was observed for 3 months postoperatively.

Conclusion

Thoracoscopic pericardio-pleural fenestration under local anesthesia via a single trocar is feasible as an alternative approach in critically ill patients, allowing effective pericardial drainage, evaluation of the pleural cavity, and accurate biopsies of the pericardium and parietal pleura simultaneously.

Survival Following Video-Assisted Thoracic and Mini-Thoracotomy Pericardial Fenestration

Objective:

Surgical pericardial fenestration (sPF) is more invasive than interventional pericardiocentesis (PC) and requires general anesthesia. Severe complications such as ventricular puncture and chamber lacerations are, however, reported in association with PC and not with sPF. Is survival after sPF only determined by nonsurgical factors?

Methods:

Between July 2000 and December 2015, data of all patients who had undergone sPF—either thoracoscopically or by anterior mini-thoracotomy—were investigated. The 2 techniques were analyzed retrospectively and the outcome (effectiveness, change in shock index) and the survival were assessed.

Results:

32 patients underwent 33 sPF. One-half of the patients had a benign underlying disease; the other half suffered from a malignant tumor. Four procedures were performed thoracoscopically and 29 via mini-thoracotomy. Both techniques were hemodynamically effective (P &lt; 0.0001) in increasing blood pressure and decreasing pulse rate). There was no death due to failure to control the pericardial effusion and no procedure related mortality. Of the 16 patients with benign underlying disease 14 (87.5%) are still alive. Two died due to reasons unrelated to the procedure or the underlying disease. All 16 patients (100%) with malignant underlying disease died due to tumor progression.

Conclusions:

In our patient cohort minimally invasive thoracic PF was safe and effective. The survival in our study was only related to the nature of the underlying disease. We conclude that sPF is an excellent procedure to treat pericardial effusions: both examined surgical techniques, thoracoscopic video assisted and access via mini-thoracotomy, were equally effective and safe.

Treatment of Malignant Pleural Mesothelioma: American Society of Clinical Oncology Clinical Practice Guideline

Purpose To provide evidence-based recommendations to practicing physicians and others on the management of malignant pleural mesothelioma. Methods ASCO convened an Expert Panel of medical oncology, thoracic surgery, radiation oncology, pulmonary, pathology, imaging, and advocacy experts to conduct a literature search, which included systematic reviews, meta-analyses, randomized controlled trials, and prospective and retrospective comparative observational studies published from 1990 through 2017. Outcomes of interest included survival, disease-free or recurrence-free survival, and quality of life. Expert Panel members used available evidence and informal consensus to develop evidence-based guideline recommendations. Results The literature search identified 222 relevant studies to inform the evidence base for this guideline. Recommendations Evidence-based recommendations were developed for diagnosis, staging, chemotherapy, surgical cytoreduction, radiation therapy, and multimodality therapy in patients with malignant pleural mesothelioma. Additional information is available at www.asco.org/thoracic-cancer-guidelines and www.asco.org/guidelineswiki .

8th International conference on management and rehabilitation of chronic respiratory failure: the long summaries – Part 3

This paper summarizes the Part 3 of the proceedings of the 8^th International Conference on Management and Rehabilitation of Chronic Respiratory Failure, held in Pescara, Italy, on 7 and 8 May, 2015. It summarizes the contributions from numerous experts in the field of chronic respiratory disease and chronic respiratory failure. The outline follows the temporal sequence of presentations.

This paper (Part 3) presents a section regarding Moving Across the Spectrum of Care for Long-Term Ventilation (Moving Across the Spectrum of Care for Long-Term Ventilation, New Indications for Non-Invasive Ventilation, Elective Ventilation in Respiratory Failure - Can you Prevent ICU Care in Patients with COPD?, Weaning in Long-Term Acute Care Hospitals in the United States, The Difficult-to-Wean Patient: Comprehensive management, Telemonitoring in Ventilator-Dependent Patients, Ethics and Palliative Care in Critically-Ill Respiratory Patients, and Ethics and Palliative Care in Ventilator-Dependent Patients).

