Pericardial Decompression

Pericardial tamponade and chronic pericardial effusion were treated in 32 patients by creating a subxiphoid pericardial window under local anesthesia in preference to pericardiocentesis or pericardiectomy. Chest roentgenograms, fluoroscopy, and cardiac catheterization as standard clinical methods of diagnosis have been largely replaced by echocardiography as the most sensitive method for detecting pericardial effusion. Eleven patients had pericarditis of viral, uremic, or purulent origin. Two had intrapericardial hemorrhage following catheter perforation of the heart. Four had pericardial effusion associated with cardiomyopathy and rheumatoid arthritis. In the remaining 15 patients malignancy was the cause of tamponade. In 10 patients we attempted to control the effusion initially with pericardiocentesis. Five of these (50%) required an additional procedure. In 22 patients subxiphoid pericardial decompression was the primary method of treatment; there were no fatalities during or immediately following operation. None of these patients has had any recurrence of tamponade or effusion for up to three years.     

The Subxiphoid Approach to Pericardial Disease

During the 36-month period from July, 1978, through July, 1981, 25 patients underwent a subxiphoid pericardial window procedure for diagnosis and therapy. Twelve patients were operated on for uremic pericarditis, 6 for malignancy, and 7 for etiological diagnosis of the pericarditis. All 12 patients with renal failure had enlarging effusions, despite aggressive dialysis. Eleven of the 12 are alive, free from recurrence, 3 to 36 months postoperatively. Six patients were operated on for suspected pericardial malignancy with hemodynamic compromise. Histological diagnosis was made from the pericardial tissue in all patients; only 1 patient lived more than 43 days following the procedure.In the group of 7 patients operated on for diagnosis, 4 were thought preoperatively to have tuberculous pericarditis. All 4 were treated with antituberculosis chemotherapy and are asymptomatic, without evidence of calcification, 12 to 31 months postoperatively.This diverse group of patients demonstrates that the subxiphoid pericardial window is an effective approach for relief of uremic effusions and may adequately treat effusive tuberculous pericarditis when combined with multidrug chemotherapy. Patients with suspected malignant pericardial disease and hemodynamic compromise need to be carefully studied before an operative procedure is considered as a means of diagnosis and therapy.     

Subxiphoid Pericardial Window in Patients with Suspected Traumatic Pericardial Tamponade

The technique, indications, and results of subxiphoid pericardial window in penetrating chest wounds with suspected traumatic pericardial tamponade are reported.The classic signs of pericardial tamponade (elevated central venous pressure, muffled heart sounds, and paradoxical pulse) are unreliable in an emergency situation. Chest roentgenograms and electrocardiograms are of little diagnostic value. Pericar-dicentesis was either falsely positive or negative in 50% of our patients. Therefore, unexplainedhigh central venous pressure and hypotension were considered to be pericardial tamponade until disproved by the results of a subxiphoid pericardial window.There were 4 negative and 46 positive findings of tamponade in 50 consecutive patients with suspected traumatic pericardial tamponade who underwent creation of a subxiphoid pericardial window. There were no deaths or complications from the procedure. The early use of subxiphoid pericardial window has been a major factor in reducing our mortality rate from penetrating heart wounds to 12% overall, and 8% in the past three years.     

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.     

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.     

Pericardial window: mechanisms of efficacy

Although the term implies a persistent communication through which fluid might drain, how a pericardial window works is not clear. We believe that the mechanism of success is not window but rather fusion of the epicardium to the pericardium with obliteration of the potential space. To evaluate this, we studied 28 patients, all of whom underwent a subxiphoid pericardial window procedure with tube drainage maintained until output was minimal. There were no operative deaths, and 26 patients (92.9%) obtained permanent relief. Postoperative echocardiograms demonstrated thickening of the pericardium/epicardium and obliteration of the pericardial space. Autopsy performed on 4 patients who died of their underlying malignancy confirmed this fusion, which begins as an inflammatory process. A subxiphoid pericardial window relieves effusions with a low operative mortality and good long-term success (92.9%, 26 of 28). This success is dependent on the inflammatory fusion of the epicardium to pericardium and not maintenance of a window. Tube decompression should be maintained until fluid output is minimal to allow apposition and fusion of the two surfaces.     

