Symptomatic Pericardial Effusion Research Articles

Invited commentary

This is another helpful paper from the Toronto Hospital for Sick Children. Postoperative pericardial and pleural effusions are not uncommon, especially in postoperative patients with certain congenital heart diagnoses. Conditions that result in elevated right atrial or superior vena caval pressures not infrequently have pericardial and pleural effusions postoperatively, and it is not surprising that the large database from Toronto confirms prior findings that those same patients are the ones more likely to experience chylous effusions. The authors also remind us that the increased lymphatic permeability associated with the lymphatic dysplasia contributes to chylous effusions (7 of 16 chylopericardium patients had Trisomy 21). Although the reported overall incidence of chylous pericardium is low, a full 15% of symptomatic postoperative pericardial effusions that required drainage were chylous in nature. Not surprisingly, 15% of the patients with an associated chylous pleural effusion had chylous pericardial effusions.In this series only 2 patients, once their diagnosis of chylous pericardial effusion was established could be treated with diet alteration alone, most requiring pericardial drainage by means of a tube or a pericardial window. Only 3 thoracic duct ligations were done, and all were associated with chylous pleural and pericardial drainage. It is important to note that in the authors’ experience, failure to respond to aspirin or anti-inflammatory medical treatment for pericardial effusion occurred in 8 of the 16 patients and raised the suspicion that the effusion was, in fact, chylous. The findings of this study support the observations of many that patients with both pleural and pericardial effusions postoperatively should be suspected of having chylous effusions, especially if the postoperative courses have been associated with elevated pressures in the superior vena cava or right atrium. If the patient is a child with Trisomy-21, the titer of suspicion should be much higher. This is another helpful paper from the Toronto Hospital for Sick Children. Postoperative pericardial and pleural effusions are not uncommon, especially in postoperative patients with certain congenital heart diagnoses. Conditions that result in elevated right atrial or superior vena caval pressures not infrequently have pericardial and pleural effusions postoperatively, and it is not surprising that the large database from Toronto confirms prior findings that those same patients are the ones more likely to experience chylous effusions. The authors also remind us that the increased lymphatic permeability associated with the lymphatic dysplasia contributes to chylous effusions (7 of 16 chylopericardium patients had Trisomy 21). Although the reported overall incidence of chylous pericardium is low, a full 15% of symptomatic postoperative pericardial effusions that required drainage were chylous in nature. Not surprisingly, 15% of the patients with an associated chylous pleural effusion had chylous pericardial effusions. In this series only 2 patients, once their diagnosis of chylous pericardial effusion was established could be treated with diet alteration alone, most requiring pericardial drainage by means of a tube or a pericardial window. Only 3 thoracic duct ligations were done, and all were associated with chylous pleural and pericardial drainage. It is important to note that in the authors’ experience, failure to respond to aspirin or anti-inflammatory medical treatment for pericardial effusion occurred in 8 of the 16 patients and raised the suspicion that the effusion was, in fact, chylous. The findings of this study support the observations of many that patients with both pleural and pericardial effusions postoperatively should be suspected of having chylous effusions, especially if the postoperative courses have been associated with elevated pressures in the superior vena cava or right atrium. If the patient is a child with Trisomy-21, the titer of suspicion should be much higher.

Management of pericardial effusion by drainage: a survey of 10 years' experience in a city centre general hospital serving a multiracial population

The aim of the study was to determine the aetiology of large and symptomatic pericardial effusions and to review the management and subsequent outcome. A survey was done on a consecutive cases of patients who had undergone percutaneous pericardiocentesis over a 10 year period in a city centre general hospital serving a multiethnic catchment population. In all, 46 patients (24 male, 22 female; age range 16 to 90 years, mean 54 years) underwent a total of 51 pericardial drainage procedures (or attempted pericardiocentesis) between 1989 and 1998. Malignancy (44%), tuberculosis (26%), idiopathic (11%), and post-cardiac surgery (9%) were the most common causes of pericardial effusion. The most common presenting symptoms were breathlessness (90%), chest pain (74%), cough (70%), abdominal pain (61%) (presumed to be related to hepatic congestion), and unexplained fever (28%). In the 12 cases of tuberculous pericarditis, nine occurred in patients of Indo-Asian origin, and three in patients of Afro-Caribbean origin. Fever, night sweats, and weight loss were common among these patients, occurring in over 80% of cases of tuberculous pericarditis. Pulsus paradoxus was the most specific sign (100%) for the presence of echocardiographic features of tamponade, with strongest positive predictive value (100%). Although malignancy remains the most common cause in developed countries, tuberculous disease should be considered in patients from areas where tuberculosis is endemic. Percutaneous pericardiocentesis remains an effective measure for the immediate relief of symptoms in patients with cardiac tamponade, although its diagnostic yield in tuberculous pericarditis is relatively low.