Anterior parasternal approach for creation of a pericardial window

INTRODUCTION

The optimal method for creation of a pericardial window (PW) is still controversial and it remains a surgical challenge, mainly in obese patients. The aim of this study was to evaluate the efficacy and safety of a novel approach that has not been described previously, for creation of a PW in patients with symptomatic, chronic, large pericardial effusion.

METHODS

We retrospectively analysed the records of 30 patients (14 men, 16 women) who underwent a PW procedure between 2001 and 2011. The mean age was 63 years (standard deviation [SD]: 17 years, median: 60 years, range: 27-90 years) and the mean body mass index was 34 kg/m(2) (SD: 2 kg/m(2)). The operation was performed through a curvilinear parasternal approach, 6-8 cm in length, followed by a mini-thoracotomy between ribs 4 and 5. Discharged patients were followed up clinically.

RESULTS

The mean operative time was 73 minutes (SD: 21 minutes) and a median of 658 ml (range: 300-1,500 ml) of fluid was evacuated. The main aetiologies were idiopathic in 17 patients (57%) and malignant in 9 (30%). Seven patients (23%) died in hospital owing to underlying malignancy. Postoperative complications included mild renal failure (20%), respiratory failure (20%), pneumonia (13%), atrial fibrillation (10%) and atelectasis (6%). There were no wound infections. The median length of stay following the procedure was 8 days. In a median follow-up period of 3.8 years, 16 patients with non-malignant effusion were free of recurrence of pericardial effusion.

CONCLUSIONS

The anterior parasternal approach for creation of a PW is simple, safe and efficacious, and results in long-term symptomatic improvement, specifically in patients with non-malignant effusions. This approach may be more appealing in obese patients.

Pericardioscopy and epi- and pericardial biopsy - a new window to the heart improving etiological diagnoses and permitting targeted intrapericardial therapy

The etiology of pericardial effusions remains unresolved in many cases because not the full spectrum of diagnostic methods including cytology, histology, immunohistology and PCR on cardiotropic agents, which are currently available, used in many institutions. After comprehensive clinical workup and use of imaging methods, such as echocardiography and cardiac MRI, pericardiocentesis and epicardial and pericardial biopsy were carried out under pericardioscopical control of the biopsy site. Biopsies and fluid were evaluated by cytological, histological, immunological and molecular (PCR) methods in 259 patients of our tertiary referral center following an identical clinical pathway, diagnostic and therapeutic algorithm in all cases. A standard clinical pathway and the same diagnostic and therapeutic algorithms were used in all cases. When all methods are applied to patients with pericardial effusions, "idiopathic" pericardial effusion is no longer a relevant diagnosis. Autoreactive and lymphocytic pericardial effusions are the leading diagnosis in 35 % of patients in the prospective Marburg registry, followed by malignant effusions in 28 % of cases. Viral genome was assessed in fluid and epi- as well as pericardial biopsies in 12 %, followed by post-traumatic/iatrogenic effusions in 15 % and purulent/bacterial effusions in only 2 %. Pericardioscopy permits the macroscopic inspection of the pulsating heart and its disease-associated macroscopic alterations. It also permits safe and targeted biopsy for further investigations of the tissue. Therapy, tailored to the individual etiology, can be selected such as intrapericardial instillation in autoreactive effusions with triamcinolone and with cisplatin or thiotepa in neoplastic effusions. With this approach the recurrence of pericardial effusion can be avoided effectively. A comprehensive approach to the diagnosis of pericardial effusions in conjunction with pericardioscopy for targeted tissue sampling is the prerequisite for an etiologically based intrapericardial and systemic treatment, which improves outcome and prognosis.

Identifying oncological emergencies

Prompt identification and treatment of life-threatening oncological conditions is of utmost importance and should always be included in the differential diagnosis. Oncological emergencies can have a myriad of presentations ranging from mechanical obstruction due to tumor growth to metabolic conditions due to abnormal secretions from the tumor. Notably, hematologic and infectious conditions may complicate the presentation of oncological emergencies. Advanced testing and imaging is generally required to recognize these serious presentations of common malignancies. Early diagnosis and treatment of these conditions can significantly affect the patient's clinical outcome.

