HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Mohan G. Kulkarni Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Buchanan, C. L. Articles by Kulkarni, M. G. Search for Related Content PubMed PubMed Citation Articles by Buchanan, C. L. Articles by Kulkarni, M. G. Related Collections Pericardium

Ann Thorac Surg 2003;76:817-820
© 2003 The Society of Thoracic Surgeons

---

Original article: cardiovascular

Pericardiocentesis with extended catheter drainage: an effective therapy

^a Department of Surgery, St. Joseph Mercy Hospital, Ann Arbor, Michigan, USA
^b Department of Surgery, Foote Hospital, Jackson, Michigan, USA

Accepted for publication March 27, 2003.

^* Address reprint requests to Dr Lampman, St. Joseph Mercy Hospital, P.O. Box 995, 5333 McAuley Dr, Reichert Health Building, Suite 2111, Ann Arbor, MI 48106, USA.
e-mail: lampmanr{at}trinity-health.org

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
BACKGROUND: The most effective method for managing pericardial effusions has yet to be identified. This study evaluates the efficacy and safety of echocardiographic-guided placement of indwelling catheters into the pericardial space.

METHODS: This study consists of a 5-year retrospective chart review of consecutive patients coded with benign or malignant pericardial effusions who presented for drainage procedures to a single surgeon at a 260-bed hospital. Complication, recurrence, and survival rates were studied.

RESULTS: Between January 1996 and August 2001, a total of 29 pericardial drainage procedures were performed; eight of those also underwent talc sclerosis. Mean follow-up was 16 months. Three patients (10%) required conversion to thoracotomy; of those remaining, 25 of the 26 procedures were performed under local anesthesia with intravenous sedation. The identified etiologies for pericardial effusions were malignancy (76%), idiopathic (14%), postcoronary artery bypass grafting procedure (3%), viral pericarditis (3%), and uremia (3%). Echocardiographic features of tamponade were documented in 72%. Mean ± SEM length of postprocedure in-hospital stay was 6.7 ± 0.82 days. The overall complication rate was 10% (pneumothorax and cardiac injury). Recurrence rate within 30 days was 7%. Thirty-day mortality was 21%, and more than 90-day survival was 72%.

CONCLUSIONS: Pericardiocentesis with extended catheter drainage is a safe treatment for management of clinically significant, malignant and benign, pericardial effusions and can be performed effectively under local anesthesia with intravenous sedation.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
The most effective management of pericardial effusions has yet to be identified. The conventional procedure is a surgically placed pericardial window under general anesthesia. This procedure portends significant operative and anesthetic risks because these patients often have multiple comorbidities [1, 2]. Less invasive techniques such as blind needle pericardiocentesis have high complication and recurrence rates [3, 4]. The technique of echocardiographic-guided pericardiocentesis with extended catheter drainage is performed under local anesthetic with intravenous sedation. Creating a pericardiostomy with a catheter in place allows for extended drainage and sclerotherapy, when indicated. Therefore, this type of procedure provides prompt treatment in patients with pericardial effusions, resolving potentially lethal hemodynamic complications. Echocardiographic-guided pericardiocentesis has been shown to be a safe and successful procedure when performed at university-affiliated or academic institutions [5]. However, practices in community hospitals have rarely been studied in detail

This study examined the efficacy and safety of pericardiocentesis with extended catheter drainage when performed in a community hospital setting for both malignant and benign pericardial effusions.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
This study is a retrospective chart review conducted between January 1996 and August 2001 of a single, board-certified general thoracic surgeon's experience (M.K.) at a 260-bed community hospital. Eight-five patients had ICD-9 codes for pericardial effusions. Of these, 52 patients were identified through billing codes for pericardiostomy and pericardiocentesis. Twenty patients were excluded because of miscoding or incomplete medical records. Of the 32 patients remaining who underwent pericardiocentesis with extended catheter drainage, 3 were excluded due to inadequate follow-up, leaving a total of 29 patients studied. The outcomes of interest included demographic data, clinical presentation, type of procedure performed, type of anesthetic used, amount of fluid drained, cytology results, complication rate, length of stay postprocedure, 30-day recurrence rate, and more than 90-day survival rate. Complications were defined as clinically significant events occurring intraoperatively, postoperatively, or both. Recurrence was defined as a clinically relevant reaccumulation of pericardial fluid necessitating a second procedure within 30 days of the initial pericardiocentesis.

