Comparison of open subxiphoid pericardial drainage with percutaneous catheter drainage for symptomatic pericardial effusion

BACKGROUND: The optimal therapy for symptomatic pericardial effusions remains controversial. This paper compares outcomes after the two most commonly used techniques, percutaneous catheter drainage and operative subxiphoid pericardial drainage. METHODS: We performed a 5-year retrospective, single-institution study to analyze outcomes after either percutaneous catheter drainage or subxiphoid open pericardial drainage for symptomatic pericardial effusions. RESULTS: Symptomatic pericardial effusions in 246 patients were treated by open pericardiotomy and tube drainage (n = 150) or percutaneous catheter drainage (n = 96). Drainage duration, total drainage volume, and duration of follow-up (2.6 years) were similar in both groups. Effusions were classified malignant in 79 (32%) patients and benign in 167 (68%) patients. No direct procedural mortality occurred, but the hospital mortality was 16 patients (10.7%) in the open group and 22 (22.9%) in the percutaneous group (p = 0.01) The 5-year survival rate was 51% in the open group versus 45% in the percutaneous group, despite a greater percentage of the open group having a preoperative malignant diagnosis (35% versus 28%). Symptomatic effusions recurred in 16.5% of the percutaneous group compared with 4.6% in the open group (p = 0.002), and sclerosis did not appear to reduce recurrence rates (10.7% with sclerosis versus 15.6% without; p > 0.05). The diagnosis of malignancy was confirmed in 16 of 27 (59%) percutaneous procedures performed on patients with known malignancy. In the open group, cytologic and pathologic evaluation of the pericardial specimen revealed malignancy in 32 of 52 (62%) patients with known malignancy. CONCLUSIONS: Subxiphoid and percutaneous pericardial drainage of symptomatic pericardial effusions can be performed safely; however, death occurs from underlying disease. Open subxiphoid pericardial drainage with pericardial biopsy appears to decrease recurrence but does not improve diagnostic accuracy of malignancy over cytology alone.     

Delayed pericardial effusion following stab wounds to the chest.

INTRODUCTION: Delayed pericardial effusion following penetrating cardiac trauma has not been commonly reported, and the exact incidence remains unknown. It was more common before 1960, when pericardiocentesis was still a popular treatment for stable patients presenting with a stab wound to the heart. MATERIAL AND METHODS: During an 8-year period, 24 patients were diagnosed with delayed pericardial effusions following a recent stab wound over the chest. Nine patients had been initially treated at our trauma unit, and the remaining 15 patients were referred by a peripheral clinic. RESULTS: Diagnosis was confirmed by cardiac ultrasound or echocardiogram. Sixteen patients were adequately treated by subxiphoid drainage. Sternotomy was performed in five patients, left thoracotomy in two and right thoracotomy in one patient. No actively bleeding injuries were found. Three patients had active infection in the pericardial space. Fever, pleural effusions and ascites were common associated findings. Additional procedures performed included laparotomy for acute abdominal pain in two patients (both negative), and simultaneous drainage of a pleural empyema. Two patients with staphylococcal pericardial infections required subsequent pericardiectomy. SUMMARY: The diagnosis of a penetrating cardiac patient may be missed in a stable patient, and patients may present with delayed pericardial effusions and tamponade. Post pericardiotomy syndrome may be the most common cause of delayed pericardial effusion, followed by sepsis. Subxiphoid pericardial window is an adequate form of treatment. Recent literature reveals that occult cardiac injury is not uncommon, thus a case should be made to actively investigate all patients with precordial stab wounds with cardiac ultrasound or echocardiogram.     

Posterior pericardiotomy reduces the incidence of supra-ventricular arrhythmias and pericardial effusion after coronary artery bypass grafting.

OBJECTIVE: The aim of this prospective study was to demonstrate the effectiveness of posterior pericardiotomy in reducing the incidence pericardial effusions and consequently reducing the related supraventricular tachyarrhythmias and development of delayed posterior cardiac effusions. METHODS: This prospective randomized study was carried out in 150 patients undergoing coronary artery bypass grafting in Bayindir Hospital Department of Cardiovascular Surgery between April 2000 and October 2001. One hundred and fifty patients were divided into two groups; each group included 75 patients. A 4-cm longitudinal incision was made parallel and posterior to the left phrenic nerve, extending from the left inferior pulmonary vein to the diaphragm in posterior pericardiotomy group (group I). Posterior pericardiotomy was not performed in conventional treatment group (group II). RESULTS: Atrial fibrillation was developed in seven patients (9.3%) in group I and in 24 patients (32%) in group II (P<0.001). Atrial flutter and other supraventricular tachyarrhythmia (SVT) prevalence was not statistically significant. Early pericardial effusion was developed 42.6% (32/75) and 10.6% (8/75), respectively, in group II and group I (P<0.0001), but no late pericardial effusion developed in group I despite seven (9.3%) late pericardial effusions developing in group II (P<0.013). CONCLUSION: Posterior pericardiotomy is a simple, safe and effective technique for reducing not only the prevalence of early pericardial effusion and related atrial fibrillation but also delayed posterior pericardial effusion and tamponade.     