Thoracoscopic pericardiotomy for management of purulent pneumococcal pericarditis in a child

Purulent pericarditis is an extremely rare complication of pneumococcal pneumonia in children that may result in to cardiac tamponade. While image-guided pericardiocentesis is the treatment of choice for such a condition, it may fail in the presence of thick pus; loculations and thoracoscopic pericardiotomy are useful procedures for such situations. Herein, we report such a case involving a 6-year-old boy who presented with purulent pneumococcal pericarditis that was managed with thoracoscopic pericardiotomy and who recovered well. Thoracoscopic pericardiotomy is a safe procedure that allows effective drainage under vision, pericardial biopsy for diagnosis, and a simultaneous opportunity to perform thoracoscopic pleural drainage.

Surgical properties and survival of a pericardial window via left minithoracotomy for benign and malignant pericardial tamponade in cancer patients

Background

Surgical drainage is a rapid and effective treatment for pericardial tamponade in cancer patients. We aimed to investigate the effectiveness of pericardial window formation via mini-thoracotomy for treating pericardial tamponade in cancer patients, and to evaluate clinical factors affecting long-term survival.

Methods

Records of 53 cancer patients with pericardial tamponade treated by pericardial window formation between 2002 and 2008 were examined. Five patients were excluded due to insufficient data. Kaplan-Meier and Cox regression analysis were used for analysis.

Results

Forty-eight patients (64.7% male), with a mean age of 55.20 ± 12.97 years were included. Patients were followed up until the last control visit or death. There was no surgery-related mortality and the 30-day mortality rate was 8.33%; all died during postoperative hospitalization. Morbidity rate was 18.75%. Symptomatic recurrence rate was 2.08%. Cancer type and nature of the pericardial effusion were the major factors determining long-term survival (P <0.001 and P <0.004, respectively).

Overall median survival was 10.41 ± 1.79 months. One- and 2-year survival rates were 45 ± 7% and 18 ± 5%, respectively.

Conclusion

Pericardial window creation via minithoracotomy was proven to be a safe and effective approach in surgical treatment of pericardial tamponade in cancer patients. Cancer type and nature of pericardial effusion were the main factors affecting long-term survival.

Erdheim-Chester disease: The role of video-assisted thoracoscopic surgery in diagnosing and treating cardiac involvement

INTRODUCTION

Erdheim-Chester disease is a rare, non-Langerhans histiocytosis in which pericardial involvement is diagnosed with increasing frequency and is associated with high mortality rates.

PRESENTATION OF CASE

A 53-year-old woman presented with progressive exertional dyspnea and pericardial effusion was discovered. Further investigations revealed the presence of a diffuse, infiltrating process and a diagnosis of Erdheim-Chester disease was made. An emergent pericardiocentesis by subxiphoid approach was completed but recurrent drainage obviated removal of the pigtail catheter. A pleuro-pericardial window was placed using video-assisted thoracoscopic surgery (VATS) and analysis of the resected specimen confirmed pericardial involvement.

DISCUSSION

In this case, high pericardial fluid output demanded definitive treatment of the pericardial effusion. Traditionally this would be completed via thoracotomy. VATS is a minimally invasive alternative which permits exploration of the thoracic cavity and the creation of a pleuropericardial window.

CONCLUSION

We describe, for the first time, the successful use of VATS for both diagnostic confirmation and therapeutic relief of recurrent pericardial fluid drainage due to pericardial involvement by Erdheim-Chester disease.

[Pericardial window by videothorascopy]

INTRODUCTION

Pericardial effusion is a clinical condition requiring multidisciplinary management. There are several surgical techniques for its diagnosis and treatment. In the present study we report our experience in performing a pericardial window (PW) by videothorascopy.

MATERIAL AND METHODS

We performed surgery on 56 patients (20 females and 36 males), with a mean age of 56±1.22 years, and diagnosed with moderate to severe chronic pericardial effusion. The side chosen for the approach depended on whether there was an associated pleural effusion or lung lesion, and if not the left side was chosen.

