Symptomatic Pericardial Effusion Research Articles

EComment. Surgical or percutaneous pericardiocentesis in symptomatic pericardial effusion

It was with great interest that we read the recent article by Mirhosseini et al. [1]. They aimed to determine the risk factors affecting the survival rate of patients with symptomatic pericardial effusion who underwent surgical interventions. They showed that the underlying malignancy, the presence of a mass on computed tomography and echocardiographic findings compatible with tamponade are the three predictors of postoperative death. We believe that these findings will act as a guide for further studies. Thanks to the authors for their valuable contribution. Several methods have been described for fluid drainage including percutaneous pericardiocentesis, balloon pericardiotomy, or surgical drainage. More recently, echocardiography-guided pericardiocentesis has been shown to be a safe and effective method that can be performed at the bedside [2]. Echocardiography is also the primary imaging modality for the diagnosis and clinical follow-up of pericardial effusion, and has some advantages, including high sensitivity and specificity, lack of ionizing radiation, and low cost. All patients in the current study underwent surgical interventions [1]. Echocardiography-guided pericardiocentesis should be performed in patients with symptomatic pericardial effusion, if appropriate. Surgical approach should be recommended only in patients with very large and repeated chronic effusion, and/or if percutaneous therapy was not successful [3]. Conflict of interest: none declared.

EComment. Minimally invasive techniques for malignant pericardial effusions

We have read with great interest the article by Mirhosseini et al. concerning risk factors affecting the survival rate in patients with symptomatic pericardial effusion undergoing surgical intervention [1]. They conclude that patients with underlying malignant diseases, particularly lung cancer or an invasion of the thorax, detected by computed tomography, have poor survival and are at a greater risk of postoperative death. Therefore, minimally-invasive therapies should be considered as a more acceptable alternative for these high-risk patients. The aim of our brief comment is to highlight the advantages of pericardiocentesis followed by intrapericardial cisplatin administration in patients with cardiac tamponade due to lung cancer. At our centre, we consider pericardiocentesis and subsequent cisplatin administration as the method of choice for preventing recurrence of malignant pericardial effusion. Our results were documented in a 5-year study [2]. In our study, death was attributed to generalized carcinomatosis causing respiratory failure in all patients. No patient died of recurrent cardiac tamponade. The main advantage of this treatment is that cisplatin infusion neither causes pain nor influences the haematological profile, because of the minimal systemic absorption from the pericardium. Intrapericardial fibrosis due to cisplatin infusion proved not to cause constrictive pericarditis even in long-term survivors. Pericardiocentesis followed by intrapericardial administration of cisplatin is safe and effective in preventing the re-accumulation of malignant pericardial effusion in the majority of oncologic patients and should be the gold standard. In case of recurrence or diagnostic dilemmas, the creation of a pleuropericardial window through a mini-thoracotomy or a video-assisted thoracoscopic surgery procedure is the last alternative and is absolutely indicated. Conflict of interest: none declared.

Risk factors affecting the survival rate in patients with symptomatic pericardial effusion undergoing surgical intervention

The optimal management and treatment of pericardial effusion are still controversial. There is limited data related to the risk factors affecting survival in these patients. The aim of this study was to determine the risk factors affecting the survival rate of patients with symptomatic pericardial effusion who underwent surgical interventions. From 2004 to 2011, we retrospectively analysed 153 patients who underwent subxiphoid pericardial window as their surgical intervention to drain pericardial effusions at the National Research Institute of Tuberculosis and Lung diseases (NRITLD). To determine the effects of risk factors on survival rate, demographic data, clinical records, echocardiographic data, computed tomographic and cytopathological findings and also operative information of patients were recorded. Patients were followed annually until the last clinical follow-up (August 2011). To determine the prognostic factors affecting survival, both univariate analysis and multivariate Cox proportional hazards model were utilized. There were 89 men and 64 women with a mean age of 50.3 ± 15.5 years. The most prevalent symptom was dyspnoea. Concurrent malignancies were present in 66 patients. Lungs were the most prevalent primary site for malignancy. The median duration of follow-up was 15 (range 1-85 months). Six-month, 1-year and 18-month survival rates were 85.6, 61.4 and 36.6%, respectively. In a multivariate analysis, positive history of lung cancer (hazard ratio [HR] 2.894, 95% confidence interval [CI] 1.362-6.147, P = 0.006) or other organ cancers (HR 2.315, 95% CI 1.009-50311, P = 0.048), presence of a mass in the computed tomography (HR 1.985, 95% CI 1.100-3.581, P = 0.023), and echocardiographic findings compatible with tamponade (HR 1.745, 95% CI 1.048-2.90 P = 0.032) were the three independent predictors of postoperative death. In the surgical management of pericardial effusion, patients with underlying malignant disease, especially with lung cancer, patients with a detectable invasion of thorax in computed tomography and those with positive echocardiographic findings compatible with tamponade have a poor survival. Therefore, minimally invasive therapies could be considered as a more acceptable alternative for these high-risk patients.

