Percutaneous Therapy in Pericardial Diseases

The BALTO Registry: Long-term results of percutaneous BALloon pericardioTomy in oncological patients

OBJECTIVES

The aim of this study was to analyze the efficacy and safety of percutaneous balloon pericardiotomy (PBP) in oncological patients who present with a malignant pericardial effusion (MPE).

BACKGROUND

The use of PBP as a treatment for MPE is not standardized due to the limited evidence. Furthermore, the performance of a second PBP for a recurrence after a first procedure is controversial.

METHODS

The BALTO Registry (BALloon pericardioTomy in Oncological patients) is a prospective, single-center, observational registry that includes consecutive PBP performed for MPE from October 2007 to February 2022. Clinical and procedural, characteristics, as well as clinical outcome were analyzed.

RESULTS

Seventy-six PBP were performed in 61 patients (65% female). Mean age was of 66.4 ± 11.2 years. In 15 cases, a second PBP procedure was performed due to recurrence despite the first PBP. The procedure could be performed effectively in all cases with only two serious complications. Ninety-five percent of cases were discharged alive from the hospital. During a median follow-up of 6.3 months (interquartile range [IQR], 0.9-10.8), MPE recurred in 24.5% cases although no recurrences were reported after the second procedure. No evidence of malignant pleural effusion developed on follow-up. The median overall survival time was 5.8 months (IQR, 0.8-10.2) and the time to recurrence after the first PBP was 2.4 months (IQR, 0.7-4.5).

CONCLUSIONS

PBP is a safe and effective treatment for MPE. It could be considered an acceptable therapy in most MPE, even in those who recur after a first procedure.

Cardiac tamponade

Cardiac tamponade is a medical emergency caused by the progressive accumulation of pericardial fluid (effusion), blood, pus or air in the pericardium, compressing the heart chambers and leading to haemodynamic compromise, circulatory shock, cardiac arrest and death. Pericardial diseases of any aetiology as well as complications of interventional and surgical procedures or chest trauma can cause cardiac tamponade. Tamponade can be precipitated in patients with pericardial effusion by dehydration or exposure to certain medications, particularly vasodilators or intravenous diuretics. Key clinical findings in patients with cardiac tamponade are hypotension, increased jugular venous pressure and distant heart sounds (Beck triad). Dyspnoea can progress to orthopnoea (with no rales on lung auscultation) accompanied by weakness, fatigue, tachycardia and oliguria. In tamponade caused by acute pericarditis, the patient can experience fever and typical chest pain increasing on inspiration and radiating to the trapezius ridge. Generally, cardiac tamponade is a clinical diagnosis that can be confirmed using various imaging modalities, principally echocardiography. Cardiac tamponade is preferably resolved by echocardiography-guided pericardiocentesis. In patients who have recently undergone cardiac surgery and in those with neoplastic infiltration, effusive-constrictive pericarditis, or loculated effusions, fluoroscopic guidance can increase the feasibility and safety of the procedure. Surgical management is indicated in patients with aortic dissection, chest trauma, bleeding or purulent infection that cannot be controlled percutaneously. After pericardiocentesis or pericardiotomy, NSAIDs and colchicine can be considered to prevent recurrence and effusive-constrictive pericarditis.

A Rare Case of Primary Purulent Pericarditis Caused by Streptococcus constellatus

Background: Bacteria-caused acute pericarditis is a very rare entity. It is usually associated with an underlying infection or compromised immune system. Primary purulent pericarditis in a previously healthy individual is highly unexpected; therefore, it is likely to have a delayed diagnosis and poor outcomes. Case: We report a case of an adult immunocompetent patient with primary bacterial pericarditis caused by a member of the commensal oral flora Streptococcus constellatus. The patient presented with septic shock and cardiac tamponade, and was further complicated with constrictive pericarditis, which was successfully treated with pericardiectomy. Conclusions: Bacterial pericarditis is a fulminant disease with a high mortality and complication rate. Fast recognition and prompt therapy are required to achieve a full recovery.

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.

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.

Interventional Strategies in Cancer-induced Cardiovascular Disease

PURPOSE OF REVIEW

To highlight the range of illnesses and procedures that the interventional onco-cardiologists face in their daily practice, along with the recent additions to anti-cancer therapies and their related cardiotoxicity.

