Percutaneous balloon pericardiotomy for patients with malignant pericardial effusion including three malignant pleural mesotheliomas

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.

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.

Percutaneous balloon pericardiotomy as the initial and definitive treatment for malignant pericardial effusion

INTRODUCTION AND OBJECTIVES

Malignant pericardial effusion has a high recurrence rate after pericardiocentesis. We sought to confirm the efficacy of percutaneous balloon pericardiotomy as the initial treatment of choice for these effusions.

METHODS

Retrospective analysis of the clinical, echocardiographic, and follow-up characteristics of a consecutive series of percutaneous balloon pericardiotomies carried out in a single center in patients with advanced cancer.

RESULTS

Seventeen percutaneous balloon pericardiotomies were performed in 16 patients with a mean age of 66.2 (15.2) years. Fourteen patients had pathologically confirmed metastatic neoplastic disease, 3 had previously required pericardiocentesis, and in the remaining patients percutaneous balloon pericardiotomy was the first treatment for the effusion. All patients had a severe circumferential effusion, and most presented evidence of hemodynamic compromise on echocardiography. In all cases, the procedure was successful, there were no acute complications, and it was well tolerated at the first attempt. There were no infectious complications during follow-up (median, 44 [interquartile range, 36-225] days). One patient developed a large pleural effusion that did not require treatment. Three patients needed a new pericardial procedure: 2 had elective pericardial window surgeries and 1 had a second percutaneous balloon pericardiotomy.

CONCLUSIONS

Percutaneous balloon pericardiotomy is a simple, safe technique that can be effective in the prevention of recurrence in many patients with severe malignant pericardial effusion. The characteristics of this procedure make it particularly useful in this group of patients to avoid more aggressive, poorly tolerated approaches.

Primary percutaneous balloon pericardiotomy for malignant pericardial effusion

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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