Percutaneous balloon pericardiotomy for the treatment of cardiac tamponade and large pericardial effusions: description of technique and report of the first 50 cases

Pericardial Effusion and Cardiac Tamponade Pathophysiology and New Approaches to Treatment

PURPOSE OF REVIEW

The objective of this manuscript is to examine up-to-date approaches to the diagnosis and treatment of pericardial effusions and cardiac tamponade.

RECENT FINDINGS

Recent recommendations from the American Society of Echocardiography and the European Society of Cardiology have improved our management of the patient with pericardial effusion and cardiac tamponade, but significant knowledge gaps remain. Novel diagnostic and triage strategies have been suggested, and recent information have improved our facility to assess the presence and size of a pericardial effusion, assess its hemodynamic impact, and determine its cause. Despite these recent findings, there is a scarcity of evidence-based data to direct the management of pericardial effusion and cardiac tamponade. While the first-line function of echocardiography in managing these disorders is undisputed, there are increasingly niche functions for multimodality imaging.

Peritoneal Carcinoma Unveiling a Hidden Threat: A Case of Malignant Pericardial Effusion

Malignant pericardial effusion (MPE) is a slowly progressive and potentially clinically silent condition. Pericardial effusion can arise in oncology patients due to several factors, including disease spreading directly or metastatically, anticancer therapy side effects, or both. Solid and hematological malignancy metastasis more frequently involves the pericardium than primary tumors, with lung cancer being the most common metastatic tumor to involve the pericardium. While 5%-20% of all patients with metastatic neoplasms have pericardial involvement, MPE rarely appears with hemodynamic instability. Occasionally, MPE constitutes the initial manifestation of an underlying malignancy. Diagnosis and treatment require a multidisciplinary approach and a high degree of clinical suspicion. We present a case of a 59-year-old female with a history of peritoneal carcinoma who presented with persistent dyspnea on exertion following an episode of pneumonia that was treated with antibiotics. Physical examination and bedside point-of-care ultrasound (POCUS) revealed fluid in the pericardial sac. The cytological examination of the fluid revealed it to be of malignant origin, resulting from metastasis from gynecologic adenocarcinoma. Pericardiocentesis was done, and symptoms improved after fluid drainage.

Percutaneous balloon pericardiotomy: efficacy in a series of malignant and nonmalignant cases

OBJECTIVE

In the case of malignant pericardial effusion and cardiac tamponade, balloon pericardiotomy is an established minimally invasive option to the surgical creation of a subxiphoid pericardial window. Percutaneous balloon pericardiotomy effectively drains recurrent pericardial fluid by creating a pleuro (-abdominal-) pericardial communication. Design. A series of 26 patients with underlying malignant (n = 12) and nonmalignant (n = 14) diseases underwent percutaneous balloon pericardiotomy between 2008 and 2021. All interventions were done through a subxiphoid access under local anesthesia. Results. The mean survival in the malignant and nonmalignant groups was 1.2 versus 48.0 months, respectively (p < .001). There were neither severe periinterventional complications nor in-hospital deaths. In two patients with nonmalignant disease the surgical creation of a pericardial window was necessary during follow-up. The originally described procedure was modified by the removal of all catheters at the end of the intervention. The procedure was safe. It prevented immobility and facilitated an early discharge from the hospital. Conclusion. Our experiences show that percutaneous balloon pericardiotomy is a minimally invasive approach to successfully provide palliation in the group of patients with underlying malignant disease. On the other hand, we have shown that this technique is safe and feasible in the treatment of pericardial effusion based on nonmalignant disease. We think thereby that pericardial balloon pericardiotomy can be considered as a less invasive alternative to surgery in both groups of patients.

