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Ann Thorac Surg 2005;80:607-610
© 2005 The Society of Thoracic Surgeons
a Department of Cardiothoracic Surgery, Rabin Medical Center, Beilinson Campus, Petah Tiqwa, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
b Institute of Pathology, Rabin Medical Center, Beilinson Campus, Petah Tiqwa, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
Accepted for publication February 23, 2005.
* Address reprint requests to Dr Saute, Thoracic Surgery Unit, Department of Cardiothoracic Surgery, Rabin Medical Center, Beilinson Campus, Petah Tiqwa 49100, Israel (Email: saute{at}netvision.net.il).
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Abstract |
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METHODS: Between January 2001 and February 2004, 18 patients (10 men, 8 women; mean age 57 years) with echocardiographically diagnosed pericardial effusion underwent video-assisted thoracoscopy at our center. Pericardial windows were created under general anesthesia and single-lung ventilation using 2 to 3 trocars. Mean operating time was 46 minutes. A right thoracic approach was used in 16 patients and a left thoracic approach in 2.
RESULTS: Microbiology and virology cultures of the pericardial fluid were negative. Histologic findings were compatible with tuberculosis in 2 cases and granulocytic sarcoma, infiltrating breast carcinoma, and infiltrating nonsmall cell carcinoma in 1 case each. In the remaining patients, the histologic diagnosis was chronic or subacute nonspecific pericarditis. Talc pleurodesis was performed in 3 patients for concomitant malignant pleural effusion. In 4 patients, the pericardial effusion occurred secondary to cardiac surgery; 3 were receiving anticoagulants after valve replacement, and 1 had a heart transplant. There were no complications of the thoracoscopy technique.
CONCLUSIONS: Video-assisted thoracoscopic fenestration is an effective technique for pericardial drainage and biopsy. Apart from its diagnostic value, it allows the physician to fashion a pleuropericardial window for effective drainage while avoiding the complications of classic surgical procedures. Concomitant pleural and pulmonary disorders may be managed simultaneously.
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Introduction |
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TopAbstractIntroductionPatients and MethodsResultsCommentReferences |
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While percutaneous catheter drainage and balloon pericardiotomy are increasingly performed for diagnostic and therapeutic purposes, recurrent or loculated effusions are best managed surgically with a pericardial window [2].
Subxiphoid pericardiotomy is a simple technique for the treatment of cardiac tamponade, but it allows for only limited pericardial resection because of its restricted access, and it is associated with a 2% to 10% relapse rate (depending on the etiology) [9–12]. Therefore, in high-risk patients, partial pericardiectomy by thoracotomy or median sternotomy may be preferable [11, 12]. Thoracotomy is more often followed by pulmonary complications and involves a longer postoperative hospitalization [11].
Video-assisted thoracoscopy combines the advantages of subxiphoid pericardiotomy and pericardiectomy. It is minimally invasive and permits exploration of the thoracic cavity; drainage is achieved by the creation of a pleuropericardial window. Since 2001, video-assisted thoracoscopic fenestration has been offered at our institute to patients with symptomatic pericardial effusion or effusion of unknown origin. This study focuses on the use of this method for effusions with or without concomitant pleural disease.
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Patients and Methods |
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TopAbstractIntroductionPatients and MethodsResultsCommentReferences |
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A computed tomography (CT) scan was performed to identify additional pleural pathology and to determine the predominant localization of the loculated pericardial effusions and concomitant findings at the pleura for planning the side of intervention. A single prophylactic dose of cephalosporin was given at the beginning of surgery. The procedure was performed in the lateral decubitus position under general anesthesia and double-lumen intubation. Trocars for the passage of the endoscopic camera and the various surgical instruments were introduced through 2 or 3 thoracic incisions of less than 10 mm at the level of the fourth and sixth intercostal spaces.
The pleural cavity and lung were examined first, and any pleural effusion was evacuated and sent for cytology. Pericardiocentesis was then performed under direct vision, and the fluid was collected for cytologic and microbiologic analysis (Fig 1A). After the phrenic nerve was identified (Fig 1B), a stab incision was usually created on the surface of the distended pericardium using electrocautery (Fig 1C). The pericardium was then grasped with endoscopic forceps and incised with curved endoscopic scissors. Loculations and septa were broken down, and the heart was circumferentially freed with a thoracoscopic suction device. A large pericardial window was created with careful protection of the phrenic nerve. A pericardial specimen was sent for histologic and microbiologic analysis. In the event of a combined malignant pericardial and pleural effusion, talc was applied under direct vision on the pleural dome, chest wall, and diaphragm, but not on the mediastinal part of the chest cavity. A chest drain was inserted into the cavity, through one of the port sites with no attempt to drain the pericardium. The patient was extubated and transferred to the recovery room for a few hours’ observation, and then returned to the ward on the same day. The chest tube or tubes were removed when the amount of daily drainage was less than 100 mL. Patient-controlled analgesia was provided postoperatively in all cases. Postoperative morbidity and duration of chest tube drainage and hospitalization were noted.
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Results |
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The preoperative examinations combined with the postoperative results confirmed the presence of malignancy in 3 patients, including 1 with myelofibrosis. In 11 patients, there was no evidence of neoplasia. In the remaining 4 patients, all with septations and loculations, the pericardial effusion occurred as a complication of cardiac surgery. The average interval between cardiac surgery and pericardial drainage was 24 days (range, 7 to 44). Three of our patients were receiving anticoagulation treatment before the procedure, which may have contributed to the formation of the effusions.