Management of pericardial effusion

Pericardial effusion is a common finding in clinical practice either as incidental finding or manifestation of a systemic or cardiac disease. The spectrum of pericardial effusions ranges from mild asymptomatic effusions to cardiac tamponade. The aetiology is varied (infectious, neoplastic, autoimmune, metabolic, and drug-related), being tuberculosis the leading cause of pericardial effusions in developing countries and all over the world, while concurrent HIV infection may have an important promoting role in this setting. Management is guided by the haemodynamic impact, size, presence of inflammation (i.e. pericarditis), associated medical conditions, and the aetiology whenever possible. Pericardiocentesis is mandatory for cardiac tamponade and when a bacterial or neoplastic aetiology is suspected. Pericardial biopsy is generally reserved for cases with recurrent cardiac tamponade or persistence without a defined aetiology, especially when a bacterial or neoplastic aetiology is suspected and cannot be assessed by other conventional and less invasive means. A true isolated effusion may not require a specific treatment if the patient is asymptomatic, but large ones are at risk of progression to cardiac tamponade (up to one third). Pericardiocentesis alone may be curative for large effusions, but recurrences are also common and pericardiectomy or less invasive options (i.e. pericardial window) should be considered with recurrent cardiac tamponade or symptomatic pericardial effusion (either circumferential or loculated). The aim of this paper was to summarize and critically evaluate current knowledge on the management of pericardial effusion.

Hyponatremia in patients with symptomatic pericardial effusion

BackgroundHyponatremia is related to cardiac tamponade in isolated case reports. However, the incidence of hyponatremia in patients with cardiac tamponade is still undetermined. MethodsIn a tertiary referral medical center, patients who presented with cardiac tamponade necessitating evacuation of pericardial effusion were included. Medical records were reviewed for the diagnosis of effusion and the underlying disease in each patient. Serum sodium concentrations before and after evacuation of effusion were analyzed. ResultsA total of 48 patients were identified during a 3-year period and 26 patients (54.2%) were found to have hyponatremia. The condition was mild (130–134 mEq/L) in eight; moderate (120–129 mEq/L) in 16; and severe (<120 mEq/L) in two patients. The frequency of hyponatremia was significantly higher in patients with malignancy-related rather than nonmalignancy-related cardiac tamponade (62.2% vs. 27.3%, p = 0.041). Nineteen patients had hyponatremia at presentation and had paired serum sodium concentrations measured after evacuation of pericardial effusion. The postevacuation serum sodium concentrations were significantly higher than the pre-evacuation levels in all patients (p < 0.001). ConclusionHyponatremia is common in patients with cardiac tamponade. However, prompt management of pericardial effusion will result in spontaneous and rapid recovery from hyponatremia.

Symptomatic Pericardial Effusion in Hodgkin's Lymphoma: A Rare Occurrence. Case Report and Review of the Literature

Pericardial effusion is observed in approximately 5% of patients with Hodgkin's lymphoma but is rarely symptomatic. We report a case in which a 21-year-old woman with newly diagnosed Hodgkin's lymphoma was found to have symptoms and radiographic evidence of pericardial effusion. Symptomatic pericardial effusion in patients with Hodgkin's lymphoma is extremely rare, with few reports in the literature. The mechanism for the heart and pericardial involvement is reviewed along with a description of the presenting symptoms and differential diagnosis.

Pericardiocentesis: A clinical anatomy review

The safe and successful performance of pericardiocentesis demands a working and specific knowledge of anatomy. Misunderstanding of anatomy may result in failure or serious complications. This review attempts to aid understanding of the anatomical framework, pitfalls, and complications of pericardiocentesis. Pericardiocentesis is carried out for aspiration of blood from the pericardial cavity in cases of cardiac tamponade and symptomatic pericardial effusion. In addition, this technique may be used for the diagnosis of neoplastic effusions, purulent pericarditis, and introduction of cytotoxic agents into the pericardial space. Most complications of the procedure are due to the needle penetrating the heart and surrounding structures such a coronary arteries, lungs, stomach, colon, and liver. These complications, if severe, may result in pneumothorax, hemothorax, arrhythmias, infections or arterial bleeding. Therefore, the more fluid or blood there is between the myocardium and pericardium--within the pericardial cavity--the less chance of complications. With a thorough knowledge of the complications, regional anatomy and rationale of the technique, and adequate experience, a pericardiocentesis can be carried out safely and successfully.

