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 . 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.
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.  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 .
The study of McDonald et al.  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 .
Allen et al. , 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].
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