Pericardial Drain Placement in Interventional Radiology: An Overview

Pericardial effusions can occur from multiple different etiologies. Although often incidentally noted or clinically silent, pericardial effusions may cause significant hemodynamic compromise. In some of these patients, pericardiocentesis may be temporizing only and either repeat procedures or placement of pericardial drains may be preferable. While cardiologists typically perform pericardial drain placement, it is a procedure that may also be performed by interventional radiologists. This article describes for the interventional radiologist the indications and placement technique, as well as potential complications occurring from pericardial drain placement.

Single center experience of pediatric percutaneous balloon pericardiotomy

BACKGROUND

Percutaneous balloon pericardiotomy is a percutaneous procedure that creates a window in the parietal pericardium by balloon dilation. The use of percutaneous balloon pericardiotomy has not been reported well in children.

OBJECTIVES

The objective of this study was to describe the single centre experience of percutaneous balloon pericardiotomy in children.

METHODS

This was a retrospective study to describe all the children aged <20 years undergoing percutaneous balloon pericardiotomy during an 18-year period (2001-2019). Patient characteristics, technical and ultimate procedural success, and repeat interventions were collected.

RESULTS

A total of 13 percutaneous balloon pericardiotomy's were performed in 11 children at the median age of 12 years (range 1.8-19). The etiologies of pericardial effusion were post-pericardiotomy syndrome (n = 4), restrictive cardiomyopathy (n = 1), autoimmune diseases (n = 3), malignancy (n = 2), and idiopathic (n = 1). Two patients received two percutaneous balloon pericardiotomy. The technical success of percutaneous balloon pericardiotomy was 100% with no acute adverse events (balloon rupture or local bleeding). Five (45%) required re-intervention and ultimately three required a surgical pericardial window 6 to 35 days after the percutaneous balloon pericardiotomy. As a result, ultimate procedural success rate was 73% (8/11).

CONCLUSION

Percutaneous balloon pericardiotomy was performed safely with high technical success in children. Percutaneous balloon pericardiotomy may be considered for recurrent and persistent pericardial effusion, before considering a surgical pericardial window.

Percutaneous Balloon Pericardiotomy (PBP) Revisited: A Case Report and Review of Literature

Background

A Percutaneous Balloon Pericardiotomy (PBP) procedure is a reemerging nonsurgical technique that helps in preventing the reaccumulation of pericardial effusion. It is done percutaneously without general anaesthesia. It has been proved to be effective in alleviating and preventing recurrent pericardial effusion. Case Presentation. We reported a 52-year-old male with stage IV adenocarcinoma causing recurrent pericardial effusion. The patient experienced a worsening shortness of breath. A surgical pericardial window was denied by the surgery team secondary to severe respiratory distress; subsequently, the patient underwent Percutaneous Balloon Pericardiotomy.

Conclusion

Percutaneous Balloon Pericardiotomy is efficacious and safe when done by well-trained physicians. We think it should be considered as a preferred treatment modality in most sicker patients with recurrent pericardial effusion.

Cardiac Interventional Procedures in Cardio-Oncology Patients

Comorbidities specific to the cardio-oncology population contribute to the challenges in the interventional management of patients with cancer and cardiovascular disease (CVD). Patients with cancer have generally been excluded from cardiovascular randomized clinical trials. Endovascular procedures may represent a valid option in patients with cancer with a range of CVDs because of their minimally invasive nature. Patients with cancer are less likely to be treated according to societal guidelines because of perceived high risk. This article presents the specific challenges that interventional cardiologists face when caring for patients with cancer and the modern tools to optimize care.

A "Vanishing", Tuberculous, Pericardial Effusion

We present an iatrogenic, pleuro-pericardial connection resulting from pericardiocentesis of a large, tuberculous, pericardial effusion. Recognition of this situation is paramount when one is unable to aspirate pericardial fluid after a successful, initial puncture. Such knowledge will help prevent myocardial or coronary artery injury with further attempts at aspiration.

Echocardiographic Assessment of Pericardial Effusion

Echocardiography is routinely used to evaluate diseases of the pericardium, including effusion, tamponade, and, to a lesser extent, constriction. Doppler evaluation provides information regarding the attendant alterations of cardiac filling. This review details the role of echocardiography in the diagnosis and management of common abnormalities of the pericardium.