All patients underwent echocardiography before intervention and intraoperatively. When clinically indicated, postoperative echocardiography was performed. Local anesthesia with intravenous sedation was used in the initiation of all cases, except one, for which the patient preferred a general anesthetic. Patients who were converted to thoracotomy (3/29) were given general anesthetic at the time of conversion.

Details of procedure
The patient was placed in a semi-Fowler position. Intravenous sedation was administered. Under sterile conditions, a surface echocardiogram with a sterile probe cover was used to evaluate the subxiphoid and pericardial windows. Patients who were found to have multiloculated or posterior effusions were excluded since these types of effusions are not amenable to catheter drainage. If the distance between the pericardium and the myocardium was greater than 1 cm, the procedure was initiated. The skin in the subxiphoid area was anesthetized with 1% xylocaine. A PeriVac Kit (Pericardial Fluid Aspiration/Drainage Kit, Boston Scientific/EP Technologies, San Jose, CA) was used. A small 3-mm incision was made and an 18-gauge needle and attached 20-mL syringe was directed towards the left scapula. The needle was advanced until pericardial fluid was aspirated. A 0.035-in x 80-cm guidewire was passed into the pericardial space, using the Seldinger technique, with echocardiographic-guidance. A number 8 Fr dilator was used to dilate the track, and a catheter with spiral side holes was advanced into the pericardial space over the guidewire. Once the guidewire was removed, the pericardial fluid was drained and the catheter left in place. Complete drainage was confirmed with an echocardiogram and the catheter was secured to the skin with 3-0 silk sutures. A stopcock and a collection device were attached at the conclusion of the procedure.

Those patients with cytologic confirmation of a malignant pericardial effusion and an anticipated life expectancy of less than 6 months were given talc sclerotherapy. Due to the high incidence of constrictive pericarditis that can result from talc sclerosis, not all patients were suitable candidates. Administration of talc was typically performed 1 to 2 days postprocedure at the bedside. A slurry was formed using 500 mg of talc mixed in 50 mL of sterile normal saline and instilled through the catheter. The catheter was removed 24 hours after talc administration.

Data were collected and stored using Microsoft Excel 2000 for Windows (Microsoft Corporation, Seattle, WA), and descriptive statistics were performed using Sigma Stat for Windows, Version 2.03 (SPSS, Inc, Chicago, IL). Data are presented as means ± SEM.

	Results

Top Abstract Introduction Material and methods Results Comment References

 
Twenty-nine patients receiving pericardiocentesis with extended catheter drainage were studied. There were 19 men and 10 women. Mean age was 65 years (range, 48 to 88 years). A total of 29 procedures were performed and eight of those also underwent talc sclerosis. Mean follow-up was 16 months (range, 1 to 60 months). A preoperative history of malignancy was identified in 76% (22/29), the overwhelming majority (16/29) from adenocarcinoma of the lung (Table 1). Benign etiologies were seen in 24% (7/29). The most common symptom on presentation was dyspnea, noted in 72%. Three patients underwent pericardiocentesis with catheter drainage for diagnostic purposes. Echocardiographic features of tamponade were documented in 76%.