RESULTS

The mean duration of the surgery was 37.6±16 minutes. The definitive diagnoses were malignant processes in 23% of cases, including bronchogenic carcinoma and breast cancer. The intra-operative mortality was 0%.

CONCLUSIONS

Videothorascopic pericardial window is an effective and safe technique for the diagnosis and treatment of chronic pericardial effusion, and which enables it to be drained and perform a pleuro-pulmonary and/or mediastinal biopsy during the same surgical act.

Anesthesia and the patient with pericardial disease

PURPOSE

Pericardial diseases present unique perioperative considerations for the anesthesiologist. The purpose of this review is to provide a summary of the pertinent issues related to the etiology, diagnosis, pathophysiology, and perioperative management of patients presenting for operative treatment of pericardial disease.

SOURCE

A selective search of the anesthesia, cardiology, and cardiothoracic surgical literature was carried out with particular emphasis on acute pericarditis, effusion, tamponade, and constrictive pericarditis.

PRINCIPAL FINDINGS

The anesthesiologist needs to be well versed in the etiology (i.e., differential diagnosis), pathophysiology, and diagnostic modalities in order to best prepare the patient for surgery. Diagnosis and guidance of management requires a working knowledge of the specific associated hemodynamic consequences, particularly of the impaired diastolic function that can occur. Echocardiography is essential in the diagnosis and management of these patients.

CONCLUSIONS

Patients with acute and chronic pericardial diseases often require the need for surgical intervention. Several unique features of acute tamponade and constrictive pericarditis require careful perioperative consideration. With proper preparation and pre-anesthetic optimization, patients with a variety of pericardial diseases can be safely managed before, during, and after their surgical intervention.

[Management of malignant pericardial effusion with parasternal fenestration]

Numerous methods exist for the treatment of pericardial effusions. These methods, however, can be applied with limitations only for long-term eradication of malignant pericardial effusion. Lately, several new methods, including minimally invasive procedures, have been published, and the VATS technique has become fairly popular. This technique needs special instruments and single lung ventilation, which is relatively risky in case of contralateral malignancy. We apply a new and simple minimally invasive fenestration method using the well-known approach of the parasternal mediastinoscopy by Stemmer. No recurrence of pericardial effusions was noted in long-term follow-up. In the past 10 years 73 patients were treated for pericardial effusion in our department and 22 pericardium fenestrations have been performed with parasternal approach. This method is recommended for the definitive treatment of pericardial effusion with malignant origin.

The pericardial window: is a video-assisted thoracoscopy approach better than a surgical approach?

OBJECTIVES

The approach to the pericardial window in patients with pericardial effusion (PE) remains undefined as to whether a surgical (transthoracic or subxiphoid) or a thoracoscopic pericardial window is the optimal operative approach to PE. We hypothesized that the window into the pleural space created by the thoracoscopy might improve the outcome.

METHODS

We conducted a prospective study between September 2007 and October 2009. All patients with PE diagnosed by echocardiography who attended the Cardiothoracic Department in King Fahd Hospital are included in this study. They were 30 patients (18 males, 12 females aged 44±1.22 years). Patients were subdivided into two groups. Group A, 15 patients underwent the surgical (transthoracic or subxiphoid) procedure and Group B, 15 patients underwent the video-assisted thoracoscopy procedure. Preoperative, intraoperative and postoperative variables, morbidity, recurrence, and survival were compared in both groups.

RESULTS

Preoperative variables were well-matched for age, sex, preoperative tamponade, echocardiographical characteristics and co-morbidities between both groups. No recurrence of effusion was observed in the two groups. Operative time was statistically highly significant (P<0.001); it was longer in Group B. There was no intraoperative complication in both groups. There was no postoperative complication in both groups except one case of superficial wound infection in Group A. There was no significance difference between both groups as regard duration of chest tube drainage and length of hospital stay. There was no in-hospital mortality in both groups.