Imunização anti-influenza: universal ou selecionada?

Dear Editor, Our recently published article in the Brazilian Archives of Cardiologia1 aimed to evaluate the implementation of vaccination against influenza (INF) and Pneumococcus virus (pneumonia) in a specific subgroup of patients with heart failure (HF), due to consensus recommendation of the NorthAmerican, European and Brazilian guidelines on HF. The increased susceptibility to respiratory infections in patients with heart failure is attributed to pulmonary congestion. Dear Editor, Martins et al1 recommend measures for increasing influenza and pneumococcal immunization based on the reduced rates detected in patients with heart failure in the city of Teresopolis. We understand that, in spite of the benefit of this strategy at the population level to prevent infections and complications, we must evaluate mass vaccination and immunization extended to special groups such as immunologically susceptible individuals and those with comorbidities2. Even vaccines made from inactivated agents may trigger important and unpredictable reactions, such as, for instance, Guillain-Barre syndrome. We recently reported a case series of symptomatic pericardial effusion with increased incidence in patients who received influenza vaccine. The patients, mostly elderly and individuals with compensated diseases, showed viral symptoms, increased incidence in the peri-immunization period and resolution of the clinical draw with anti-inflammatory drug use3. Post-vaccination myopericarditis has been reported and may be underdiagnosed and sub-notified4,5.

Markers of uremia and pericardial effusion in peritoneal dialysis

Inadequate dialysis causes accumulation of toxic residues that may lead to the development of dialysis-associated pericardial effusion, but several other factors could be associated with this abnormality. The purpose of this study was to evaluate clinical risk factors to asymptomatic pericardial effusion in peritoneal dialysis. This cross-sectional study included 34 patients aged ≥ 18 years on peritoneal dialysis for at least 3 months, who showed no symptomatic pericardial effusion, hepatic cirrhosis, neoplasias, lupus or amputations, none in minoxidil use. Asymptomatic pericardial effusion was diagnosed by echocardiography. Risk factors were evaluated by logistic regression and Roc curve. Significance level was set at P < 0.05. Patient age was 51 ± 15.9 years. Of the 34 patients enrolled, 16 were men and 11 diabetic. Five of them presented pericardial effusion. Logistic regression identifies low hemoglobin level (RR 0.454 CI 95%: 0.225-0.913; P = 0.027), low phase angle (RR 0.236 CI 95%: 0.057-0.984; P = 0.048) and low Kt/V (RR 0.001 CI 95%: 0.0-0.492; P = 0.03) as risk factors to pericardial effusion. Roc curve showed that hemoglobin levels below 12.2 g/dL, Kt/V lower than 1.9 and phase angle lower than 4.5° were the best cutoffs to predict pericardial effusion. Four patients showed these three parameters in the unfavorable range, and all these four patients presented pericardial effusion. The other patient with pericardial effusion had two of these parameters reduced. These findings corroborate the hypothesis that uremia plays a significant role in the pathogenesis of dialysis-associated pericardial effusion.

Late Cardiac Tamponade by Chylous Pericardial Effusion after Coronary Artery Bypass Surgery: Case Report

Chylopericardium is an uncommon but serious complication after open heart surgery that often necessitates surgical treatment. We describe a case of continuous and severely symptomatic chylous pericardial effusion after coronary artery bypass grafting in which the diagnosis was established by lipid electrophoresis. Initial conservative management failed, and ligation of the thoracic duct and pericardial fenestration were finally required for a successful outcome.

Chronic myelomonocytic leukemia (CMML) associated with symptomatic pericardial effusion.

