Which treatment in pericardial effusion?

BACKGROUND: Pericardiocentesis, pleuro-pericardial window, subxiphoid pericardial drainage and pericardioscopy: which methodology to treat pericardial effusion? Each of these surgical treatments can be effective, depending on clinical factors and history of the patients. We considered pericardial effusions during 5 years. METHODS: We reviewed 64 cases: 14 acute pericardial effusions (5 patients with cardiac tamponade), 39 subacute, 11 chronic. Epidemiology and aetiology: 8 cases were between 20 and 25 years old (all affected by lymphoma), 56 were distributed in every age, especially over 60, and of these 45 were neoplastic and 11 non- neoplastic. Non-neoplastic cases were connectivitis (3 patients), uncertain origin effusion (7 patients), tubercular (1 patient). In neoplastic effusions we found lymphoma (at older age) in 7, small cell lung cancer in 6, NSCLC in 12, mesothelioma in 2, breast cancer in 7. RESULTS: Acute pericardial effusions with cardiac tamponade underwent echo-guided pericardiocentesis. In 43 we had a subxiphoid pericardial drainage, among these cases we performed 4 pericardioscopies. We created a pleuro-pericardial window on VATS in 13, on thoracotomy in 4 for technical reasons. CONCLUSIONS: Pericardiocentesis is to be preferred in acute pericardial effusion with cardiac tamponade to avoid general anaesthesia. Pleuro-pericardial window on VATS is better in chronic pericardial effusion (for infective or systemic disease) and in recurrence, after performing subxiphoid drainage. Subxiphoid drainage is suitable for all neoplastic patients, and in case of unknown aetiology in order to perform a pericardioscopy.     

Pericardioscopy and biopsy

Summary The diagnosis of malignant pericardial effusion is usually made by pericardial fluid cytology or open pericardial biopsy. A case is reported where diagnostic difficulty warranted flexible pericardioscopy under fluoroscopic guidance. The technique is described.     

Thoracoscopic pericardial fenestration: diagnostic and therapeutic aspects.

The cause of cardiac tamponade is only established in 50% of cases. This problem is most commonly treated by pericardiocentesis alone, pericardiotomy being reserved for cases of recurrence and pericardiectomy for those patients presenting with constrictive pericarditis. A series of 16 patients treated with pericardial fenestration via a thoracoscope is presented. Pericardial and pleural biopsies were performed, together with cytological and biochemical analysis of the pericardial and pleural fluid where present. This procedure established the aetiology of effusion in all cases. In malignant pericardial effusion bleomycin was used for pericardial sclerosis. This resulted in fewer recurrences than in those patients where sclerosis was not attempted (12.5% v 60%).     

Everolimus-Induced Systemic Serositis After Simultaneous Liver and Kidney Transplantation: A Case Report

Although everolimus, a mammalian target of rapamycin inhibitor, has been used as a potent immunosuppressive agent in organ transplantation, data regarding its adverse effect profile compared with that of sirolimus in clinical circumstances are limited. A 50-year-old man who underwent simultaneous liver and kidney transplantation 14 months previously was admitted with large pleural effusion, pericardial effusion, and ascites. Laboratory findings and cultures for possible infectious causes were all negative. Pericardial window surgery with drainage of the pericardial fluid was performed on day 3. Pleural and pericardial biopsy revealed non-specific inflammation without evidence of malignant cells. Everolimus was discontinued and replaced by mycophenolate mofetil on day 4. Significant clinical improvement was observed after discontinuation of everolimus, and follow-up echocardiography and chest radiography showed no recurrence of the pericardial or pleural effusion after discharge.     

Nonmalignant pericardial effusion associated with thymic cancer

We report a case of thymic carcinoma with massive pericardial effusion in a 74-year-old man. This patient with dyspnea was referred to our hospital because of pericardial effusion detected by echocardiography. A chest computed tomography and magnetic resonance imaging showed an anterior mediastinal mass measuring 8.0 × 5.0 cm with massive pericardial effusion. The mass lesion was suggestive of thymic carcinoma or invasive thymoma. Initially, he underwent pericardial drainage. The collected fluid was serous and yellow, and cytological examination found no malignant cells. The tumor with partial pericardium was resected. Histopathological findings confirmed the lesion to be squamous cell carcinoma of the thymus. The etiology of a massive nonmalignant pericardial effusion associated with thymic carcinoma warrants further studies. The patient is alive without recurrence and without pericardial effusion at 3 years to date after the operation. Not all pericardial effusion associated with thymic cancer involves malignant effusion.     

