Pericardial effusion: subxiphoid pericardiostomy versus percutaneous catheter drainage

Comparing Outcomes of CT-Guided Percutaneous Pericardial Drainage with Surgical Pericardial Window in Patients with Symptomatic Pericardial Effusions

RATIONALE AND OBJECTIVES

To compare short-term outcomes of CT-guided percutaneous pericardial drainage (PPD) versus subxiphoid surgical pericardial window (PW) drainage and analyze the risk factors associated with their outcomes.

MATERIALS AND METHODS

A retrospective chart review of patients who underwent either percutaneous drainage with drainage catheter placement or PW with surgical drain placement for symptomatic pericardial effusion between January 1, 2006 and August 31, 2016 was performed after institutional review board approval (decision number 16-783). The primary objective was to test for associations between the short-term (≤30 days post procedure) complication and recurrence rates in patients with symptomatic pericardial effusions. The secondary objectives were to test for associations between short-term complications with changes in vital signs.

RESULTS

Of the 257 procedures included in the final analysis, 142 were in the percutaneous drainage group. Short-term complication rate was significantly greater (p < 0.001) in patients undergoing PW, 17% (19/114), as compared with PPD, 2% (3/142). The estimated odds of having complications in the PW cohort was 9 times greater than the percutaneous drainage cohort (OR = 9.3, 95% CI:  2.7-32.3). No significant difference was observed between whether or not a patient experienced a short-term recurrence and any of the explanatory variables (patient demographics, imaging, and vital signs).

CONCLUSION

CT-guided PPD is a safer alternative to surgical PW as it leads to fewer complications without a significant difference in recurrence rate of pericardial effusion.

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 or surgical drainage: A national comparison of clinical outcomes and resource use

Background

While institutional series have sought to define the optimal strategy for drainage of pericardial effusions, large-scale comparisons remain lacking. Using a nationally representative sample, the present study examined clinical and financial outcomes following pericardiocentesis (PC) and surgical drainage (SD) in patients admitted for pericardial effusion and tamponade.

Methods

Adults undergoing PC or SD within 2 days of admission for non-surgically related pericardial effusion or tamponade were identified in the 2016–2019 Nationwide Readmissions Database. Multivariable logistic and linear models were developed to evaluate the association between intervention type and outcomes. The primary outcome of interest was mortality while secondary endpoints included reintervention, periprocedural complications, hospital length of stay (LOS), hospitalization costs and 30-day non-elective readmission.

Results

Of an estimated 44,637 records meeting inclusion criteria, 28,862 (64.7%) underwent PC while the remainder underwent SD for initial management of pericardial effusion or tamponade. PC was associated with significantly increased odds of in-hospital mortality, reintervention and 30-day readmission relative to SD. PC was also associated with greater odds of cardiac complications but lower odds of infection, respiratory failure and blood transfusions compared to SD. Although PC was associated with shorter index hospital length of stay and costs, the two strategies yielded similar 30-day cumulative costs.

Conclusion

Management of pericardial effusion with PC is associated with greater odds of mortality, reintervention and 30-day readmission but similar 30-day cumulative costs compared to SD. In the setting of adequate hospital capability and operator expertise, SD is a reasonable initial treatment strategy for pericardial effusion.

A Case of Pericardial Decompression Syndrome Following Surgical Pericardial Fluid Drainage

Pericardial decompression syndrome (PDS) is a rare and serious complication that follows often-initially-uncomplicated pericardial drainage in patients with pericardial effusion and tamponade physiology. The pathophysiology of PDS is not yet completely understood, although several mechanisms have been postulated. In this report, we present a case of PDS in a 70-year-old male with end-stage renal disease (ESRD) after he underwent a surgical pericardial window for drainage of a moderate pericardial effusion with tamponade physiology. This case provides further evidence that rapid pericardial decompression, notably with pericardiotomy, can lead to acute life-threatening low cardiac output heart failure, particularly in patients with underlying cardiac risk factors. Early recognition, diagnosis, and supportive treatment in the ICU are crucial for improving survival rates in these patients.

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.

Laparoscopic transdiaphragmatic pericardial fenestration in palliative care: how I do it

BACKGROUND

The optimal therapeutic strategy for drainage of malignant pericardial effusion is not yet determined. Several techniques are described, with different benefits and disadvantages. The literature suggests that surgical drainage of pericardial effusions has less effusion recurrence; however, randomized controlled trials are not available. Due to the nature of the disease, quality of life should always be considered while making treatment decisions.

METHODS

A retrospective analysis of all consecutive patients from November 2016 until June 2019 of our institution in the Netherlands was performed. All patients underwent laparoscopic pericardial fenestration after echocardiography and request for operative treatment by the cardiologist. The same operation technique was performed in every case.

RESULTS

Four out of five of our patients needed pericardial fenestration because of oncological diseases. No hemodynamically instability was noted during this fast technique, achieving direct relief of symptoms. No treatment-related morbidity or mortality, nor the need for re-intervention was encountered. We compared the outcome of our five patients with the existing evidence in the literature.

CONCLUSIONS

In this article, we highlight the laparoscopic transdiaphragmatic pericardial fenestration as a treatment of preference in a non-acute palliative setting. This laparoscopic approach is safe, and can be a valuable alternative among the other well-known approaches.

A Comprehensive Systemic Literature Review of Pericardial Decompression Syndrome: Often Unrecognized and Potentially Fatal Syndrome

BACKGROUND

Pericardial Decompression Syndrome (PDS) is defined as paradoxical hemodynamic deterioration and/or pulmonary edema, commonly associated with ventricular dysfunction. This phenomenon was first described by Vandyke in 1983. PDS is a rare but formidable complication of pericardiocentesis, which, if not managed appropriately, is fatal. PDS, as an entity, has discrete literature; this review is to understand its epidemiology, presentation, and management.

METHODOLOGY

Medline, Science Direct and Google Scholar databases were utilized to do a systemic literature search. PRISMA protocol was employed. Abstracts, case reports, case series and clinical studies were identified from 1983 to 2019. A total of 6508 articles were reviewed, out of which, 210 were short-listed, and after removal of duplicates, 49 manuscripts were included in this review. For statistical analysis, patient data was tabulated in SPSS version 20. Cases were divided into two categories surgical and percutaneous groups. t-test was conducted for continuous variable and chi-square test was conducted for categorical data used for analysis.

