心脏外科术后心包积液的危险因素与治疗

目的 探讨心脏外科手术后心包积液的危险因素和治疗方法.方法 回顾分析22 462例患者临床资料,定义心包积液诊断标准.观察心包积液患者与无积液患者的临床表现,对症治疗,分析危险因素.结果 509例(2.3％)患者有心包积液262例有临床特殊症状,其中51例有心包压塞的临床表现.有、无心包积液的患者年龄、性别、冠心病史等因素差异无统计学意义(P＞0.05);而大体重、瓣膜病、主动脉阻断和体外循环时间差异有统计学意义(P＜0.05).结论 心包积液的危险因素有大体重,术前心功能Ⅲ、Ⅳ级,瓣膜病,先天性心脏病,大血管疾病,体外循环和主动脉阻断时间延长.超声引导下的心包积液穿刺引流是安全有效的.     

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.     

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.     

Pericardial effusion following pulmonary resection

Objective Postoperative pericardial effusion commonly occurs after open heart surgery. However, after general thoracotomy such as pulmonary resection, there have been few reports of pericardial effusion. The purpose of this study is to investigate patients with pericardial effusion following pulmonary resection.Methods: Among 2,385 patients with pulmonary resection for lung neoplasm in our institute, eight patients, whose pericardium had never been opened during the operation, developed pericardial effusion. The clinical characteristics of the eight patients were analyzed.Results: Pericardial effusion after pulmonary resection was divided into two subtypes: pericardial effusion in three patients with left thoracotomy occurring within 30 days postoperatively, and pericardial effusion in the remaining five patients with right thoracotomy occurring more than 30 days postoperatively. Pericardiotomy or pericardiocentesis was performed in three symptomatic patients, and the remaining five asymptomatic patients were treated with diuretics. Pericardial effusion disappeared in three of the five patients about 1–3 months after the conservative treatment, while, in the remaining patients, because pericardial effusion had increased gradually, pericardiocentesis was performed.Conclusion: From our experience, the treatment strategy of drainage for early pericardial effusion and diuretics for late pericardial effusion seems to be appropriate. (Jpn J Thorac Cardiovasc Surg 2006; 54:193-198)     

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.     

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.     

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.     

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.     

Pleuropericardial effusions in children with non-Hodgkin's lymphoma. A report of 2 cases

Two children with non-Hodgkin's lymphoma (NHL) who presented with pleuropericardial effusions are reported on. Pericardial effusions are very unusual in children with mediastinal nodal NHL. In the first patient, who presented with a pleural effusion and pericardial tamponade, the diagnosis of NHL was obscured by a false-positive report of acid-fast bacilli in the pleural fluid. The second patient presented with a pleural effusion and a pericardial effusion with superior vena cava obstruction. Rapid filling of the serous cavities was a striking feature in both cases. Cytological and biochemical investigation of the pleural fluid and pleural biopsy are of limited diagnostic value. Pleuropericardial effusions in NHL are reviewed. The patients have been in disease-free remission for 18 and 16 months respectively.     

Erdheim-Chester disease: The role of video-assisted thoracoscopic surgery in diagnosing and treating cardiac involvement

INTRODUCTIONErdheim–Chester disease is a rare, non-Langerhans histiocytosis in which pericardial involvement is diagnosed with increasing frequency and is associated with high mortality rates.PRESENTATION OF CASEA 53-year-old woman presented with progressive exertional dyspnea and pericardial effusion was discovered. Further investigations revealed the presence of a diffuse, infiltrating process and a diagnosis of Erdheim–Chester disease was made. An emergent pericardiocentesis by subxiphoid approach was completed but recurrent drainage obviated removal of the pigtail catheter. A pleuro-pericardial window was placed using video-assisted thoracoscopic surgery (VATS) and analysis of the resected specimen confirmed pericardial involvement.DISCUSSIONIn this case, high pericardial fluid output demanded definitive treatment of the pericardial effusion. Traditionally this would be completed via thoracotomy. VATS is a minimally invasive alternative which permits exploration of the thoracic cavity and the creation of a pleuropericardial window.CONCLUSIONWe describe, for the first time, the successful use of VATS for both diagnostic confirmation and therapeutic relief of recurrent pericardial fluid drainage due to pericardial involvement by Erdheim–Chester disease.     