The Subxiphoid Approach in the Treatment of Pericardial Effusion

Subxiphoid pericardiotomy for diagnosis and treatment of pericardial effusion is a safe procedure. Not only does it appear to be safer than aspiration, but it yields more information because of its ability to obtain pericardial tissue. The recurrence rate of pericardial effusion is lower using subxiphoid pericardiotomy. For these reasons it is the technique of choice for diagnosis and treatment of nontraumatic 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.     

Effect of posterior pericardiotomy on postoperative supraventricular arrhythmias and late pericardial effusion (posterior pericardiotomy).

OBJECTIVE: The aim of this prospective study was to evaluate the effectiveness of posterior pericardiotomy from the point of pericardial effusion related with supraventricular tachycardia and development of delayed posterior cardiac effusions. Materials and methods: This prospective randomized study was carried out in 200 patients undergoing coronary artery bypass surgery in Gülhane Medical Academy Department of Cardiovascular Surgery between June 1996 and June 1997. Patients were divided into 2 groups; each group included 100 patients. Longitudinal incision was made parallel and posterior to the left phrenic nerve, extending from the left inferior pulmonary vein to the diaphragm in group I patients. Posterior pericardiotomy was not done in group II. RESULTS: Atrial fibrillation was developed in 6 patients (6%) in group I and in 34 patients (34%) in group II (P =.0000007). Atrial flutter and other supraventricular arrhythmia prevalence was not statistically significant. Early and late pericardial effusion were developed 54% and 21%, respectively, in group II, but neither early nor late pericardial effusion were developed in group I (P =.00001). Delayed pericardial tamponade was also significantly lower in group I (0% vs 10%; P =.001). CONCLUSION: Posterior pericardiotomy is technically easy to perform and a safe and effective technique that reduces not only the prevalence of early pericardial effusion and related atrial fibrillation but also delayed posterior pericardial effusion and tamponade.     

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.     

Treatment of Uremic Pericardial Effusion by Local Steroid Instillation VIA Subxiphoid Pericardiotomy

Seven maintenance hemodialysis patients suffering from intractable uremic pericardial effusion were treated with instillation of a non-absorbable steroid, triamcinolone hexacetonide, into the pericardial sac via a large-bore catheter. The latter was placed under direct vision by subxiphoid pericardiotomy. All patients responded to the treatment while complications of the procedure were few and minor.     

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.     

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.     

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.     

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.     

Evaluation of occult cardiac injuries using subxiphoid pericardial window

During 1987, we performed diagnostic subxiphoid pericardial windows on all stable patients with juxta-cardiac penetrating injuries. This excluded any patient with clinically diagnosed tamponade or shock. Fifty-one patients underwent subxiphoid diagnostic pericardiotomy for suspected cardiac injuries. Forty patients were normotensive on presentation and 11 experienced transient hypotension. All patients were easily resuscitated in the Emergency Department. The time from admission to operation ranged from 20 minutes to 6 hours (average, 2.5 hours). Twelve patients (23.5%) had hemopericardium at the time of subxiphoid diagnostic pericardiotomy (SDP), and cardiac injury was confirmed at sternotomy in all. Two patients (16%) in the positive group were admitted with systolic blood pressures less than 100 mm Hg compared to nine (23%) in the negative group. One patient had a systolic to diastolic pressure gradient less than 30. Central venous pressures in this group of patients ranged from 8 to 23 cm H2O. Nine patients who had pericardial window solely on the basis of location of the injury had positive findings. All nine patients were normotensive on admission, had CVP's less than 12, and had no other overt clinical signs of injury. This represents an overall occult injury rate of 17.6%. At sternotomy, there were eight ventricular, two pulmonary artery, one aortic root, and one atrial injury, all repaired. Two patients in this group had associated abdominal injuries as did 11 in the negative group, all of whom required operation, and may have explained the hypotension in negative patients. There were no complications of SDP and all negative patients were discharged on the second hospital day.(ABSTRACT TRUNCATED AT 250 WORDS)     

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.     