RESULTS

A total of 42 full-length case reports, 2 poster abstracts, 3 case series of 2 patients, 1 case series of 4 patients and 1 case series of 5 patients were included in the study. A total of 59 cases were included in this manuscript. Our data had 45.8% (n=27) males and 54.2% (n=32) females. The mean age of patients was 48.04 ± 17 years. Pericardiocentesis was performed in 52.5% (n=31) cases, and pericardiostomy was performed in 45.8% (n=27). The most common identifiable cause of pericardial effusion was found to be malignancy in 35.6% (n=21). Twenty-three 23 cases reported pre-procedural ejection fraction, which ranged from 20%-75% with a mean of 55.8 ± 14.6%, while 26 cases reported post-procedural ejection fraction which ranged from 10%-65% with a mean of 30% ± 15.1%. Data was further divided into two categories, namely, pericardiocentesis and pericardiostomy. The outcome as death was significant in the pericardiostomy arm with a p-value of < 0.00. The use of inotropic agents for the treatment of PDS was more common in needle pericardiocentesis with a p-value of 0.04. Lastly, the computed recovery time did not yield any significance with a p-value of 0.275.

CONCLUSION

Pericardial decompression syndrome is a rare condition with high mortality. Operators performing pericardial drainage should be aware of this complication following drainage of cardiac tamponade, since early recognition and expeditious supportive care are the only therapeutic modalities available for adequate management of this complication.

Rare complication after pericardial window: symptomatic diaphragmatic hernia containing bowel and liver

A 37-year-old woman presented to her local district general hospital with a cough, pleuritic chest pain and intermittent cyanosis. Eight months prior, she underwent a successful pericardial window for recurrent, symptomatic pericardial effusions. On presentation she was hypoxic but haemodynamically stable. Her chest radiograph raised the suspicion of a diaphragmatic hernia, confirmed by CT imaging. This identified herniation through the diaphragm of the transverse colon and left lobe of the liver resulting in cardiac compression and right ventricular dysfunction. She continued to deteriorate and required emergency intubation to allow safe transfer to a tertiary upper gastrointestinal unit. She underwent a laparotomy and repair of the diaphragmatic hernia with an uneventful inpatient recovery. In the literature, diaphragmatic liver herniation is a recognised complication secondary to trauma or congenital defects, however, to our knowledge, there are currently no cases described following pericardial windowing.

Effectiveness and outcomes of 2 therapeutic interventions for cardiac tamponade: A retrospective observational study

Pericardial effusions can either be drained by percutaneous pericardiocentesis (PCC) or by surgical pericardiotomy (SP), with limited evidence of superiority for the management of cardiac tamponade (CTa).This study uses the US Nationwide Emergency Department Sample database to investigate the effectiveness of SP and PCC in patients with CTa in terms of clinical outcomes and healthcare costs.Retrospective observational study conducted on the US Nationwide Emergency Department Sample 2014 dataset CTa patients. Descriptive and multivariate logistic regression analyses were done to assess the impact of different procedures (none, SP, PCC, SP, and PCC) on mortality.A total of 10,410 CTa patients were included, of which 28.9% underwent no procedure, 32.9% underwent SP, 30.2% underwent PCC and 8.0% underwent SP and PCC. Mortality rates were highest in patients undergoing no procedure (22.3%) followed by PCC (15.0%), SP and PCC (11.5%), and then SP (9.6%) (P < .001). SP patients had longer length of stay (11.65 vs 8.16 days, P < .001) and higher total charges ($162,889.1 vs $100,802, P < .001) compared to PCC patients. Undergoing any procedure for CTa reduced the rate of mortality compared to no procedure with SP being the most effective (OR = 0.323, 95%CI 0.244-0.429), followed by SP & PCC (OR = 0.387, 95% CI 0.239-0.626), and then PCC (OR = 0.582, 95% CI 0.446-0.760).Adult CTa patients treated with SP had lower mortality rates but longer length of stay and higher healthcare expenses. This SP associated benefit remained consistent across different subpopulations after stratifying by age and potential disease etiology.

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.

Pericardial decompression syndrome: A comprehensive review

Pericardial decompression syndrome (PDS) is an infrequent, life-threatening complication following pericardial drainage for cardiac tamponade physiology. PDS usually develops after initial clinical improvement following pericardiocentesis and is significantly underreported and may be overlooked in the clinical practice. Although the precise mechanisms resulting in PDS are not well understood, this seems to be highly associated with patients who have some underlying ventricular dysfunction. Physicians performing pericardial drainage should be mindful of the risk factors associated with the procedure including the rare potential for the development of PDS.

Surgical pericardial drainage procedures have a limited diagnostic sensitivity

Purpose

Cardiothoracic surgeons are frequently called upon to perform surgical pericardial drainage procedures (pericardial window) for pericardial effusions. These procedures have therapeutic value, but the diagnostic value of such procedures is debated. We set out to determine the sensitivity of pericardial drainage to detect the disease when cytology, microbiology, and pathology are evaluated.

Methods

A retrospective chart review of patients who underwent pericardial windows from 1 July 2011 to 1 January 2018 at a single academic institution was conducted. All patients who had undergone a recent trauma or cardiac procedure were excluded. Cytology, microbiology, and pathology were examined. The charts were then carefully reviewed to determine if a clinical diagnosis was reached. Sensitivity was then calculated for all diseases and for those that should have been able to be detected.

Results

One hundred sixty‐two patients who had undergone a pericardial drainage procedure were identified; 49 patients were excluded for recent cardiac procedure or trauma. Of the 113 patients who met our inclusion criteria, 56 patients (49.6%) were female with a mean age of 59.7 ± 15.1 years. A diagnosis based on the pathology, microbiology, or cytology was obtained for 27 patients. The most common pathologies detected were adenocarcinoma (11), bacteremia (9), and small cell lung cancer (3); 56 patients had underlying pathologies that would have been possible to detect with either pathology, microbiology, or cytology. The most common detectable diagnoses were adenocarcinoma (20), bacteremia (12), and lymphoma (7). The most common undetectable diagnoses were idiopathic (17), cardiorenal fluid overload (17), and viral (11). The sensitivity of a pericardial drainage procedure for detecting disease was 0.24 for all cases, and 0.48 when restricted to cases where a detectable disease was present.