Sixteen surgical procedures (89%) were performed on the right side and 2 (11%) on the left. Routine microbiology and virology cultures of the pericardial fluid were negative in all cases. Histologic biopsy findings were compatible with tuberculosis in 2 cases (11%) and with granulocytic sarcoma (the patient with myelofibrosis), infiltrating breast carcinoma, and infiltrating nonsmall cell carcinoma in 1 case each (5%). In the remaining patients, the histologic diagnosis was chronic or subacute nonspecific pericarditis. Additional talc pleurodesis was performed in 3 patients (17%) with malignant pleural effusion.
Mean operating time was 46 minutes and ranged from 30 to 60 minutes. There were no intraoperative complications. Mean duration of postoperative chest tube drainage was 2.3 days (range, 1 to 5), and of hospitalization, 6.4 days (range, 3 to 16). Hospital stays longer than 3 days were related to the underlying disease (malignancy) and not to the procedure. A single postoperative complication was noted in 1 patient and consisted of supraventricular arrhythmia related to a chest tube that moved into the pericardium. The arrhythmia resolved spontaneously after removal of the drain. There was no treatment-related 30-day mortality; however, 1 patient (5%) died of progression of malignancy (lung cancer). At the 3-month postoperative follow-up, symptoms were alleviated in all surviving patients. Echocardiography showed no recurrent pericardial effusion, even in the patients who underwent talc pleurodesis for concomitant malignant pleural effusion. Eleven of the 15 patients with nonmalignant disease underwent a second echocardiography examination at a mean of 12 months after surgery (range, 6 to 18 months). None showed recurrent pericardial effusion.
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Comment |
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TopAbstractIntroductionPatients and MethodsResultsCommentReferences |
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Various approaches have been described for the diagnostic and therapeutic assessment of pericardial disease, including pericardiocentesis, percutaneous catheter drainage and balloon pericardiotomy, subxiphoid pericardial drainage, pericardioperitoneal shunt, subxiphoid pericardial fenestration, and pericardial window through anterior thoracotomy/thoracoscopy. Although researchers agree that constrictive pericarditis is best treated with pericardiectomy through a sternotomy, the optimal drainage procedure for nonconstricting effusions is still controversial, and varies according to individual needs and circumstances [2].
Pericardial fenestration by video-assisted thoracoscopy was introduced in order to gain simultaneous access to the pleural and pericardial regions and to treat loculated pericardial effusions under direct vision [3–6, 13–16]. Our results indicate that the technique is well suited for these purposes. It provided us an excellent view of the pleural cavity and the pericardium in all cases, so that all suspicious sites, whether pericardial, pleural, lung, or mediastinal, could be precisely localized for biopsy. This diagnostic advantage had important implications in our series. Apart from the pericardial biopsies and cytologic examination of pericardial fluid that established a firm diagnosis in 5 patients, biopsy of the pleural and pulmonary nodules revealed the presence of carcinoma in 2 others.
The procedure was also technically and therapeutically advantageous: the surgical approach was less traumatic than for anterior thoracotomy, and a more extensive pericardial resection was possible compared with the subxiphoid route [17]. Furthermore, better visualization was afforded than with the subxiphoid approach. Loculated effusions, even those located posteriorly that cannot normally be reached without open thoracotomy, were easily drained. Furthermore, 50% of our patients had an additional pathologic finding in one pleural cavity on the CT scan, which we were able to treat in the same operative session. In one third of them (n = 3), a malignant pleural effusion was noted during thoracoscopy and treated by talc pleurodesis after pericardial fenestration was completed. This group, like the rest of the sample, showed no recurrence of the effusion, radiographically or echocardiographically, at the 3-month follow-up. Indeed, the incidence of recurrence may be lower for thoracoscopy because a larger window of pericardium can be excised than through the subxiphoid route [12]. Piehler and associates [12] suggested a direct relationship between the extent of pericardium resected and the incidence of recurrence or development of constriction. They, therefore, advocated complete pericardiectomy instead of the subxiphoid resection. Using video-assisted thoracoscopy, we could also avoid the subxiphoid (adhesion) route in the patients with delayed tamponade after heart surgery. For our whole sample, the operative time (mean, 45 minutes) was comparable with subxiphoid drainage [9], and the method was cost effective in that no expensive single-use materials were required. We did not observe infections in any of our patients.
It should be noted that video-assisted thoracoscopy is contraindicated for patients with tamponade or altered respiratory function in whom one-lung ventilation or the lateral operative position is necessary. In these circumstances, subxiphoid drainage remains the method of choice in patients with hemodynamic compensation. Furthermore, in the setting of malignancies, pericardial effusions develop in some cases as a near-terminal event. In this group of patients, the simplest method of relieving the effusion should be used. The subxiphoid procedure can be performed with local anesthesia. Our patient with malignant effusion secondary to lung cancer may have been representative of patients with a short expected life span and with little hope of effective treatment for their malignancy.
During the period of the study, 2 patients in our department with malignant effusions underwent subxiphoid pericardiectomy. The subxiphoid route was selected because of the presence of advanced malignancy, the patient’s poor health, and a limited expected life span. One patient showed little hemodynamic benefit and died within 10 days. The other patient died 2 months after the procedure. Video-assisted pericardiectomy has been our preferred approach for patients with malignant effusions who can be expected to respond to oncologic treatment (eg, breast cancer), or who appear likely to enjoy a prolonged survival, or those with benign effusions.
In conclusion, although video-assisted thoracoscopy with the creation of a pericardial window requires general anesthesia and single-lung ventilation, it is a safe, minimally invasive technique that allows for effective pericardial drainage, especially for loculated effusions, accurate biopsies, and effusions with concomitant pleural disease. We suggest that it should be used in carefully selected patients with proper indications. Future prospective randomized trials are needed to compare video-assisted thoracoscopic pericardiectomy to subxiphoid pericardiectomy.
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