Diagnosis and Management of Pericardial Disease

The pericardium serves many important functions but is not essential for life. Pericardial heart disease comprises only pericarditis and its complications, tamponade and constriction, and congenital lesions. However, the pericardium is affected by virtually every category of disease. Thus the critical care physician is likely to encounter the patient with pericardial disease in a variety of settings, either as an isolated phenomenon or as a complication of a variety of systemic disorders, trauma, or certain drugs. Despite exhaustive etiological lists, the cause of pericardial heart disease is often never identified. This article reviews the diagnosis and management of acute and chronic pericarditis with an emphasis on those areas of greatest interest to the intensivist.

Prolonged Drainage and Intrapericardial Bleomycin Administration for Cardiac Tamponade Secondary to Cancer-Related Pericardial Effusion

Malignant pericardial effusion (MPE) is a serious complication of several cancers. The most commonly involved solid tumors are lung and breast cancer. MPE can give rise to the clinical picture of cardiac tamponade, a life threatening condition that needs immediate drainage. While simple pericardiocentesis allows resolution of the symptoms, MPE frequently relapses unless further procedures are performed. Prolonged drainage, talcage with antineoplastic agents, or surgical creation of a pleuro-pericardial window are the most commonly suggested ones. They all result in MPE resolution and high rates of long-term control. Patients suitable for further systemic treatments can have a good prognosis irrespective of the pericardial site of disease. We prospectively enrolled patients with cardiac tamponade treated with prolonged drainage associated with Bleomycin administration. Twenty-two consecutive patients with MPE and associated signs of hemodynamical compromise underwent prolonged drainage and subsequent Bleomycin administration. After injection of 100 mg lidocaine hydrochloride, 10 mg Bleomycin was injected into the pericardial space. The catheter was clumped for 48 h and then reopened. Removal was performed when the drainage volume was <25 mL daily. Twelve patients (54%) achieved complete response and 9 (41%) a partial response. Only 1 (5%) had a treatment failure and underwent a successful surgical procedure. Acute toxicity was of a low degree and occurred in 7 patients (32%). It consisted mainly in thoracic pain and supraventricular arrhythmia. The 1-year pericardial effusion progression-free survival rate was 74.0% (95% confidence interval [CI]: 51.0-97.3). At a median follow-up of 75 months, a pericardial progression was detected in 4 patients (18%). One- and two-year overall survival rates were 33.9% (95% CI: 13.6-54.2) and 14.5% (95% CI: 0.0-29.5), respectively, with lung cancer patients having a shorter survival than breast cancer patients. The worst prognosis, however, was shown in patients not suitable for systemic treatments, irrespective of the site of the primary tumor.Prolonged drainage and intrapericardial Bleomycin is a safe and effective treatment, which should be considered as first choice at least in patients suitable for active systemic treatment.

Systematic review of percutaneous interventions for malignant pericardial effusion

The present systematic review assessed the safety and efficacy of percutaneous interventions for malignant pericardial effusion (MPE), with primary endpoint of recurrence of pericardial effusion. Electronic searches of six databases identified thirty-one studies, reporting outcomes following isolated pericardiocentesis (n=305), pericardiocentesis followed by extended catheter drainage (n=486), pericardial instillation of sclerosing agents (n=392) or percutaneous balloon pericardiotomy (PBP) (n=157). Isolated pericardiocentesis demonstrated a pooled recurrence rate of 38.3%. Pooled recurrence rates for extended catheter drainage, pericardial sclerosis and PBP were 12.1%, 10.8% and 10.3%, respectively. Procedure-related mortality ranged from 0.5-1.0% across the percutaneous interventions. Although isolated pericardiocentesis can safely deliver immediate symptomatic relief, subsequent catheter drainage or sclerotherapy are required to minimize recurrence. PBP has been shown to be highly effective and may be particularly useful in managing recurrent effusions. Ultimately, the choice of intervention must be based on the clinical status of patients, their underlying malignancy and the expertise available.

