Surgical Pericardial Window Research Articles

Differences in outcomes between surgical pericardial window and pericardiocentesis in children with postpericardiotomy syndrome.

Children with postpericardiotomy syndrome may develop hemodynamically significant pericardial effusions warranting drainage by surgical pericardial window or pericardiocentesis. The optimal approach is unknown. We performed a retrospective observational study at two pediatric cardiac centers. We included 42 children aged <18 years who developed postpericardiotomy syndrome following cardiac surgery between 2014 and 2021. Thirty-two patients underwent pericardial window and 10 underwent pericardiocentesis. Patients in the pericardial window group presented with postpericardiotomy syndrome sooner than those who underwent pericardiocentesis (median 7.5 days vs. 14.5 days, P = 0.03) and tended to undergo earlier intervention (median 8 days vs. 16 days, P = 0.16). No patient required subsequent drainage. There were no differences between groups in days of pericardial tube duration (median 4 days), complications, and subsequent days of intensive care or hospitalization. For children with postpericardiotomy syndrome with a pericardial effusion warranting drainage, these data suggest that pericardial window and pericardiocentesis have similar efficacy, safety, and resource utilization.

Surgical Pericardial Window Versus Pericardiocentesis in Patients with Pericardial Effusion Indicated for Drainage

Surgical Pericardial Window Versus Pericardiocentesis in Patients with Pericardial Effusion Indicated for Drainage

Comparing Outcomes of CT-Guided Percutaneous Pericardial Drainage with Surgical Pericardial Window in Patients with Symptomatic Pericardial Effusions

To compare short-term outcomes of CT-guided percutaneous pericardial drainage (PPD) versus subxiphoid surgical pericardial window (PW) drainage and analyze the risk factors associated with their outcomes. A retrospective chart review of patients who underwent either percutaneous drainage with drainage catheter placement or PW with surgical drain placement for symptomatic pericardial effusion between January 1, 2006 and August 31, 2016 was performed after institutional review board approval (decision number 16-783). The primary objective was to test for associations between the short-term (≤30 days post procedure) complication and recurrence rates in patients with symptomatic pericardial effusions. The secondary objectives were to test for associations between short-term complications with changes in vital signs. Of the 257 procedures included in the final analysis, 142 were in the percutaneous drainage group. Short-term complication rate was significantly greater (p < 0.001) in patients undergoing PW, 17% (19/114), as compared with PPD, 2% (3/142). The estimated odds of having complications in the PW cohort was 9 times greater than the percutaneous drainage cohort (OR=9.3, 95% CI: 2.7-32.3). No significant difference was observed between whether or not a patient experienced a short-term recurrence and any of the explanatory variables (patient demographics, imaging, and vital signs). CT-guided PPD is a safer alternative to surgical PW as it leads to fewer complications without a significant difference in recurrence rate of pericardial effusion.

Best management of patients with malignant pericardial effusion: a comparative study between imaging-guided pericardiocentesis and surgical pericardial window

Best management of patients with malignant pericardial effusion: a comparative study between imaging-guided pericardiocentesis and surgical pericardial window

Clinical outcome of patients with severe malignant pericardial effusion due to neoplastic disease undergoing percutaneous balloon pericardiotomy during COVID-19 pandemic

