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Ann Thorac Surg 1997;64:1422-1427
© 1997 The Society of Thoracic Surgeons
Thoracic Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
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Abstract |
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 TopFootnotes Abstract IntroductionMaterial and MethodsResultsCommentReferences |
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Methods. A retrospective review was performed of one surgeon's experience (M.E.B.) with the surgical treatment of malignant pericardial effusions at a tertiary-care cancer center.
Results. Sixty patients underwent 72 procedures during 8 years. Thirty-seven (51%) pericardiocenteses and 35 (49%) open procedures were performed in patients with effusions. There was no significant difference in the complication rates seen between those effusions drained via pericardiocentesis (n = 5; 13%) and those drained in an open surgical procedure (n = 5; 14%). Similar results were seen with respect to the development of a recurrent effusion. There were no procedure-related deaths. The median survival for all patients was 97 days. Patients with breast cancer as their primary malignancy survived significantly longer after drainage than did all others (p = 0.01). The type of procedure did not influence survival. Costs of surgical drainage exceed those of pericardiocentesis by nearly fortyfold.
Conclusions. Pericardiocentesis with intrapericardial sclerotherapy is as effective as open surgical drainage for the management of malignant pericardial effusions.
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Introduction |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Malignant pericardial effusions remain a formidable problem. Approximately 21% of all patients with advanced malignancies have cardiac or pericardial involvement with tumor [1]. Although a large percentage of these effusions remain asymptomatic [2], hemodynamic compromise requiring intervention can develop in these patients. Additionally, it may be necessary to drain these effusions before proceeding with intensive chemotherapy or irradiation for the primary tumor. The optimal approach to the management of pericardial effusions has remained controversial since the introduction of pericardiocentesis in 1841 [3]. Excellent results from open drainage performed through a subxiphoid pericardial window or anterolateral thoracotomy with pericardiectomy have been noted in many surgical series [4–7]. In addition, newer approaches to treatment have been introduced that are also reported to be associated with acceptable results in terms of procedure-related complications and recurrence [8–13]. Few studies, however, have examined the efficacy of pericardiocentesis as the primary therapy for effusions resulting from malignancy [14–17]. We reviewed one surgeon's experience with malignant pericardial effusions requiring intervention to compare the effectiveness of the various treatments.
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Material and Methods |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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All patients had chest x-ray studies, electrocardiography, and laboratory tests performed at their initial evaluation. Based on this information, all patients suspected of harboring a malignant pericardial effusion underwent two-dimensional echocardiography. All data were reviewed by the surgeon of record, including the echocardiogram, to determine the appropriate method of drainage.
One of four methods of drainage was utilized: (1) pericardiocentesis with an indwelling catheter and intrapericardial sclerotherapy; (2) a subxiphoid pericardial window procedure; (3) anterolateral thoracotomy with partial pericardiectomy, or (4) a video-assisted thoracoscopic surgery (VATS)–created pericardial window. All patients were monitored in the intensive care unit or the recovery room until their condition was deemed stable enough for them to be transferred to the floor. All patients had continuous arterial blood pressure monitoring, whereas Swan-Ganz catheters and ventilator support were used selectively.
All open drainage procedures were performed in the operating room with patients receiving either monitored sedation (n = 3) or general anesthesia (n = 32). Thoracostomy tubes were used for drainage. Intrapericardial sclerotherapy was not a standard part of therapy for those undergoing an open procedure. Rather it was used in patients with drainage persisting for more than 3 postoperative days (n = 4). Tubes were removed when drainage was less than 100 mL for a 24-hour period.
All pericardiocenteses were performed in the intensive care unit. Indwelling triple-lumen catheters (Arrow International, Reading, PA) were inserted in all patients by the Seldinger technique without the use of real-time echocardiography and were placed to gravity drainage. If drainage during 24 hours was less than 100 mL, intrapericardial sclerotherapy with thiotepa (15 mg diluted in 50 mL of normal saline solution) was performed. Catheters were removed 3 hours later. Follow-up echocardiography was performed only if clinically indicated.
