Original article: cardiovascular
Comparison of open subxiphoid pericardial drainage with percutaneous catheter drainage for symptomatic pericardial effusion

Presented at the Forty-ninth Annual Meeting of the Southern Thoracic Surgical Association, Miami Beach, FL, Nov 7–9, 2002.
https://doi.org/10.1016/S0003-4975(03)00665-9Get rights and content

Abstract

Background

The optimal therapy for symptomatic pericardial effusions remains controversial. This paper compares outcomes after the two most commonly used techniques, percutaneous catheter drainage and operative subxiphoid pericardial drainage.

Methods

We performed a 5-year retrospective, single-institution study to analyze outcomes after either percutaneous catheter drainage or subxiphoid open pericardial drainage for symptomatic pericardial effusions.

Results

Symptomatic pericardial effusions in 246 patients were treated by open pericardiotomy and tube drainage (n = 150) or percutaneous catheter drainage (n = 96). Drainage duration, total drainage volume, and duration of follow-up (2.6 years) were similar in both groups. Effusions were classified malignant in 79 (32%) patients and benign in 167 (68%) patients. No direct procedural mortality occurred, but the hospital mortality was 16 patients (10.7%) in the open group and 22 (22.9%) in the percutaneous group (p = 0.01) The 5-year survival rate was 51% in the open group versus 45% in the percutaneous group, despite a greater percentage of the open group having a preoperative malignant diagnosis (35% versus 28%). Symptomatic effusions recurred in 16.5% of the percutaneous group compared with 4.6% in the open group (p = 0.002), and sclerosis did not appear to reduce recurrence rates (10.7% with sclerosis versus 15.6% without; p > 0.05). The diagnosis of malignancy was confirmed in 16 of 27 (59%) percutaneous procedures performed on patients with known malignancy. In the open group, cytologic and pathologic evaluation of the pericardial specimen revealed malignancy in 32 of 52 (62%) patients with known malignancy.

Conclusions

Subxiphoid and percutaneous pericardial drainage of symptomatic pericardial effusions can be performed safely; however, death occurs from underlying disease. Open subxiphoid pericardial drainage with pericardial biopsy appears to decrease recurrence but does not improve diagnostic accuracy of malignancy over cytology alone.

Section snippets

Patients

From January 1995 to December 1999, 246 patients with clinical and echocardiographic evidence of tamponade underwent treatment of their effusion at Barnes-Jewish Hospital in St. Louis, Missouri. This retrospective study was reviewed and approved by the Washington University Human Studies Committee (HSC #00-1118, 1/10/01). The choice of procedure was determined in many cases by the cardiologist performing the echocardiogram. If the echocardiogram suggested that the effusion was mostly posterior

Results

Two hundred forty-six patients underwent 271 procedures. Two hundred twenty-four patients underwent one procedure, 20 underwent two procedures, and one each underwent three and four procedures. One hundred thirty patients were female (53%), and 116 were male (47%), with age ranging from 16 to 91 years and a mean of 56 years. Patient characteristics, treatment characteristics, and etiology by treatment group is shown in Table 2. Etiology was presumed to be malignant if an underlying malignancy

Comment

Symptomatic pericardial effusions occur as a result of multiple disease processes and can be treated with many different procedures. For this reason, the optimal procedure for treatment of these effusions remains controversial. The ideal procedure would be easy to perform, result in minimal morbidity and mortality, have infrequent recurrences, and allow for diagnosis of the cause of the effusion if malignant. The two primary modalities utilized to drain symptomatic pericardial effusions have

Discussion

DR JOSEPH I. MILLER (Atlanta, GA): I very much enjoyed your presentation. I would just raise two potential questions. First, in your patients with malignant pericardial effusion, were the majority of these from lung cancer or were they from other causes?

Second, we have done the same thing you have done in utilizing the subxiphoid approach, particularly for lung cancer; however, when there has been a malignant effusion from breast cancer, lymphoma, or leukemia, we have used a limited parietal

References (28)

  • R.E. Zipf et al.

    The role of cytology in the evaluation of pericardial effusions

    Chest

    (1972)
  • E.L. Larrey

    New surgical procedure to open the pericardium in the case of fluid in the cavity

    Clin Chir

    (1829)
  • P.T. Vaitkus et al.

    Treatment of malignant pericardial effusion

    JAMA

    (1994)
  • E.L. Kaplan et al.

    Non parametric estimation from incomplete observations

    J Am Stat Assoc

    (1958)
  • Cited by (79)

    • Recurrence of pericardial effusion after different procedure modalities in patients with non-small-cell lung cancer

      2022, ESMO Open
      Citation Excerpt :

      These paramalignant etiologies include pericardial effusion due to inflammation, lymphatic or venous drainage obstruction, or treatment-related effusion.8-13 Intervention procedures are crucial steps for preventing death due to pericardial tamponade, and different procedures show varying success rates, safety, and pericardial effusion recurrence rates.14-27 Nowadays, simple pericardiocentesis, balloon pericardiotomy, or surgical pericardiectomy are often carried out on patients harboring symptomatic pericardial effusion.

    • Cardiovascular complication from cancer therapy

      2022, Cardiovascular Toxicity and Therapeutic Modalities Targeting Cardio-oncology: From Basic Research to Advanced Study
    • Cardiac Interventional Procedures in Cardio-Oncology Patients

      2019, Cardiology Clinics
      Citation Excerpt :

      Establishing a definitive diagnosis was thought to be an additional argument for the surgical approach as well, which allows pericardial tissue sampling.155 More recent studies have shown that there is no additional diagnostic yield from direct surgical observation, cytologic analysis, and pericardial histopathology in patients with negative pericardial fluid cytology.141,169,172,182 Endomyocardial biopsy (EMB) is commonly used for the surveillance of cardiac allograft rejection and, to a lesser extent, for the diagnosis of unexplained ventricular dysfunction.183

    View all citing articles on Scopus
    View full text