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Ann Thorac Surg 1997;64:1427
© 1997 The Society of Thoracic Surgeons
DR DARROCH W. O. MOORES (Albany, NY): I congratulate Dr Girardi and his colleagues for an excellent presentation and an interesting paper.
This paper, as Dr Girardi stated, presents one surgeon's experience with pericardial effusion over an 8-year period. There were 60 patients who underwent four different procedures.
The title of the paper is somewhat of a misnomer. The procedure carried out is not simple pericardiocentesis, but actually a percutaneous tube pericardiostomy using a small-bore catheter, followed by the instillation of a sclerosing agent. The 13% recurrence rate for the procedure was based on the three failures and the two catheter obstructions.
We reported on 155 patients with both benign and malignant pericardial effusions treated with subxiphoid pericardial drainage. We had a 2.5% recurrence rate; however, there were no recurrences in patients who had a malignant effusion.
Like Dr Girardi and his colleagues, we found survival was significantly longer in patients with pericardial tamponade who had breast cancer. This was particularly so in those patients with a history of breast cancer who did not have malignancy in their pericardium. Therefore, in patients with pericardial tamponade who have a history of breast cancer, it is important to obtain tissue so that prognostic determination and therapeutic decisions can be made, because cytologic results will only be positive in 50%.
With regard to the issue of cost, certainly pericardiocentesis and drainage is cheaper than any of the open procedures; however, if you factor back in the cost of the surgical intervention required for management of the five failures and add that to the cost of the pericardiocentesis, the cost numbers are not so different.
This paper does show that pericardiocentesis in combination with the instillation of a sclerosing agent is safe and may be effective in controlling a malignant pericardial effusion. However, because of the small numbers of patients and the multiple therapeutic procedures carried out in this series, no significant conclusion as to the most effective therapy can be made. I believe that subxiphoid drainage remains the procedure of choice for the management of a malignant pericardial effusion with tamponade.
I have one question: because these data reflect only one surgeon's experience, has this experience changed the approach to the management of malignant pericardial effusions in the whole thoracic surgery service at Memorial Sloan-Kettering?
DR THOMAS R. J. TODD (Toronto, Ont, Canada): Given Dr Moores' comments, I would like to point out that we, in the fall, published a report of our experience with a similar technique at the University of Toronto. We have been using this technique for many years. I have not done a pericardial window procedure in 10 years, Dr Moores. And I would have to say that, without question, in our mind, we would support the conclusion of Girardi and associates that the insertion of a catheter into the pericardium followed by sclerotherapy is without question efficacious, has an extremely low morbidity, and is undoubtedly cost-effective.
DR FREDERIC W. GRANNIS, JR (New York, NY): I have two questions. First, before we accept this technique, I would like to know about selection factors. Was the same surgeon doing half of the cases by pericardiocentesis? Were the cases randomized or were they selected in some way?
The second question regards the method of follow-up. Were only recurrences that were clinically obvious noted, or was the patient followed up with serial chest roentgenograms, echocardiograms, or some other technique?
DR JOHN A. ELEFTERIADES (New Haven, CT): The patients did not survive too long after the procedure. How do you know that the thiotepa contributed anything over just complete drainage of the pericardial space?
A second question is, did you do any postmortem examinations to identify the effect of the sclerosing agent on the tissues in the pericardium?
DR GIRARDI: In response to Dr Moores' comments, we try to perform a pericardiocentesis as first-line therapy in all patients with malignant effusions. The key to choosing the method of drainage, we believe, is for the surgeon to review the echocardiogram. If the effusion is located posteriorly, or loculated posteriorly, the patient is clearly not a candidate for catheter pericardiocentesis and we would prefer in such patients to perform an open procedure. Certainly in those patients who lack a diagnosis at the time an effusion develops or who have a concomitant pleural effusion or a pulmonary nodule of undetermined cause, a videothoracoscopic procedure may be more appropriate.
The reimbursement fees depicted are not necessarily those in New York City. The fees depicted are also those in Houston. Therefore we believe there is a very large cost savings to be reaped from performing this procedure at the bedside without going to the operating room. Even including the patients who were converted to an open procedure, there was an overall cost savings.
Doctor Moores' recurrence rate of 2.5% is certainly admirable.
The selection criteria for the procedure were as I described. The primary criteria depend on the echocardiographic findings. In addition, though earlier in our series we were inclined to perform open procedures, we rarely perform open procedures today.
And finally, in response to Dr Elefteriades' question, no, we did not have autopsy data with which to evaluate the pericardial space and see if it was fused. However, a paper was published in approximately 1990 that described 4 patients who underwent subxiphoid window drainage, and all those patients were clearly found to have fusion of the pericardial space. This supports what we are trying to say in this paper, which is not so much that pericardiocentesis with intrapericardial sclerotherapy is superior, but that it is equivalent and is associated with less morbidity, and it certainly costs less.
Related Article
Ann. Thorac. Surg. 1997 64: 1422-1427.
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