Abstract Background Neoplastic pericardial effusion (NPE) is a serious complication that occurs in the setting of advanced oncological disease and is associated with a high recurrence rate. Currently, pericardiocentesis (PCT) remains the first therapeutic option and the use of percutaneous balloon pericardiotomy (PBP) is limited to the treatment of recurrences. However, it is not known whether some aspects of the procedure during PBP lead to different outcomes in terms of survival and recurrence, and no such patients have been included in studies during COVID-19 pandemic. Purpose The aim is to analyses the success, complications and recurrence rate (defined as recurrence of NPE requiring PCT, PBP or surgical pericardial window (SPW) of both procedures (BP) in order to establish the optimal entry treatment for these patients. Methods This research analyzed the clinical characteristics and prognostic factors of patients with severe pericardial effusion of neoplastic etiology who underwent PBP during the COVID-19 pandemic. A prospective study was conducted involving 23 patients admitted between January 2020 and January 2022 for severe NPE who underwent PCT or PBP as initial treatment of NPE. Results We included 23 patients, 62.9% were male with a mean age of 51.2±14.9 years NPE was the first manifestation of the oncological process in 12 patients (52.1%) with lung cancer being the most frequently associated primary cancer (58.7%) followed by breast cancer in 12.7% of cases. A total of 26 procedures were performed, 10 PCT, 15 PBP, 1 SPW, with tumors cells identified in the pericardial fluid in 13.0% of cases. PCT was used as an entry point in 10 patients (43.5%), 6 patients were COVID-19 positive and PCT was performed as the first treatment. While PBP was chosen as the first therapeutic option in 13 patients (56.5%) (2 Re-PBP). The initial efficacy of the procedure was 93.1% and 92.2% respectively (p=0.88), with 1 complication occurring in the PBP group but not requiring scheduled SPW. In the former group, the percentage of recurrences was higher (34.7%; 8 recurrences in 10 patients) compared to patients treated with upfront PBP (8.6%; 2 recurrences in 13 patients), p=0.09. In addition, only one patient had to resort to surgery. When analyses according to the BP. used, the recurrence rate was 4.0 times higher for PCT (34.7 vs. 8.6% recurrences), although without reaching statistical significance (p=0.16). Conclusions The PBP is a simple, safe and effective technique for the treatment of NPE during the COVID-19 pandemic, in our series it was associated with a lower recurrence rate. Therefore, it could replace PCT in these patients during the COVID-19 pandemic as optimal first line treatment, providing better quality of life and reducing the need for re-interventions. Funding Acknowledgement Type of funding sources: None.

Electrocardiogram Findings Associated With Malignant Pericardial Effusion and Cardiac Tamponade.

Electrocardiogram Findings Associated With Malignant Pericardial Effusion and Cardiac Tamponade.

Combined management of esophagopericardial fistula sustained after catheter ablation for atrial fibrillation

Radiofrequency ablation (RFA) is an effective treatment modality for atrial fibrillation (AF); however, serious complications can occur. We present the case of a highly morbid consequence, the esophagopericardial fistula (EPF). A hemodynamically unstable patient with a history of AF and recent RFA presented with chest pain and was found to have pneumopericardium and pericardial effusion. The patient went to the operating room emergently for combined management with surgical pericardial window and endoscopic stent placement. EPF must be on the differential diagnosis while evaluating patients who develop constitutional symptoms or sudden onset chest pain days or weeks after catheter ablation for AF. Early detection followed by aggressive management with a combined surgical and endoscopic approach may be considered for successful treatment of this type of postablation esophageal perforation if an atrioesophageal fistula is effectively ruled out.

Single center experience of pediatric percutaneous balloon pericardiotomy.

Percutaneous balloon pericardiotomy is a percutaneous procedure that creates a window in the parietal pericardium by balloon dilation. The use of percutaneous balloon pericardiotomy has not been reported well in children. The objective of this study was to describe the single centre experience of percutaneous balloon pericardiotomy in children. This was a retrospective study to describe all the children aged <20 years undergoing percutaneous balloon pericardiotomy during an 18-year period (2001-2019). Patient characteristics, technical and ultimate procedural success, and repeat interventions were collected. A total of 13 percutaneous balloon pericardiotomy's were performed in 11 children at the median age of 12 years (range 1.8-19). The etiologies of pericardial effusion were post-pericardiotomy syndrome (n = 4), restrictive cardiomyopathy (n = 1), autoimmune diseases (n = 3), malignancy (n = 2), and idiopathic (n = 1). Two patients received two percutaneous balloon pericardiotomy. The technical success of percutaneous balloon pericardiotomy was 100% with no acute adverse events (balloon rupture or local bleeding). Five (45%) required re-intervention and ultimately three required a surgical pericardial window 6 to 35 days after the percutaneous balloon pericardiotomy. As a result, ultimate procedural success rate was 73% (8/11). Percutaneous balloon pericardiotomy was performed safely with high technical success in children. Percutaneous balloon pericardiotomy may be considered for recurrent and persistent pericardial effusion, before considering a surgical pericardial window.