RECENT FINDINGS

Immune checkpoint inhibitors (ICI) are not devoid of cardiotoxicity as thought earlier and lead to an increased incidence of myocarditis. Transcatheter valve replacement has been shown to be a safer alternative to surgical replacement in cancer patients. Interventional onco-cardiology is a novel field that addresses cardiovascular diseases in the setting of cancer. Traditionally excluding cancer patients from clinical trials has led to a dearth of information needed to tackle cardiac conditions like Takotsubo cardiomyopathy, malignant pericardial effusions, and radiation-induced vascular diseases encountered either exclusively or predominantly in this high-risk population. This review discusses the various treatment options available in the interventional armamentarium with a particular focus on ICI-myocarditis and transcatheter aortic valve replacement in cancer patients.

Single center experience of pediatric percutaneous balloon pericardiotomy

BACKGROUND

Percutaneous balloon pericardiotomy is a percutaneous procedure that creates a window in the parietal pericardium by balloon dilation. The use of percutaneous balloon pericardiotomy has not been reported well in children.

OBJECTIVES

The objective of this study was to describe the single centre experience of percutaneous balloon pericardiotomy in children.

METHODS

This was a retrospective study to describe all the children aged <20 years undergoing percutaneous balloon pericardiotomy during an 18-year period (2001-2019). Patient characteristics, technical and ultimate procedural success, and repeat interventions were collected.

RESULTS

A total of 13 percutaneous balloon pericardiotomy's were performed in 11 children at the median age of 12 years (range 1.8-19). The etiologies of pericardial effusion were post-pericardiotomy syndrome (n = 4), restrictive cardiomyopathy (n = 1), autoimmune diseases (n = 3), malignancy (n = 2), and idiopathic (n = 1). Two patients received two percutaneous balloon pericardiotomy. The technical success of percutaneous balloon pericardiotomy was 100% with no acute adverse events (balloon rupture or local bleeding). Five (45%) required re-intervention and ultimately three required a surgical pericardial window 6 to 35 days after the percutaneous balloon pericardiotomy. As a result, ultimate procedural success rate was 73% (8/11).

CONCLUSION

Percutaneous balloon pericardiotomy was performed safely with high technical success in children. Percutaneous balloon pericardiotomy may be considered for recurrent and persistent pericardial effusion, before considering a surgical pericardial window.

State of the Art Imaging Review of Blunt and Penetrating Cardiac Trauma

Traumatic cardiovascular injuries are only second to the central nervous system injuries as a cause of death in young adult population. Multidetector computed tomography is the gold standard diagnostic modality in patients with blunt or penetrating chest trauma and clinical suspicion of cardiac injury. The imaging spectrum of cardiac injuries includes but not limits to pericardial rupture, myocardial contusions, valve rupture, coronary artery injuries, cardiac herniations, and cardiac tamponade. In this review article, we discuss clinical presentation, types, and mechanism of cardiac trauma with emphasis on the imaging findings and illustrations in blunt, penetrating traumatic, and iatrogenic cardiac injuries.

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.

Technologies for intrapericardial delivery of therapeutics and cells

The pericardium, which surrounds the heart, provides a unique enclosed volume and a site for the delivery of agents to the heart and coronary arteries. While strategies for targeting the delivery of therapeutics to the heart are lacking, various technologies and nanodelivery approaches are emerging as promising methods for site specific delivery to increase therapeutic myocardial retention, efficacy, and bioactivity, while decreasing undesired systemic effects. Here, we provide a literature review of various approaches for intrapericardial delivery of agents. Emphasis is given to sustained delivery approaches (pumps and catheters) and localized release (patches, drug eluting stents, and support devices and meshes). Further, minimally invasive access techniques, pericardial access devices, pericardial washout and fluid analysis, as well as therapeutic and cell delivery vehicles are presented. Finally, several promising new therapeutic targets to treat heart diseases are highlighted.

A contemporary look at pericardiocentesis

Percutaneous drainage is the default strategy for evacuating a pericardial effusion. A pericardiocentesis can be necessary or required in a wide variety of clinical settings ranging from urgent tamponade to relieve in iatrogenic hemorrhagic effusions in the electrophysiology or catheterization room, to planned diagnostic procedures in patients with suspected or known malignancy or infections. With the help of several procedural improvements over the past decades, echocardiography and fluoroscopy-guided percutaneous pericardiocentesis has become the standard intervention for evacuating pericardial effusions, as well as an essential tool in the diagnostic work-up of an unexplained pericardial effusion. When performed by skilled physicians assisted by appropriate imaging it is a very safe procedure, and provided that an indwelling catheter is placed, it is also very effective with an acceptably low risk of recurrences. In this review, the indications and standard techniques for pericardiocentesis are discussed, as well as their consequences for patients with iatrogenic and malignant effusions.