Approach Considerations
Pharmacotherapy for pericardial effusion may include use of the following agents, depending on etiology:
-
Aspirin/NSAIDs
-
Colchicine
-
Steroids
-
Antibiotics
Antineoplastic therapy (eg, systemic chemotherapy, radiation) in conjunction with pericardiocentesis has been shown to be effective in reducing recurrences of malignant effusions. Corticosteroids and NSAIDs are helpful in patients with autoimmune conditions.
Pericardial sclerosis
Several pericardial sclerosing agents have been used with varying success rates (eg, tetracycline, doxycycline, cisplatin, 5-fluorouracil). The pericardial catheter may be left in place for repeat instillation if necessary until the effusion resolves.
Complications include intense pain, atrial dysrhythmias, fever, and infection. Success rates are reported to be as high as 91% at 30 days.
Surgery
Surgical treatments for pericardial effusion include the following:
-
Pericardiostomy
-
Pericardotomy
-
Thoracotomy
-
Sternotomy
-
Pericardiocentesis
Inpatient care
Patients with pericardial effusion who present with significant symptoms or cardiac tamponade require emergent treatment and admission to the intensive care unit (ICU). The pericardial catheter (if placed) should be removed within 24-48 hours to avoid infection. Symptomatic patients should remain hospitalized until definitive treatment is accomplished and/or symptoms have resolved
Outpatient care
Patients should be educated with regard to symptoms of increasing pericardial effusion and should be evaluated whenever these symptoms begin to occur. Indications for echocardiography after diagnosis include the following:
-
A follow-up imaging study to evaluate for recurrence/constriction - Repeat studies may be performed to answer specific clinical questions.
-
The presence of large or rapidly accumulating effusions - To detect early signs of tamponade
Transfer
Symptomatic patients requiring treatment (who are surgical candidates) should receive care at an institution with cardiothoracic surgery capabilities.
Consultations
A cardiologist should be involved in the care of patients with pericardial effusion. Cardiothoracic surgery may be required for recurrent or complicated cases.
Aspirin/NSAIDs
Most acute idiopathic or viral pericarditis occurrences are self-limited and respond to treatment with aspirin (650 mg q6h) or another NSAID. For idiopathic or viral pericarditis, ibuprofen is preferred, given its low adverse effect profile, favorable impact on the coronary blood flow, and large dose range. Based on severity and response, the dose can range from 300-800 mg every 6-8 hours. [28]
Aspirin may be the preferred nonsteroidal agent to treat pericarditis after myocardial infarction because other NSAIDs may interfere with myocardial healing. Indomethacin should be avoided in patients who may have coronary artery disease.
In a study of 196 patients at high risk for tamponade because of pericardial effusion more than 7 days after cardiac surgery, Meurin et al found that diclofenac was not effective in reducing the size of the effusion or in preventing late cardiac tamponade. In the multicenter, randomized, double-blind trial, patients received either diclofenac (50 mg) or placebo twice daily for 14 days. [29]
Colchicine
The routine use of colchicine in combination with conventional therapy is supported by results from the COlchicine for acute PEricarditis (COPE) trial. In this study, 120 patients with a first episode of acute pericarditis (idiopathic, acute, postpericardiotomy syndrome, or connective tissue disease) entered a randomized, open-label trial comparing aspirin treatment alone with aspirin plus colchicine (1-2 mg for the first day followed by 0.5-1 mg daily for 3 mo). [30]
In the study, colchicine reduced symptoms at 72 hours (11.7% vs 36.7) and reduced recurrence at 18 months (10.7% vs 36.7%). Colchicine was discontinued in 5 patients because of diarrhea, but no other adverse events were noted. Importantly, none of the 120 patients developed cardiac tamponade or progressed to pericardial constriction. The ICAP Trial (Investigation on Colchicine for Acute Pericarditis) will provide further information regarding the use of colchicine as first-line therapy. [31]
However, colchine may not be effective for patients with asymptomatic postoperative pericardial effusion. A study involving 149 patients with mild or moderate pericardial effusion on transthoracic echocardiography found no significant difference on pretreatment and posttreatment effusion values and changes in isolated coronary artery bypass graft surgery patients who received colchicine (n = 74) and those who received placebo (n = 75). [89] The investigators attributed these findings to the likelihood that most of the cases of pericardial effusion were from noninflammatory causes.