Perioperative Imaging to Guide Epicardial Mapping and Ablation.

Accessing the epicardial space without a sternotomy or a surgical pericardial window to treat ventricular arrhythmias in Chagas disease became a medical necessity in South America. Since the introduction of the dry percutaneous epicardial access approach, epicardial access has been standard procedure for management of ventricular arrhythmias in ischemic and nonischemic cardiomyopathies and atrioventricular accessory pathways after failed conventional endocardial ablation. Understanding the epicardial space and neighboring structures has become an important subject of teachings in electrophysiology. The evolution of complex ablation procedures to treat atrial and ventricular arrhythmias and device interventions to prevent cardioembolic stroke requires thorough understanding of pericardial anatomy.

Percutaneous pericardiocentesis versus pericardial window: A retrospective subset analysis in a cancer population.

e23093 Background: Malignant pericardial effusions (PEs) must often, and for a multitude of reasons, be managed invasively. Options for intervention include percutaneous or surgical drainage. There is a paucity of data directly comparing efficacy of these interventions. This study compares efficacy of surgical pericardial window (PW) percutaneous pericardiocentesis (PP) in cancer subjects with PEs, with respect to mortality, readmission, and repeat procedure. Methods: We performed a 5 year, retrospective, single center study at a major academic center. 79 patients were selected using ICD codes for PP (n = 19) and PW (n = 59) and grouped by first procedure performed. Log Rank Regression of Kaplan-Meier Curves was performed for major adverse events, as defined by repeat procedure, readmission, or mortality during the surveillance period. Results: Log Rank Tests of readmission and mortality were not statistically significant (P = 0.54, 0.656 respectively). Single Variate Log Rank Test of repeat procedure favored PW (P = 0.008, event rates: PP 21.1% vs PW 3.4%. Multivariate Log Rank Test of and all 3 events was not statistically significant (P = 0.168). Fig 1: Kaplan-Meier Analysis of PP (0) vs PW (1) by any event (repeat procedure, readmission, or mortality). Event Rate = 89.5% PC, 89.5% PW. Conclusions: PW patients had a lower incidence of repeat procedures. There were no differences in readmission, mortality, or a composite of all 3 events. Future aims will identify risk factors associated with repeat procedures in PCs and PWs.

Prevention of cardiac herniation and left artery descending obstruction in cases of extensive surgical pericardial window procedure.

The thoracotomy approach for pericardial window surgery was shown to be more effective at preventing effusion recurrence and the need for repeat surgery. However, cardiac herniation remains a common complication after extensive pericardial excision. This technical note describes a simple and effective technique to prevent potential heart herniation through the pericardial window and at the same time to avoid potential obstruction of the left artery descending.

Comparison of Outcomes of Pericardiocentesis Versus Surgical Pericardial Window in Patients Requiring Drainage of Pericardial Effusions

