Surgical pericardiotomy is often preferred as a primary option in patients with malignant pericardial effusions. Recent series have revealed that prolonged drainage substantially reduces pericardial effusion recurrence rates, even in the setting of malignancy. The aim of the study was to directly compare the efficacy of pericardiocentesis with prolonged drainage with the primary surgical pericardiotomy in patients with symptomatic pericardial effusion associated with a malignancy. We retrospectively evaluated 88 patients who presented with pericardial tamponade associated with a malignancy. Pericardiocentesis with extended drainage was performed in 43 patients and surgical pericardiotomy in 45 patients. The recurrence rate was not significantly different in patients with prolonged catheter drainage versus surgical pericardiotomy (12% vs 13%, respectively, p = 0.78). In addition, there was no significant difference in diagnostic yield between percutaneous drainage and surgical window (44% vs 53%, respectively, p = 0.39). The overall rate of complications was significantly lower in the prolonged drainage group (2% vs 20%, p = 0.007). Moreover, there were no serious complications in the prolonged drainage group versus 9% in the surgical pericardiotomy group. In conclusion, (1) surgical pericardiotomy with pericardial biopsy does not add significant diagnostic value beyond the cytologic assessment available with pericardiocentesis, (2) surgical pericardiotomy does not improve clinical outcomes over pericardiocentesis, and (3) surgical pericardiotomy is associated with a higher rate of complications.
Small, single-center retrospective studies have shown that simple pericardiocentesis in patients with malignant pericardial effusion have recurrence rates up to 90%. These earlier studies were used to establish surgical pericardiotomy as the definitive treatment. However, recent larger series have revealed that using prolonged drainage substantially reduces pericardial effusion recurrence rates. The largest series at the Mayo clinic revealed that prolonged drainage reduced recurrence rates to 12% in patients with malignancy-associated pericardial effusions after 3-month follow-up. With these new data, it is necessary to further explore the role of pericardiocentesis with prolonged drainage in patients with malignant pericardial effusions and with a longer follow-up. The aim of our study was to compare the efficacy of pericardiocentesis with prolonged drainage with the primary surgical pericardiotomy in patients with symptomatic pericardial effusions associated with a malignancy.
Methods
We retrospectively evaluated patients presenting with clinically significant malignancy-associated pericardial effusions from January 2000 to January 2007. The indication for therapeutic intervention in all patients was a large pericardial effusion causing symptoms, signs, and hemodynamic compromise consistent with pericardial tamponade. Patients underwent either pericardiocentesis with extended drainage or surgical pericardiotomy. The therapeutic intervention was at the discretion of the treating physician.
From the medical records, we determined the clinical characteristics, echocardiographic findings, details of the pericardiocentesis and surgical pericardiotomy, origin and characteristics of the effusion, and outcomes including success and complications, recurrence, and survival. The effusion was classified as an exudate or a transudate using previously published criteria. Survival data were obtained from the medical records or the social security death index. The study was approved by our Institutional Review Board. Waiver for patient consent was granted owing to the retrospective nature of the study. All data were collected and maintained by a single investigator in a Health Insurance Portability and Accountability Act–compliant database.
Standard 2-dimensional echocardiography was performed using commercially available ultrasound systems before all pericardiocentesis procedures. Chamber compression or collapse, inferior vena cava size and lack of inspiratory collapse, and inspiratory variation of Doppler mitral and tricuspid inflow velocities were used to evaluate the hemodynamic consequences of pericardial effusion. Large pericardial effusion was defined as a circumferential effusion with an echo-free space of >1 cm at its greatest width.
Pericardiocentesis was performed under echocardiographic or fluoroscopic guidance as previously described. The pericardial catheter was left in place until complete drainage of the pericardial effusion was obtained, which was defined as drainage of ≤100 ml over a 24-hour period and a follow-up 2-dimensional echocardiogram with residual pericardial effusion, noncircumferential and <1 cm in size.