Conclusion

Cytology, microbiology, and pathology for pericardial drainage procedures were unable to detect a diagnosis for 76% of all cases and greater than 50% of cases with the theoretically detectable disease. Pericardial drainage procedures have a clear therapeutic value, but they have limited diagnostic utility.

Management of neoplastic pericardial disease

At present, there is no accurate and effective method for treating neoplastic pericardial effusion. This study analyzed the current literature on the treatment of neoplastic pericardial effusion to provide advice and guidance for clinical treatment. Surgical treatments include pericardial puncture, extension of catheter drainage, pericardial window, and surgical pericardiotomy. Each surgical procedure has a corresponding indication, and the best treatment is selected according to the patient's specific conditions. Systemic chemotherapy is effective in lymphoma and small cell lung cancer that are sensitive to chemotherapeutic drugs. Although pericardial injection of drugs is effective for pericardial tamponade and recurrent pericardial effusion, these methods can only temporarily relieve symptoms and cannot prolong the life of patients. In recent years, immunotherapy, especially adoptive immunotherapy, has achieved good results in the treatment of neoplastic pericardial effusion, thus providing a novel treatment option for neoplastic pericardial effusion.

Treatment of Pericardial Effusion Through Subxiphoid Tube Pericardiostomy and Computerized Tomography- or Echocardiography - Guided Percutaneous Catheter Drainage Methods

Objective

In this retrospective study, we aimed to observe the efficacy of pericardial effusion (PE) treatments by a survey conducted at the Department of Cardiovascular Surgery, Faculty of Medicine, Atatürk University.

Methods

In order to get comparable results, the patients with PE were divided into three groups - group A, 480 patients who underwent subxiphoid pericardiostomy; group B, 28 patients who underwent computerized tomography (CT)-guided percutaneous catheter drainage; and group C, 45 patients who underwent echocardiography (ECHO)-guided percutaneous catheter drainage.

Results

In the three groups of patients, the most important symptom and physical sign were dyspnea and tachycardia, respectively. The most common causes of PE were uremic pericarditis in patients who underwent tube pericardiostomy, postoperative PE in patients who underwent CT-guided percutaneous catheter drainage, and cancer-related PE in patients who underwent ECHO-guided percutaneous catheter drainage. In all the patients, relief of symptoms was achieved after surgical intervention. There was no treatment-related mortality in any group of patients. In patients with tuberculous pericarditis, the rates of recurrent PE and/or constrictive pericarditis progress were 2,9% and 2,2% after tube pericardiostomy and ECHO-guided percutaneous catheter drainage, respectively.

Conclusion

Currently, there are many methods to treat PE. The correct treatment method for each patient should be selected according to a very careful analysis of the patient's clinical condition as well as the prospective benefit of surgical intervention.

Evolution of the pericardiocentesis technique

: Pericardiocentesis is a valuable technique for the diagnosis and treatment of patients with pericardial effusion and cardiac tamponade, although it may be associated with potentially serious complications. Through the years, many different imaging approaches have been described to reduce the complication rate of the procedure. This systematic review provides a focused overview of the different techniques developed in recent years to reduce the procedural complications and to increase the related success rate.

Complicated Complication: How Interventional Radiologists Should Manage Acute Iatrogenic Cardiac Tamponade

Computed tomography guided biopsies are common interventional procedures that are necessary for confirmation of imaging findings. Additionally, percutaneous biopsies are necessary for the elucidation of a patient’s clinical findings with disease pathology. Though interventionists perform these procedures regularly without consequence, various complications may arise depending on the tissues biopsied. Examples of such complications may include hemorrhage, hematoma formation, or perforation of surrounding vessels. In the case of mediastinal biopsies, less common but higher-risk complications may include pneumothorax, perforation of arterial vessels, and damage to the cardiac tissues resulting in decompensation. Interventionists should understand the risks of performing these procedures and should be prepared to intervene if life-threatening complications arise. As interventional cardiologists are often prepared to manage decompensating cardiac complications, interventional radiologists must likewise anticipate the same to occur when conducting procedures that may affect cardiac tissues. The following case demonstrates a technique for correcting a complicated complication arising from a mediastinal biopsy, which resulted in a pericardial effusion and patient decompensation.

Pericardial windows have limited diagnostic success

Background

Pericardial effusion (PE) is a common finding in patients who have chronic cardiac failure, who had undergone cardiac surgery, or who have certain other benign and malignant diseases. Pericardial drainage procedures are often requested for both diagnostic and therapeutic purposes. The perceived benefit is that it allows for diagnosis of malignancy or infection for patients with PEs of unclear etiology. The purpose of the study is to determine the diagnostic yield of surgical drainage procedures.

Methods

We conducted a retrospective chart review of patients who underwent surgical drainage procedures of PEs from July 1st, 2011 to January 1st, 2017 at a single institution. The variables included data on preoperative, intraoperative, and postoperative findings; morbidity; and survival.

Results

A total of 145 patients with an average age of 61 ± 5 and primarily men (53%) were evaluated. All of the surgical drainage procedures were performed through the sub-xiphoid approach. Twenty-five of the 145 patients (17.2%) had diagnostic findings in either the pericardial tissue or fluid. The cytology alone was diagnostic in 4.8% (N = 7) of patients with mixed findings including adenocarcinoma of the lung and breast. The pathology was diagnostic for cancer in 1.4% (N = 2) of patients with Melanoma and Lung cancer identified. The cytology and pathology were concordant in 4.0% (N = 6) identifying cancers that included mesothelioma and adenocarcinoma. Infection was identified in the pericardial fluid in 6.9% (N = 10) of the patients.

Conclusion

Surgical pericardial drainage procedures allow for removal of PE that may lead to tamponade physiology and potential mortality. Although there is therapeutic benefit from these procedures there is only a small diagnostic benefit.