The total protein content was measured and the cell count determined in the pericardial fluid. Cytologic preparations of the fluid were also studied and cultures performed. A treatment failure was defined as a recurrence of the pericardial effusion at any time after the procedure until the time of the patient's death or last follow-up. Actuarial survival was calculated using the method of Kaplan and Meier [18]. Comparison of survival data was performed by the log-rank test.
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Results |
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Fifty-three patients (88%) presented with dyspnea and 26 (43%) with fatigue and malaise. Four patients (7%) complained of chest pain, and 4 (7%) complained of orthopnea. Jugular venous distention was noted on physical examination in 43 patients (72%). Tachycardia was present in 30 (50%) and pulsus paradoxus in 29 (48%) patients. Seven patients (12%) were hypotensive at the time of diagnosis. Thirty-nine patients (65%) had clinical or echocardiographic evidence of pericardial tamponade at the time of presentation. Three patients (5%) were completely asymptomatic.
Twenty-seven effusions (37%) were secondary to lung cancer, whereas leukemias or lymphomas and breast cancer were the primary tumors in 13 (18%) and seven (10%) effusions, respectively (Fig 1
). The combination of the acquired immune deficiency syndrome (AIDS) and Kaposi's sarcoma was present in five (7%) of the effusions, adenocarcinoma of an unknown primary tumor in four (5%), ovarian tumors in four (5%), and thymomas in two (3%). Other tumors (n = 10) included esophageal carcinoma, endometrial carcinoma, malignant mesothelioma, melanoma, squamous cell carcinoma of the base of the tongue, and pancreatic cancer.
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), broken down as follows: 37 pericardiocenteses with indwelling catheters, 25 subxiphoid pericardial window procedures, six anterolateral thoracotomies with partial pericardiectomy, and four VATS pericardial window procedures. Intrapericardial sclerotherapy with thiotepa was performed in all of the patients undergoing pericardiocentesis. It was also performed because of persistent pericardial drainage in 4 patients who underwent open procedures. The median volume of pericardial fluid evacuated was 964 mL (range, 500 to 2,500 mL). The median duration of drainage in all patients was 3.8 days. The median duration of drainage in patients undergoing pericardiocentesis or VATS pericardial window drainage was 2.7 days, whereas it was 3.7 and 5.0 days in those having a subxiphoid window procedure or thoracotomy, respectively, before thoracostomy tube removal. Postdrainage echocardiography was not routinely performed unless clinically indicated.
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Twelve percent of all procedures were associated with minor postdrainage complications (Table 1). Of the patients undergoing pericardiocentesis, a supraventricular tachyarrhythmia developed in 4, whereas 1 required an open window procedure to rule out the existence of a ventricular puncture (13% of total). There was no ventricular injury, and the patient's postoperative course was otherwise uneventful. Four patients (16%) undergoing a subxiphoid window procedure had complications: 2 had a supraventricular tachyarrhythmia and 2 had pneumonia. Supraventricular tachyarrhythmias also occurred after a VATS window procedure (25%). There were no complications after the anterolateral thoracotomies. There were no infections in any group.
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). Three patients (8.1%) who underwent pericardiocentesis required a second procedure. Three patients (12%) who underwent subxiphoid window drainage and 2 (33%) who had a thoracotomy also required further intervention. No effusions recurred in the patients who underwent a VATS window procedure. Two additional patients (5.4%) in the pericardiocentesis group required a subxiphoid window procedure because of failure to drain as the result of a clotted catheter.
The 2-year actuarial survival for all patients was 9%, with a median survival of 97 days (Fig 3). Patients with breast cancer had the longest median survival of 407 days, with 28% of the patients alive at 2 years (Fig 4). This is significantly better than the 3-month median survival in patients with all other cell types combined (p < 0.01) or with any individual cell type. Lung cancer patients had a limited life expectancy after the development of a malignant pericardial effusion, with a median survival of only 102 days and no survivors beyond 2 years. The median survival in patients with lymphoma or leukemia as the primary tumor was 138 days, whereas the median survival in those with AIDS and Kaposi's sarcoma was 90 days. The median survival in a patient with an adenocarcinoma of unknown primary was only 22 days. Patients with all other types of primary malignancies had a median survival of 40 days. There was no difference in survival with respect to the type of drainage procedure performed (Fig 5).