Ten-year surgical experience with nontraumatic pericardial effusions: a comparison between the subxyphoid and transthoracic approaches to pericardial window

HYPOTHESIS: The approach to pericardial window in patients with nontraumatic pericardial effusion impacts outcome. DESIGN: Retrospective review and comparison of all cases of pericardial window performed over 10 years. Follow-up was to patient death. SETTING: Three hospitals performing cardiothoracic surgery at a single university. PATIENTS: All patients in whom pericardial window was performed for nontraumatic pericardial effusion. MAIN OUTCOME MEASURES: Outcomes associated with the subxyphoid approach to pericardial window were compared with those associated with the transthoracic approach. The primary outcome was postsurgical recurrence of pericardial effusion. Secondary outcomes included operative time, intraoperative and postoperative complications, in-hospital mortality, hospital and intensive care unit lengths of stay, and days between surgery and death. RESULTS: Over 10 years, there were 342 patients with procedural codes for pericardial window in the medical record databases of 3 hospitals performing cardiothoracic surgery at 1 university center. One hundred fifty-one patients were excluded because the operation was performed for trauma, postoperative tamponade, or pericardial biopsy without effusion. The results are, therefore, based on the remaining 191 procedures. The subxyphoid approach was used in 78 patients, and the transthoracic approach in 113 patients. Patients were well matched for age (P = .31), sex (P = .05), preoperative tamponade (P = .08), and comorbidities (P > .05). No differences were observed between the 2 approaches in terms of recurrence of effusion, operative time, overall intraoperative or postoperative complications, and hospital or intensive care unit lengths of stay. In-hospital mortality was significantly greater in the subxyphoid group (27 of 78 vs 18 of 113 patients; P = .003). CONCLUSIONS: Over 10 years, there were 191 pericardial windows performed for nontraumatic pericardial effusions. The subxyphoid and transthoracic approaches were well tolerated by patients, required short operative times, and resulted in similar rates of overall postoperative complications and intensive care unit and hospital lengths of stay. Recurrence rates were low with both procedures.     

Clinical experience with subxyphoid pericardial decompression

Between 1971 and 1981, 108 patients with pericardial effusion were treated by subxyphoid pericardial decompression. 68 patients (63%) had local anesthesia, while general anesthesia was used in 40 (37%). The total group included nonspecific (viral) pericarditis in 35 patients (32.4%), uremic pericarditis in 30 (27.8%); and 20 patients (18.5%) with a malignant etiology, traumatic in ten patients (9.3%), six patients (5.6%) following radiation for malignant disease, and seven patients (6.5%) due to other causes. Echocardiography was diagnostic in all cases. Acute cardiac tamponade necessitated pericardiocentesis as an initial procedure in seven patients (6.5%). Subxyphoid pericardial decompression included drainage of the pericardial fluid and performance of a 5 X 5 cm pericardial window and biopsy of all patients. There were two (1.8%) operative deaths in the general anesthesia group but none in the local anesthesia group. There were no major complication in the local anesthesia group, but one patient in the general anesthesia group, who was severely hypertensive preoperatively, developed hemiplegia on the left side. There were five recurrences (4.6%) requiring total pericardiectomy at a later date. Subxyphoid pericardial decompression under local anesthesia was seen to be a safe and effective procedure for primary decompression and diagnosis of acute or chronic pericardial effusion.     

Mediastinoscope-controlled parasternal fenestration of the pericardium: definitive surgical palliation of malignant pericardial effusion