Isolated coronary bypass operation in the 9th decade of life

The average age of patients undergoing cardiac surgery has increased continuously during the last three decades due to a progressively increasing number of older people in the population and the advances in operative and perioperative treatment in open heart surgery. Consequently we have investigated the short- and long-term results of isolated myocardial revascularization in patients who are in their ninth decade of life. Between 1 January 1995 and 31 December 1998, 121 patients (51 women, 70 men, age 80 to 88 years, median: 82 years) underwent isolated coronary artery bypass grafting. As part of the revascularization, a unilateral internal mammary artery graft (IMA) was used in 87% of cases. The in-hospital mortality was 6.6%. Analysis of predictors of mortality unveiled the following factors: ejection fraction less than 50%; history of recent left ventricular failure; extent of coronary artery disease; perioperative use of an intraaortic balloon pump (IABP) and symptomatic pericardial effusion. Use of the IMA revealed no influence on in-hospital mortality. The median follow-up time was 20 months (range: 2-48 months). Survival rates after 1, 2, and 3 years were 93.1%, 87.3% and 73.7% for women and 86.9%, 82.5% and 65.1% for men. These survival rates were comparable with those of the entire 82 year old population. Predictors for late death were male gender, history of stroke, history of arterial embolism, and postoperative pulmonary failure resulting in mechanical ventilation. During the follow-up period myocardial infarcts were subsequently not observed. Freedom from angina after 1, 2 and 3 years was 90.1%, 82.6% and 78.1%, respectively. At an interval of 1 year after the operation 87.6% of patients had not been hospitalized as a result of cardiac disorders (2 years: 80.1%, 3 years: 73.2%). Permanent nursing care was not required 1 year after the operation by 94.3% of patients (2 years: 91.5%, 3 years: 91.5%). Four percent of the survivors suffered from permanent delirium, 3% from depression, 5% from lack of concentration, and 6% from vertigo. In summary this study has revealed that, in patients over eighty years of age suffering from ischemic heart disease, coronary artery bypass grafting has acceptable short- and long-term results. Yearly mortality rates during the first 3 years after the operation are comparable with the expected mortality rate in an age-matched population.

Pericardiocentesis: differential aspects of a common procedure.

To evaluate the risk and effectiveness of pericardiocentesis in primary and repeat cardiac tamponade. Retrospective analysis. Intensive care unit in a medical university hospital. Sixty-three consecutively admitted patients with cardiac tamponade. In all patients pericardiocentesis was performed via the subxiphoid pathway after echocardiographic detection of the pericardial effusion. There was no adverse event in patients undergoing primary pericardiocentesis, which was sufficient to resolve pericardial effusion in 51 of 63 patients (81%). However, repeat pericardiocentesis necessitated by the recurrence of symptomatic pericardial effusion yielded suboptimal results in 10 of 12 patients (83%). Pericardiocentesis is the treatment of choice for primary symptomatic pericardial effusion. In recurrent pericardial effusion surgical approaches appear to be preferable.

Malignancies involving the pericardium.

Malignancies rarely arise from the pericardium. Mesothelioma, the most common of these, is usually unresectable and almost always incurable. Malignancies may secondarily involve the pericardium by direct extension. Carcinoma of the lung and malignant thymoma with limited direct invasion of the pericardium both can undergo complete and potentially curative resections, but adjuvant therapy is usually indicated. More frequently, malignancies involve the pericardium by a process of retrograde lymphangitic spread or hematogenous dissemination. These patients present with a symptomatic pericardial effusion and occasionally pericardial tamponade. Subxiphoid pericardiostomy and drainage is a safe procedure that provides effective and durable symptomatic relief in these terminally ill patients. More aggressive open procedures should be reserved for loculated or recurrent pericardial effusions.