Steroids
Steroid administration early in the course of acute pericarditis appears to be associated with an increased incidence of relapse after the steroids are tapered. In the COPE trial, steroid use was an independent risk factor for recurrence. Also, an observational study strongly suggested that the use of steroids increases the probability of relapse in patients treated with colchicine. [30]
Systemic steroids should be considered only in patients with recurrent pericarditis that is unresponsive to NSAIDs and colchicine or as needed for treatment of an underlying inflammatory disease. If steroids are to be used, an effective dose (1-1.5 mg/kg of prednisone) should be given, and it should be continued for at least 1 month before slow tapering. The European Society of Cardiology recommends that systemic corticosteroid therapy be restricted to connective-tissue diseases, autoreactive pericarditis, or uremic pericarditis. [28]
The intrapericardial administration of steroids has been reported to be effective in acute pericarditis without producing the frequent reoccurrence of pericarditis that complicates the use of systemic steroids, [32] but the invasive nature of this procedure limits its use.
Antibiotics
Purulent pericarditis
In patients with purulent pericarditis, urgent pericardial drainage combined with intravenous (IV) antibacterial therapy (eg, vancomycin 1 g bid, ceftriaxone 1-2 g bid, and ciprofloxacin 400 mg daily) is mandatory. Irrigation with urokinase or streptokinase, using large catheters, may liquify the purulent exudate, but open surgical drainage is preferable.
Tuberculous pericarditis
The initial treatment of tuberculous pericarditis should include isoniazid 300 mg daily, rifampin 600 mg daily, pyrazinamide 15-30 mg/kg daily, and ethambutol 15-25 mg/kg daily. Prednisone 1-2 mg/kg daily is given for 5-7 days and progressively reduced to discontinuation in 6-8 weeks. Drug sensitivity testing is essential. Uncertainty remains whether adjunctive corticosteroids are effective in reducing mortality or progression to constriction.
Surgical resection of the pericardium remains the appropriate treatment for constrictive pericarditis. The timing of surgical intervention is controversial, but many experts recommend a trial of medical therapy for noncalcific pericardial constriction and pericardiectomy in nonresponders after 4-8 weeks of antituberculosis chemotherapy.
Hemodynamic Support
Patients who have an effusion with actual or threatened tamponade should be considered to have a true or potential emergency. Most patients require pericardiocentesis to treat or prevent tamponade. However, treatment should be carefully individualized.
Hemodynamic monitoring with a balloon flotation pulmonary artery catheter is useful, especially in patients with tamponade or threatened tamponade in whom a decision is made to defer pericardiocentesis. Hemodynamic monitoring is also helpful after pericardiocentesis to assess reaccumulation and the presence of underlying constrictive disease. However, insertion of a pulmonary artery catheter should not be allowed to delay definitive therapy in critically ill patients.
IV fluid resuscitation may be helpful in cases of hemodynamic compromise. In patients with tamponade who are critically ill, IV positive inotropes (dobutamine, dopamine) can be used but are of limited use and should not be allowed to substitute for or delay pericardiocentesis.
Pericardiocentesis
As previously mentioned, pericardiocentesis is used for diagnostic as well as therapeutic purposes. Pericardial fluid drainage can be performed by percutaneous catheter drainage or open surgical approach. Individual patient characteristics (eg, loculated vs circumferential, recurrent pericardial effusion, need for pericardial biopsy and location of pericardial effusion) and local practice patterns aid in deciding the optimal method of drainage.
Percutaneous pericardial fluid drainage (pericardiocentesis) is the most common method used for pericardial fluid removal. It can be performed under fluoroscopic, echocardiographic, or CT guidance.
Echocardiographic pericardial fluid drainage has established itself as the criterion standard technique. In study of 1127 procedures performed on 977 patients, echocardiographic-guided pericardiocentesis was successful in 97%, with 1.2% major and 3.5% minor complications. [33] It also established the extended drainage as a means to reduce the recurrence rate.
Use of a needle that is at least 5cm long and 16-gauge in diameter and that has a short bevel can minimize the risk of complications and should allow for adequate pericardial drainage. A system allowing placement of a catheter over the needle is preferred.
Contrast echocardiography using agitated saline is useful in cases in which bloody fluid is aspirated, to determine if the needle is in the ventricular cavity.
Attaching an ECG electrode to the pericardiocentesis needle is also useful for avoiding myocardial puncture. Electrical activity will be seen on the monitor when the needle comes into contact with atrial or ventricular myocardium. These changes may be delayed, however, and instill a false sense of security in needle placement. Sense of touch and the findings on aspiration should guide the procedure, with the clinician ultimately relying on good clinical sense.
Complications of pericardiocentesis include ventricular rupture, dysrhythmias, pneumothorax, myocardial and/or coronary artery laceration, and infection. Recurrence rates for pericardial effusion within 90 days may be as high as 90% in patients with cancer.