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). Only the cost of performing the procedure was calculated, because the workup, periprocedural care, and materials are essentially equivalent, regardless of whether one performs a pericardiocentesis or subxiphoid pericardial window procedure. The surgeons' fee for performing a pericardiocentesis is approximately $900. The fee for a pericardial window procedure performed in the operating room is approximately $2,860. Additionally, the anesthesiologists' fee is $2,000, and the operating room fee is nearly $3,200 for a procedure that takes, on average, 60 minutes from the time the patient enters the room to the time he or she leaves the room. If these costs are recalculated based on Medicare reimbursement, the total operative costs for a subxiphoid window procedure still exceed those of pericardiocentesis by more than $4,200.
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Comment |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Since the first successful pericardiocentesis performed by Schuh in 1841 [3], there has been debate over the superiority of the various methods of draining pericardial effusions. Much of the disdain for pericardiocentesis arose on the basis of data generated before the advent of invasive monitoring and echocardiography. Wong and associates' [19] review of this early experience revealed complication rates for this procedure of as high as 50%, with the incidence of ventricular puncture exceeding 20%. Procedure-related mortality routinely ranged from 5% to 10%. However, one must remember that the decision to perform pericardiocentesis was based only on clinical evidence of an effusion. Critical care medicine and routine invasive monitoring were in their infancy, and most of these procedures were performed at the bedside. Vaitkus and colleagues [20] reviewed a more recent experience with pericardiocentesis and found a complication rate of only 2.9%. The morbidity rate associated with subxiphoid windows routinely ranges from 10% to 15% [4, 21]; it was 16% in our experience. This was not significantly different from the 13% incidence of complications in our group undergoing pericardiocentesis, with most of these being supraventricular tachyarrhythmias requiring only pharmacologic intervention. Additionally, there were no procedure-related deaths associated with any of our techniques, despite the fact that nearly 65% of all our patients had clinical or echocardiographic evidence of pericardial tamponade.
The safety of pericardiocentesis versus that of an open procedure is evident from these data. It is most likely the result of a careful analysis of the preprocedural echocardiogram by the surgeon performing the procedure. To minimize the risk of myocardial or coronary artery laceration, patients who are candidates for closed drainage of a malignant pericardial effusion must have an effusion with a large anterior or inferior component. Those not fulfilling these criteria should undergo an open drainage procedure in the operating room. Patients with both pericardial and pleural effusions are best drained using anterolateral thoracotomy or a VATS procedure. Those with isolated pericardial effusions are drained using a subxiphoid window.
Factors related to the sclerosant must also be considered. In most reports, doxycycline (and previously tetracycline) or bleomycin has been used as their sclerosing agent. However, doxycycline can produce intense pain after its instillation, necessitating the intravenous administration of narcotics in most patients [16, 17]. Fevers in excess of 38.5°C may develop in 50% of patients. Our choice of thiotepa as a sclerosing agent was based on its use for pleural sclerosis at our institution over the past 25 years. Like bleomycin it does not produce pain, and unlike either agent it rarely generates a pronounced febrile response. Additionally, no patient required multiple sclerosant instillations with thiotepa. It is also more cost-effective than either of the other agents. Fifteen milligrams of thiotepa costs $137, whereas the median doses of bleomycin (20 U) and doxycycline (1,500 mg) required for successful sclerosis [16] cost $600 and $465, respectively. Given the low recurrence rate seen in association with the use of thiotepa, it seems reasonable to continue its use for this procedure.