Intracavitary chemotherapy with thiotepa in malignant pericardial effusions: an active and well-tolerated regimen.

Malignant pericardial effusion, although highly variable, is an uncommon complication of cancer. It is often associated with symptoms like dyspnea, chest pain, and cough, which may be severe and disabling. We analyzed the results of our current treatment policy to evaluate the effectiveness and tolerance of a new approach for this disorder. Patients with malignant pericardial effusions were treated with intracavitary thiotepa (15 mg on days 1, 3, and 5) through an indwelling pericardial cannula after extraction of as much pericardial fluid as possible on day 0. Responses were assessed by clinical examination, computed tomographic (CT) scan, and echocardiography before treatment, 1 month after treatment, and every 2 months thereafter. Twenty-three patients with malignant symptomatic pericardial effusion were treated and all were assessable for effectiveness and tolerance of the procedure. Nine patients with breast cancer, 11 with lung cancer, two with an unknown primary tumor, and one with metastatic melanoma were treated. In all but three patients, systemic medical treatment was started after completion of intracavitary therapy. Nineteen patients responded to treatment (83%; 95% confidence interval, 61% to 95%) with a rapid improvement of symptoms. The median time to pericardial effusion progression was 8.9 months (range, 1 to 26). No significant side effects were registered, except one patient who had transient grade III thrombocytopenia and leukopenia and one patient who had grade I leukopenia. A short course of intracavitary treatment with thiotepa is highly effective and well tolerated in the treatment of malignant pericardial effusion.

Surgical Management of Radiation-Induced Heart Disease

Background. With the increasing population of patients with prior mediastinal irradiation, cardiac surgeons will encounter patients with radiation-induced damage to the heart and the great vessels. Awareness of the pathology and the surgical management is essential to provide optimal care for these patients. Methods. Eight patients with radiation-induced heart disease were encountered in the last 10 years. After a brief clinical presentation, the surgical management of radiation-induced heart disease is reviewed. Results. Radiation can affect all the structures in the heart, including the coronary arteries, the valves, and the conduction system. The pericardium is the most commonly involved, and the conduction system is the least involved. Pericardiectomy is quite effective in patients with symptomatic pericardial effusion or constriction. The coronary lesions are located predominantly in the ostial or proximal regions of the epicardial vessels. Percutaneous transluminal coronary angioplasty alone appears to have a high rate of restenosis. Surgical revascularization has good long-term results, and the internal mammary artery should be used if it is satisfactory. The aortic and mitral valves are more commonly involved than the tricuspid and pulmonary valves. Myocardial dysfunction predominantly affects the right ventricle and requires particular attention during cardiopulmonary bypass and in the postoperative period. Restoration of sinus rhythm is essential in view of stiffness of the ventricles. Flexibility in the surgical approach with selective use of thoracotomy will facilitate the surgical procedure in certain patients. Conclusions. Surgeons should be well versed in all the manifestations and the management of radiation-induced heart disease.

Long-term results of surgical subxiphoid pericardial drainage.

A series of 64 consecutive patients who underwent surgical subxiphoid drainage of pericardial effusion over an 11-year period, was analysed both for recurrence of pericardial pathology and survival. The mean follow-up time was 4 years (6 months to 10 years). Twelve patients had recurrent effusion (18%), all except one within 6 months: six patients (9%) had another drainage procedure which was the definitive treatment except in one terminal cancer patient with intractable malignant effusion who died of cardiac tamponade. The remaining six recurrent effusions could be treated conservatively. One patient with idiopathic effusion developed late constrictive pericarditis. Patients with underlying malignancy (n = 26) had significantly worse actuarial survival than the others (actuarial survival at 1 and 5 years of 51% and 0% vs 87% and 76%, respectively). However, their probability of remaining free of recurrence did not differ significantly (actuarial freedom at 1 year of 89% vs 76%). In conclusion, subxiphoid drainage provides a simple, safe and expeditious treatment of most symptomatic pericardial effusions with one in ten patients requiring a repeat drainage for recurrence. In particular, it offers a good palliation in most patients with underlying neoplastic disease. Routine echocardiography is recommended at one and six months to catch most of the recurrent effusions.