ABSTRACT: BACKGROUND: The tumorous infiltration or carcinosis of the pericardium could cause pericardial effusion in up to one-third of cases of malignancy, thus potentially interfere with the otherwise desirable oncological treatment. The existing surgical methods for the management of pericardial fluid are well-established but are not without limitations in the symptomatic relief of malignant pericardial effusion (MPE). The recurrence rate ranges between 43 and 69% after pericardiocentesis and 9 to 16% after pericardial drainage. The desire to overcome relative limitations of the existing methods led us to explore an alternative approach. METHODS: The standard armamentarium of the Carlens collar mediastinoscopy procedure was utilized in a Chamberlain parasternal approach of the pericardial sac. The laterality of approach was decided based upon the pleural involvement, as tumor-free pericardiopleural reflection is required. A pericardio-pleural window at least 3 cm in diameter was created. From January 2000 to December 2009, 22 cases were operated on with mediastinoscope-controlled parasternal fenestration (MCPF). Considering the type of the primary tumor, there were 11 lung cancer, 6 breast cancers, 2 haematologic malignancies and in 3 patients the origin of malignancy could not be verified. RESULTS: There were no operative deaths. We lost one patient (4.5%) in the postoperative hospital period. All of the surviving patients had a minimum of 2 months of symptom-free survival. We detected transient recurrence of MPE in one patient (4.5%) 14 days after the MCPF, which disappeared spontaneously after 24 hours. CONCLUSION: The MCPF offers a real alternative in certain cases of pericardial effusion. We recommend this method especially for the definitive surgical palliation of MPE.     

超声引导穿刺置入微导管法治疗恶性心包积液的评价

目的探讨超声引导下穿刺置入微导管法在恶性心包积液治疗中的价值.方法13例恶性心包积液在超声引导下进行心包穿刺,置入硬膜外麻醉导管（微导管）,通过导管抽出心包积液并注入化疗药物.结果13例均成功穿刺并顺利置入微导管,引流积液400～780 ml,平均530 ml.治疗后3、12、24个月存活率分别为92%（12/13）,78%（7/9）和60%（3/5）,无心包积液复发.结论超声引导穿刺置入微导管法治疗恶性心包积液安全、微创、有效、可行.     

Surgical treatment of large pericardial effusions. Etiology and long-term survival

From 1977 to 1988 60 patients were treated for large pericardial effusion. The operation consisted of a small left anterior thoracotomy with formation of a pericardial window. In 28 patients (47%) the etiology was a malignant disease. Eight patients (29%) had malignant cells in the pericardial fluid and 23 patients (82%) had metastases to the pericardium. Seven patients (12%) had purulent pericarditis; in 4 cases Staphylococcus was found. Of the remaining 25 patients, the etiology remained unknown in 13. The 5-year survival rate was 60% among patients with nonmalignant effusions. In patients with malignant effusions only 20% were alive after 2 years. There were no deaths related to the operation. We conclude that large pericardial effusions of unknown etiology can be safely treated with a small left anterior thoracotomy. This access gives optimal possibilities for rapid diagnosis and treatment.     

Laparoscopic pericardio-peritoneal window: an alternative approach in the treatment of recurrent pericardial effusion, in-hospital evolution and survival

BACKGROUND: Although cardiac tamponade due to pericardial effusion is not frequently seen it may, in many cases require surgical drainage. The aim of this study is to show our experience with a laparoscopic approach to perform the pericardio-peritoneal window in the management of recurrent pericardial effusion. METHODS: We included 16 patients with recurrent pericardial effusion and echocardiographic global tamponade. A pneumoperitoneum was made and 3 trocars were placed; an avascular area of the diaphragm was chosen and a pericardial window was made (4 cm diameter). RESULTS: Pericardial-peritoneal window was carried out successfully (mean operative time 40 min). All patients presented relief of symptoms. The mean follow-up was 729 days. No patient experienced recurrence on repeated ecocardiographic examinations. There were no fatal events related to the procedure. CONCLUSIONS: Laparoscopic pericardial window is a simple, safe, and effective alternative for the treatment of recurrent pericardial effusion with global cardiac tamponade.     

Pericardial Window for Malignant Pericardial Effusion

Seventeen patients with malignant pericardial effusion were treated by the creation of a pericardial window. This was done through a subxiphoid approach in 13 patients and through limited anterior thoracotomy or sternotomy incisions in 4.There were no deaths and no major complications attributable to the operation. In all patients, relief of the cardiac compression caused by the effusion was immediate and complete. No patient showed a clinically significant recurrence of the effusion, although 1 patient who had received irradiation required pericardiectomy for constriction 5 months later.Survival was determined principally by the extent of the primary malignancy. Six patients died of the primary tumors within 30 days, but 6 survived 3 to 12 months and 2 are alive at 8 and 21 months.It is concluded that creation of a pericardial window, preferably by the subxiphoid approach, is the treatment of choice for malignant pericardial effusion. The procedure provides an accurate diagnosis, carries virtually no mortality or morbidity, and affords immediate and long-lasting relief of cardiac compression.     