Two patients (7%) had a recurrence within 30 days. Both had recurrent dyspnea within 72 hours and underwent a formal pericardial window during the same admission. These patients both had malignancies (squamous cell and ovarian cancers), but negative cytology results. As talc was not used unless cytology results confirmed a malignant pericardial effusion, no talc was used in either case. Thirty-day mortality was 21% (6/29). All 6 patients that died within 30 days of the procedure had documented adenocarcinoma, 5 with a lung primary, and 1 patient with an unknown primary. The more than 90-day survival rate was 72% (21/29). Overall mean survival was 449 ± 102 days. In regard to those patients with malignant effusions, 8 patients with malignant effusions who underwent talc sclerosis showed a mean ± SD postprocedure survival of 224.3 ± 237.0 days (range, 13 to 515 days): and 14 patients with malignant effusions not receiving talc sclerotherapy showed a mean ± SD survival of 234.2 ± 271.1 days (range, 1 to 760 days).

	Comment

Top Abstract Introduction Material and methods Results Comment References

 
Management of pericardial effusions continues to be a challenge, as similarly reported in 1829 by Napoleon's surgeon, Larrey [8]. Even today, there is no uniform consensus regarding the best way to treat this difficult clinical entity. Academic centers will continue to study treatment modalities in large patient population studies. Community physicians must attempt to extrapolate these data to often times small groups of patients, and ultimately devise the best treatment strategy for an individual patient with the goal of symptomatic relief, safely and without recurrence.

Results of this study confirm that percutaneous pericardiocentesis with extended catheter drainage for malignant and benign pericardial effusions is an effective procedure with relatively low morbidity and recurrence. The low complication rate in this study is lower than data presented by Allen and associates [6], who used a similar technique. In addition this study's recurrence rate was also lower (7% vs 33%) than data presented by Girardi and associates [7].

Echocardiography is paramount to the success of pericardiocentesis with extended catheter drainage. It allows for the intervention to be image directed in real time, decreases the risk of complications, and makes it possible to recognize complications earlier when they occur. Study results also show that this procedure can be done safely and proficiently in a community hospital setting. Allen and associates [6] showed higher morbidity and mortality with percutaneous catheter drainage procedures, but patients studied also had a higher incidence of hemodynamic instability, leading to the conclusion, "percutaneous catheter drainage should be reserved for patients with life threatening hemodynamic instability." In contrast, patients presented herein were all hemodynamically stable, except one who underwent a percutaneous procedure, but ultimately required a formal window for recurrent symptoms.

Whereas Allen and associates [6] showed that the subxiphoid pericardiostomy had superior results over percutaneous catheter drainage, only 51% of their patients were treated under local anesthesia with sedation. In comparison, 96% of our patients undergoing pericardiocentesis with catheter drainage received local anesthetic with intravenous sedation. Therefore, the majority of our patients had definitive treatment with a single, less-invasive procedure without general anesthesia. In addition, this less-invasive technique resulted in a short operative time and decreased supply, surgeon, and anesthetic costs. When comparing procedure costs of a pericardial window versus an echo-guided pericardiocentesis with catheter drainage at our institution, there was a cost savings of approximately $1,800/case in favor of catheter drainage. In an era of accelerating medical costs, these savings can be of considerable importance.

Limitations of this study are the small sample size and that only a small percentage of our patients received talc sclerosis (27%). Because of the lower number of patients receiving talc sclerosis, our mortality results are difficult to compare with the findings of Girardi and associates [7], where all patients underwent talc sclerotherapy. Whereas this a very small number of patients to draw definitive conclusions, the similarity of survival data of patients who received talc versus those who did not suggests intervention in this group was unwarranted, as both groups had similar survival rates (approximately 7 months). In other words, we may simply lack sufficient knowledge to determine the life expectancy of patients with malignancies. On the other hand, one might conclude that talc sclerotherapy slightly prolonged the life of these patients, causing their survival to be nearly equivalent to their nontalc counterparts. These observations suggest that more objective standards need to be determined through further study. However, the mean survival rate of 449 days for all patients in this study was favorable as compared with other studies showing only 66 days [6] or 97 days [7]. In this study, the definition of recurrence was limited to 30 days, thereby allowing for the potential to miss recurrences beyond this time frame.