CONCLUSIONS

Pericardial window by video-assisted thoracoscopy is an effective technique for pericardial drainage and biopsy. Apart from its diagnostic value, it allows the physician to fashion a pleuropericardial window for effective drainage while avoiding the complications of classic surgical procedures.

Oncologic emergencies

Oncologic emergencies represent a wide variety of conditions that can occur at any time during the course of a malignancy, from an initial presenting manifestation in someone with an undiagnosed cancer, to end-stage incurable metastatic disease. Emergent conditions can also arise after a malignancy has been in remission for many years, even decades, so clinicians must be aware of any prior history of cancer in patients. Oncologic emergencies include conditions caused by the cancer itself or side effects of therapy. Emergent conditions include metabolic, cardiac, neurologic, or infectious disorders. Many of these emergencies are imminently life-threatening, and can occur in patients with curable disease (such as lymphomas or leukemias); however, many also present in patients with incurable advanced disease. Prompt recognition and treatment of these conditions can lead to markedly improved quality and quantity of life.

Spectrum of pericardial disease: part I

Pericardial disease is a common disorder seen in varying clinical settings and may be the first manifestation of an underlying systemic disease. It may be due to multiple causes. Epidemiologic studies are lacking, and the exact incidence and prevalence are unknown. New diagnostic techniques have improved diagnosis, allowing early diagnosis and management. There are few randomized data to guide physicians in the management of pericardial diseases. Part I of our review focuses on the current state of knowledge and management of the more common pericardial diseases: acute pericarditis, pericardial effusion, cardiac tamponade, chronic pericarditis and relapsing pericarditis.

Video-Assisted Pericardial Fenestration for Effusions after Cardiac Surgery

Delayed-onset pericardial effusion following cardiac surgery can give rise to significant morbidity due to its presentation as well as management by traditional surgical techniques. An institutional experience of a video-assisted thoracoscopic technique to create a pericardial window, with the advantages of a minimally invasive approach combined with excellent visualization in such patients, was reviewed. A retrospective analysis was conducted on all patients undergoing video-assisted thoracoscopic for delayed pericardial effusion after cardiac surgery from January 2001 to January 2006 at our center. Seven patients with echocardiographically diagnosed delayed tamponade underwent video-assisted thoracoscopy; 5 were receiving anticoagulants after valve replacement, and 2 had undergone heart transplantation. Pericardial windows were created under general anesthesia and single-lung ventilation using 2 to 3 trocars. Mean operative time was 45 min. There were no complications of the thoracoscopic technique. Video-assisted thoracoscopic creation of a pericardial window is safe and effective treatment for loculated pericardial effusions secondary to cardiac surgery.

Massive intractable pericardial effusion in a patient with systemic lupus erythematosus treated successfully with pericardial fenestration alone

Systemic lupus erythematosus (SLE) is often complicated by pericarditis with effusion, which generally responds well to glucocorticoid. We report herein a Japanese patient with SLE who showed a sign of cardiac tamponade and severe chest and back pain because of massive intractable pericardial effusion. Pulse glucocorticoid and pulse cyclophosphamide gained marginal effects. Pericardial effusion accumulated again soon after ultrasound-guided pericardiocentesis and drainage. Pericardial fenestration performed surgically as a last resort, for draining pericardial fluid into the pleural space, was very effective, and only a much smaller amount of fluid was observed in the space thereafter in comparison with the volume before the surgery. Pathological examination of the retrieved pericardium unfolded intense hyperplasia of small vessels and capillaries. Levels of IL-6 and TNF-α in pericardial effusion were extremely higher than those in serum. Pericardial effusion with extensive capillary hyperplasia in SLE would be resistant to medical treatment and require surgical fenestration.

[Pericardial window by videothoracoscope in the treatment of pericardial effusion and tamponade]

INTRODUCTION

Malignancies are the most common causes of pericardial effusion (PE) or tamponade (PT). Lung and breast carcinoma are the most frequent. The treatment of PE consists in the performance of drainage and/or pericardial window (PW) usually subxiphoid. In the present study we describe our experience with the PW by videothoracoscopic (VATS) approach, a procedure scarcely referred to in the literature.