Pericardial-peritoneal window for chronic exudative pericarditis using a subxiphoidal approach: report of three cases

From August 1986 to February 2000, three patients were given a pericardial-peritoneal window using a subxiphoidal approach, for pericardial effusion associated with chronic exudative pericarditis. Complete drainage without recurrence was achieved in two patients with a large pericardial-peritoneal window (4 cm diameter) and effusion recurred in another with a small pericardial-peritoneal window (3 cm diameter). No complications were encountered. The pericardial-peritoneal window, approached subxiphoidally, is a simple, safe, and effective procedure and applicable in most patients with noninfectious benign pericardial effusion. We herein describe our techniques, clinical characteristics, and the results for three patients undergoing this treatment. Received: May 24, 2001 / Accepted: November 20, 2001     

Surgical Management of Symptomatic Pericardial Effusion in Patients with Solid Malignancies

Background Symptomatic pericardial effusion in patients with cancer may lead to a life-threatening event that requires diligent treatment, but the best surgical treatment is still controversial. The purpose of this study was to identify predictors of survival for patients with solid malignancies and symptomatic pericardial effusion, which might help to select the best surgical treatment for each patient.Methods We retrospectively analyzed 47 patients with solid malignancies concomitant with symptomatic pericardial effusion who underwent surgery between 1994 and 2004. Overall survival was calculated from date of surgery, and prognostic importance of clinical and pathological variables was assessed.Results The most common primary sites of disease were breast (46.8%) and lung (25.6%). Initial pericardiocentesis were performed in 29 patients; median volume of fluid drained was 480 mL. Median interval from the diagnosis of primary cancer to the development of pericardial effusion (pericardial effusion-free interval) was 34.8 months. Definitive surgical treatment was performed in 43 patients, as follows: subxiphoid pericardial window (n = 21); thoracotomy and pleuropericardial window (n = 10); pericardiodesis (n = 8); and videothoracoscopic pleuropericardial window (n = 4). Pericardiocentesis was the only procedure in four patients. Median follow-up was 2.9 months. Median overall survival was 3.7 months. Pericardial effusion-free interval longer than 35 months and more than 480 mL of fluid drained at initial pericardiocentesis were determinants of better survival.Conclusions Pericardial window and pericardiodesis seem to be safe and efficacious in treating effusion of the pericardium. Pericardial effusion-free interval and volume drained at initial pericardiocentesis are determinants of outcome.     

Thoracoscopic pericardial fenestration for persistent pericardial effusion after radiotherapy for esophageal cancer; report of a case

We performed thoracoscopic pericardial fenestration for persistent pericardial effusion after radiotherapy for esophageal cancer. An 85-year-old man who had radiation therapy (70.2 Gy) for esophageal cancer was admitted for shortness of breath. Chest computed tomography showed a pericardial effusion. During the 6 months prior to this admission, the patient had undergone percutaneous pericardial drainage 3 times for cardiac tamponade. We performed thoracoscopic partial pericardiectomy with creation of a pleuropericardial window via one access port. Histopathologically, no malignant cells were found in either the resected pericardium or the pericardial effusion. Therefore, we believe the persistent pericardial effusion was secondary to radiotherapy. There was no recurrence of the pericardial effusion for 7 months postoperatively. In summary, thoracoscopic pericardial fenestration is useful in both the diagnosis and treatment of persistent pericardial effusion.     