Malignant pericardial effusion--an uncommon complication of multiple myeloma: case report

Multiple myeloma is a condition usually associated with lesions of the skeleton. However, under rare circumstances, the malignant plasma cells may infiltrate the pericardium, resulting in an effusion. If left untreated, the abnormal accumulation of pericardial fluid will result in cardiac tamponade, requiring drainage. The following report describes a multiple myeloma patient who developed secondary pericardial and pleural effusions, which were surgically drained via a pleuropericardial window.     

Pericardial Effusion Associated With Sirolimus Use After Renal Transplantation: A Single-Center Case Series

Pericardial effusion and cardiac tamponade following renal transplantation have been recognized as a potentially serious complications associated with the use of sirolimus for immunosuppression. Our study aims to analyze the development of sirolimus-associated pericardial effusion.Patients who underwent renal transplantation at our institution between 2001 and 2014 were reviewed and the correlation between sirolimus exposure and pericardial effusion was determined. Nineteen out of 792 patients who received a renal transplant over this 14-year period (incidence 2.4%) developed symptomatic pericardial effusion (determined by the need for pericardiocentesis or a pericardial window). All patients had a pre-transplantation cardiac workup, including echocardiogram, which did not reveal the presence of pericardial effusion. Our cohort of patients is mostly male (57.9%) and Caucasian (73.7%), which is consistent with the makeup of transplant recipients at our center. The mean age was 52.42 years at the time of transplantation. The development of symptomatic pericardial effusions occurred at a mean of 5.06 (.5–9.8) years after renal transplant while on sirolimus therapy. Sirolimus levels at diagnosis were 5.19–7.47 ng/mL. No significant pericardial effusion (resulting in tamponade physiology) recurred after therapeutic intervention, including cessation of sirolimus with or without pericardial drainage. This study is the largest single-center report of the possible association between pericardial effusion in renal transplant recipients who received sirolimus. Due to the widespread use of sirolimus in organ transplantation, clinicians must remain vigilant for this potential cardiac complication.     

Intraoperative Management to Prevent Cardiac Collapse in a Patient With a Recurrent,Large-volume Pericardial Effusion and Paroxysmal Atrial Fibrillation During Liver Transplantation: A Case Report

Background

Pericardial effusion is a common feature of end-stage liver disease. In this case report we describe the intraoperative management of recurrent pericardial effusion, without re-pericardiocentesis, to prevent circulatory collapse during a critical surgical time-point; that is, during manipulation of the major vessels and graft reperfusion.

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.     

Severe Pericardial Effusion in Patients with Concurrent Malignancy: A Retrospective Analysis of Prognostic Factors Influencing Survival

Background  The treatment of massive and/or symptomatic pericardial effusion in patients with cancer remains a subject of discussion. Medical and surgical management have been proposed. In the present study, we aimed to determine the prognostic factors influencing survival of cancer patients admitted in intensive care unit (ICU) with severe pericardial effusion to better select the treatment strategies. Methods  All patients with cancer and massive or symptomatic pericardial effusion were retrospectively analyzed. Patients were followed up until death or last time known to be alive. Univariate and multivariate analyses were performed to determine prognostic factors influencing survival. Results  Between January 1999 and August 2004, 55 eligible patients were admitted in the ICU for pericardial effusion, including 30 with lung cancer, 9 with breast cancer, 5 with hematological malignancies, and 11 patients with other types of solid tumors. Forty-three patients underwent a surgical drainage. No operative death occurred. Four patients presented with an asymptomatic recurrence. Median survival of the entire group was 112 days. Survival rates for 1, 2, and 3 years were 27%, 17%, and 12%, respectively. In univariate analysis, the following variables were significantly associated with a reduced survival: histopathological diagnosis of malignant pericardial effusion, age (>60 years), the volume of pericardial effusion (<550 cc), and the cancer status (complete or partial response). After multivariate analysis, the cancer status was the only statistically significant clinical factor influencing overall survival (P = .005). Conclusion  In this series of patients presenting with severe pericardial effusion, the control of the underlying neoplasm was the only significant factor influencing survival and could be helpful in making decision to the optimal (invasive) treatment that should balance treatment efficacy with life expectancy.     

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%).     

