Surgical Pericardial Window Research Articles

PERICARDIAL FLUID CYTOLOGY HAS A BETTER DIAGNOSTIC YIELD THAN SURGICAL PATHOLOGY IN PATIENTS WITH SUSPECTED MALIGNANT PERICARDIAL EFFUSION

PURPOSE: Percutaneous pericardial catheter (PPC) drainage is an effective and safe procedure. However, there is controversy about its use in patients with suspected malignant pericardial effusions. Although PPC drainage is less invasive than surgical pericardial window (SPW), a major criticism against its use is the presumed low cytologic yield obtained from pericardial fluid versus the positive histologic yield obtained from the pericardium during SPW. Our aim was to evaluate the diagnostic yield of pericardial fluid cytology vs.

Left Ventricular Collapse Secondary to Pericardial Effusion Treated with Pericardicentesis and Percutaneous Pericardiotomy in Severe Pulmonary Hypertension

A 61-year-old white female, a Jehovah's Witness, with severe pulmonary hypertension, presented with worsening heart failure symptoms. She had a pericardial effusion with left ventricular (LV) diastolic collapse on transthoracic echocardiography. She was not a candidate for surgical pericardial window and therefore underwent pericardiocentesis and percutaneous balloon pericardiotomy with remarkable improvement in her clinical condition and with no recurrence of the effusion. LV diastolic collapse, an atypical presentation of cardiac tamponade, is commonly seen in postoperative patients with localized pericardial effusions. However, outside the surgical setting, isolated LV diastolic collapse is rare. Our case is one of the first cases described in the literature of LV diastolic collapse in the setting of severe pulmonary hypertension treated successfully with pericardiocentesis and percutaneous balloon pericardiotomy.

QS7. Using Apache ® III-J to Predict Outcome in Patients Undergoing Pericardial Window for Malignant Pericardial Effusion

Introduction: The Acute Physiology and Chronic Health Evaluation (APACHE) III-J system has been used to predict mortality in hospitalized ICU patients. Patients presenting with suspected malignant pericardial effusions needing urgent therapy are generally felt to be poor operative candidates with dismal long-term survival. Options for therapy include urgent percutaneous pericardial drainage with a pigtail catheter or more definitive surgical pericardial window. We hypothesized that the APACHE III-J system can be used to predict long-term survival in these patients and can be used to triage patients with a high APACHE score to percutaneous drainage rather than surgical window.

Pericarditis

Pericarditis (inflammation of the pericardium) may be caused by infectious agents, autoimmune disorders, metabolic conditions, or malignancy, or it may be a complication of drug therapy, trauma, cardiac surgery, or smallpox vaccination. Diagnosis, based on clinical findings, electrocardiographic changes, chest radiograph, and ultrasound, may be confirmed as appropriate by pericardiocentesis. Although contemporary imaging technologies, such as computed tomography and magnetic resonance imaging, are useful, echocardiography remains the simplest and most expeditious noninvasive tool to assess inflammatory and infectious diseases of the pericardium. Although contemporary management of pericardial disease remains relatively unchanged, reports of innovative approaches to the management of pericardial effusion include the installation of intrapericardial thrombolytic agents to facilitate drainage of purulent effusions or balloon pericardiotomy for recurrent effusions. Both offer potential alternatives to the surgical pericardial window.

Prognostic Factors in the Surgical Management of Pericardial Effusion in the Patient With Concurrent Malignancy

Pericardial effusion in the patient with cancer presents a unique management problem. Although multiple methods of operative and nonoperative drainage of pericardial effusions have been described, surgical pericardial window remains the standard approach to long-term drainage. Selecting the patient who may benefit from an operative approach presents a difficult challenge. In the present study, we retrospectively analyzed the clinical outcome of 63 consecutive patients with malignancy who underwent surgical pericardial window for symptomatic pericardial effusion between January 1, 1990, and July 1, 2001, at City of Hope National Medical Center in order to try to determine whether the type of cancer, the presence of malignant cells in pericardial fluid, or tissue specimens or the method of surgery influenced the incidence of recurrent pericardial effusion or duration of survival. The cohort was comprised of 15 patients with non-small cell lung cancer (NSCLC), 22 patients with breast cancer, 17 patients with hematologic malignancy, and 9 patients with other solid tumors. Pertinent clinical, laboratory, hospital stay, and outcome data including long-term follow-up were recorded. Patients were followed up until the time of last clinical follow-up or death. Univariate survival analyses were performed to determine significant clinical factors contributing to outcome. Median follow-up was 6.6 months for the group and 8.3 months for those alive at last follow-up. Median survival rates for patients with lung, breast, hematologic, and other solid-tumor malignancies were 3.2 months, 8.8 months, 17 months, and 16.4 months, respectively. Preoperative factors that negatively correlated with survival included a diagnosis of NSCLC (p = 0.0014), the presence of a pleural effusion (p = 0.003), or positive pathologic (p = 0.02) or cytologic findings (p = 0.02). A surgical approach to pericardial drainage is effective (< 5% failure rate) and provides an opportunity for continued therapy with the potential for relief of dyspnea and improvement in quality of life and survival in selected patients.