Diagnostic Utility of Cyfra 21-1 and Cea Assays in Pericardial Fluid for the Recognition of Neoplastic Pericarditis

A positive cytology result in pericardial fluid is the gold standard for recognition of malignant pericardial effusion. Unfortunately, in 30–50% of patients with malignant pericardial effusion cytological examination of the pericardial fluid is negative. Tumor marker assessment in pericardial fluid may help to recognize malignant pericardial effusion. The aim of our study was to estimate the value of CYFRA 21-1 and CEA measurement in pericardial fluid for the recognition of malignant pericardial effusion. To our knowledge this is the first study on CYFRA 21-1 assessment in pericardial effusion. The examined group consisted of 50 patients with malignant pericardial effusion and 34 patients with non-malignant pericardial effusion. Median CEA concentrations in malignant pericardial effusion and non-malignant pericardial effusion were 80 ng/mL (0–317) and 0.5 ng/mL (0–18.4), respectively (p<0.001). Median CYFRA 21-1 concentrations in malignant pericardial effusion and non-malignant pericardial effusion were 260 ng/mL (5.3–10080) and 22.4 ng/mL (1.87–317.6), respectively (p<0.001). The optimal cutoff value for CYFRA 21-1 in pericardial effusion was 100 ng/mL. CYFRA 21-1 >100 ng/mL or CEA >5 ng/mL were found in 14/15 patients with malignant pericardial effusion and negative pericardial fluid cytology. We therefore strongly recommend the use of CYFRA 21-1 and/or CEA in addition to pericardial fluid cytology for the recognition of malignant pericardial effusion.

Non-operative management is feasible for selected blunt trauma patients with pericardial effusion

BACKGROUND

Blunt pericardial effusion (BPE) in trauma patients can be suggestive of injuries to the heart or great vessels. Surgical exploration is the mainstay of management; however, the effectiveness of non-operative management in this patient group remains unclear.

METHODS

Patients presenting with BPE in the trauma registry system at our level I trauma center were reviewed. Patients with and without cardiovascular (CVS) injury were compared to identify predictors for CVS injury and to understand the factors related to the requirement for surgery. Patients with and without CVS injury who presented with stable hemodynamics and initially received conservative management were also compared.

RESULTS

Thirty patients were enrolled in the study with a mean age of 53.2 (standard deviation (SD) 18.0) years and a mean injury severity score (ISS) of 26.7 (SD 9.0). Eleven patients presented with systolic blood pressure (SBP)<100mmHg, and immediate surgical intervention was performed. Eight patients had evidence of CVS injury (73%). Nineteen patients had stable hemodynamics and initially received conservative treatment. Of these, twelve patients received further surgical interventions, and only three had evidence of CVS injury (16%, 3/19). Comparisons of individuals with and without CVS injury revealed that the SBP on presentation was higher in patients without CVS injury than in those with CVS injury (132.7 (SD 41.3) mmHg vs. 95.6 (SD 21.1) mmHg). Clinically irrelevant differences between the two groups were observed for the creatine kinase (CK)-MB level, the troponin I level, the presence of an echocardiography tamponade sign, associated chest trauma and ISS. No remarkable predictors for CVS injury were found in hemodynamically stable patients.

CONCLUSION

Non-operative management can be considered for patents with traumatic BPE and stable hemodynamics; however, this approach must be performed at an institution with adequate facilities and well-trained staff.

Comparison of Outcomes of Pericardiocentesis Versus Surgical Pericardial Window in Patients Requiring Drainage of Pericardial Effusions

Comparative outcomes of patients undergoing pericardiocentesis or pericardial window are limited. Development of pericardial effusion after cardiac surgery is common but no data exist to guide best management. Procedural billing codes and Cleveland Clinic surgical registries were used to identify 1,281 patients who underwent either pericardiocentesis or surgical pericardial window between January 2000 and December 2012. The 656 patients undergoing an intervention for a pericardial effusion secondary to cardiac surgery were also compared. Propensity scoring was used to identify well-matched patients in each group. In the overall cohort, in-hospital mortality was similar between the group undergoing pericardiocentesis and surgical drainage (5.3% vs 4.4%, p = 0.49). Similar outcomes were found in the propensity-matched group (4.9% vs 6.1%, p = 0.55). Re-accumulation was more common after pericardiocentesis (24% vs 10%, p <0.0001) and remained in the matched cohorts (23% vs 9%, p <0.0001). The secondary outcome of hemodynamic instability after the procedure was more common in the pericardial window group in both the unmatched (5.2% vs 2.9%, p = 0.036) and matched cohorts (6.1% vs 2.0%, p = 0.022). In the subgroup of patients with a pericardial effusion secondary to cardiac surgery, there was a lower mortality after pericardiocentesis in the unmatched group (1.5% vs 4.6%, p = 0.024); however, after adjustment, this difference in mortality was no longer present (2.6% vs 4.5%, p = 0.36). In conclusion, both pericardiocentesis and surgical pericardial window are safe and effective treatment strategies for the patient with a pericardial effusion. In our study there were no significant differences in mortality in patients undergoing either procedure. Observed differences in outcomes with regard to recurrence rates, hemodynamic instability, and in those with postcardiac surgery effusions may help to guide the clinician in management of the patient requiring therapeutic or diagnostic drainage of a pericardial effusion.

Diagnosis and Management of Pericardial Disease

The pericardium serves many important functions but is not essential for life. Pericardial heart disease comprises only pericarditis and its complications, tamponade and constriction, and congenital lesions. However, the pericardium is affected by virtually every category of disease. Thus the critical care physician is likely to encounter the patient with pericardial disease in a variety of settings, either as an isolated phenomenon or as a complication of a variety of systemic disorders, trauma, or certain drugs. Despite exhaustive etiological lists, the cause of pericardial heart disease is often never identified. This article reviews the diagnosis and management of acute and chronic pericarditis with an emphasis on those areas of greatest interest to the intensivist.

Efficacy and safety of thoracoscopic pericardial window in patients with pericardial effusions: a single-center case series

Background

Pericardial effusion (PE) is a common finding in patients who had chronic cardiac failure, who had undergone cardiac surgery, or who had certain other benign and malignant diseases. PE ranges in severity from mild, asymptomatic effusions to cardiac tamponade. Although a thoracoscopic pericardial window (TPW) is a minimally invasive surgical option for patients with PE, there are few published data regarding the outcomes of TPW for PE. We investigated the contribution of the TPW to the treatment of PEs that are recurrent or difficult to drain percutaneously.

Methods

We conducted a retrospective chart review of the indications for TPW that included data on preoperative, intraoperative, and postoperative variables; morbidity; recurrence; and survival. Fourteen consecutive patients with PE that was recurrent or difficult to drain percutaneously and who underwent treatment with a TPW were enrolled in this study. Trocars for passage of the thoracoscope and surgical instruments were introduced through two or three incisions. Mini-thoracotomy was also performed in patients with hemopericardium and loculated fibrinous effusions. All patients were evaluated by face-to-face interviews, transthoracic echocardiography (TTE), and chest radiography 3–6 months after the TPW was obtained.