Role of echocardiography in the treatment of cardiac tamponade

Accumulation of fluid within the pericardial sac results in elevation of intrapericardial pressure with consequent cardiac compression or tamponade. Cardiac tamponade is a life-threatening condition which requires urgent evacuation of pericardial effusion (PE). Current pericardial evacuation techniques and approaches are varied. Echocardiography provides valuable insights into identifying patients who are suitable candidates and further facilitates pericardiocentesis by improving guidance techniques. Several previous publications have provided excellent reviews of the pathophysiology of cardiac tamponade. We review the clinical presentation and role of echocardiography for diagnosis of tamponade. We focus on medical and surgical approaches for the removal of PE. Moreover, as the clinical and hemodynamic consequences of PE depend on the volume and the rate of accumulation of PE, we review the various scenarios of "small" PE resulting in cardiac tamponade.

Clinical applications of exercise stress echocardiography in the treadmill with upright evaluation during and after exercise

Exercise stress echocardiography is the most frequently used stress test in our laboratory. Exercise echocardiography is used mainly in the study of patients with coronary artery disease. However, the technique is increasingly being used to study other diseases. In our centre, we use an original methodology, published by us in 2000, in which we evaluate heart function during exercise in the treadmill. After the exercise, patients are maintained in orthostatic position when appropriate or lying down in left lateral decubitus for further evaluation. Since this method seems to increase the quality and the quantity of information obtained in so many clinical arenas, we now present a detailed review of this methodology and its applications.

Percutaneous balloon pericardiotomy as the initial and definitive treatment for malignant pericardial effusion

INTRODUCTION AND OBJECTIVES

Malignant pericardial effusion has a high recurrence rate after pericardiocentesis. We sought to confirm the efficacy of percutaneous balloon pericardiotomy as the initial treatment of choice for these effusions.

METHODS

Retrospective analysis of the clinical, echocardiographic, and follow-up characteristics of a consecutive series of percutaneous balloon pericardiotomies carried out in a single center in patients with advanced cancer.

RESULTS

Seventeen percutaneous balloon pericardiotomies were performed in 16 patients with a mean age of 66.2 (15.2) years. Fourteen patients had pathologically confirmed metastatic neoplastic disease, 3 had previously required pericardiocentesis, and in the remaining patients percutaneous balloon pericardiotomy was the first treatment for the effusion. All patients had a severe circumferential effusion, and most presented evidence of hemodynamic compromise on echocardiography. In all cases, the procedure was successful, there were no acute complications, and it was well tolerated at the first attempt. There were no infectious complications during follow-up (median, 44 [interquartile range, 36-225] days). One patient developed a large pleural effusion that did not require treatment. Three patients needed a new pericardial procedure: 2 had elective pericardial window surgeries and 1 had a second percutaneous balloon pericardiotomy.

CONCLUSIONS

Percutaneous balloon pericardiotomy is a simple, safe technique that can be effective in the prevention of recurrence in many patients with severe malignant pericardial effusion. The characteristics of this procedure make it particularly useful in this group of patients to avoid more aggressive, poorly tolerated approaches.

Percutaneous balloon pericardiotomy for the treatment of recurrent malignant pericardial effusion

Malignant disease with pericardial metastasis is one of the most common causes of recurrent pericardial effusion (PE) with tamponade. While surgical pericardiotomy in these patients is very morbid and may not be a viable option, a palliative treatment percutaneously with percutaneous balloon pericardiotomy (PBP) can be a preferred treatment. We report herewith a case of PBP technique done using our day-to-day catheterisation laboratory equipment.