Pericardial Tamponade

To the Editor: Pericardial tamponade restricts diastolic filling of the heart [1-5]. Then, high intravascular volume and preload are required for adequate and end-diastolic volume and stroke volume. Increased heart rate and contractility and peripheral vasoconstriction help maintain blood pressure in the face of decreased stroke volume [1-4]. Any anesthetic (including ketamine and etomidate) or even positive pressure ventilation [6] can decrease preload, afterload, contractility, or heart rate and precipitate cardiovascular collapse [1,3,7-9]. Accordingly, removal of fluid from the pericardial sac should always be considered before anesthesia induction for pericardial tamponade. Percutaneous pericardiocentesis is often not helpful in traumatic pericardial tamponade [2,7] because clots may prevent aspiration of blood [2], continued hemorrhaging rapidly refills the pericardial sac with blood [2,6,7], and the needle can traumatize the heart with additional hemorrhage into the pericardial sac [5]. Pericardiocentesis, however, can be a temporizing measure in the severely compromised patient [4,7,8] until definitive surgical establishment of a pericardial window. A pericardial window can be established under local anesthesia [9] via the subxiphoid or lateral thoracotomy approach [1,2,5,8,9]. The subxiphoid approach is less useful for trauma because limited surgical exposure may preclude repair of cardiac wounds [2]. However, a pericardial window during awake lateral thoracotomy may be both poorly tolerated and dangerous in the distressed, moving patient [7]. A blunt trauma victim [2] recently presented for an emergent surgical pericardial window for recurrent acute pericardial tamponade. Although the patient was not hypotensive, jugular venous distention, pulsus paradoxus [1,3,7], patient distress [4], and echocardiographic signs were present. As an alternative to endotracheal intubation after induction of anesthesia with cardiovascular depressant anesthetics, we considered awake intubation of the trachea without sedation; we found no reports of this technique in the literature. With persuasive explanation of the procedure to the patient (but without sedation) [9], along with lidocaine topical anesthesia to the pharynx, larynx, and trachea, we placed an orotracheal tube over a bronchoscope in a few minutes without patient reaction. Then, anesthesia was gently induced (N (2) O, isoflurane, and fentanyl) without cardiovascular depression. The flexible bronchoscope was chosen as the least stimulating technique for awake intubation. In the trauma patient, awake fiberoptic intubation may also be the ideal intubation technique if a full stomach and a cervical spine injury coexist. We further speculate that awake fiberoptic intubation, which avoids depressant anesthetics, could be considered in other conditions of decreased cardiovascular reserve, such as ischemic heart disease. This work was supported in part by National Heart, Lung, and Blood Institute Grant HL-42637. Peter H. Breen, MD, FRCPC Mark A. MacVay, MD Department of Anesthesiology University of California at Irvine UCI Medical Center, Orange, CA 92613

Mechanism of pericardial window creation by balloon pericardiotomy

Surgical creation of a pericardial window has been the standard procedure for relieving symptoms of patients with recurrent pericardial effusion due to pericardial metastasis. 1 Recent preliminary reports indicated that percutaneous balloon pericardiotomy was a safe and efficacious alternative to surgical pericardial window for the treatment of refractory pericardial effusion. 2,3 The present in vitro study is designed to evaluate the mechanism of this nonsurgical creation of pericardial window using the Inoue balloon catheter.

Percutaneous balloon pericardiotomy in the treatment of malignant pericardial effusion

Recurrent pericardial effusion can be a manifestation of metastatic malignant disease. Repeated catheter drainage or surgical pericardial window are two common treatment modalities. We report a case of recurrent malignant pericardial effusion treated successfully with percutaneous balloon pericardiotomy, a relatively new technique avoiding the need for surgery.