Video-thoracoscopic pericardial window in the diagnosis and treatment 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.

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.

Associated Pleural and Pericardial Effusions: An Extensive Differential Explored

Concurrent pleural and pericardial effusions are not an unusual finding, but their differential diagnosis remains uncertain. Medline-based review identified an extensive list of infectious, inflammatory, neoplastic, iatrogenic, and myriad other etiologies. A single retrospective study had addressed this presentation. Several principles of a diagnostic workup are suggested, acknowledging that a significant minority of patients may not require a comprehensive workup and remain 'idiopathic'.

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.

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.

[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.

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

BACKGROUND

Video-assisted thoracoscopy with the creation of a pericardial window is a noninvasive method of pericardial drainage. It also allows an excellent view of both the pleural cavity and pericardium and the precise selection of biopsy sites. We review our 3-year experience with this technique.

METHODS

Between January 2001 and February 2004, 18 patients (10 men, 8 women; mean age 57 years) with echocardiographically diagnosed pericardial effusion underwent video-assisted thoracoscopy at our center. Pericardial windows were created under general anesthesia and single-lung ventilation using 2 to 3 trocars. Mean operating time was 46 minutes. A right thoracic approach was used in 16 patients and a left thoracic approach in 2.

RESULTS

Microbiology and virology cultures of the pericardial fluid were negative. Histologic findings were compatible with tuberculosis in 2 cases and granulocytic sarcoma, infiltrating breast carcinoma, and infiltrating nonsmall cell carcinoma in 1 case each. In the remaining patients, the histologic diagnosis was chronic or subacute nonspecific pericarditis. Talc pleurodesis was performed in 3 patients for concomitant malignant pleural effusion. In 4 patients, the pericardial effusion occurred secondary to cardiac surgery; 3 were receiving anticoagulants after valve replacement, and 1 had a heart transplant. There were no complications of the thoracoscopy technique.

CONCLUSIONS

Video-assisted thoracoscopic fenestration 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. Concomitant pleural and pulmonary disorders may be managed simultaneously.

Comparative study of subxiphoid versus video-thoracoscopic pericardial "window"

BACKGROUND

It remains undefined whether surgical subxiphoid drainage or thoracoscopic pericardial "window" is the optimal operative approach to pericardial effusion. We hypothesized that the true window into the pleural space created by the latter might improve the duration of freedom from recurrent effusion.

METHODS

We conducted a retrospective chart review of indications, preoperative and intraoperative variables, morbidity, recurrence, and survival.

RESULTS

Fifty-six patients underwent the subxiphoid procedure and 15 underwent the thoracoscopic procedure. Echocardiographic evidence of tamponade was present before 8 of 10 thoracoscopic procedures (80%) and 43 of 56 subxiphoid procedures (81%) for which descriptions of hemodynamics were available. In addition, non-pericardial procedures were performed in 10 (67%) and 18 (32%) patients, respectively (p = 0.020). Anesthesia time was longer at thoracoscopy (117.1 +/- 32.4 vs 81.1 +/- 25.5 minutes; p < 0.001). Procedural morbidity was higher after thoracoscopy (4 [27%] vs 1 [2%]; p = 0.006), but was generally minor. Hospital mortality tended to be higher after the subxiphoid procedure (7 [13%] vs 0 [0%]; p = 0.332), but none of the deaths was procedure-related. Follow-up was complete for 65 patients (92%). Recurrence occurred in 1 thoracoscopy patient (8%) and 5 subxiphoid patients (10%) (p = 1.000). Mean time to recurrence by Kaplan-Meier analysis trends were longer after thoracoscopy (36.1 vs 11.4 months; p = 0.16), and multivariate analysis identified the thoracoscopic approach as an independent predictor of freedom from recurrence (relative risk, 0.41; p = 0.014).

CONCLUSIONS

Operative time and minor procedural morbidity are higher with thoracoscopic pericardial window, but long-term control of effusion seemed to be better than after subxiphoid surgical drainage.

Delayed hemopericardium after penetrating chest trauma: thoracoscopic pericardial window as a therapeutic option

A 41-year-old male developed a hemothorax after sustaining a stab wound in the right chest. The patient was managed conservatively with thoracostomy tube drainage for 3 days and was subsequently discharged home. Two weeks later the patient returned to the hospital with pleuritic chest pain and shortness of breath. Imaging studies revealed a right-sided pleural effusion and an enlarged cardiac silhouette, which was consistent with pericardial effusion as per ultrasonography. Thoracoscopic exploration revealed an enlarged heart, that following pericardiotomy drained 400 mL of frank blood. Subsequently, cardiac contractility improved, and no further bleeding was evident.