Comparative outcomes of patients undergoing pericardiocentesis or pericardial window are limited. Development of pericardial effusion after cardiac surgery is common but no data exist to guide best management. Procedural billing codes and Cleveland Clinic surgical registries were used to identify 1,281 patients who underwent either pericardiocentesis or surgical pericardial window between January 2000 and December 2012. The 656 patients undergoing an intervention for a pericardial effusion secondary to cardiac surgery were also compared. Propensity scoring was used to identify well-matched patients in each group. In the overall cohort, in-hospital mortality was similar between the group undergoing pericardiocentesis and surgical drainage (5.3% vs 4.4%, p = 0.49). Similar outcomes were found in the propensity-matched group (4.9% vs 6.1%, p = 0.55). Re-accumulation was more common after pericardiocentesis (24% vs 10%, p <0.0001) and remained in the matched cohorts (23% vs 9%, p <0.0001). The secondary outcome of hemodynamic instability after the procedure was more common in the pericardial window group in both the unmatched (5.2% vs 2.9%, p = 0.036) and matched cohorts (6.1% vs 2.0%, p = 0.022). In the subgroup of patients with a pericardial effusion secondary to cardiac surgery, there was a lower mortality after pericardiocentesis in the unmatched group (1.5% vs 4.6%, p = 0.024); however, after adjustment, this difference in mortality was no longer present (2.6% vs 4.5%, p = 0.36). In conclusion, both pericardiocentesis and surgical pericardial window are safe and effective treatment strategies for the patient with a pericardial effusion. In our study there were no significant differences in mortality in patients undergoing either procedure. Observed differences in outcomes with regard to recurrence rates, hemodynamic instability, and in those with postcardiac surgery effusions may help to guide the clinician in management of the patient requiring therapeutic or diagnostic drainage of a pericardial effusion.

Alternative Intervention For Pericardial Effusion

Pericardial effusion is defined as the increase in the fluid levels between pericardial sheets. It may occur as a result of many etiological factors. Cardiac tamponade is the most important complication of the Pericardial effusion. Therefore it requires close follow-up and primary treatment. There are many treatment approaches. It can be treated with pericardiocentesis needle and catheter, surgical pericardial window opening with subxiphoidal approach and left anterior thoracotomy, pericardiectomy with open thoracotomy and video thoracoscopic pericardiectomy assists (VATS) can also be applied. Nowadays especially for recurrent PE less invasive procedures are becoming more popular than open surgery. For this reason in this article, we mentioned about video assisted thoracoscopic surgery (VATS) method in a patient diagnosed with a recurrent pericardial effusion without any underlying etiologic factors. VATS method should be considered in elective cases which pericardiocentesis cannot be drained, effusion with fibrinous formation, treatment of posterior side effusions. VATS method is recommended especially in patients with pericardial effusion accompanied by pleural and lung disease.

Malignant Cardiac Tamponade from Non-Small Cell Lung Cancer: Case Series from the Era of Molecular Targeted Therapy.

Cardiac tamponade complicating malignant pericardial effusion from non-small cell lung cancer (NSCLC) is generally associated with extremely poor prognosis. With improved systemic chemotherapy and molecular targeted therapy for NSCLC in recent years, the prognosis of such patients and the value of invasive cardiothoracic surgery in this setting have not been adequately examined. We report outcomes from a contemporary case series of eight patients who presented with malignant cardiac tamponade due to NSCLC to an Australian academic medical institution over an 18 months period. Two cases of cardiac tamponade were de novo presentations of NSCLC and six cases were presentations following previous therapy for NSCLC. The median survival was 4.5 months with a range between 9 days to alive beyond 17 months. The two longest survivors are still receiving active therapy at 17 and 15 months after invasive surgical pericardial window respectively. One survivor had a histological subtype of large cell neuroendocrine carcinoma and the other received targeted therapy for epidermal growth factor receptor mutation. These results support the consideration of active surgical palliation to treating this oncological emergency complicating NSCLC, including the use of urgent drainage, surgical creation of pericardial window followed by appropriate systemic therapy in suitably fit patients.