A major objective of draining a malignant pericardial effusion is preventing recurrence. Regardless of the method chosen, 3% to 10% of all patients will require further intervention for the management of a recurrent effusion [4, 6–8, 12, 21]. The overall rate of recurrence in our series of patients undergoing pericardiocentesis was 8.1%. Although there were no recurrences in the VATS window group and a 33% recurrence rate in the group requiring an anterolateral thoracotomy, these are small numbers of patients from which conclusions cannot be drawn. There was, however, no significant difference in the recurrence rate between patients who underwent subxiphoid window drainage and those who underwent pericardiocentesis. There have been previous reports of recurrence rates as high as 25% in patients undergoing pericardiocentesis in whom catheter drainage alone was used [20]. The addition of intrapericardial sclerotherapy appears to reduce the recurrence rate to an acceptable level. The median duration of catheter drainage in our patients was only 2.7 days, which is significantly less than that reported for open drainage [7]. If we allowed our catheters to remain in place until the drainage was substantially less or if we were to use a closed suction drainage system, perhaps we could eliminate recurrence altogether.
Survival after the drainage of a malignant pericardial effusion is limited. Mills and associates [21] reported a median survival of approximately 4 months in 40 patients undergoing a pericardial window procedure for a malignant effusion, whereas Park [4], Celermajer [15], and Maher [17] and their colleagues reported a median survival ranging from 83 to 98 days. Our overall median survival of 3.2 months is consistent with that cited in most other reports, with only 9% of our patients alive at 24 months.
The finding of pericardial fluid that is cytologically malignant portends a shorter survival. Moores and coworkers [7] recently reported on 82 patients with malignant pericardial effusions. The median survival in patients with cytologically positive effusions was 56 days, whereas those with cytologically negative effusions survived 105 days, with an overall median survival of 83 days. Our data confirm this survival advantage for those with cytologically negative effusions.
Previous studies have shown that patients with pericardial effusions secondary to breast cancer [15, 21] survive for significantly longer than do patients with lung cancer primaries [22]. Our data confirm these findings and also show a significant survival advantage for our patients with pericardial effusions secondary to breast carcinoma as opposed to many other cell types as a whole or individually. Although their relatively longer median survival puts them at greater risk for a recurrence, we still prefer pericardicentesis as primary therapy in this group of patients. We would consider more aggressive surgical intervention such as pericardiectomy for those patients with recurrent effusions.
We also noted improved survival (median, 5.8 months) in patients with pericardial effusions who had advanced leukemias and lymphomas as compared with the abysmal survival in patients with effusions secondary to other malignancies. Patients with AIDS and Kaposi's sarcoma had a poor outcome as well but in general succumbed to overwhelming opportunistic infections rather than to advanced malignancy.
No advantage of one procedure over another could be demonstrated with respect to efficacy in the prevention of recurrent effusion. This is not surprising, given the evidence noted by Sugimoto and colleagues [23] in an autopsy series of 4 patients who had their malignant effusions drained by a subxiphoid window. Examination of the pericardial space revealed fusion of the epicardium and pericardium into a single plane with obliteration of the window space by fibrinous debris. The window itself was not responsible for preventing a recurrent effusion. Rather, it is the apposition of surfaces that is desired. This can easily be accomplished in patients undergoing pericardiocentesis and sclerotherapy.
We found the cost comparison of the two most commonly performed procedures to be of great interest. An open procedure performed in the operating room is nearly forty times more expensive than a pericardiocentesis performed in an intensive care unit. The diagnostic and periprocedural costs are equivalent, regardless of the method used. It is the use of the operating room and all the personnel required in this setting, including an anesthesiologist, that dramatically increases the cost. Although clinical decisions should not be made on the basis of cost alone, it would seem advantageous to use a less expensive but equally efficacious procedure such as pericardiocentesis to accomplish rapid palliation in patients with this life-threatening problem.
We recommend the use of pericardiocentesis in combination with intrapericardial sclerotherapy as the first-line treatment of malignant pericardial effusions. The person performing the procedure must also carefully review the echocardiogram to ensure that pericardiocentesis is technically feasible and to minimize procedure-related morbidity and mortality. The use of sclerotherapy will keep the rate of recurrent effusions at an acceptable level, thus minimizing the in-hospital time in these patients with a limited life expectancy.
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Footnotes |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Address reprint requests to Dr Burt, Thoracic Service, C-861, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021.
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