Management of Pericardial Effusions – When to Intervene, and How?
- Dhruvin H. Hirpara
- Najib Safieddine
Pericardial effusions are often classified based on size, with small effusions (50-100mL) measuring less than 10mm in thickness, moderate effusions (100-500mL) measuring 10-20mm in thickness, and large effusions (>500mL) measuring more than 20mm in thickness on echocardiographic assessment.1 The timing (acute, subacute, chronic when lasting >3 months), distribution (circumferential or loculated), and hemodynamic impact (none, cardiac tamponade, or effusive-constrictive) are other important clinical considerations in the management of pericardial effusions.2-4 Optimal therapy often involves medical treatment of the underlying etiology of the effusion.3 However, pericardial fluid drainage (via pericardiocentesis or surgery) may be required for large, recurrent, loculated, and/ or hemodynamically significant effusions. Effusions with unclear etiology may also mandate pericardial fluid sampling and/or pericardial biopsy for diagnostic purposes.4,5
We review indications for intervention and discuss the role of percutaneous versus surgical drainage. The below recommendations and associated algorithm (Figure 1, Table 1) are derived from a thorough review of the literature, including clinical practice guidelines and expert consensus.1-10
1. Percutaneous pericardiocentesis (echocardiography, fluoroscopy, or CT guided) is recommended in the following cases:
- Patients with evidence of hemodynamic compromise (i.e. cardiac tamponade)
- Symptomatic moderate to large pericardial effusions non-responsive to medical therapy
- Patients suspected to have tuberculous, neoplastic or bacterial pericarditis
- Patients with large (>20mm on echocardiography in diastole) idiopathic chronic (>3months) pericardial effusions to minimize the risk of overt cardiac tamponade
2. Percutaneous pericardiocentesis (echocardiography, fluoroscopy, or CT guided) with an indwelling pericardial catheter is recommended:
- In patients with neoplastic pericardial involvement and longer expected survival (>3 months) to minimize the risk of fluid re-accumulation. Duration of catheter drainage should be guided by patient’s clinical condition and prognosis.
3. Pericardiodesis with intra-pericardial instillation of anti-neoplastic and sclerosing agents is NOT recommended due to risk of constrictive pericarditis and paucity of evidence demonstrating benefit over prolonged catheter drainage alone.
4. Percutaneous balloon pericardiotomy (the balloon allows for dilation of the pericardiotomy if needed for rewiring of a larger bore catheter) is recommended as an option in patients with malignant pericardial effusions, reduced life expectancy (<3 months) and/or prohibitive surgical risk
5. Surgical pericardiotomy and drainage is recommended in the following cases:
- Patients with “surgical tamponade” (i.e. secondary to aortic dissection or post-infarction myocardial rupture) due to risk of exacerbating the dissection or rupture after rapid pericardial decompression and restoration of systemic arterial pressure with percutaneous techniques.
- Recurrent and/or loculated pericardial effusions
- If biopsy of the pericardium is required for diagnostic purposes
- Patients on anticoagulant therapy, or those with uncorrected coagulopathy, and/or thrombocytopenia (platelet count < 50,000/mm3).
6. Surgical approach: both VATS and subxiphoid pericardial window have similar efficacy. Choice of surgical technique may vary based on surgeon experience, and patient factors including hemodynamic status (positioning and need for single-lung ventilation for the VATS approach may impede emergent access), as well as the need to perform concurrent procedures such as lung/pleural biopsies or drainage of concurrent pleural effusions (facilitated by a VATS approach).
Abbreviations: CT, Computed Tomography; VATS, Video-Assisted Thoracic Surgery
Table 1: Indications for Percutaneous Pericardiocentesis and Surgical Pericardiectomy
*secondary to aortic dissection or post-infarction myocardial rupture
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