The role of posterior pericardiotomy on the incidence of atrial fibrillation after coronary revascularization

AIM: Pericardial effusion and atrial fibrillation (AF) are two common complications in coronary revascularization surgery. The aim of this study was to evaluate the efficiency of posterior pericardiotomy in pericardial effusion and AF. METHODS: This randomized prospective study includes 113 patients who underwent isolated CABG procedure between May 2000 and December 2000 in our hospital. Posterior pericardiotomy incision was done in Group I (n=54). Group II constituted the control group (n=59). Postoperative pericardial effusion was assessed by echocardiography and rhythm follow-up was done by the same cardiologist. RESULTS: There was no significant difference between study group and the control group considering the chest drainage (940.18+/-367.96 vs 894.92+/-360.65; p=0.507). The number of patients with remarkable intrapericardial effusion (>50 ml) was significantly lower in the posterior pericardiotomy group (25.93% vs 47.45%, p=0.020). The incidence of postoperative AF was no different between the posterior pericardiotomy group and the control group (12.96% vs 20.34%; p=0.32). In both groups, the incidence of AF was significantly higher in patients with mild or moderate pericardial effusion (29%), compared to patients with no or minimal pericardial effusion (10%), (p=0.017). CONCLUSION: Posterior pericardiotomy significantly reduces the pericardial effusion in coronary bypass procedure postoperatively. Patients with pericardial effusion were subjected to AF more frequently.     

Clinical course and predictors of pericardial effusion following cardiac transplantation

OBJECTIVE: Pericardial effusions occur frequently after orthotopic heart transplantation. There have been conflicting reports describing etiology, prognosis, and outcomes associated with these early postoperative effusions. METHODS: A retrospective review of 91 patients transplanted between January 2001 and September 2004 was performed. Pericardial effusion was defined by serial echocardiography and graded as none, small, moderate, or large. A total of 1088 echocardiograms were evaluated during the first posttransplant year. Perioperative variables were evaluated by logistic regression analysis to define predictors for occurrence of effusions. RESULTS: Echocardiographic data were available for 88 patients. Thirty-one patients (35%) developed moderate to large effusion in the immediate postoperative period. Three patients developed hemodynamic compromise that required immediate intervention. All other effusions resolved within 3 months of heart transplantation without any specific intervention. Only prolonged donor ischemic time was associated with higher risk of occurrence of moderate to large pericardial effusions (odds ratio 1.012, 95% confidence interval 1.001 to 1.019, P = .033). There was no difference in morbidity or early mortality between patients with and without pericardial effusions. CONCLUSION: Moderate to large pericardial effusions occur frequently after heart transplantation. In a vast majority, these effusions are not associated with any adverse clinical outcomes and resolve within 3 months postoperatively. Early postoperative close monitoring is still required to evaluate for tamponade.     

Predictors of pericardial effusion after orthotopic heart transplantation

OBJECTIVES: Pericardial effusion occurs frequently after orthotopic heart transplantation, but the causes of this complication have not been well described. This study was designed to identify factors predisposing toward the development of significant postoperative pericardial effusions in a large, single-institution population of orthotopic heart transplant recipients. METHODS: A retrospective review of more than 90 preoperative, intraoperative, and postoperative variables was conducted for 241 patients undergoing orthotopic heart transplantation from September 1988 to December 1999. Patients who had significant postoperative pericardial effusions develop were identified from postoperative echocardiograms by standard criteria. Factors associated with the development of significant pericardial effusions were determined by multivariate logistic regression analysis. RESULTS: Echocardiographic data were available for 203 of 241 transplant recipients. Forty-two patients (21%) had significant effusions develop. According to multivariate analysis, pericardial effusions were less likely to occur in recipients with a history of previous cardiac surgery (odds ratio 0.13, 95% confidence interval 0.05-0.36, P <.0001) and with greater weight (odds ratio 0.96, 95% confidence interval 0.94-0.99, P <.0048). Pericardial effusions were more likely to occur in patients who had received aminocaproic acid during the operation (odds ratio 5.92, 95% confidence interval 2.23-15.72, P <.0008). Patient survival and hospital length of stay did not differ between patients with and without postoperative pericardial effusions. CONCLUSIONS: Postoperative pericardial effusions develop in approximately 20% of patients undergoing orthotopic cardiac transplantation. On the basis of the risk factors identified in this study, prevention may prove difficult, although avoidance of the intraoperative use of aminocaproic acid may be helpful.     

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%).     

LAPAROSCOPIC CREATION OF PERICARDIAL WINDOW

Malignant pericardial effusions are frequently symptomatic and usually recur after aspiration. Surgical options include pericardiectomy and transthoracic or subxiphoid pericardial window formation and, more recently, thoracoscopic pericardial window formation. The authors report their first four cases of laparoscopic creation of pericardial windows. The treatment has been effective and minimally traumatic.     

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.