Pericardial window was done under general anesthesia, an incision was made in the area of the xiphoid, and the pericardium was grasped, pulled inferiorly, and opened. Fluid was drained, a pericardial window was created, and a chest tube was put into the pericardial space. The incision was closed with a running suture.
Statistical analysis was performed using SPSS, version 18.0 (SPSS Inc., Chicago, Illinois). Data are presented as mean ± SD, and categorical data are expressed as percentages or absolute numbers. A p value <0.05 was considered statistically significant.
Between the 2 groups, comparisons of baseline data were performed using the independent samples t test. All categorical variables were compared between the 2 groups using the Pearson’s chi-square test. Test of homogeneity of variances was performed for each individual variable with Lavene statistic. Nonparametric variables were analyzed by Wilcoxon rank-sum test.
Clinically and statistically significant variables were further evaluated using the multivariate Cox regression analysis. Hazard ratios (HRs) were estimated using Cox proportional hazards models. HRs with 95% confidence intervals are provided when appropriate. Multiple models were created to study the significance of various variables. Kaplan-Meier analysis was used to estimate recurrence-free survival. The log-rank test was used to compare recurrence-free survival across the 2 groups.
Results
A total of 88 patients were included in this analysis. Of which, 43 patients (49%) were treated using pericardiocentesis followed by extended catheter drainage and 45 patients (51%) underwent surgical pericardiotomy. The mean age of the present study cohort was 60 ± 14 years and 40% were men. One-year follow-up was available in all of the participants. There were no significant differences in the baseline clinical or laboratory characteristics of the study population between the 2 study groups as listed in Table 1 .
| Variable | All (n = 88) | Pericardiocentesis With Catheter (n = 43) | Pericardiotomy (n = 45) | p |
|---|---|---|---|---|
| Age (yrs) | 60 ± 14 | 61 ± 15 | 58 ± 12 | 0.342 |
| Men | 35 (40%) | 14 (33%) | 21 (47%) | 0.176 |
| Serum creatinine (mg/dl) | 1.0 ± 0.6 | 1.1 ± 0.8 | 0.9 ± 0.4 | 0.145 |
| Exudative (based on Light’s criteria) | 70 (80%) | 32 (74%) | 38 (84%) | 0.658 |
| Fluid lactate dehydrogenase (IU/L) | 1,793 ± 2,449 | 2,034 ± 2,601 | 537 ± 568 | 0.216 |
| Fluid protein (g/dl) | 4.6 ± 1.4 | 4.8 ± 1.2 | 3.3 ± 2.0 | 0.183 |
| Fluid glucose (mg/ml) | 83 ± 79 | 82 ± 83 | 91 ± 48 | 0.852 |
| International normalized ratio | 1.4 ± 0.4 | 1.4 ± 0.4 | 1.3 ± 0.3 | 0.330 |
An average of 814 ml of fluid was removed in the prolonged pericardial drainage group versus 740 ml in the surgical group. The mean duration of catheter drainage in the pericardiocentesis group was 38 ± 25 hours. Of these patients, 42% had the catheter removed at 24 hours and 82% at 48 hours. As listed in Table 2 , the major causes of malignancy included lung cancer (38%), breast cancer (19%), and hematologic malignancies (24%). Two patients had concomitant cancers (lung and lymphoma). Cytology of the effusion had a positive finding for malignant cells in 19 (44%) of the patients who underwent prolonged catheter drainage, whereas cytology of the pericardial fluid had a positive finding for malignant cells in 24 (53%) of the patients who underwent surgical drainage (no significant difference between the 2 groups, p = 0.39). Looking at the origin of malignancy, of the 17 patients with hematologic malignancy, 44% had a positive cytologic finding. Of the remaining patients with other malignancy-associated effusions, 50% had a positive cytologic finding. The highest incidence of positive cytologic finding was for patients with breast or gynecologic malignancies; in this group of 17 patients, 71% had a positive cytologic finding.