Diagnosis and management of pericardial effusion

Pericardial effusion is a common finding in everyday clinical practice. The first challenge to the clinician is to try to establish an etiologic diagnosis. Sometimes, the pericardial effusion can be easily related to a known underlying disease, such as acute myocardial infarction, cardiac surgery, end-stage renal disease or widespread metastatic neoplasm. When no obvious cause is apparent, some clinical findings can be useful to establish a diagnosis of probability. The presence of acute inflammatory signs (chest pain, fever, pericardial friction rub) is predictive for acute idiopathic pericarditis irrespective of the size of the effusion or the presence or absence of tamponade. Severe effusion with absence of inflammatory signs and absence of tamponade is predictive for chronic idiopathic pericardial effusion, and tamponade without inflammatory signs for neoplastic pericardial effusion. Epidemiologic considerations are very important, as in developed countries acute idiopathic pericarditis and idiopathic pericardial effusion are the most common etiologies, but in some underdeveloped geographic areas tuberculous pericarditis is the leading cause of pericardial effusion. The second point is the evaluation of the hemodynamic compromise caused by pericardial fluid. Cardiac tamponade is not an "all or none" phenomenon, but a syndrome with a continuum of severity ranging from an asymptomatic elevation of intrapericardial pressure detectable only through hemodynamic methods to a clinical tamponade recognized by the presence of dyspnea, tachycardia, jugular venous distension, pulsus paradoxus and in the more severe cases arterial hypotension and shock. In the middle, echocardiographic tamponade is recognized by the presence of cardiac chamber collapses and characteristic alterations in respiratory variations of mitral and tricuspid flow. Medical treatment of pericardial effusion is mainly dictated by the presence of inflammatory signs and by the underlying disease if present. Pericardial drainage is mandatory when clinical tamponade is present. In the absence of clinical tamponade, examination of the pericardial fluid is indicated when there is a clinical suspicion of purulent pericarditis and in patients with underlying neoplasia. Patients with chronic massive idiopathic pericardial effusion should also be submitted to pericardial drainage because of the risk of developing unexpected tamponade. The selection of the pericardial drainage procedure depends on the etiology of the effusion. Simple pericardiocentesis is usually sufficient in patients with acute idiopathic or viral pericarditis. Purulent pericarditis should be drained surgically, usually through subxiphoid pericardiotomy. Neoplastic pericardial effusion constitutes a more difficult challenge because reaccumulation of pericardial fluid is a concern. The therapeutic possibilities include extended indwelling pericardial catheter, percutaneous pericardiostomy and intrapericardial instillation of antineoplastic and sclerosing agents. Massive chronic idiopathic pericardial effusions do not respond to medical treatment and tend to recur after pericardiocentesis, so wide anterior pericardiectomy is finally necessary in many cases.

Neoplastic pericardial disease: Old and current strategies for diagnosis and management

The prevalence of neoplastic pericardial diseases has changed over time and varies according to diagnostic methods. The diagnostic factor is usually the detection of neoplastic cells within the pericardial fluid or in specimens of pericardium, but the diagnosis may be difficult. Accurate sampling and cytopreparatory techniques, together with ancillary studies, including immunohistochemical tests and neoplastic marker dosage, are essential to obtain a reliable diagnosis. The goals of treatment may be simply to relieve symptoms (cardiac tamponade or dyspnea), to prevent recurrent effusion for a long-term symptomatic benefit, or to treat the local neoplastic disease with the aim of prolonging survival. Immediate relief of symptoms may be obtained with percutaneous drainage or with a surgical approach. For long term prevention of recurrences, various approaches have been proposed: extended drainage, pericardial window (surgical or percutaneous balloon pericardiostomy), sclerosing local therapy, local and/or systemic chemotherapy or radiation therapy (RT) (external or with intrapericardial radionuclides). The outcomes of various therapeutic approaches vary for different tumor types. Lymphoma and leukemias can be successfully treated with systemic chemotherapy; for solid tumors, percutaneous drainage and the use of systemic and/or local sclerosing and antineoplastic therapy seems to offer the best chance of success. The use of "pure" sclerosing agents has been replaced by agents with both sclerosing and antineoplastic activity (bleomycin or thiotepa), which seems to be quite effective in breast cancer, at least when associated with systemic chemotherapy. Local chemotherapy with platinum, mitoxantrone and other agents may lead to good local control of the disease, but the addition of systemic chemotherapy is probably relevant in order to prolong survival. The surgical approach (creation of a pericardial window, even with the mini-invasive method of balloon pericardiostomy) and RT may be useful in recurring effusions or in cases that are refractory to other therapeutic approaches.