An acute presentation of tuberculous pericarditis: Diagnosis and management

Aims/objectives: Tuberculosis is an infectious disease caused by Mycobacterium tuberculosis, with pulmonary and extra-pulmonary manifestations; cardiovascular involvement is rare, estimated to occur in less than 8% of cases. Material and methods: A 27-year-old Indian man, with no known history of cardiac disease, presented with a 4-week history of left sided chest pain. He had associated shortness of breath, weight loss and fevers. His sister had recently been diagnosed with a tuberculous abscess, but the patient had declined participating in contact tracing. Results: Initial bloods showed a negative troponin, elevated CRP, positive Elispot and negative for HIV. The chest radiograph identified a new cardiomegaly. Electrocardiogram (ECG) demonstrated a micro-voltage tachycardia and subsequent echocardiogram identified a large circumferential pericardial effusion with early signs of tamponade. The chest computed tomography (CT) identified associated mediastinal lymphadenopathy. The patient was transferred and underwent surgical pericardial drainage and window (approximately 900 mL). The patient was started on empirical quadruple anti-tuberculous therapy and a high dose oral steroid as per current guidelines. Pericardial fluid was culture negative, with cytology revealing lymphocytes. On follow-up, symptoms were resolving and subsequent chest radiograph demonstrated no evidence of cardiomegaly. Discussion and conclusion: Tuberculous pericarditis is extremely rare in western countries but may still present in migrant populations. It is a diagnostic and treatment challenge; with a high untreated mortality rate, extremely difficult to confirm a diagnosis and very little evidence based treatment.

Feasibility of Transumbilical Surgical Lung Biopsy and Pericardial Window Creation

To date there are no practical platforms for performing natural orifice transluminal endoscopic surgery in the thoracic cavity. This study evaluates the feasibility of transumbilical thoracosopy for lung biopsy and pericardial window creation. Eleven dogs (6 in the nonsurvival group and 5 in the survival group) were used for this study. A homemade metallic tube was advanced into the abdominal cavity via a 12-mm umbilical incision. The metallic tube was advanced into the thoracic cavity through a subxyphoid diaphragmatic incision under video guidance. Access to the thoracic cavity was achieved by a flexible bronchoscope via the metallic tube. Surgical lung biopsy and pericardial window creation were performed using an electrocautery loop and needle knife. The animals were euthanized 20 minutes after the surgery was complete (nonsurvival group) or 14 days postsurgery (survival group) for necropsy evaluation. Eight pericardial window creations and 21 of 22 preplanned lung biopsies were completed in a median time of 72.18 minutes (range 50-105 minutes). One dog in the nonsurvival group died after tension pneumothorax due to postprocedure massive air leaks. In the survival group, the postoperative period was uneventful in all 5 dogs. Autopsies revealed no signs of vital organ injury and complete healing of the diaphragmatic incision occurred in all animals. The study demonstrated that transumbilical thoracoscopic surgical lung biopsy and pericardial window creation is feasible. The safety and efficacy of the transumbilical approach need to be verified by a more detailed survival study.

Transoral endoscopic surgery versus conventional thoracoscopic surgery for thoracic intervention: safety and efficacy in a canine survival model

Transoral endoscopic surgery has been shown to be feasible and safe in both humans and animal models. The purpose of this study was to evaluate the safety and efficacy of transoral and conventional thoracoscopy for thoracic exploration, surgical lung biopsy, and pericardial window creation. The animals (n = 20) were randomly assigned to the transoral endoscopic approach group (n = 10) or conventional thoracoscopic approach group (n = 10). Transoral thoracoscopy was performed with a flexible bronchoscope via an incision over the vestibulum oris. In conventional thoracoscopy, access to the thoracic cavity was obtained through a thoracic incision. Surgical outcomes (body weight, operating time, operative complications, and time to resumption of normal diet), physiologic parameters (respiratory rate, body temperature), inflammatory parameters [white blood cell (WBC) counts and C-reactive protein (CRP)], and pulmonary parameters (arterial blood gases) were compared for both procedures. The surgical lung biopsy and pericardial window creation were successfully performed in all animals except one animal in the transoral group. There was no significant difference in operating times between the groups. The increase in WBC in the transoral thoracoscopy group was significantly smaller on postoperative day 1 than in the conventional thoracoscopy group (p = 0.0029). The transoral group had an earlier return to preoperative body temperature (p = 0.041) and respiratory rate (p = 0.045) on day 7. With respect to pulmonary parameters, there was no significant difference in blood pH, pCO2, or PaCO2 between the transoral and transthoracic groups. All animals survived without complications 14 days after surgery. This study demonstrated that the transoral approach was comparable to conventional thoracoscopic surgery for lung biopsy and pericardial window creation in terms of safety and efficacy.