Results

The mean age of the patients was 70 years (range 28–83 years). The operative time was 72.1 ± 29.5 min. Six patients had undergone open heart surgery during the month prior to their presentation with PE. No intraoperative or postoperative complications occurred, although PE had recurred in one patient. Two patients died of malignant disease several months after the TPW. The cardiothoracic ratio (determined on chest radiographs) and the ejection fraction ratio (determined using TTE) had improved at the 3- and 6-month follow-up evaluations (p < 0.0001 and p = 0.012, respectively). Some patients could discontinue diuretics after the procedure, as assessed by the cardiologist based on symptom alleviation, chest radiography, and TTE findings.

Conclusions

For patients with PEs that are recurrent or difficult to drain percutaneously, TPW is an effective, safe surgical approach in terms of cardiac function and radiological findings.

Contemporary outcomes after pericardial window surgery: impact of operative technique

Background

The optimal window procedure for drainage of a large pericardial effusion has yet to be established. The purpose of this study was to compare the outcomes associated with the subxiphoid and thoracotomy pericardial window techniques, with a focus on perioperative pain and effusion recurrence rates.

Methods

A retrospective single-center observational study of all pericardial window operations was performed, with the incision based on surgeon preference. Perioperative data was recorded including time to extubation, narcotic requirements, and the development of a recurrent pericardial effusion.

Results

From 2002 to 2015, 179 patients with a large pericardial effusion underwent either a subxiphoid (n = 127) or left anterior mini-thoracotomy (n = 52) pericardial window procedure. Patients (mean age 73.2 years, 56 % female) had a high incidence of previous malignancy (49 %), chronic anticoagulation (34 %), recent infection (26 %), or renal failure (18 %). Cardiac tamponade was present in 50 %, and 12 % had undergone previous pericardiocentesis. Comparing the two techniques, there was no difference in the amount of fluid drained or in the perioperative mortality rate. Postoperatively, patients who had the subxiphoid approach required less time before extubation (P = 0.002) and needed less narcotics within 48 h after surgery (P = 0.0001) compared to thoracotomy patients. However, patients treated with the subxiphoid technique more often developed recurrent moderate or large pericardial effusions (P = 0.02), and there was a trend towards more repeat operations needed (P = 0.15).

Conclusion

Pericardial window surgery via a subxiphoid incision is associated with less postoperative pain and faster time to extubation. However, the thoracotomy approach may be more effective at preventing effusion recurrence and the need for repeat surgery.

Pericardiocentesis versus pericardiotomy for malignant pericardial effusion: a retrospective comparison

BACKGROUND

Treatment of malignant pericardial effusion remains controversial, because no randomized controlled trials have been conducted to determine the best approach, and results of retrospective studies have been inconsistent. The objective of the present study was to compare pericardiocentesis and pericardiotomy with respect to efficacy for preventing recurrence, and to determine, for those two procedures, diagnostic yields, complication rates, and effects on survival. We also aimed to identify clinical and procedural factors that could predict effusion recurrence.

METHODS

We retrospectively assessed 61 patients who underwent a procedure for treatment of a malignant pericardial effusion at the Institut universitaire de cardiologie et de pneumologie de Québec between February 2004 and September 2013.

RESULTS

Pericardiocentesis was performed in 42 patients, and pericardiotomy, in 19 patients. The effusion recurrence rate was significantly higher in patients treated with pericardiocentesis than with pericardiotomy (31.0% vs. 5.3%, p = 0.046). The diagnostic yield of the procedures was not significantly different (92.9% vs. 86.7%, p = 0.6). The overall rate of complications was similar in the two groups, as was the median overall survival (2.4 months vs. 2.6 months, p = 0.5). In univariate analyses, the procedure type was the only predictor of recurrence that approached statistical significance. Age, sex, type of cancer, presence of effusion at the time of cancer diagnosis, prior chest irradiation, tamponade upon presentation, and total volume of fluid removed did not influence the recurrence rate.

CONCLUSIONS

Compared with pericardiocentesis, pericardiotomy had higher success rate in preventing recurrence of malignant pericardial effusion, with similar diagnostic yields, complication rates, and overall survival.

Systematic review of percutaneous interventions for malignant pericardial effusion

The present systematic review assessed the safety and efficacy of percutaneous interventions for malignant pericardial effusion (MPE), with primary endpoint of recurrence of pericardial effusion. Electronic searches of six databases identified thirty-one studies, reporting outcomes following isolated pericardiocentesis (n=305), pericardiocentesis followed by extended catheter drainage (n=486), pericardial instillation of sclerosing agents (n=392) or percutaneous balloon pericardiotomy (PBP) (n=157). Isolated pericardiocentesis demonstrated a pooled recurrence rate of 38.3%. Pooled recurrence rates for extended catheter drainage, pericardial sclerosis and PBP were 12.1%, 10.8% and 10.3%, respectively. Procedure-related mortality ranged from 0.5-1.0% across the percutaneous interventions. Although isolated pericardiocentesis can safely deliver immediate symptomatic relief, subsequent catheter drainage or sclerotherapy are required to minimize recurrence. PBP has been shown to be highly effective and may be particularly useful in managing recurrent effusions. Ultimately, the choice of intervention must be based on the clinical status of patients, their underlying malignancy and the expertise available.

Prognostic factors affecting survival of patients with cancer-related pericardial effusion managed by surgery

Background

Although pericardial effusion (PE) is not uncommon in patients with cancer, it may lead to cardiac tamponade, a life-threatening condition. Prompt life-saving treatment is essential, and also allows the continuation of the cancer treatment. The aim of this study was to determine the prognostic factors for survival in patients with cancer who were treated surgically for PE.

Methods

We retrospectively reviewed the medical records of 55 patients with cancer with PE between January 2003 and October 2012, who were treated with a pericardial window operation. Overall survival (OS) was estimated from the date of surgery, and patients were followed until the time of the final visit or time of death. Clinical outcomes and candidate prognostic factors were analyzed.