Pericardiotomy and Pericardiostomy
Balloon pericardotomy
In this procedure, a catheter is placed in the pericardial space under fluoroscopy. Inflation of the balloon creates a channel for passage of fluid into the pleural space, where reabsorption occurs more readily. Balloon pericardiotomy may be useful for recurrent effusions.
CT-guided pericardiostomy
Patients with effusions after cardiothoracic surgery often have limited echocardiographic windows, as well as loculated effusions, and may be on continued ventilatory support, all of which increase the difficulty of echo-guided pericardiocentesis.
CT pericardial fluid drainage has evolved as an emerging technique suited to overcome this dilemma. It has been shown as an alternative technique in patients in whom fluoroscopically or echocardiographically guided pericardiocentesis is difficult. Echocardiography can be limited due to various patient characteristics (eg, postoperative state, obesity, or chronic obstructive pulmonary disease) or due to a limitation of echocardiography in differentiating pericardial fluid from other possible surrounding structures.
In one large series, CT-directed diagnostic and therapeutic pericardiocentesis was attempted in 261 patients, with 98.4% success, 0.3% major complications and 6.9% minor complications. [34]
In 2010, Eichler et al reported their data on CT-guided pericardiocentesis in 20 patients who were poor candidates for echocardiographic drainage or pericardial fluid was not well visualized by echocardiography. All patients had successful drainage, with 0% mortality and no major complications. [35]
A report by Palmer et al suggested that, in postsurgical cases, CT-guided pericardial drainage is both safe and cost effective. The authors reported on 36 patients—33 of whom underwent major cardiothoracic surgery and 3 of whom were treated with minimally invasive procedures—whose symptomatic pericardial effusions were drained using CT-guided percutaneous placement of an indwelling pericardial catheter. [36]
There were no clinically significant complications associated with any of the placement procedures. Thirty-three patients experienced no symptom recurrence following catheter removal, although pericardial effusion did recur in the remaining 3 patients, requiring a repeat treatment.
Comparing procedure costs, the authors determined that the CT-guided tube pericardiostomies cost 89% less than intraoperative pericardial window procedures would have. No significant procedure-cost differences were found between CT-guided and ultrasonographically guided tube pericardiostomies.
Subxiphoid Pericardial Window With Pericardiostomy
This procedure is associated with low morbidity, mortality, and recurrence rates, and can be considered as a reasonable alternative diagnostic or treatment modality to pericardiocentesis in selected patients. [37]
The surgery can be performed under local anesthesia. This is advantageous because general anesthesia often leads to decreased sympathetic tone, resulting in hemodynamic collapse in patients with pericardial tamponade and shock. This procedure may be less effective when effusion is loculated.
One study indicated that the procedure may be safer and more effective at reducing recurrence rates than pericardiocentesis. However, only patients who were hemodynamically unstable underwent pericardiocentesis, and no change in overall survival rate was observed.
Thoracotomy and Median Sternotomy
Thoracotomy
This procedure should be reserved for patients in whom conservative approaches have failed. Thoracotomy allows for creation of a pleuropericardial window, which provides greater visualization of the pericardium. Thoracotomy requires general anesthesia and thus has higher morbidity and mortality rates than does the subxiphoid approach.
Median sternotomy
This procedure is reserved for patients with constrictive pericarditis. The operative mortality rate is high (5-15%).
Video-Assisted Thoracic Surgery
Video-assisted thoracic surgery (VATS) allows resection of a wider area of the pericardium than the subxiphoid approach does, without the morbidity of thoracotomy. [38] The surgeon is able to create a pleuropericardial window and address concomitant pleural pathology, which is especially common in patients with malignant effusions.
One disadvantage of VATS is that it requires general anesthesia with single lung ventilation, which may be difficult in otherwise seriously ill patients.
-
This image is from a patient with malignant pericardial effusion. Note the "water-bottle" appearance of the cardiac silhouette in the anteroposterior (AP) chest film.
-
Echocardiogram (parasternal, long axis) of a patient with a moderate pericardial effusion.
-
This image is from a patient with malignant pericardial effusion. The effusion is seen as an echo-free region to the right of the left ventricle (LV).
-
This electrocardiogram (ECG) is from a patient with malignant pericardial effusion. The ECG shows diffuse low voltage, with a suggestion of electrical alternans in the precordial leads.
-
Subcostal view of an echocardiogram that shows a moderate to large amount of pericardial effusion.
-
This echocardiogram shows a large amount of pericardial effusion (identified by the white arrows).