6625 Background: CMML is a rare myeloid neoplasm which may possess the characteristics of both myelodysplastic and myeloproliferative disorders. Clinical manifestations may be protean. CMML is rarely associated with serous effusion in the pericardium, a phenomenon which is poorly understood. We report one patient with CMML with symptomatic pericardial effusion. Methods: Chart review of patient record including laboratory and pathology results. The retrospective chart review was approved by the MSKCC IRB. Results: Pt was a 63 y/o woman diagnosed with CMML in 7/2010, who presented with a white blood cell count (WBC) of 49,600/microliter, shortness of breath, and signs and symptoms consistent with impending cardiac tamponade. CT chest showed a large pericardial effusion and the pt was transferred to intensive care unit, where a subxiphoid pericardial window was formed. Approx. 700 cc of serosanguineous fluid was drained. Differential cell ct of the pericardial fluid showed 32% monocytes and 19% myeloid blasts. A review of the literature showed only 6 adult pts reported: a pt reported in 2000 (Corinna Strupp, Ulrich Germing et al. Pericardial Effusion in CMML: a case report and review of literature. Leuk Research 2000;24:1059); Mani et al. reported four patients with CMML and pericardial effusion (Sridhar Mani and Thomas P.Duffy. Pericardial Tamponade in CMML. Chest 1994;106;967-970); in 1993, Bradford et al. reported a single pt with CMML who also developed pericardial effusion (C R Bradford et al. Pericardial extramedullary haemopoiesis in CMML. J Clin Pathol 1993; 46: 674-675). Conclusions: CMML can be associated with isolated pericardial effusion, and in our pt who was previously untreated it was the first treatment-emergent disease manifestation. Patients with CMML who develop cardiopulmonary instability, should be evaluated for the presence of a pericardial effusion should be considered in the differential diagnosis. Extramedullary hematopoiesis has been documented in patients with CMML, most commonly in the skin and gingivae. However, the mechanisms involved in the development of extramedullary hematopoiesis, including pericardial effusion, are not well understood.

The Convergent Procedure: A Multidisciplinary Atrial Fibrillation Treatment

Persistent atrial fibrillation (AF) and long-standing persistent AF (LSPAF) are difficult to treat. Epicardial surgical and percutaneous catheter ablations have lower success rates in these patients. The convergent procedure, an endoscopic transdiaphragmatic ablation procedure with conventional percutaneous endocardial ablation, is examined. Twenty-eight patients with persistent AF or LSPAF underwent the convergent procedure. All underwent combined surgical epicardial radiofrequency ablation and electrophysiological transseptal endocardial ablation to electrically isolate the 4 pulmonary veins, to exclude the posterior left atrium, to ablate the coronary sinus, and to confirm block at the cavotricuspid isthmus. Follow-up was with 24-hour Holter monitoring at 3 months, and 24-hour or 7-day monitoring at 6 and 12 months. The mean duration of the procedure was 187 minutes (102 surgical ablation minutes; 85 endocardial ablation minutes). The mean total fluoroscopy time was 35.1 minutes. Two patients developed symptomatic pericardial effusions requiring percutaneous drainage, and 1 patient has demonstrated phrenic nerve paresis. There were no deaths. At 3 months, 87% were in sinus rhythm, and 43% were free of AF and antiarrhythmic medications (AADs). At 6 months, 76% were free from AF and AADs. The convergent procedure effectively combines surgical and electrophysiological AF expertise to provide a viable treatment option to patients with persistent AF or LSPAF. Long-term follow-up is under way.

Effect of Therapeutic INR on Activated Clotting Times, Heparin Dosage, and Bleeding Risk During Ablation of Atrial Fibrillation

Ablation of atrial fibrillation (AF) with international normalized ratio (INR) ≥ 2.0 is safe and may reduce thromboembolic complications. Heparin is administered during the procedure, but the effect of elevated INR on heparin requirements and target activation clotting times (ACT) ≥ 350 seconds during ablation is unknown. To study the effect of INR on intraprocedural anticoagulation during ablation of AF. We retrospectively studied 427 consecutive patients over an 18-month period when we were transitioning to continuation of warfarin for AF ablation. Baseline INR, procedural ACT measurements, heparin doses and major complications were analyzed according to Group 1 with INR < 2.0 (n = 246) and Group 2 with INR ≥ 2.0 (n = 181). In Group 1, the mean INR was lower (1.3 ± 0.3 s vs 2.4 ± 0.3; P < 0.001), and the mean heparin dose was greater (106.82 ± 40.01 vs 77.03 ± 18.5 U/kg; P < 0.001). A single heparin bolus achieved ACT ≥ 350 seconds throughout the procedure in 51 patients (20.7%) in Group 1 compared to 108 patients (59.7%) in Group 2 (P < 0.01). Mean ACT values were higher in Group 2. Symptomatic pericardial effusions were similar (2.4% in Group 1 and 2.2% in Group 2). There were 3 thromboembolic cerebrovascular events in Group 1 and none in Group 2. Femoral hematomas occurred more frequently in Group 1 (8.1%) than in Group 2 (3.3%) (P = 0.007). AF ablation with INR ≥ 2.0 provides a consistent anticoagulant milieu during the procedure, with lower heparin requirements that are important to anticipate.