Results

The median age of patients was 57 years (range 29 to 82 years), and 31 patients (56.4%) were male. The most common primary malignancy was lung cancer (65.5%), followed by breast cancer (10.9%). Fifteen patients (27.3%) developed recurrence of PE after surgery. The median OS duration was 4 months (range 0 to 39 months). Multivariate analysis found that evidence of pericardial metastasis on preoperative imaging (P = 0.029) and confirmation of malignant cells in the PE and/or pericardial tissue (P = 0.034) were associated with reduced OS.

Conclusion

Evidence of pericardial metastasis on preoperative imaging and cytopathologic confirmation that the PE and/or pericardial tissue are positive for malignant cells can be used to predict poor clinical outcomes in patients with cancer-related PE.

Long and wrong way: Unintended pericardial catheter insertion through stomach

Complications of percutaneous pericardial catheter insertion for pericardial effusion are rare. We describe a rare complication of percutaneous pericardial catheter insertion that penetrated the stomach and diaphragm before getting into the pericardial sac in a patient with lymphoma. The misplaced catheter was extracted surgically and subxiphoid pericardial tube insertion with pleural pericardial window was performed. <Learning objective: Although similar outcomes have been reported with both percutaneous and subxiphoid techniques, major complications may arise with the percutaneous technique. This case emphasizes that percutaneous pericardial catheter insertion may have serious complications and these procedures should be performed by experienced clinicians with the standby of a cardiac team.>.

Pericardial window formation complicated by intrapericardial diaphragmatic hernia

In rare circumstances, a diaphragmatic defect may allow for herniation of intra-abdominal contents into the pericardial space. These occurrences are exceedingly rare and may be due to trauma or congenital defects of the septum transversum or as the result of surgical procedures. We describe a 73-year-old female who presented with cardiac and abdominal symptoms one month after undergoing a subxiphoid pericardioperitoneal window for treatment and evaluation of a symptomatic pericardial effusion.

Pericardial effusions in pulmonary arterial hypertension: characteristics, prognosis, and role of drainage

BACKGROUND

The presence and size of a pericardial effusion in pulmonary arterial hypertension (PAH) and its association with outcome is unclear.

METHODS

In this single-center cohort study of 577 patients with group 1 PAH seen between January 1, 1995, and December 31, 2005, all patients underwent transthoracic echocardiography and were followed for ≥ 5 years. Echocardiography-guided pericardiocentesis was performed as needed.

RESULTS

Pericardial effusions on index echocardiography occurred in 150 patients (26%); 128 patients had small and 22 had moderate-sized or larger effusions. Most of the moderate or greater effusions occurred in patients who had connective tissue disease (82%). Mean right atrial pressure was 13.4 ± 4.4 mm Hg (no effusion), 15.1 ± 4.4 mm Hg (small effusion), and 17.0 ± 4.0 mm Hg (moderate or greater effusion) (P &lt; .0001). Median survival for patients with moderate or greater effusion, mild effusion, or no effusion was 11.3 months, 42.3 months, and 76.5 months, respectively. Four of the 22 patients with moderate or greater pericardial effusions eventually required echocardiography-guided pericardiocentesis because of clinical and echocardiographic evidence of hemodynamic impact. When drained, the effusions were large (858 ± 469 mL) and generally serous. All pericardiocenteses were performed cautiously under echocardiographic guidance by a highly experienced echocardiologist, with low immediate morbidity and mortality.

CONCLUSIONS

Pericardial effusions are relatively common but rarely of hemodynamic significance in patients with PAH. However, even modest degrees of pericardial fluid are associated with a significant increase in mortality and appear to reflect the presence of associated collagen vascular disease and high right atrial pressure.

Retrospective comparison of outcomes, diagnostic value, and complications of percutaneous prolonged drainage versus surgical pericardiotomy of pericardial effusion associated with malignancy

Surgical pericardiotomy is often preferred as a primary option in patients with malignant pericardial effusions. Recent series have revealed that prolonged drainage substantially reduces pericardial effusion recurrence rates, even in the setting of malignancy. The aim of the study was to directly compare the efficacy of pericardiocentesis with prolonged drainage with the primary surgical pericardiotomy in patients with symptomatic pericardial effusion associated with a malignancy. We retrospectively evaluated 88 patients who presented with pericardial tamponade associated with a malignancy. Pericardiocentesis with extended drainage was performed in 43 patients and surgical pericardiotomy in 45 patients. The recurrence rate was not significantly different in patients with prolonged catheter drainage versus surgical pericardiotomy (12% vs 13%, respectively, p = 0.78). In addition, there was no significant difference in diagnostic yield between percutaneous drainage and surgical window (44% vs 53%, respectively, p = 0.39). The overall rate of complications was significantly lower in the prolonged drainage group (2% vs 20%, p = 0.007). Moreover, there were no serious complications in the prolonged drainage group versus 9% in the surgical pericardiotomy group. In conclusion, (1) surgical pericardiotomy with pericardial biopsy does not add significant diagnostic value beyond the cytologic assessment available with pericardiocentesis, (2) surgical pericardiotomy does not improve clinical outcomes over pericardiocentesis, and (3) surgical pericardiotomy is associated with a higher rate of complications.

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.

Transabdominal ligation of the thoracic duct with pericardial-peritoneal shunting in a case of primary idiopathic chylous pericardial effusion

Primary chylous pericardial effusion is a rare entity with few cases reported so far. We report a case of idiopathic etiology in a previously healthy 16-year-old boy. The patient presented with intermittent chest pain and dizziness caused by a chronic pericardial effusion. An echocardiogram revealing a pericardial effusion and open pericardiocentesis with a drainage of approximately of 500 ml of chylous fluid established the diagnosis. Patient had no history of trauma, cardiac surgery, central insertion of subclavian catheters or blunt injury. Computed tomography ruled out malignancies in the abdomen and chest. Clinical, laboratory and radiological investigations for the possible underlying cause of the condition were not determined. Management with a dietary regimen consisting of a medium-chain triglyceride-rich diet, octreotide pharmacological treatment and initial subxiphoid resection with pericardial tube drainage was unsuccessful. Surgical approach was required consisting of pericardio-peritoneal window with trans-abdominal ligation (clipping) of the thoracic duct above the diaphragm. Postoperative outcome was uneventful and there was a rapid recovery after surgical management.

