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Ann Thorac Surg 1999;67:437-440
© 1999 The Society of Thoracic Surgeons

Original Articles

Pericardial effusion: subxiphoid pericardiostomy versus percutaneous catheter drainage

Keith B. Allen, MDa, L. Penfield Faber, MDa, William H. Warren, MDa, Carl J. Shaar, PhDa

a Department of Cardiovascular and Thoracic Surgery, Rush-Presbyterian-St. Lukes Medical Center, Chicago, Illinois, USA

Accepted for publication July 3, 1998.

Address reprint requests to Dr Allen, 8333 Naab Rd, Suite 300, Indianapolis, IN 46260


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 References
 
Background. Optimal management of cardiac tamponade resulting from pericardial effusion remains controversial.

Methods. Cardiac tamponade in 117 patients was treated with either subxiphoid pericardiostomy (n = 94) or percutaneous catheter drainage (n = 23). Percutaneous catheter drainage was used for patients with hemodynamic instability that precluded subxiphoid pericardiostomy. Effusions were malignant in 75 (64%) of 117 patients and benign in 42 (36%) of 117.

Results. Subxiphoid pericardiostomy had no operative deaths and a complication rate of 1.1% (1 of 94). In contrast, percutaneous drainage had significantly (p < 0.05) higher mortality and complication rates of 4% (1 of 23) and 17% (4 of 23), respectively. Patients with an underlying malignancy had a median survival of 2.2 months, with a 1-year actuarial survival rate of 13.8%. In comparison, patients with benign disease had a median survival of 42.8 months and a 1-, 2-, and 4-year actuarial survival rate of 79%, 73%, and 49%, respectively (p < 0.05). Effusions recurred in 1 (1.1%) of 94 patients after subxiphoid pericardiostomy compared with 7 (30.4%) of 23 patients with percutaneous drainage (p < 0.0001).

Conclusions. Benign and malignant pericardial tamponade can be safely and effectively managed with subxiphoid pericardiostomy. Percutaneous catheter drainage should be reserved for patients with hemodynamic instability.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 References
 
The optimal treatment of benign and malignant pericardial effusions for patients who develop tamponade remains controversial. Ideal effusion management should ensure complete and permanent drainage and provide sufficient histologic, cytologic, and microbiologic material for diagnostic study. In addition, the procedure should be performed with minimal discomfort and risk to the patient.

Napoleon’s surgeon Larrey [1], in 1829, reported the use of the subxiphoid approach for drainage of the pericardial cavity. Since then the subxiphoid pericardial window, or more appropriately, subxiphoid pericardiostomy, has been commonly used by general and thoracic surgeons to treat pericardial effusion. Alternative surgical techniques with similar objectives have been used, including sternotomy and pericardiectomy [2, 3] or creation of a pericardial "window" through a thoracotomy [3, 4] or a subxiphoid [4–18] or video-assisted approach [19–20]. Recent enthusiasm for minimally invasive techniques has fostered the use of percutaneous drainage methods with or without instillation of sclerosing material [22–28].

The present retrospective study compared the safety and efficacy of subxiphoid pericardiostomy and percutaneous catheter drainage for the management of pericardial effusions associated with tamponade.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 References
 
Patients
From January 1986 to July 1994, 117 patients with clinical and echocardiographic evidence of tamponade underwent either subxiphoid pericardiostomy (n = 94) or percutaneous catheter drainage (n = 23) at Rush-Presbyterian-St. Luke’s Medical Center, Chicago, Illinois. Patients underwent percutaneous drainage if hemodynamic instability precluded operative subxiphoid pericardiostomy. Hemodynamic instability reflected surgical judgment that prompt pericardial drainage was required that would be delayed if a surgical approach was taken. The cause of the effusion was malignancy in 75 (64%) of 117 patients and benign disease in 42 (36%) of 117 (Table 1).


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  		Table 1. Etiologic Causes of Pericardial Tamponade in 117 Patients

 
The technique used for subxiphoid pericardiostomy has been described elsewhere [17]. Local anesthesia and intravenous sedation were used in 48 (51%) of 94 patients undergoing subxiphoid pericardiostomy. When general anesthesia was used, patients were prepared and draped before induction to allow rapid effusion drainage if hypotension developed. A 6- to 8-cm upper abdominal incision was made with resection or splitting of the xiphoid process. The anterior pericardium was identified and incised to remove a piece of pericardium 2 to 4 cm in diameter. The pericardial specimen was submitted for bacteriologic and histologic analysis, and the pericardial fluid was submitted for culture and cytologic analysis. Adhesions and tumor deposits were identified by gentle exploration. A single posterior 32F tube or two tubes, one anterior and one posterior, were introduced through separate stab incisions and connected to suction. Mediastinal drainage was maintained for an average of 5 days, and tubes were left in place at least 4 days, regardless of drainage amount. No sclerosant, such as tetracycline or talc, was instilled after the procedure.

Twenty-three patients were considered too hemodynamically unstable to undergo surgical subxiphoid pericardiostomy, even under local anesthesia. For that reason, they underwent percutaneous catheter drainage guided by ultrasound or fluoroscopy.

Percutaneous drainage was initiated with an 8-cm, 18-gauge angiocatheter. When the pericardial sac was entered, the sheath was advanced and the needle withdrawn. A guidewire was then advanced through the angiocatheter, followed by a dilator and a 60-cm, 8F pigtail catheter. Pericardial fluid was fully drained and submitted for culture and cytologic analysis. Pigtail catheters remained in place for an average of 4.2 days. No pericardial biopsy specimen was obtained, and catheters were periodically flushed with heparinized saline.