Asymptomatic patients that require diagnosis and symptomatic patients with pericardial effusions are appropriate candidates for this technique given the following conditions. Patients must be able to tolerate the procedure with local anesthetic and sedation. Effusions must be simple, nonseptated, and noncompartmentalized. They must be located anteriorly or circumferentially, and the distance between the pericardium and myocardium must be greater than 1 cm to allow for safe needle approach.

An echocardiographic-guided pericardiocentesis with extended catheter drainage can effectively resolve malignant and benign pericardial effusion and avoid potential hemodynamic compromise. It is a safe alternative when performed by a trained surgeon in a community setting provided that the surgeon is prepared to convert to a thoracotomy when necessary and is knowledgeable in echocardiography.

	References

Top Abstract Introduction Material and methods Results Comment References

 

1. Park J.S., Rentschler R., Wilbur D. Surgical Management of pericardial effusion in patients with malignancies: comparison of subxiphoid window versus pericardiectomy. Cancer 1991;67:76-80.[Medline]
2. Hankins J.R., Saterfield J.R., Aisner J., Wiernik P.H., Mclaughlin J.S. Pericardial window for malignant pericardial effusion. Ann Thorac Surg 1980;30:465-471.[Abstract/Free Full Text]
3. Vaitkus P.T., Herrmann H.C., LeWinter M.M. Treatment of malignant pericardial effusion. JAMA 1994;272:59-64.[Medline]
4. Wong B., Murphy J., Chang C.J., Hassenein K., Dunn M. The risk of pericardiocentesis. Am J Cardio 1979;44:1110-1114.
5. Salem K., Mulji A., Lonn E. Echocardiographically guided pericardiocentesis: the gold standard for the management of pericardial effusion and cardiac tamponade. Can J Cardio 1999;15:1251-1255.
6. Allen K.B., Faber L.P., Warren W.H., Shaar C.J. Pericardial effusion: subxiphoid pericardiostomy versus percutaneous catheter drainage. Ann Thorac Surg 1999;67:437-440.[Abstract/Free Full Text]
7. Girardi L.N., Ginsberg R.J., Burt M.E. Pericardiocentesis and intrapericardial sclerosis: effective therapy for malignant pericardial effusions. Ann Thorac Surg 1997;64:1422-1428.[Abstract/Free Full Text]
8. Larrey E.L. New surgical procedure to open the pericardium in the case of fluid in the cavity. Clinical Chir 1829;36:303-337.

This article has been cited by other articles:

				J. Hajj-Chahine, C. Jayle, H. Houmaida, and P. Corbi Subxiphoid echocardiography-guided pericardiocentesis with extended catheter drainage for delayed cardiac tamponade Eur J Cardiothorac Surg, January 1, 2011; 39(1): 142 - 143. [Full Text] [PDF]

				B. Rylski, M. Siepe, J. Schoellhorn, and F. Beyersdorf Reply to Demaria and Poignet, Reply to Hajj-Chahine et al. Eur J Cardiothorac Surg, January 1, 2011; 39(1): 143 - 143. [Full Text] [PDF]

				N Becit, Y Unlu, M Ceviz, C U Kocogullari, H Kocak, and Y Gurlertop Subxiphoid pericardiostomy in the management of pericardial effusions: case series analysis of 368 patients Heart, June 1, 2005; 91(6): 785 - 790. [Abstract] [Full Text] [PDF]

				C. L. Buchanan, V. V. Sullivan, R. Lampman, and M. G. Kulkarni Reply Ann. Thorac. Surg., January 1, 2005; 79(1): 387 - 387. [Full Text] [PDF]

				K. B. Allen Subxiphoid Pericardiostomy Versus Percutaneous Extended Catheter Drainage Ann. Thorac. Surg., January 1, 2005; 79(1): 386 - 387. [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Mohan G. Kulkarni Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Buchanan, C. L. Articles by Kulkarni, M. G. Search for Related Content PubMed PubMed Citation Articles by Buchanan, C. L. Articles by Kulkarni, M. G. Related Collections Pericardium