Effectiveness and prognosis of initial pericardiocentesis in the primary management of malignant pericardial effusion

We retrospectively reviewed the records of 100 patients with malignant disease and symptomatic pericardial effusion initially treated with pericardiocentesis at the National Cancer Institute of Mexico between 1985 and 2009. We analyzed predictive factors for recurrence of pericardial effusion by bi- and multivariate analyses. The group comprised 74 women and 26 men. Twenty patients had developed malignant pericardial effusion at the time of primary cancer diagnosis. Recurrence rate after pericardiocentesis was 33%. Progression-free survival for pericardial effusion at one year was 59% (range, 47-71%). Median overall survival (OS) after pericardiocentesis was 40.3+/-7.9 weeks (95% Confidence interval, 24.9-55.7). The sole factor that correlated with increased progression-free survival for pericardial effusion was the presence of bloody pericardial effusion. For OS, multivariate analysis yielded that female gender and presence of pericardial effusion at time of primary malignancy diagnosis were associated with higher life expectancy. Initial pericardiocentesis can provide successful management of patients with a control rate of 67%. In spite of the high effectiveness of the primary management of pericardial effusion with pericardiocentesis in oncologic patients, it might be considered for initial treatment, especially those with poor prognosis, leaving pericardial window as a secondary strategy for recurrence.

CT-Guided Tube Pericardiostomy: A Safe and Effective Technique in the Management of Postsurgical Pericardial Effusion

The purpose of this study was to analyze the efficacy and examine the competitive cost of CT-guided tube pericardiostomy in the management of symptomatic postsurgical pericardial effusion. Over a 4-year period, 36 patients with symptomatic pericardial effusion were treated with CT-guided percutaneous placement of an indwelling pericardial catheter, for a total of 39 CT-guided tube pericardiostomy procedures. Thirty-three patients (92%) had undergone major cardiothoracic surgery, and three patients (8%) had undergone minimally invasive procedures. The medical records were retrospectively reviewed for clinical presentation, surgical history, imaging studies performed, procedural details, fluid characterization, and outcome. Charge comparison was performed with the American Medical Association Current Procedural Terminology codes and information acquired from the billing department at our facility. All 39 CT-guided tube pericardiostomy procedures were performed successfully without clinically significant complications. After 33 of the 39 procedures (85%), symptoms did not recur after the catheter was removed. Three of 36 patients (8%) had a recurrence of pericardial effusion. Comparison of procedure charges showed an 89% saving over intraoperative pericardial window procedures and no significant difference compared with ultrasound-guided tube pericardiostomy. Eight patients (21% of procedures) needed pleural drainage procedures, all of which were performed in the CT suite immediately after the tube pericardiostomy procedure. CT-guided tube pericardiostomy is a safe and effective alternative to surgical drainage in the care of patients with clinically significant pericardial effusion after cardiothoracic surgery and has the additional benefit of substantial cost savings.

Subclavian Vein to Right Atrial Appendage Bypass without Sternotomy to Maintain Arteriovenous Access in Patients with Complete Central Vein Occlusion, a New Approach

Given the increasing numbers of patients requiring long-term hemodialysis, there is an inevitably increasing population of patients with occluded central venous inflow (subclavian, innominate, and caval) despite access or access possibilities in the arm. In an effort to avoid sternotomy, we have attempted to treat these patients with a substernally tunneled subclavian to right atrial bypass. Patients treated in this fashion have an existing fistula with symptomatic venous hypertension or good fistula options but complete central vein obstruction, a patent subclavian/axillary vein to the costoclavicular junction, and no other options in the contralateral arm. Claviculectomy is performed and the subclavian vein isolated. Through a third intercostal space "minipericardiotomy," the right atrial appendage is exposed. A retrosternal tunnel is fashioned, and bypass is performed from the subclavian vein to atrial appendage. Eleven patients aged 20-70 (mean 46) years underwent surgery at our institution between February 2004 and March 2007. Three bypasses were performed with autogenous vein (two femoral and one saphenous), while eight were performed with polytetrafluoroethylene in an effort to preserve the superficial femoral vein for later leg bypass. There was one early mortality due to sepsis, and early morbidity was limited to one patient with a symptomatic pericardial effusion. Mean follow-up was 16 (range 3-43) months. Sixty-seven percent and 33% of arteriovenous fistulas remained functional at 6 and 10 months, respectively; and one patient's fistula remained functional at 21 months. Four patients (36%) developed central bypass stenosis or occlusion, one requiring a redo bypass and three angioplasty. Infection occurred in two patients (18%), with removal of autogenous vein graft in one. While a significant number of these bypasses fail, upper extremity access is maintained in a reasonable number of patients (67% at 6 months) who are not candidates for local repair or stenting and would thus have no other upper extremity access options. This technique offers an alternative to sternotomy and brachiocephalic vein reconstruction, although the superiority of one method over the other will require direct comparison.