| Variable | All, n = 88 (%) | Pericardiocentesis With Catheter, n = 43 (%) | Pericardiotomy, n = 45 (%) |
|---|---|---|---|
| Hematologic | 17 (19) | 11 (26) | 6 (13) |
| Nonhematologic | 74 (84) | 35 (76) | 39 (87) |
| Gastrointestinal | 9 (10) | 5 (12) | 4 (9) |
| Esophageal | 1 (1) | 1 (2) | 0 |
| Gastric | 3 (3) | 0 | 3 (7) |
| Colon | 2 (2) | 1 (2) | 1 (2) |
| Anal | 1 (1) | 1 (2) | 0 |
| Pancreatic | 2 (2) | 2 (5) | 0 |
| Lung † | 33 (38) | 13 (30) | 20 (45) |
| Breast | 17 (19) | 9 (21) | 8 (18) |
| Gynecological | 6 (7) | 4 (9) | 2 (4) |
| Cervical | 1 (1) | 1 (2) | 0 |
| Ovarian ∗ | 4 (5) | 3 (7) | 1 (2) |
| Uterine | 1 (1) | 0 | 1 (2) |
| Other | 9 (10) | 4 (9) | 5 (11) |
∗ One patient had concomitant cervical cancer.
The decision to perform pericardiotomy as the primary procedure was left to the discretion of the treating physicians and was influenced by some of the factors listed in Table 3 . Of the 45 patients who underwent surgical pericardiotomy, 39 also had a pericardial biopsy performed. Of these, 18 revealed chronic inflammation, 4 showed fibrinous pericarditis, and 17 had a biopsy finding positive for malignancy; however, all these patients had a known history of malignancy. Interestingly, in the surgical pericardiotomy group, of the 24 patients with positive cytologic finding, only 15 had definite findings of malignancy on the pericardial biopsy. Of the 15 patients with negative cytologic finding, 2 had biopsy findings positive for malignancy. Colchicine and nonsteroidal anti-inflammatory drugs were significantly used more in the patients with prolonged catheter drainage: 30% versus 9% were treated with colchicine (p = 0.01) and 35% versus 7% with nonsteroidal anti-inflammatory drugs (p = 0.01). There was no difference in the use of aspirin or steroids between the 2 groups.
| Reason for Primary Pericardiotomy | n = 45 (%) |
|---|---|
| Diagnostic biopsy | 3 (7) |
| Simultaneous lymph node biopsy | 2 (4) |
| Simultaneous mass biopsy | 1 (2) |
| Failed attempt at pericardiocentesis ∗ | 2 (4) |
| Pericardiocentesis not attempted † | 2 (4) |
| Physician’s choice as definitive treatment | 20 (44) |
| Physician’s choice as patient coagulopathic | 2 (4) |
| Physician’s choice as recent cardiac surgery | 1 (2) |
| Simultaneous pleurodesis | 12 (27) |
∗ Unable to enter pericardial space or minimal drainage.
The rates of all and serious complications were significantly lower in the prolonged drainage group as listed in Table 4 . Immediate complications in the patients with surgical pericardiotomy included supraventricular tachyarrhythmia (n = 1), hemothorax (n = 1), and intraprocedural hypotension (n = 1). Other late (>24 hours) complications in the surgical group were paroxysmal atrial fibrillation (n = 3) and prolonged intubation >2 weeks (n = 3).
| Variable | All, n = 88 (%) | Pericardiocentesis With Catheter, n = 43 (%) | Pericardiotomy, n = 45 (%) |
|---|---|---|---|
| Serious complications ∗ | 4 (5) | 0 | 4 (9) |
| All complications | 10 (11) | 1 (2) | 9 (20) |
| Supraventricular tachycardia or atrial fibrillation | 4 (5) | 0 | 4 (9) |
| Hemothorax | 1 (1) | 0 | 1 (2) |
| Hypotension | 2 (2) | 1 (2) † | 1 (2) |
| Prolonged intubation >2 weeks | 3 (3) | 0 | 3 (7) |
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