Evaluation and Management of Radiation-Induced Pericardial Effusion

Abstract

Pericardial effusion is an uncommon clinical manifestation of Hodgkin's disease although recognized with some frequency postmortem (1–3). However, the occurrence of pericardial effusion after mediastinal irradiation for Hodgkin's disease is of significant frequency to merit discussion of its treatment (4, 5). Since 1965 seven of our patients have undergone pericardiectomy. The mediastinum of these patients was irradiated through anterior fields with doses of 3,000 to 4,000 rads delivered to the mid chest in four to six weeks. The dose to the anterior cardiac region varied from 5,000 to 7,000 rads depending on the anteroposterior diameter of the chest wall and the dose delivered to the mid chest. The diagnosis of pericardial effusion in our patients is based largely on the enlarging cardiac silhouette on the roentgenogram. Cardiac scan with technetium albumin has confirmed the diagnosis of pericardial effusion when suggested by the serial chest films. Elevated venous or right atrial pressures, dyspnea, or pulsus paradoxieus have appeared only after the enlarged cardiac silhouette has been present for some time. In a minority of patients there have been electrocardiographic (EKG) changes consisting of nonspecific ST segment changes, Twave flattening and inversion, and decreased voltage of the QRS complex. Often these EKG abnormalities have been difficult to evaluate because of the lack of preirradiation cardiograms. The problems associated with surgical intervention at the time of fusion of the epicardium and pericardium have been recognized (Fig. 1). This fact combined with our unsatisfactory experience with two patients who had recurrent Hodgkin's disease in the mediastinum and who died of acute cardiac tamponade directed us to initiate early surgical intervention to ensure prompt relief of constriction. It also prompted us to evaluate the possibility of recurrent Hodgkin's disease. We have elected to perform pericardiectomy in all symptomatic patients and those asymptomatic ones who had a 5 ern increase in transverse cardiac diameter, when compared to base-line films, persisting for six to nine months. Pericardiectomy at this time can be performed with relative ease and avoids the secondary complications which eventually result from constrictive heart disease. Seven patients who presented with chronic pericardial effusion are the subject of this paper. Signs or symptoms of constrictive heart disease were present in only 4 of the 7. Dyspnea and pulsus paradoxicus of over 10mm Hg was the most common finding. Elevated right atrial and end-diastolic ventricular pressures were found in 4 out of 5 patients having cardiac catheterization. Pericardiectomy was accomplished through a left horizontal thoracotomy incision. At surgery some mild thickening (2 to 10 mm) of most of the irradiated pericardium was found in all cases, and the epicardial fat appeared dull. The pericardial fluid has been straw-colored in 3 patients and serosanguinous in 4. Bacterial cultures have been negative.