Percutaneous balloon pericardiotomy: a double-balloon technique

Technical and prognostic outcomes of double-balloon pericardiotomy for large malignancy-related pericardial effusions

OBJECTIVE

To investigate both the use of immediate or elective double-balloon pericardiotomy (DBP) in patients with a large amount of malignancy-related pericardial effusion, and the prognosis of this subgroup.

DESIGN

Observational study after DBP intervention.

SETTING

Tertiary referral center.

PATIENTS AND INTERVENTIONS

Fifty patients with malignancy, mainly lung and breast cancer, who were admitted to our critical care unit with a large amount of pericardial effusion. All received echocardiographic-guided pericardiocentesis. Group 1 consisted of 12 patients (24%) who received immediate DBP, and group 2 consisted of 38 patients (76%) who received delayed DBP 2.5 +/- 1.7 days later (mean +/- SD) after emergency pericardiocentesis with pigtail catheter drainage.

MEASUREMENTS

After the procedure, and at 1 month, 3 months, and 6 months, echocardiography and chest radiography were performed to check for pneumothorax, pericardial effusion reaccumulation, or the appearance of pleural effusion after pigtail catheter removal.

MAIN RESULTS

The procedure was successful and without recurrence in 44 patients (88%). Procedural complications were fever in 4 patients (33%) and 10 patients (26%) in group 1 and group 2, respectively (p = 0.72), and mild pneumothorax in 2 patients (17%) and 1 patient (3%) in group 1 and group 2, respectively (p = 0.14). Fifty percent of the patients died within 4 months, while 25% survived to 11 months. High serum calcium, a low albumin/globulin ratio, and positive results on pericardial effusion cytology were poor prognostic factors for long-term survival.

CONCLUSION

Both immediate and delayed DBP are a safe and effective method of relieving large pericardial effusions in patients with cancer. Successful DBP without recurrence of pericardial effusion was achieved in 88% of all patients. Survival was related to the extent of the disease.

Percutaneous balloon pericardiotomy for patients with malignant pericardial effusion including three malignant pleural mesotheliomas

Ten patients were enrolled in this study to evaluate the therapeutic value of percutaneous balloon pericardiotomy in patients with symptomatic pericardial effusion secondary to malignant diseases. Four patients had breast cancer; 2 had lung cancer; 1 had non-Hodgkin's lymphoma; and 3 had malignant pleural mesothelioma, which is commonly seen in Central Anatolian region of Turkey. All patients underwent percutaneous balloon pericardiotomy with monofoil balloons (Mansfield, NuMed). No complication was seen during these procedures. In 3 patients, the balloon could not be expanded completely and was entered from a more lateral position by a second puncture. There was no recurrence of pericardial effusion in 6 of 7 patients without mesothelioma. After percutaneous balloon pericardiotomy, surgical subxiphoid windowing was performed due to drainage greater than 100 mL/day in a patient with lung cancer and in 1 patient with mesothelioma. In the other 2 patients with mesothelioma, recurrence of pericardial effusion was seen and then subxiphoid surgical windowing was performed due to development of cardiac tamponade in 1 of them. All the patients died 68.6 +/- 36 days later due to the primary malignancies. The survival time of patients with mesothelioma was shorter than that of the others (p < 0.05). These results suggest that percutaneous balloon pericardiotomy may be used in the treatment of patients with malignant pericardial effusion as an alternative to surgical pericardial window creation. But in patients with malignant pleural mesothelioma, the success rate of this procedure was lower than that of the others.

The cutting pericardiotome: another option for pericardiopleural draining in recurrent pericardial effusion. Initial experience

Large recurrent pericardial effusion can be managed by repeat pericardiocentesis or by surgery. A relatively new, catheter-based method uses a balloon catheter (percutaneous balloon pericardiotomy) for drainage from the pericardial sac to the pleural space. As an alternative, we present a newly developed device: Cutting pericardiotome.

Pericardial Effusion and Tamponade

Pericardial effusion may occur as a result of a variety of clinical conditions, including viral, bacterial, or fungal infections and inflammatory, postinflammatory, autoreactive, and neoplastic processes. More common causes of pericardial effusion and tamponade include malignancy, renal failure, viral and bacterial infectious processes, radiation, aortic dissection, and hypothyroidism. It can also occur after trauma or acute myocardial infarction (as in postpericardiotomy syndrome following cardiac or thoracic surgery) or as an idiopathic pericardial effusion. Although pericardial effusion is common in patients with connective tissue disease, cardiac tamponade is rare. Among medical patients, malignant disease is the most common cause of pericardial effusion with tamponade. Table 1 shows the causes of pericardial tamponade. The effusion fluid may be serous, suppurative, hemorrhagic, or serosanguineous. The pericardial fluid can be a transudate (typically occurring in patients with congestive heart failure) or an exudate. The latter type, which contains a high concentration of proteins and fibrin, can occur with any type of pericarditis, severe infections, or malignancy. Once the diagnosis of pericardial effusion has been made, it is important to determine whether the effusion is creating significant hemodynamic compromise. Asymptomatic patients without hemodynamic compromise, even with large pericardial effusions, do not need to be treated with pericardiocentesis unless there is a need for fluid analysis for diagnostic purposes (eg, in acute bacterial pericarditis, tuberculosis, and neoplasias). The diagnosis of pericardial effusion/tamponade relies on a strong clinical suspicion and is confirmed by echocardiography or other pericardial imaging modalities. Alternatively, when the diagnosis of cardiac tamponade is made, there is a need for emergency drainage of pericardial fluid by pericardiocentesis or surgery to relieve the hemodynamic compromise. Following pericardiocentesis, it is necessary to prevent recurrence of tamponade. Intrapericardial injection of sclerosing agents, surgical pericardiotomy, and percutaneous balloon pericardial window creation are techniques used to prevent reaccumulation of pericardial fluid and recurrence of cardiac tamponade.

Percutaneous balloon pericardiotomy for patients with recurrent pericardial effusion: using a novel double-balloon technique with one long and one short balloon

Percutaneous balloon pericardiotomy is effective and less invasive for the treatment of recurrent pericardial effusion. This study suggests that the double-balloon method with 1 longer and 1 shorter balloon is the procedure of choice for percutaneous balloon pericardiotomy.