Subxiphoid pericardial window for pericardial effusion in end-stage renal disease

Fifty-seven patients with end-stage renal disease who were on maintenance dialysis underwent pericardial fluid drainage surgically between January 1980 and December 1991. All patients had echocardiographically proven pericardial effusion of more than 300 to 500 mL. Seven patients had pericardiectomy by left thoracotomy under general anesthesia in the first 2 years. Subsequently, 50 patients underwent a subxiphoid pericardial window by a left subcostal incision. A pericardial drainage tube was inserted at surgery and removed after 4 to 5 days. All but five patients undergoing subxiphoid pericardial window surgery received local anesthesia. The xiphoid process was not resected during surgery and steroids were not instilled in the pericardial cavity. There were minimal complications, no surgery-related deaths, and no recurrence of fluid in patients after pericardial window surgery. With our present experience, we advise a subxiphoid pericardial window with pericardial drainage under local anesthesia for all end-stage renal disease patients on dialysis who have a symptomatic or large pericardial effusion of more than 300 to 500 mL. Steroid instillation is not necessary for the prevention of recurrence of effusion.

Postpericardiotomy syndrome and chylopericardium: Two unusual complications after aortopexy for tracheomalacia

In two boys (aged 10 years and 7 months), large symptomatic pericardial effusions developed after aortopexy for tracheomalacia. Both patients underwent percutaneous pericardial drainage. The delayed presentation (3 weeks postoperatively) and associated findings in the 10 year old were typical of postpericardiotomy syndrome, and he had an uneventful recovery after a course of aspirin therapy. The 7 month old had chylopericardium and was treated with pericardial drainage and a low-fat, medium-chain triglyceride diet. Both cases represent previously unreported complications of aortopexy.

Pericardioperitoneal shunt: An alternative treatment for malignant pericardial effusion

The treatment of 37 consecutive cases of symptomatic malignant pericardial effusion over a period of 13 years was retrospectively analyzed. The most common diagnoses were lung cancer (59%) and breast cancer (11%). In the most recent 4 patients, the Denver pleuroperitoneal shunt was used to drain the pericardial effusion into the peritoneal cavity. In each case, the procedure was performed under local anesthesia, and the patient was discharged 2 to 4 days later without complications. Three of the patients subsequently died of the disease process without evidence of cardiac failure or tamponade during 6-month follow-up. The more traditionl events of pericardial drainage, the subxiphoid approach (14 patients) and the anterior thotacotomy approach (19 patients), were associated with higher postoperative morbidity (21% and 53%, respectively) and mortality (7% and 42%, respectively). Because of the small number of patients treated by pericardioperitoneal shunting, a significant difference was demonstrated only in the length of hospital stay (shunt, 2.8 ± 0.5 days; subxiphoid, 11.2 ± 4.6 days; thoracotomy, 14.9 ± 6.1 days). Median survivals were essentially the same (shunt, 3.5 months; subxiphoid, 2.7 months; thoracotomy, 1.2 months). It is apparent that the pericardioperitoneal shunt, although a much simpler procedure, can accomplish similar palliation effectively in the treatment of malignant pericardial effusion.

Recurrent pericardial effusion as a complication of gonococcal salpingitis in a teenager

Pericardial effusion and pericarditis are rare complications of disseminated gonococcal disease and gonococcal endocarditis, which usually present with mild and self-limited symptomatology. We present the case of a 14-year-old female in which symptomatic pericardial effusion was the dominant feature associated with gonococcal salpingitis. This association has not been previously described.