Primary Effusion Lymphoma Diagnosed by Pericardiocentesis

Primary effusion lymphoma (PEL), formerly known as body cavity-based lymphoma, is a high-grade B-cell non-Hodgkin's lymphoma associated with Kaposi's sarcoma and human herpesvirus 8 infection. It usually affects serous body cavities and results in recurrent lymphomatous effusions. PEL is often diagnosed in patients with HIV infection and carries a poor prognosis, with median survival near 6 months. We describe a patient who presented with symptomatic pericardial effusion, secondary to newly diagnosed PEL, and no prior history of HIV infection.

Prognosis of Large, Symptomatic Pericardial Effusion Treated by Echo‐guided Percutaneous Pericardiocentesis

The causes and prognosis of pericardial effusion (PE) may be different according to time, region, economy, and hospital. This study was performed to evaluate the etiology, clinical outcome, and prognosis of patients with large, symptomatic PE treated by echo-guided pericardiocentesis at Kangnam St. Mary's Hospital (the Catholic University of Korea, Seoul, Korea). According to etiologies of large, symptomatic PE, the prognosis of patients may be different. We reviewed 116 consecutive patients who underwent echo-guided pericardiocentesis due to large, symptomatic PE over the last 12 y. The Kaplan-Meier survival curve with log-rank method was applied for the survival analysis. Procedural success rate of echo-guided pericardiocentesis was 99.1%. Common causes of PE requiring pericardiocentesis were lung cancer (27.6%), tuberculosis (TB) (13.8%), and uremia (6.9%). The mortality rate of 6 mo after the pericardiocentesis was 80.3% in malignant PE, whereas the over-all mortality rate was 18.2% in nonmalignant PE (p < 0.0001). Among the malignant PE, lung cancer (27.6%) and breast cancers (6.9%) were the most common causes. The mean cytologic detection rate and mean life expectancy of malignant PE were 44% and 5-7 mo. Patients with breast cancer and lymphoma had relatively better life expectancy (11.4 and 7.7 mo), whereas those with stomach cancer and metastases of unknown origin (MUO) had poorer prognosis (1.2 and 2.3 mo). The most common causes of nonmalignant PE were TB, uremia, and iatrogenic, and their mean life expectancy was approximately 54 mo. Malignancy, especially lung cancer and TB, were the most common causes of large symptomatic PE. The prognosis of large symptomatic PE was related to the underlying disease. Malignant PE was associated with the poorest prognosis.

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

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. 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. 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). 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.

Perkutane Ballonperikardiotomie zur Behandlung einer malignen Perikardtamponade

A 72-year old man was admitted because of increasing dyspnoea, failing fitness and weight loss. Physical examination was unremarkable except for decreased heart sounds. He was anaemic (haemoglobin 11.7 g/dl), erythrocyte sedimentation rate was raised (80/90 mm) as was C-reactive protein (169 mg/dl). Chest radiogram showed tent-like widening of the cardiac silhouette and a 6 cm space-occupying lesion in the left hilus. Echocardiography revealed pericardial effusion of up to 2.3 cm (epi- to pericardium). Because of an increase in dyspnoea and pericardial effusion a pericardiocentesis was performed. This fluid and needle biopsy of the space-occupying lesion revealed small-cell carcinoma. 6 days after the pericardiocentesis the dyspnoea further increased as did the pericardial effusion (to 3.9 cm). Percutaneous balloon pericardiotomy was uneventfully performed. During a follow-up period of 14 months there were no further pericardial effusions. Percutaneous balloon pericardiotomy can be undertaken as a minimally invasive treatment of symptomatic pericardial effusion. It should be considered as an alternative to surgical creation of a pericardial window, especially in very ill patients.