Pericardial effusion: subxiphoid pericardiostomy versus percutaneous catheter drainage

BACKGROUND: Optimal management of cardiac tamponade resulting from pericardial effusion remains controversial. METHODS: Cardiac tamponade in 117 patients was treated with either subxiphoid pericardiostomy (n = 94) or percutaneous catheter drainage (n = 23). Percutaneous catheter drainage was used for patients with hemodynamic instability that precluded subxiphoid pericardiostomy. Effusions were malignant in 75 (64%) of 117 patients and benign in 42 (36%) of 117. RESULTS: Subxiphoid pericardiostomy had no operative deaths and a complication rate of 1.1% (1 of 94). In contrast, percutaneous drainage had significantly (p < 0.05) higher mortality and complication rates of 4% (1 of 23) and 17% (4 of 23), respectively. Patients with an underlying malignancy had a median survival of 2.2 months, with a 1-year actuarial survival rate of 13.8%. In comparison, patients with benign disease had a median survival of 42.8 months and a 1-, 2-, and 4-year actuarial survival rate of 79%, 73%, and 49%, respectively (p < 0.05). Effusions recurred in 1 (1.1%) of 94 patients after subxiphoid pericardiostomy compared with 7 (30.4%) of 23 patients with percutaneous drainage (p < 0.0001). CONCLUSIONS: Benign and malignant pericardial tamponade can be safely and effectively managed with subxiphoid pericardiostomy. Percutaneous catheter drainage should be reserved for patients with hemodynamic instability.     

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.     

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 catheter sclerosis versus surgical procedures for pericardial effusions in cancer patients

BACKGROUND: Approximately 21% of patients with advanced malignancies have cardiac or pericardial involvement with tumor. Controversy exists regarding the optimal approach to the pericardial space when hemodynamic compromise due to effusions occurs. METHODS: A six-year retrospective review of 59 cancer patients with pericardial effusions. RESULTS: Thirty-six patients had subxiphoid pericardial window (SXPW) alone (Group A), 5 had pericardial catheter drainage (PCD) followed by a SXPW (Group B), 10 had PCD with sclerosis (Group C), 5 had PCD alone (Group D), 2 had PCD with pericardial-pleural window (Group E), and one had pericardial-peritoneal window (Group F). The method of procedure, complications, number of hospital and ICU days, cytological or pathologic evidence of malignancy, solid versus hematological tumors, and survival were analyzed. The median survival for those patients in group C was one month compared to 4 months for Group A and 6 months for Group B. Essentially, results were similar regardless of method performed with the exception that professional and hospital charges averaged $4830 for SXPW compared to $1625 for PCD. CONCLUSIONS: Pericardial catheter drainage and sclerosis provides a viable option for the treatment of pericardial effusions in selected cancer patients at markedly reduced cost and patient discomfort.     

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.     

Abdominal cavity unidirectional shunt for refractory pericardial effusion 7 months after cardiac valve replacement: A case report

Refractory pericardial effusion after repeated pericardial drainage and drug therapy for nearly half a year after cardiac valve replacement is rare. We present the case of a 36‐year‐old female patient who underwent an abdominal cavity unidirectional shunt for refractory massive pericardial effusion through a subxiphoid mini‐incision, 7 months after cardiac valve replacement. The head end of a prefabricated bovine pericardial short tube with double leaflets on the tail was sutured to the small incised hole of the diaphragm, whereas the body and the tail of the short tube were dissociated in the left anterior hepatic space. Three months later, the pericardial effusion completely disappeared, no peritoneal effusion occurred, and all symptoms vanished.     

Emergency subxiphoid pericardial decompression for malignant pericardial effusion

Malignant pericardial effusion can result in acute cardiac tamponade with serious hemodynamic compromise. This condition requires prompt pericardial decompression for relief of symptoms; however, the risks of general anesthesia in this setting are considerable. In a series of 12 patients, all operated on under local anesthesia without operative mortality, there were six patients with malignant pericardial effusion secondary to lung carcinoma; four patients, secondary to breast carcinoma; one patient, secondary to squamous cell carcinoma of the oral cavity; and one patient, secondary to an unknown primary. The clinical presentation of each was abrupt and echocardiography was definitive. The procedure is performed through an upper abdominal midline incision. The xiphoid process is excised, the diaphragm is visualized, and a pericardial window is created through which two chest tubes are placed through separate stab incisions. The tubes are removed when the drainage has subsided, usually 3-7 days. No medication or irritant is instilled. There was no recurrence following this treatment. The average survival time was 27 weeks with a range of 2-153 weeks. This operation should be part of the repertoire of the general surgeon who treats breast cancer and of the thoracic surgeon who treats lung cancer.     