Cardiac tamponade as a complication of laparoscopic hiatal hernia repair: Case report and literature review

We report the case of a 61-year old female with history of gastroesophageal reflux disease and hiatal hernia who developed hemopericardium and tamponade one day after laparoscopic hiatal hernia repair and Toupe fundoplication. The patient underwent emergent pericardiocentesis and subsequent surgical pericardial window. During surgery, a tack that had been used to secure mesh to the inferior aspect of the diaphragm was found to have penetrated the pericardium near the right ventricle. The offending foreign body was trimmed and reduced into the abdomen, and the patient recovered without further complication. A review of the literature reveals that, although rare, tamponade following diaphragmatic hernia repair and fundoplication surgery often results in fatal outcome. Tamponade must be considered in any patient who develops signs of hemodynamic instability following diaphragmatic hernia repair or fundoplication surgery, as rapid diagnosis and definitive intervention can decrease fatality from such an injury.

Gas-forming purulent pericardial effusion

A previously healthy 45-year-old woman presented with cardiac tamponade secondary to a gas-forming purulent pericardial effusion. Eight days previously, she presented to hospital with a pericardial effusion. A subxiphoid diagnostic pericardiocentesis yielded a clear strawcoloured fluid. Cultures grew group F streptococci and alpha-hemolytic streptococci, which are associated with normal oral flora. The patient’s condition worsened with increasing respiratory distress and hemodynamic instability. She was transferred to a cardiac centre, where she was diagnosed with cardiac tamponade. A chest x-ray revealed a tension pneumopericardium (Figure 1). A large air pocket (white arrows) and a clearly defined air-fluid level (black arrows) were seen on this image. Emergent diagnostic and therapeutic pericardiocentesis revealed 560 mL of purulent fluid growing prevotella, bacteroides, Streptococcus milleri and Streptococcus viridans. Both the bacteroides and anaerobic streptococci are causes of gas-forming infections. Figure 1 Bacterial pericardial effusions are primarily a complication of an infectious focus originating elsewhere in the body, arising by direct spread or hematogenous dissemination. A total of 26% to 47% of patients have an underlying systemic disease process such as rheumatoid arthritis or autoimmune pericarditis, creating a pericardial effusion that may become secondarily infected (1). In the present case, after extensive imaging and autoimmune investigations, no source of infection or concurrent disease was found. Bacterial purulent pericarditis is a rare diagnosis with a mortality rate of up to 100% if not diagnosed and treated emergently (2). Treatment with antibiotics and surgical drainage is integral to allow for a full recovery. The present patient responded promptly after appropriate antibiotics and surgical pericardial window, with dehiscence of adhesions. It can only be speculated how these specific bacteria invaded the pericardial space and it is postulated that equipment contamination or passage of the first pericardiocentesis needle through the bowel were potential sources.

Transient Ischaemic Dilation on Tc99m Adenosine Myocardial Perfusion Imaging is not due to Left Ventricular Cavity Dilation or Stunning: Comparison of Echocardiography and Myocardial Perfusion Imaging

tuberculous (2%), sarcoid (2%) andunknown (20%).Cytologywas positive in 22%of all patients tested and 94%were exudates. Procedural success was 100% with no major complications or mortality. Mean total fluid drained was 553ml with extended catheter drainage used for a mean duration of 2 (range 1–4) days. Significant recurrences were noted in 8%. Definitive therapy was chemotherapy in 29% and creation of a surgical pericardial window in 11% of patients. Conclusion:CT fluoroscopy is a safe and effective strategy for pericardiocentesis with low complication rates. It is particularly useful in high risk patients with coagulopathy and when available should be considered a first line technique in all patients that are hemodynamically stable. doi:10.1016/j.hlc.2009.05.095