An extremely rare combination: pneumopericardium, pneumoperitoneum, and subcutanous emphysema-a case report

Pneumopericardium, an accumulation of air in the pericardial cavity, occurs very rarely as compared to pneumothorax and pneumomediastinum. Clinical presentation is variable, patients are frequently asymptomatic, and mild cases usually resolve spontaneously. However, it may lead to pericardial tamponade, which requires rapid diagnosis and treatment that can be lifesaving. The traditional diagnostic, simple method of diagnosis is via an upright chest X-ray. Typical findings can be detected and a differential diagnosis can be made between pneumomediastinum and pneumopericardium. Echocardiography and chest computed tomography scans can also support the diagnosis. Only one case of pneumopericardium after surgical pericardiotomy has been reported in the literature so far. In this case report, iatrogenic pneumopericardium, which resolved spontaneously after surgical pericardiotomy, was reported in a 19-year-old patient who had a rejected liver transplantation, and had liver and kidney failure with pericardial tamponade. In this case, pneumopericardium was accompanied by pneumoperitoneum and subcutaneous emphysema; an extremely rare combination.

Risk factors affecting the survival rate in patients with symptomatic pericardial effusion undergoing surgical intervention

OBJECTIVES

The optimal management and treatment of pericardial effusion are still controversial. There is limited data related to the risk factors affecting survival in these patients. The aim of this study was to determine the risk factors affecting the survival rate of patients with symptomatic pericardial effusion who underwent surgical interventions.

METHODS

From 2004 to 2011, we retrospectively analysed 153 patients who underwent subxiphoid pericardial window as their surgical intervention to drain pericardial effusions at the National Research Institute of Tuberculosis and Lung diseases (NRITLD). To determine the effects of risk factors on survival rate, demographic data, clinical records, echocardiographic data, computed tomographic and cytopathological findings and also operative information of patients were recorded. Patients were followed annually until the last clinical follow-up (August 2011). To determine the prognostic factors affecting survival, both univariate analysis and multivariate Cox proportional hazards model were utilized.

RESULTS

There were 89 men and 64 women with a mean age of 50.3 ± 15.5 years. The most prevalent symptom was dyspnoea. Concurrent malignancies were present in 66 patients. Lungs were the most prevalent primary site for malignancy. The median duration of follow-up was 15 (range 1-85 months). Six-month, 1-year and 18-month survival rates were 85.6, 61.4 and 36.6%, respectively. In a multivariate analysis, positive history of lung cancer (hazard ratio [HR] 2.894, 95% confidence interval [CI] 1.362-6.147, P = 0.006) or other organ cancers (HR 2.315, 95% CI 1.009-50311, P = 0.048), presence of a mass in the computed tomography (HR 1.985, 95% CI 1.100-3.581, P = 0.023), and echocardiographic findings compatible with tamponade (HR 1.745, 95% CI 1.048-2.90 P = 0.032) were the three independent predictors of postoperative death.

CONCLUSIONS

In the surgical management of pericardial effusion, patients with underlying malignant disease, especially with lung cancer, patients with a detectable invasion of thorax in computed tomography and those with positive echocardiographic findings compatible with tamponade have a poor survival. Therefore, minimally invasive therapies could be considered as a more acceptable alternative for these high-risk patients.

Pericardial effusion and pericardiocentesis: role of echocardiography

Pericardial effusion can develop from any pericardial disease, including pericarditis and several systemic disorders, such as malignancies, pulmonary tuberculosis, chronic renal failure, thyroid diseases, and autoimmune diseases. The causes of large pericardial effusion requiring invasive pericardiocentesis may vary according to the time, country, and hospital. Transthoracic echocardiography is the most important tool for diagnosis, grading, the pericardiocentesis procedure, and follow up of pericardial effusion. Cardiac tamponade is a kind of cardiogenic shock and medical emergency. Clinicians should understand the tamponade physiology, especially because it can develop without large pericardial effusion. In addition, clinicians should correlate the echocardiographic findings of tamponade, such as right ventricular collapse, right atrial collapse, and respiratory variation of mitral and tricuspid flow, with clinical signs of clinical tamponade, such as hypotension or pulsus paradoxus. Percutaneous pericardiocentesis has been the most useful procedure in many cases of large pericardial effusion, cardiac tamponade, or pericardial effusion of unknown etiology. The procedure should be performed with the guidance of echocardiography.

Blind subxiphoid pericardiotomy to relieve critical acute hemopericardium: a final report

PURPOSE

Percutaneous catheter drainage (PCD) has been considered a standard method of relieving acute cardiac tamponade. Although conventional subxiphoid pericardiotomy is useful even for clotted hemopericardium, it has been believed to be unsuitable for emergency treatment because it is a time-consuming procedure. We report our modified pericardiotomy technique that can be used for emergency management.

METHODS

We designed a prospective observational study to evaluate blind subxiphoid pericardiotomy (BSP) for critical cardiac tamponade due to hemopericardium. Emergency patients (n = 148) with acute hemopericardium secondary to trauma (n = 12), acute aortic disease (n = 122), or cardiac rupture following acute myocardial infarction (n = 14) were the subjects. Early results were compared between the BSP group (n = 53) and the PCD group (n = 95).

RESULTS

BSP was effective at relieving cardiac tamponade in all 53 cases, but PCD was ineffective in 12 cases (12.6 %, p = 0.008). Procedure-related complication rates of BSP and PCD were 0 and 16.8 %, respectively (p = 0.002). Survival rates for the BSP and PCD groups were 18.9 and 6.3 %, respectively (p = 0.018). Since 2005, when we discarded the restriction that only board-certified surgeons should perform BSP, acute care physicians (including trainees) have performed BSP for 22 patients without procedure-related complications.

CONCLUSIONS

BSP was safe and effective for cardiac tamponade due to acute hemopericardium. Critical complications during PCD for hemopericardium could not be avoided in some cases because of clots in the pericardium.

Percutaneous drainage of postoperative pericardial effusion in cardiac surgery

BACKGROUND AND AIM OF THE STUDY

 Postoperative pericardial effusion is frequent and can be complicated by cardiac tamponade. Although the different drainage techniques are well described in the setting of medical effusion, there is not a standard postoperative effusion treatment. The aim of this work was to assess the feasibility and effectiveness of the percutaneous pericardial drainage.

METHODS

This a retrospective study involving 197 patients from 1990 to 2008. Drainage was performed by subxiphoid puncture (91.9%) or left parasternal puncture (8.1%) between 3 and 690 days following a cardiac procedure via median sternotomy. Effusion thickness was at least 10 mm in the subcostal echocardiography view.