Clinical experience with subxiphoid drainage of pericardial effusions

To assess the effectiveness of subxiphoid pericardial tube drainage for treatment of pericardial effusion, we reviewed 41 consecutive patients who underwent this procedure during a 14-year period. The patients ranged in age from 7 months to 75 years. All were symptomatic preoperatively. The diagnosis of pericardial effusion was confirmed by echocardiogram in all but 2 patients. Eight patients had acute pericardial tamponade. Subxiphoid pericardial drainage was performed under general (n = 35) or local anesthesia (n = 6). A portion of the anterior pericardium was excised in each patient. There were no perioperative deaths. Thirty-day mortality was 19.5%; there were five late deaths. All deaths were unrelated to pericardial effusion or to the operation. One patient had recurrent effusion requiring pericardiocentesis on the 21st postoperative day. He died five days later of extensive lymphoma. Twenty-eight patients were followed from 1 month to 10 years; mean follow-up was 31.5 months. None developed recurrent effusion or pericardial constriction. We conclude that subxiphoid pericardial drainage is effective for treatment of pericardial effusion.     

Percutaneous Tube Pericardiostomy

Abstract The classic subxiphoid pericardial window technique and the newer, minimally invasive percutaneous fluoroscopy-controlled method of surgical treatment of pericardial effusions and/or tamponade are reviewed and compared based on 12 years of surgical experience. Since 1988, 114 patients underwent surgery for treatment of pericardial effusion and/or tamponade. The classic subxiphoid approach was used on 66 patients, and since 1993, the percutaneous tube pericardiostomy method was employed on 48 patients. In choosing a method for pericardial decompression, disease etiology and patient characteristics must be considered as well as the experience of the surgeon.     

Uremic pericardial effusion. Treatment by catheter drainage and local nonabsorbable steroid administration.

Pericardial drainage via percutaneous catheter placement and local nonabsorbable steroid instillation was employed as definitive therapy for uremic patients who had intractable pericardial effusions. Twelve patients are reported. Prior daily dialysis, and in one case systemic steroids, were not curative. 11 of 12 cases suffered severe tamponade requiring pericardiocentesis. One patient had an organized pericardial effusion, making pericardiocentesis impossible. He required pericardiectomy with prolonged hospitalization (2 weeks) due to postoperative complications. There were no complications in the 11 patients where catheter drainage and local steroid instillation were employed. No patient had recurrence of his pericardial effusion (followed from 2 weeks to 32 months). Instillation of a relatively nonabsorbable steroid through an indwelling pericardial catheter provides immediate and lasting relief without either the inconvenience or postoperative complications and prolonged hospitalization associated with the surgical procedure of pericardial fenestration. This report offers initial evidence that the percutaneous approach may be a safe and effective alternative to pericardial fenestration in most uremic patients with pericardial effusion.     

Pericardoscopy for primary management of pericardial effusion in cancer patients.

OBJECTIVE: To assess the usefulness of pericardoscopy via the subxyphoid route for the diagnosis and treatment of pericardial effusion in patients with a history of cancer. METHODS: All patients with a recent or remote history of cancer and a pericardial effusion of unknown origin requiring drainage for diagnostic and therapeutic purposes were included in the study. They underwent complete exploration and cleansing of the pericardial cavity. Abnormal structures or deposits were biopsied under direct visual control, with a 24 cm long rigid pericardoscope. RESULTS: Between 1985 and 1998, pericardoscopy was completed in 112 of the 114 patients included (feasibility 98%), resulting in the immediate relief of symptoms in all the cases. Peri-operative mortality was 3.5%, and post-operative morbidity, 6.1%. After pericardioscopy pericardial effusions were considered malignant in 43 cases. One more case (2.3%) due to a false negative result of pericardioscopy was diagnosed during follow-up. Overall, 44 of the 114 patients (38.6%) had a malignant effusion, and 70 (61.4%), a non-malignant effusion according the follow up. In 10 of the 44 patients with a malignant pericardial effusion (22.7%), pericardoscopy corrected the results of cytological pericardial fluid studies and pericardial window biopsy, both false negatives. The sensitivities of cytological studies of the pericardial fluid, pathological examinations of pericardial window biopsy and pericardioscopy were 75, 65 and 97%, respectively. One patient with a malignant effusion had a non-symptomatic recurrence 1 month after pericardioscopy (2.3%). CONCLUSION: We recommend pericardioscopy to ascertain the malignant nature of the effusion and to diminish the recurrence rate, this avoiding repeat procedures in patients with a short life expectancy.     

