Abstract
Introduction and objectives
Malignant pericardial effusion has a high recurrence rate after pericardiocentesis. We sought to confirm the efficacy and feasibility of percutaneous balloon pericardiotomy (PBP) as the initial treatment of choice for these effusions.
Methods
Retrospective analysis of the clinical, echocardiographic, and follow-up characteristics of a consecutive series of PBP carried out in a single-center in patients with advanced cancer.
Results
Forty PBPs were performed in 35 patients with a mean age of 61.8 years (55% females). Thirty-four patients had pathologically confirmed metastatic neoplastic disease (26 patients with tumoral cells in the pericardial liquid), 7 had previously required pericardiocentesis, and in the remaining patients PBP was the first treatment for the effusion. All patients had a severe circumferential effusion (29 mm by mean on transthoracic echocardiography [TTE]), and most presented evidence of hemodynamic compromise on TTE. In all cases, the procedure was successful, there were no acute complications, and it was well tolerated at the first attempt. There were no infectious complications during follow-up. One patient developed a pseudoaneurysm in the right ventricle, even though no further treatment was required. Eight patients needed a new pericardial procedure: 3 had elective pericardial window surgeries and 5 had a second PBP. Eighty percent of patients died during follow-up (57 days by mean from the PBP) regarding their oncological disease.
Conclusion
PBP is a simple and safe technique that can be effective in the prevention of recurrence in many patients with severe malignant pericardial effusion. The characteristics of this procedure make it particularly useful in this group of patients to avoid more aggressive, poorly tolerated approaches, since they have a very poor prognosis regarding to their oncological disease.
Highlights
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Patients with advanced oncological disease may present complications as severe pericardial effusion due to metastatic cardiac involvement.
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Pericardial balloon pericardiotomy is a simple, safe technique that can be effective in the prevention of recurrence in many patients with severe malignant pericardial effusion.
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Pericardial balloon pericardiotomy should be considered as the treatment of choice in poor prognosis malignant pericardial effusions.
1
Introduction
Patients with advanced oncological disease may present complications due to metastatic cardiac involvement. One of the most frequent complications is the development of malignant pericardial effusion (MPE) . These MPEs can frequently lead to patient’s death. And in most cases they are associated with uncomfortable symptomatology such as dizziness and dyspnea. Lung and breast cancers are the most frequently etiologies associated with MPE.
Previously pericardiocentesis has been the most widely used therapeutic technique employed in these patients. Nonetheless, it is known that a neoplastic cause is an independent risk factor for recurrent effusion following pericardiocentesis , with reported recurrence rates reaching 36% to 62% in this population . Due to the poor prognosis of these patients, with a survival that hardly exceeds 5 months, therapeutic management should be promoted as least invasive and with the fewest interventions as possible.
Pericardiocentesis associated with the creation of a pericardial window with balloon inflation (percutaneous balloon pericardiotomy, PBP) has emerged as a technique, which is associated with fewer reinterventions, compared to pericardiocentesis alone. In recent years, records have been made with this technique in patients with MPE . A few years ago the results of the first PBPs performed in our hospital were published in 16 patients . This study aims to consolidate this technique as one of the choices for patients with MPE, presenting the results that have been obtained in our institution.
2
Methods
A retrospective review of patients with advanced oncological disease and MPE attended at our hospital that underwent a PBP was carried out. Clinical variables, echocardiography and treatment procedures were reviewed. We analyzed the baseline characteristics of the patients, the oncological disease characteristics and the results of the percutaneous interventions performed on the pericardium. The number of recurrences and the need for reinterventions were evaluated. Complications associated with the PBP procedure were also described.
2.1
Patients
Between March 2010 and April 2016, 40 PBPs were performed in 35 patients in our institution. The demographic characteristics of the patients are summarized in Table 1 . The mean age of the patients was 61.8 years and 55% were women. All of them had advanced oncological disease with previous metastatic disease demonstrated in 90%. And 65% had tumor cells in the pericardial fluid. On average the amount of pericardial fluid extracted during the PBP was 747 cm 3 . Only one patient presented a positive result in the microbiological analysis of pericardial fluid. The primary source of the most frequent cancerous disease was pulmonary followed by the breast. In all patients, the presence of severe pericardial effusion (29 mm thickness by mean) was confirmed by echocardiography. Eighty percent of the patients had never had any procedure previously on the pericardium. In 5 patients, a second PBP was required.
| Patients | 40 |
| Mean age | 61.8 years |
| Females | 55% |
| Oncological disease | 100% |
| Metastatic lesions | 90% |
| Severe pericardial effusion | 100% |
| Normal LVEF | 90% |
| Survival | 20% |
2.2
Procedure
The procedure was performed in the catheterization room guided by fluoroscopy. In most patients the procedure was performed electively, except in 4 of them that an urgent procedure had to be performed due to hemodynamic instability in relation to cardiac tamponade. To maintain the patient as comfortable as possible, low doses of sedation were used with midazolam (2 mg), analgesia with morphine (0.25–0.5 mg iv) and local anesthesia with 1% lidocaine. Cefazolin (3 doses of 1 g iv) was used for antibiotic prophylaxis, and in patients with allergy to penicillin vancomycin was used. In all patients, pericardiocentesis was initially performed by the usual technique through a percutaneous subxiphoid approach. Subsequently, a guide of 0.035 in. was advanced, confirming by fluoroscopy its situation in pericardium. A 10 F introducer was advanced and later a balloon of 40 mm diameter on average was placed, with lengths between 16 and 22 mm. The balloon was inflated leaving its middle zone at the level of the parietal pericardium and several inflations were carried out until the indentation in the balloon created by the pericardium completely disappeared ( Fig. 1 ). The procedure is completed by manual aspiration of the pericardial fluid, extracting samples for biochemical and pathological analysis. The resolution of the pericardial effusion (<5 mm maximum thickness) was checked out by echocardiography. The rest of the characteristics of the procedure are summarized in Table 2 .
| PBP | 40 |
| Recurrent PBP | 5 |
| Effusion resolution | 100% |
| Complications associated | 5% |
| Infectious complications | 0% |
| Drained effusion | 747 cm 3 |
| Tumor cells in effusion | 67.5% |
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