Surgical management of effusive pericardial disease. Influence of extent of pericardial resection on clinical course

Surgical drainage for effusive pericardial disease is usually accompanied by pericardial resection to obtain tissue for analysis and to lessen the chance of recurrent effusion or late constriction. The purpose of this study was to determine the relationship between the extent of resection and the development of late complications. From 1960 through 1983, 145 patients with pure pericardial effusive disease underwent operative drainage. The effusions were malignant in 72 patients (49.7%) and benign in 73 (50.3%). The patients were divided into three groups according to the extent of resection: complete in 72 patients (49.7%), partial in 36 (24.8%), and window in 37 (25.5%). The 30 day mortality was 19.4% for patients with malignant effusions and 5.5% for those with benign effusions (p less than 0.05). All survivors had immediate improvement in symptoms. The actuarial 1 year survival rate was 23.4% (mean 4.2 months) for patients with malignant disease and 85.6% for patients with idiopathic effusions (p less than 0.001). Survival was not influenced by the extent of resection. Fifteen patients (10.3%) had late constriction or recurrent effusion. Six of these required reoperation, all after having had a window procedure. Actuarial probability of reoperation or late complication was greater with window procedures than other resections, both for all patients (p = 0.0001) and for those with benign disease (p = 0.0001). Transthoracic complete pericardiectomy is the procedure of choice for effusive pericardial disease. Subxiphoid drainage has immediate advantages for selected patients but has a statistically greater chance of late complications.     

Clinical study of eight thymic carcinomas

Eight patients with thymic carcinoma were surgically treated at Sapporo City General Hospital from September 1990 to January 2002. The histological subtypes of thymic carcinoma were squamous cell in 5, undifferentiated in 2, and small cell in one. After median sternotomy, 5 patients had total resection of the tumor, and 3 had incomplete resection due to extensive mediastinal invasion involving the main pulmonary artery in the A-P window. Of 3 cases with intra pericardial malignant effusion, one patient survived 7 years without recurrence of the tumor after the exploratory operation followed by mediastinal irradiation without chemotherapy. In this patient, existence of the malignant cells in the pericardial effusion was not associated with poor outcome.     

Subxiphoid pericardial window for pericardial effusive disease

A subxiphoid pericardial window made in 123 patients allowed drainage and diagnosis of pericardial effusions. In 40 patients with malignancy and effusions, median drainage was 450 ml; cytology was positive in 17 or 36 (47%), and pericardial biopsy showed cancer in 13 (43%) of 30 patients. In 11 patients with malignancy, both cytology of effusions and biopsy of the pericardium were negative. In 83 patients with benign effusions, median drainage was 400 ml. Effusions recurred in 14 of the 123 patients (11%); nine patients in the benign group and five in the malignant group. Five of these 14 underwent thoracotomy (3 to 542 days postoperatively); two underwent median sternotomy and one underwent pericardiocentesis. Two intraoperative deaths resulted from cardiac arrest. Mortality at 30 days was 25% (10/40 patients) in the malignant group and 11% (9/83 patients) in the benign group. No deaths resulted from recurrent effusions. The establishment of a subxiphoid pericardial window allows rapid and safe drainage of pericardial effusions with sampling for cytology and pericardial biopsy. It has minimal morbidity and few recurrent effusions.     

Eleven years' experience with pericardial-peritoneal window in the management of malignant and benign pericardial effusions

Background: Before 1983 we routinely used subxiphoid drainage for the management of pericardial effusions. Pericardial-pleural window through a left anterior thoracotomy was used in selected patients. Due to frustration over the rate of recurrent pericardial effusions with subxiphoid drainage alone and concern over the higher morbidity with thoracotomy, the creation of a 3-cm pericardial-peritoneal window in the fused portion of the pericardium and diaphragm overlying the left lobe of the liver was added to subxiphoid drainage in 1983. Methods: This study is a retrospective chart review of the 33 patients undergoing pericardial-peritoneal window from 1983 through 1993. Eighteen patients had malignancies, mainly lung and breast, and 15 had benign pericardial effusions. Results: The procedure was well tolerated, with a 30-day mortality of 9%; however, no deaths were directly related to the pericardial effusion or the procedure. No patient developed peritoneal carcinomatosis or diaphragmatic hernia. One patient developed recurrent pericardial effusion during follow-up, and two required pericardiectomy for constrictive disease. Among those with malignancies, patients with breast cancer had the longest survival after pericardial-peritoneal window. Conclusions: Pericardial-peritoneal window is a simple, safe, and effective procedure and applicable to most patients with malignant and noninfectious benign pericardial effusion, including those with tamponade. Presented at the 47th Annual Cancer Symposium of The Society of Surgical Oncology, Houston, Texas, March 17–20, 1994.     

Pericardial window by videothorascopy

Introduction

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

Material and methods

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

Results

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

Conclusions

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