RESULTS

No deaths directly related to the procedure were observed. Complete and enduring drainage was achieved in 158 patients (80.2%). The procedure failed for 22 patients (11.2%) because no fluid was drained in 14 cases (7.1%) and a right ventricular puncture in 8 cases (4.1%). Recurrence of the effusion, which occurred for 17 patients (8.6%), was more frequent if an effusion of more than 5 mm persisted after the first drainage (P = 0.024) and if the drainage was performed outside the operating room because of emergency (P = 0.046). Risk factors for mortality were recurrence of the effusion (P = 0.04) and drainage performed outside the operating room (P = 0.007).

CONCLUSIONS

Percutaneous pericardial drainage is effective to treat postoperative pericardial effusion. When the effusion is thicker than 10 mm and accessible, it can be the initial strategy and surgical drainage can serve as an alternate strategy in case of failure and complications of this procedure.

Pericardial decompression syndrome in a patient with hypothyroidism presenting as massive pericardial effusion: a case report and review of related literature

The authors present a case of a 44-year-old female with unrecognised hypothyroidism consulting for heart failure symptoms. Echocardiogram revealed massive pericardial effusion with tamponade physiology, attributed to primary hypothyroidism from a previous thyroidectomy. Levothyroxine was started at a dose of 0.7 ug/kg/day followed by subxiphoid pericardiostomy. 9 h postpericardiostomy however, hypotension developed and despite hydration and inotropic support, patient succumbed to cardiogenic shock on the 14th hospital day.

Management of Cardiac Tamponade: A Comperative Study between Echo-Guided Pericardiocentesis and Surgery-A Report of 100 Patients

Background. Cardiac tamponade (CT) represents a life-threatening condition, and the optimal method of draining accumulated pericardial fluid remains controversial. We have reviewed 100 patients with CT at our institution over a five-year period and compared the results of echo-guided pericardiocentesis, primary surgical treatment, and surgical treatment following pericardiocentesis with regard to functional outcomes. Methods. The study group consisted of 100 patients with CT attending Yuzuncu Yil University from January 2005 to January 2010 who underwent one of the 3 treatment options (echo-guided pericardiocentesis, primary surgical treatment, and surgical treatment following pericardiocentesis). CT was defined by clinical and echocardiographic criteria. Data on medical history, characteristics of the pericardial fluid, treatment strategy, and follow-up data were collected. Results. Echo-guided pericardiocentesis was performed in 38 (38%) patients (Group A), primary surgical treatment was preformed in 36 (36%) patients (Group B), and surgical treatment following pericardiocentesis was performed in 26 (26%) patients (Group C). Idiopathic and malignant diseases were primary cause of tamponade (28% and 28%, resp.), followed by tuberculosis (14%). Total complication rates, 30-day mortality, and total mortality rates were highest in Group C. Recurrence of tamponade before 90 days was highest in Group A. Conclusions. According to our results, minimal invasive procedure echo-guided pericardiocentesis should be the first choice because of lower complication and mortality rates especially in idiopathic cases and in patients with hemodynamic instability. Surgical approach might be performed for traumatic cases, purulent, recurrent, or malign effusions with higher complication and mortality rates.

Clinical characteristics of malignant pericardial effusion associated with recurrence and survival

Purpose

We evaluated clinical outcomes after drainage for malignant pericardial effusion with imminent or overt tamponade.

Materials and Methods

Between August 2001 and June 2007, 100 patients underwent pericardiocentesis for malignant pericardial effusion. Adequate follow-up information on the recurrence of pericardial effusion and survival status was available for 98 patients.

Results

Recurrence of effusion occurred in 30 patients (31%), all of whom were diagnosed with adenocarcinoma. Multivariate analysis indicated that adenocarcinoma of the lung (hazard ratio [HR], 6.6; 95% confidence interval [CI], 1.9 to 22.3; p=0.003) and progressive disease despite chemotherapy (HR, 4.3; 95% CI, 1.6 to 12.0; p=0.005) were independent predictors of recurrence. Survival rates three months after pericardiocentesis differed significantly with the type of primary cancer; the rates were 73%, 18%, 90% and 30% in patients with adenocarcinoma of the lung, squamous cell carcinoma of the lung, breast cancer and other cancers, respectively.

Conclusion

Recurrence and survival of patients with malignant pericardial effusion are dependent on the type of primary cancer and response to chemotherapy. Patients with adenocarcinoma of the lung may be good candidates for surgical drainage to avoid repeated pericardiocentesis, but pericardiocentesis is considered effective as palliative management in patients with other cancers.

Neoplastic pericardial disease: Old and current strategies for diagnosis and management

The prevalence of neoplastic pericardial diseases has changed over time and varies according to diagnostic methods. The diagnostic factor is usually the detection of neoplastic cells within the pericardial fluid or in specimens of pericardium, but the diagnosis may be difficult. Accurate sampling and cytopreparatory techniques, together with ancillary studies, including immunohistochemical tests and neoplastic marker dosage, are essential to obtain a reliable diagnosis. The goals of treatment may be simply to relieve symptoms (cardiac tamponade or dyspnea), to prevent recurrent effusion for a long-term symptomatic benefit, or to treat the local neoplastic disease with the aim of prolonging survival. Immediate relief of symptoms may be obtained with percutaneous drainage or with a surgical approach. For long term prevention of recurrences, various approaches have been proposed: extended drainage, pericardial window (surgical or percutaneous balloon pericardiostomy), sclerosing local therapy, local and/or systemic chemotherapy or radiation therapy (RT) (external or with intrapericardial radionuclides). The outcomes of various therapeutic approaches vary for different tumor types. Lymphoma and leukemias can be successfully treated with systemic chemotherapy; for solid tumors, percutaneous drainage and the use of systemic and/or local sclerosing and antineoplastic therapy seems to offer the best chance of success. The use of "pure" sclerosing agents has been replaced by agents with both sclerosing and antineoplastic activity (bleomycin or thiotepa), which seems to be quite effective in breast cancer, at least when associated with systemic chemotherapy. Local chemotherapy with platinum, mitoxantrone and other agents may lead to good local control of the disease, but the addition of systemic chemotherapy is probably relevant in order to prolong survival. The surgical approach (creation of a pericardial window, even with the mini-invasive method of balloon pericardiostomy) and RT may be useful in recurring effusions or in cases that are refractory to other therapeutic approaches.