Preoperative and perioperative management of patients with pericardial diseases

Hemodynamic instability is the major concern in surgical patients with pericardial diseases, since general anesthesia and positive pressure ventilation may precipitate cardiac tamponade. In advanced constriction diastolic impairment and myocardial fibrosis/atrophy may cause low cardiac output during and after surgery. Elective surgery should be postponed in unstable patients with pericardial comorbidities. Pericardial effusion should be drained percutaneously (in local anesthesia) and pericardiectomy performed for constrictive pericarditis before any major surgical procedure. In emergencies, volume expansion, catecholamines, and anesthetics keeping cardiac output and systemic resistance should be applied. Etiology of pericardial diseases is an important issue is the preoperative management. Patients with neoplastic pericardial involvement have generally poor prognosis and any elective surgical procedure should be avoided. For patients with acute viral or bacterial infection or exacerbated metabolic, uremic, or autoimmune diseases causing significant pericardial effusion, surgery should be postponed until the causative disorder is stabilized and signs of pericarditis have resolved.     

Postpericardiotomy syndrome after permanent pacemaker implantation in children and young adults

Background

Postpericardiotomy syndrome (PPS) occurs in 10% to 50% of pediatric patients after cardiac surgery. The incidence and outcome of PPS after permanent pacemaker implantation in children is not described.

Methods

A retrospective analysis was performed of all pediatric patients who underwent isolated placement of a pacemaker between January 1984 and December 2002. Patients who underwent congenital heart surgery at the time of pacemaker implantation were excluded. PPS was diagnosed on the basis of clinical symptoms with echocardiographic confirmation of a pericardial effusion.

Results

Four hundred and forty-three pacemakers (237 epicardial, 206 transvenous) were implanted in 370 patients (median age 10 years, range 2 months to 24 years). Eight (2%) episodes of PPS (6 epicardial, 2 transvenous) occurred in 7 patients. The median time from implantation to PPS was 12.5 days (range 8 to 22 days). Six (75%) episodes followed primary pacemaker implantation, two occurred after subsequent lead revision. Three patients were initially treated with medical therapy (1 nonsteroidal agents, 2 steroids), and 1 required subsequent pericardiocentesis. Five patients underwent initial pericardiocentesis followed by medication. One patient had echocardiographic recurrence of a pericardial effusion 3 weeks after a nonsteroidal taper, with resolution after nonsteroidal agents were reinitiated. One patient required a pericardial window for a persistent effusion. No pacemaker was explanted.

Conclusions

PPS occurred in 2% of children undergoing isolated pacemaker implantation of both epicardial and transvenous systems. PPS is usually managed successfully with medical therapy. Patients with medical treatment failure were successfully treated with pericardiocentesis or the surgical creation of a pericardial window.     

Ultrasound guided pericardial drainage and intrapericardial instillation of mitomycin C for malignant pericardial effusion.

BACKGROUND--Conservative treatment of malignant pericardial effusion by intrapericardial instillation of a sclerosing agent may be an alternative to surgery. METHODS--Twenty patients with malignant pericardial effusion were treated by ultrasound guided pericardiocentesis and the intrapericardial instillation of mitomycin C. RESULTS--Mitomycin C was effective in controlling the pericardial effusion in 70% of patients without causing side effects, except for pericardial constriction seven months later in one subject. CONCLUSIONS--Ultrasound guided intrapericardial instillation of mitomycin C is a suitable alternative in the management of malignant pericardial effusion.     

Massive primary chylopericardium: a case report

A large pericardial effusion was discovered in an asymptomatic 12-year-old boy admitted for an elective orthopedic procedure. On physical examination, heart rate was 96 and blood pressure was 130/70 without paradox. The neck veins were not distended, but heart tones were distant. Chest roentgenogram (CXR) showed an enlarged cardiac silhouette. Echocardiogram showed a massive pericardial effusion compressing the right atrium, with depressed ventricular contractility. Pericardiocentesis yielded 450 mL of chylous fluid. A percutaneous pericardial drain was placed and drained another 400 mL of chyle. Pericardial fluid reaccumulated even though the patient was on a low-fat diet, and 1 week after admission left thoracotomy was performed with partial pericardiectomy and pericardial window. There was 1 L of chyle in the pericardial sac; frozen section of the pericardium showed lymphangiectasia. Chest tube drainage diminished rapidly and the patient was discharged. Follow-up CXR at 1 week showed fluid in both pleural spaces requiring bilateral tube thoracostomies again draining chyle. Even with total parenteral nutrition (TPN), 500 mL/d of chyle drained from the pleural tubes. Right thoracotomy with ligation of the thoracic duct was performed after 1 week of TPN. Pleural drainage abruptly dropped, and there has been no reaccumulation in either the pleural spaces or pericardium at 6-month follow-up. This case dramatically supports early thoracic duct ligation and partial pericardiectomy as the treatment of choice for primary massive chylopericardium.