OBJECTIVE

To evaluate the efficacy of the PW by videothoracoscopic (VATS) approach in the treatment of PE and/or PT.

PATIENTS AND METHOD

Retrospective study of 12 patients with PE submitted to PW by VATS in a period of 10 years, since February 1994 to October 2004. The surgical procedure employed was VATS, under general anesthesia, selective intubation and lateral decubitus. We systematically performed a PW anterior to phrenic nerve and studied pleural and pericardial fluids. Talc pleurodesis was added if neoplastic pleural effusion was objectived by a previous needle thoracocentesis and cytological analysis of pleural fluid. A single chest drain (24 F) was inserted after surgery, and removed when daily debit was under 100 ml.

RESULTS

12 patients were operated on, 4 men and 8 women, mean age of 58.6 years (range, 32-78). There was no surgical mortality. There were 8 cases of PT. The causes of PE were: breast carcinoma in 8 cases, lung carcinoma in 3 cases and infectious origin in one case. Mean duration of surgical procedure was 30 minutes. All the patients had concomitant pleural effusion. Surgical approach was by the left side in all the cases. Talc pleurodesis was added in 8 cases of the 12 that had pleural effusion, in the 8 cases cytological analysis had shown paraneoplastic origin. Chest drain was removed after a mean period of 3.5 days. There was no mortality associated with the procedure. Mean stay was 3.8 days. Mean survival was 12 months for breast cancer patients and 4 months for lung cancer.

CONCLUSIONS

PW by VATS is a suitable procedure for the management of massive PE or PT. In our experience this procedure showed no mortality and minimal morbidity, providing symptomatic improvement (in PE and pleural efusión) in all the patients. This approach also makes possible the study of pleural cavity, the obtaining of parietal pleura samples and, if necessary, the performance of talc pleurodesis.

Primary percutaneous balloon pericardiotomy for malignant pericardial effusion

OBJECTIVES

Pericardial effusion associated with malignancy is a life-threatening complication of late-stage disease. While simple drainage is effective in relieving the symptoms, reaccumulation of effusion may cause further symptomatic episodes, often during a period when overall patient management is focused on improving the quality of remaining life. Over a 16-year period, we have adopted a strategy of managing such patients with balloon pericardiotomy as the initial preferred treatment. The results are described and compared to alternative management strategies.

METHODS

A retrospective analysis of patients who presented with symptomatic, malignant pericardial effusion, their management, procedural complication rates, and the need for further therapy for the same condition was made. Survival, reaccumulation rates, and readmissions after the index procedure were recorded and compared.

RESULTS

Forty-three patients were treated for malignant pericardial effusion. Balloon pericardiotomy was the primary treatment in 27/43 patients, simple drainage in 14/43, and surgery in 2/43. Reaccumulation rates between balloon pericardiotomy and simple aspiration (7.4% vs. 14.3%, respectively, P = 0.48) and complication rates (7.4% vs. 7.1%, respectively, P = 0.98) were not statistically different. Survival following intervention was driven by the underlying pathology and was poor, with overall median survival of 56 days.

CONCLUSIONS

Balloon pericardiotomy, as initial management of symptomatic malignant pericardial effusions, allows a definitive procedure to be performed at presentation. This can be achieved with low complication rates, similar to treatment by simple drainage.

Palliation of thoracic malignancies

The sequelae of advanced malignancies of the chest, whether primary or metastatic, can be severely debilitating. In this review, we discuss the advances in palliative treatment for several intrathoracic complications of malignancy. The treatment of malignant pleural and pericardial effusions now includes a range of chemical sclerosants and percutaneous or surgical interventions. A new generation of promising stent and ablation technologies allows for the treatment of intrinsic or extrinsic airway obstruction. Similar techniques are being explored for esophageal obstruction, while the possible benefit of palliative radiation and chemotherapy continues to be investigated. Although their symptoms are often severe, patients with advanced thoracic malignancies have a growing number and variety of palliative treatment options to improve their quality of life.