Subxiphoid pericardial window and penetrating cardiac trauma

Between 1982 and 1986, 108 patients with penetrating wounds in proximity to the heart and no obvious signs of cardiac injury underwent a diagnostic subxiphoid pericardial window procedure. Eighty-four patients had stab wounds, 22 had gunshot wounds, and two had shotgun wounds. The subxiphoid pericardial window procedure produced positive results in 30 patients (28%) and negative results in 78 patients (72%). There were two false-positive subxiphoid pericardial window procedures. Eleven patients (39%) with cardiac injuries were not hypotensive and did not have signs or symptoms of cardiac injuries prior to the subxiphoid pericardial window procedure. When they were obtained (n = 80), electrocardiograms were abnormal in 57% and 21% of patients with and without cardiac injuries, respectively. At thoracotomy, 28 patients had injuries (ventricle, 20; atrium, three; and pericardium, five) and 21 required suture repair. Thirty-nine patients underwent a concomitant laparotomy. Forty-six abdominal visceral injuries were identified in 28 patients, including 21 hollow viscus injuries. There was no significant short-term or long-term morbidity (eg, pericarditis, tamponade, or post-pericardiotomy syndrome) attributable to the subxiphoid pericardial window procedure. There were no known missed cardiac injuries, and there were no deaths in the series. Some patients with penetrating wounds to the heart have no overt signs or symptoms of cardiac injury. A subxiphoid pericardial window procedure quickly identifies or excludes cardiac injuries and can be performed with minimal morbidity, even when there is contamination from the gastrointestinal tract.     

Successful repair of a diaphragmatic hernia through a pericardial window with acellular dermal matrix

A successful placement of a transabdominal pericardial window is associated with diaphragmatic hernia. In this paper, we present the case of a 5-month-old ex-31-weeks-premature baby who developed a symptomatic diaphragmatic hernia following a chronic pericardial effusion who was treated successfully with a laparoscopic transabdominal pericardial window. Laparoscopy and a pericardial window were used to manage the symptomatic effusion that developed following a bilateral thoracotomy and median sternotomy for the patient's massive hygroma. The patient was followed before and after pericardial drainage with a serial examination, chest radiography, and echocardiography. In addition, computerized tomography was also used for long-term follow-up following the repair of the hernia. An acellular dermal matrix was utilized for patching the hernia with a laparotomy. The abdominal approach in both operations offered direct access to the pericardial space and hernia, thereby avoiding previously operated thoraces. A subsequent follow-up at 9 months following the creation of the window suggested a recurrent tamponade physiology. Plain radiographs and an echocardiogram showed herniation into the pericardial sac. The hernia was operatively reduced and repaired with an acellular dermal matrix. Recovery and subsequent followup at 1 year revealed no hernia, full symptom resolution, and no recurrence of the pericardial effusion. A pericardial window is an effective approach for the management of chronic pericardial effusion. Diaphragmatic herniation through a pericardial window can be successfully repaired with an acellular dermal matrix.     

Pericardial drainage prior to operation contributes to surgical repair of traumatic cardiac injury

We report on two cases of successful surgical repair of cardiac injury: one involving a left ventricular stab injury and the other a blunt rupture of the right atrium. Each patient underwent emergency surgical repair, the former via left anterolateral thoracotomy and the latter via median sternotomy, following pericardial drainage tube insertion from the subxiphoid area. The operative approach was chosen according to the color of drained blood, i.e., arterial bleeding indicated left anterolateral thoracotomy, while venous bleeding indicated median sternotomy. We conclude that pericardial drainage via the subxiphoid approach prior to induction of anesthesia is an easy and useful technique to perform, not only to release cardiac tamponade but to determine the operative approach in patients suffering from cardiac tamponade following cardiac injury.