Frequency of Recurrence of Pericardial Tamponade in Patients With Extended Versus Nonextended Pericardial Catheter Drainage

01 Sep 2011

Cardiac tamponade is a life-threatening condition caused by cardiac compression due to accumulation of effusion, pus, blood or air in the pericardial space. It may occur rapidly, like in “surgical” tamponade when intrapericardial pressure is rising in the matter of minutes to hours (i.e. wounds causing haemorrhage), whereas a low-intensity inflammatory process is developing in days to weeks before critical cardiac compression causing “medical” tamponade. Pericardial disease of any aetiology can cause cardiac tamponade. With cardiac wounds and intrapericardial rupture of dissecting aorta as little as 150 ml of blood can be fatal in several minutes. In contrast, in “medical tamponade” critical cardiac compression may occur at the range from 200-1000 ml or more. The volume of fluid causing tamponade varies inversely with pericardial stiffness and thickness. Intense or repeated inflammation causing thickened or scared pericardium can sharply reduce the amount of effusion that can be tolerated before critical cardiac compression occurs. The clinical onset, ranging from insidious to rapid or sudden, is determined by the balance of exudation rate and pericardial “compliance” permitting compensatory responses to keep effusions tolerable longer than in “surgical tamponade” [1].
Cardiac tamponade is an absolute indication for urgent pericardial drainage [2]. Medical treatment is only a temporary measure until pericardiocentesis or surgical relief (e.g. in dissection of the aorta) can be performed. The approach for pericardiocentesis is selected according to the size and distribution of the effusion in echocardiography (subxiphoid or intercostal), but also depending on the routine clinical practice in the given institution [3]. A pigtail catheter should be inserted for drainage of the effusion, but if such is not available in the emergency setting a standard 7F central venous catheter can be used instead. It was previously shown that regardless of the aetiology, the risk of pericardial effusion recurrence and the need for additional interventions after initial pericardiocentesis is significantly lower if prolonged pericardial drainage is performed, until the volume of effusion obtained by intermittent pericardial aspiration (every 4–6 h) falls to <25 ml per day [2,4]. In the routine clinical practice the drainage is usually lasting for 3-7 days. For the prevention of drain infection all patients receive intravenous antibiotics (e.g. ceftriaxone 2g i.v. qd). Special silver-coated catheter, which became recently available, might enable even longer safe drainage of the pericardial effusion, but their true clinical safety for this indication is yet to be studied [3].

Topic(s):

Pericardial Disease

Summary of the paper

Rafique and colleagues from the Cedars-Sinai Heart Institute (Los Angeles, CA, USA) evaluated the clinical and procedural predictors of recurrent pericardial tamponade after pericardiocentesis in 157 consecutive patients with pericardial tamponade [5]. An intrapericardial catheter was used for prolonged drainage of the pericardial effusion in 78% of cases and in 22% of procedure there was no prolonged pericardial drainage. The overall recurrence rate 11.8 ± 0.6 months after pericardiocentesis was 20% and the mean interval to recurrence was 1.2 ± 2.1 months. However, patients with extended catheter drainage had a reduced recurrence rate of 12% compared to 52% in patients without extended drainage (p <0.001). In the Cox regression modelling, absence of extended drainage, incomplete drainage of pericardial effusion, loculated effusion, and malignancy independently correlated with the recurrence at 1 year.

Discussion

The present study confirmed that extended drainage of pericardial effusion should be applied not only for large pericardial effusions, but also for patients with cardiac tamponade. This procedure is effective and safe, resulting in a significant decrease in recurrent pericardial tamponade and recurrence-free survival. Importantly, extended drainage, incomplete pericardial effusion drainage, presence of loculated effusions, and malignancy were established as independent predictors of recurrent pericardial tamponade.

The possible mechanism by which extended pericardial catheter drainage prevents recurrent effusion and tamponade could include complete evacuation of the fluid and irritation of the pericardium, with enhanced apposition of the visceral and parietal pericardium. Improved survival in patients with extended catheter drainage could be caused by the lower risk of cardiac tamponade but also from a selection bias. The recurrence rate demonstrated in the study by Tsang et al. [4] was 27% after simple pericardiocentesis and 14% after extended pericardial drainage (p<0.001) at 6 months of follow-up. In the present study by Rafique et al., the recurrence rate was 52% for simple pericardiocentesis and 12% at a longer follow-up of 1 year [5].

The study of McDonald et al. [6] compared outcomes of patients treated with percutaneous pericardial catheter drainage (n=96) with outcomes after open subxiphoid pericardial drainage (n=150) performed over 5-years time in a single institution. Drainage duration, total drainage volume, and mean duration of follow-up (2.6 years) were similar in both groups. Effusions were malignant in 79 (32%) patients and benign in 167 (68%) patients. No direct procedural mortality occurred, but the hospital mortality was significantly higher in the percutaneous in comparison to the open group (22.9% vs. 10.7%; 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%). Recurrences were less frequent in the surgical group, probably because a pericardial window was created (16.5% in the percutaneous group compared with 4.6% in the open group). The diagnosis of malignancy was confirmed in 16/27 (59%) percutaneous procedures performed on patients with known malignancy. In the open group, cytological and pathologic evaluation of the pericardial specimen revealed malignancy in 32/52 (62%) patients with known malignancy [6].

Allen et al. [7], have found a 30% recurrence rate for percutaneous drainage and 1.1% for subxiphoid pericardiostomy (retrospective study). Percutaneous catheter drainage in other reported series resulted in a recurrence rate of 0-30%, mean 16.2% [8-11]. Open subxiphoid drainage in published reports resulted in a recurrence rate of 0-9.1%, mean 3.2% [7,8, 12-22]. However, these series included neither comprehensive evaluation of the aetiology of the disease nor specific systemic or intrapericardial treatment that significantly diminishes recurrence rates after pericardiocentesis [23-26].

Conclusion:

In conclusion, extended pericardial drainage after catheter placement is associated with a reduced recurrence of pericardial tamponade after initial pericardiocentesis independently of the aetiology of cardiac tamponade. Importantly, absence of extended drainage, incomplete drainage of pericardial effusion, loculated effusion, and malignancy independently correlated with the recurrence at 1 year. Prolonged catheter drainage can also improve quality of life by reducing the symptoms caused by the recurrence of a large pericardial effusions or cardiac tamponade.

References

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Notes to editor

Presented by Arsen D. Ristić, MD, PhD, FESC
Associate Professor of Internal Medicine - Cardiology
Department of Cardiology of the Clinical Centre of Serbia
Belgrade University School of Medicine,
Koste Todorovića 8, 11000 Belgrade, Serbia

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.

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