Malignant pericardial effusion from squamous cell cancer of the cervix

Although rarely diagnosed in women with gynecologic cancers, pericardial metastasis and effusion are often considered preterminal events. As newer therapies result in prolongation of survival for women with advanced cervical cancer, uncommon metastatic sites may be seen with increasing frequency, and warrant increased attention by the gynecologist with oncologic expertise. Two women with squamous cell carcinoma and symptomatic pericardial effusion, one at initial presentation and the other as recurrent disease, are presented. Following pericardiocentesis, both patients received cisplatinum-based chemotherapy. The patient with effusion at diagnosis survived four months, with recurrent effusion at death. The second patient had no return of cardiac symptoms, with twelve month survival. As demonstrated by the cumulative experience of the six reported cases of this entity, many women with pericardial involvement are candidates for aggressive radiation or chemotherapy. Duration of time from primary therapy prior to occurrence of effusion correlates with survival.

Subxiphoid partial pericardiectomy with or without sclerosant instillation in the treatment of symptomatic pericardial effusions in patients with malignancy

Twenty-two patients with malignant pericardial effusions were treated with subxiphoid partial pericardiectomy between 1984 and 1989. Thirteen patients also had a sclerosing agent instilled intrapericardially. Tamponade was relieved by pericardiocentesis before administration of general anesthesia. In 18 patients (82%), the effusions were controlled for longer than 30 days, and two patients died before 30 days without effusion. There were two recurrences at 1.5 and 7 months. There was one death due to hemorrhage from a laceration in a heavily infiltrated pericardium, and one patient had persistent dyspnea after the procedure. Complications included transient atrial arrhythmias (two patients), chest pain after sclerosant instillation (three patients), and fever greater than 37.5 degrees C after sclerosant (five patients). The survival range was 0.1 to 18 months (median, 5 months). Subxiphoid partial pericardiectomy with or without intrapericardial sclerosant is a safe and efficacious treatment for malignant pericardial effusions.

Symptomatic pericardial effusion in lung cancer patients: The role of fluid cytology : Edoute Y, Malberger E, Kuten A, Moscovitcz M, Ben-Haim SA. Department of Internal Medicine C, Rambam Medical Center, Haifa 35254. J Surg Oncol 1990;45:121-3

Symptomatic pericardial effusion in lung cancer patients: The role of fluid cytology : Edoute Y, Malberger E, Kuten A, Moscovitcz M, Ben-Haim SA. Department of Internal Medicine C, Rambam Medical Center, Haifa 35254. J Surg Oncol 1990;45:121-3

Pericardiocentesis for symptomatic malignant pericardial effusion: a study of 36 patients

We reviewed 36 cases of symptomatic malignant pericardial effusion managed with pericardiocentesis at our institution from 1982 to 1989. There were 13 men and 23 women, aged 49 +/- 12 years (range, 33-76 years). The commonest underlying tumours were lung cancer (12 cases, 33%) and breast cancer (11 cases, 30%). Pericardiocentesis was successful as the initial management in 34 of 36 patients (94%); one patient died as a result of the procedure and another required subxiphoid incision and tube drainage of the effusion. When intrapericardial sclerotherapy was performed, only three of 28 patients required repeat pericardiocentesis, and when sclerotherapy was not performed initially, four of seven patients had recurrent symptomatic effusions. Median survival following pericardiocentesis in breast cancer patients was 10 months (range, 0-36 months) and in all other malignancies was four months (range, 0-12 months). We conclude that pericardiocentesis with intrapericardial sclerotherapy provides good local control for symptomatic malignant pericardial effusion in the majority of patients. In spite of this, the median survival of such patients is poor, especially in patients with malignancies other than breast cancer, with few patients surviving more than a few months.