Statistical method
Kaplan-Meier survival analysis was use to determine the survival characteristics of each group, and Wilcoxon statistics were used to estimate the probability value when comparing survival distribution. Univariate comparison of categoric variables was done using {chi}2 analysis. Multivariate risk analysis identified factors responsible for increased risk of effusion recurrence. Statistical differences were considered significant if the probability was 0.05 or less.


   Results
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 Abstract
 Introduction
 Material and methods
 Results
Comment
 References
 
Table 2 summarizes mortality, morbidity, and effusion recurrence rates associated with subxiphoid pericardiostomy and percutaneous catheter drainage. No deaths were attributed to the subxiphoid pericardiostomy procedure; 1 patient with uremic pericarditis developed a postoperative coagulopathy that required reoperation for bleeding. The overall effusion recurrence rate among patients undergoing subxiphoid pericardiostomy was 1.1% (1 of 94). Effusions recurred in one patient with three separate malignancies and was resolved with an anterior thoracotomy and partial pericardiectomy. Autopsies performed in 6 patients who had undergone the subxiphoid procedure demonstrated complete pericardial symphysis with extensive formation of adhesions.


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  		Table 2. Results of Subxiphoid Pericardiostomy and Percutaneous Catheter Drainagea

 
The mortality rate in patients undergoing percutaneous catheter drainage was 4.3% (1 of 23). The single death resulted from a right ventricular perforation during echocardiographically guided drainage by a cardiologist. The perforation was diagnosed and repaired immediately through a median sternotomy. Additional complications after percutaneous catheter drainage included ventricular arrhythmia requiring cardioversion (1 patient), a pneumothorax (1 patient), and right ventricular perforations (2 patients). Patients with ventricular perforations had their catheters surgically removed; through the subxiphoid approach in 1 and through a median sternotomy in the other. Symptomatic recurrence of a pericardial effusion after percutaneous drainage occurred in 7 (33.3%) of 21 patients, including 2 who had doxycycline sclerosis. Effusion recurred an average of 39 days after percutaneous drainage. Subxiphoid pericardiostomy was successful in treating recurrence effusions in all 7 patients. Multivariate analysis of type of drainage procedure, age, sex, and underlying malignancy identified only percutaneous catheter drainage as a significant (p < 0.05) risk factor for effusion recurrence.

Patients with underlying malignancy, regardless of drainage technique, had a median survival of 2.2 months and a 1-year actuarial survival rate of only 13.8%. In contrast, patients with effusions resulting from benign disease had a median survival of 42.8 months, with 1-, 2-, and 4-year survival rates of 79%, 73%, and 49%, respectively.


   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
References
 
A historical summary regarding the safety and reliability of subxiphoid pericardiostomy for the treatment of pericardial tamponade is shown in Table 3. Combined results from 560 patients demonstrated a mortality rate of 0.6%, a complication rate of 1.5%, and an effusion recurrence rate of 3.2%. Table 4 summarizes the results of percutaneous drainage techniques in a similar manner [22–28]. The combined mortality, complication, and effusion recurrence rates in 331 patients were 1.9%, 10.6%, and 13.9%, respectively. Results using paricardiocentesis are not shown.


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  		Table 3. Subxiphoid Pericardiostomy for Pericardial Effusions

 

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  		Table 4. Percutaneous Catheter Drainage of Pericardial Effusions

 
Subxiphoid pericardiostomy is a simple and safe procedure for the treatment of tamponade caused by malignant and nonmalignant pericardial effusions. The procedure can performed under local anesthesia and allows direct visualization, biopsy, and exploration of the pericardium and pericardial cavity. Video-assisted transthoracic pericardial drainage has been touted as effective for prevention of effusion recurrence through a large pericardial resection with creation of a "pericardial window" [4]. However, video-assisted transthoracic pericardial drainage requires general anesthesia, along with single-lung ventilation; procedures that are difficult in critically ill patients. Furthermore, the concept of a "pericardial window" for permanent drainage of pericardial effusion into the pleural space or peritoneum is misleading because the created hole is quickly sealed by surrounding tissue. Although there is no hard and fast rule regarding the duration of subxiphoid drainage, in our experience and that of others [14], suction through a large pericardial tube for 4 to 5 days places the parietal and visceral pericardium in apposition, a prerequisite for symphysis to take place. If continued drainage is observed beyond this period, the pericardial tube should remain in place until drainage stops.

Percutaneous catheter drainage, although less invasive, is associated with increased morbidity, mortality, and effusion recurrence rates. Furthermore, the procedure does not include visualization or biopsy of the pericardium. Although both our study groups had similar demographic characteristics, they differed with regard to their hemodynamic status. The percutaneous group had a higher incidence of hemodynamic instability, which may explain their higher morbidity and mortality rates. However, this higher incidence of hemodynamic instability does not explain the significant difference in effusion recurrence rates between the two groups. No patient who underwent subxiphoid pericardial drainage developed late constriction.

Subxiphoid pericardiostomy is a safe and effective technique for management of benign and malignant pericardial tamponade. Percutaneous catheter drainage should be reserved for patients with life-threatening hemodynamic instability [21].


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 References
 

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