Surgical management of pericardial effusion in patients with malignancies. Comparison of subxiphoid window versus pericardiectomy

There is a lack of consensus regarding optimal surgical management of symptomatic pericardial effusions in patients with malignancies. Subxiphoid pericardial window formation (subxiphoid pericardial drainage) has been considered a safe and effective method for diagnostic and therapeutic purposes. To ensure adequate drainage, many surgeons prefer the formation of a larger pericardial window by performing either an anterior thoracotomy or a partial/total pericardiectomy. To evaluate the efficacy of these methods for palliation of symptomatic pericardial effusion in patients with malignancy, 28 consecutive pericardial surgery cases involving patients with malignancy were retrospectively analyzed. Ten patients (Group 1) had subxiphoid window formation, whereas 18 patients (Group 2) had partial or total pericardiectomy or pericardial window formation by anterior thoracotomy. There was no statistically significant difference (P = 0.22) in the survival rates between these two groups. A median survival time of 2.67 months (range, 0.43 to 26.6 months) was observed in Group 1 versus 1.23 months (range, 0.03 to 10.83 months) in Group 2. However, a statistically significant difference (P less than or equal to 0.02) in postoperative morbidity was observed between the two groups: 67% in Group 2 versus 10% in Group 1. Because of lower morbidity, subxiphoid pericardial window formation is recommended by this study as the preferred surgical method for palliation of symptomatic pericardial effusion in patients with malignancy.

Symptomatic pericardial effusion in breast cancer patients: The role of fluid cytology

Clinical and cytologic findings in 21 breast cancer patients with symptomatic pericardial effusion are presented. The etiology of the pericardial effusion was definitely malignant, by cytology/histology in 13 patients (62%), and suspected malignant by cytology in 2 patients (9%). One patient (5%) with definitely nonmalignant pericardial effusion by cytology was found to be histologically positive at autopsy. In 5 patients (24%) there was no histological/cytological evidence of malignancy; radiation pericarditis could be the etiology in 4 of these 5 patients. The median time from the diagnosis of breast cancer to the development of symptomatic pericardial effusion was 60 months (range: 1-219 months). Ten patients developed cardiac tamponade; they were treated by either pericardiocentesis or pericardiectomy. The mean survival of patients with negative cytology/histology was 12 months; patients with suspicious cytology had a mean survival of 9 months; patients with malignant effusion, treated by pericardiectomy, had a mean survival of 22.3 months, while patients with malignant pericardial effusion, who were not subjected to surgery, had a mean survival of 4.7 months, only. It is concluded that the etiology of symptomatic pericardial effusion in breast cancer patients is not always malignant, which emphasizes the role of fluid cytology in establishing definite diagnosis. The survival probability is a function of the extent of extracardiac disease; among patients with malignant pericardial effusion those selected for pericardiectomy have a longer than average survival.

Symptomatic pericardial effusion in lung cancer patients: The role of fluid cytology

During the years 1975-1988, twenty lung cancer patients with symptomatic pericardial effusion were treated conservatively at our center. Echocardiography demonstrated small pericardial effusion in 2 patients, medium size effusion in 3 patients and large amount of fluid in 15 patients. Fifteen patients developed cardiac tamponade; in three of these patients, this was the presenting manifestation of lung cancer. Pericardiocentesis resulted in prompt, though temporary, symptomatic relief in all patients. Fluid cytology demonstrated suspected malignant cells in 2 patients and malignant cells in 13 patients. Based on cytology, the diagnosis of adenocarcinoma was established in six patients, small cell carcinoma in three patients, and epidermoid carcinoma in one patient. All patients were dead within 9 months from the time of diagnosis of pericardial effusion; 17 died within less than 3 months. It is concluded that pericardial effusion in lung cancer is indicative of rapid tumor progression and short survival. Fluid cytology provides an immediate and accurate means of diagnosis.

Successful management of malignant pericardial effusion in metastatic squamous cell carcinoma of the uterine cervix

Malignant pericardial effusion secondary to pericardial metastases from gynecological malignancies represents an infrequent but potentially life threatening problem. A patient with recurrent squamous cell carcinoma of the cervix causing symptomatic pericardial effusion is presented, and the incidence, mechanism, pathophysiology, treatment, and outcomes of malignant pericardial effusion in patients with gynecologic malignancies are reviewed. This case represents only the fourth reported patient with metastatic carcinoma of the cervix in whom the diagnosis of malignant pericardial effusion was made antemortem, and is the longest survivor of treatment. Gratifying results, in terms of improved quality and length of survival, can be obtained in what is often perceived as a preterminal complication. Recommendations for management are presented, stressing radiation therapy and other local measures following initial pericardiocentesis.