Case report: Percutaneous balloon pericardiotomy using Inoue balloon for patients with massive pericardial effusion

Two patients presenting with huge pericardial effusion were treated with pericardiotomy, using an Inoue balloon dilating catheter, to prevent recurrences and achieve symptoms relief. The procedure is a modification of an original technique reported by Palacios et al. gaining advantage of the Inoue balloon self positioning abilities and low profile. No early recurrence was observed. In both cases the effect was excellent and lead to quick ambulation sparing the patients the risk of more aggressive surgical procedure and general anesthesia. It is concluded that percutaneous balloon pericardiotomy supported by the Inoue balloon unique versatility is a simple and safe way to drain massive pericardial effusions.

A randomised trial of intrapericardial bleomycin for malignant pericardial effusion with lung cancer (JCOG9811)

Safety and efficacy of intrapericardial (i.p.c.) instillation of bleomycin (BLM) following pericardial drainage in patients with malignant pericardial effusion (MPE) remain unclear. Patients with pathologically documented lung cancer, who had undergone pericardial drainage for MPE within 72 h of enrolment, were randomised to either arm A (observation alone after drainage) or arm B (i.p.c. BLM at 15 mg, followed by additional i.p.c. BLM 10 mg every 48 h). The drainage tube was removed when daily drainage was 20 ml or less. The primary end point was survival with MPE control (effusion failure-free survival, EFFS) at 2 months. Eighty patients were enrolled, and 79 were eligible. Effusion failure-free survival at 2 months was 29% in arm A and 46% in arm B (one-sided P=0.086 by Fisher's exact test). Arm B tended to favour EFFS, with a hazard ratio of 0.64 (95% confidence interval: 0.40-1.03, one-sided P=0.030 by log-rank test). No significant differences in the acute toxicities or complications were observed. The median survival was 79 days and 119 days in arm A and arm B, respectively. This medium-sized trial failed to show statistical significance in the primary end point. Although ipc BLM appeared safe and effective in the management of MPE, the therapeutic advantage seems modest.

Primary percutaneous balloon pericardiotomy for malignant pericardial effusion

OBJECTIVES

Pericardial effusion associated with malignancy is a life-threatening complication of late-stage disease. While simple drainage is effective in relieving the symptoms, reaccumulation of effusion may cause further symptomatic episodes, often during a period when overall patient management is focused on improving the quality of remaining life. Over a 16-year period, we have adopted a strategy of managing such patients with balloon pericardiotomy as the initial preferred treatment. The results are described and compared to alternative management strategies.

METHODS

A retrospective analysis of patients who presented with symptomatic, malignant pericardial effusion, their management, procedural complication rates, and the need for further therapy for the same condition was made. Survival, reaccumulation rates, and readmissions after the index procedure were recorded and compared.

RESULTS

Forty-three patients were treated for malignant pericardial effusion. Balloon pericardiotomy was the primary treatment in 27/43 patients, simple drainage in 14/43, and surgery in 2/43. Reaccumulation rates between balloon pericardiotomy and simple aspiration (7.4% vs. 14.3%, respectively, P = 0.48) and complication rates (7.4% vs. 7.1%, respectively, P = 0.98) were not statistically different. Survival following intervention was driven by the underlying pathology and was poor, with overall median survival of 56 days.

CONCLUSIONS

Balloon pericardiotomy, as initial management of symptomatic malignant pericardial effusions, allows a definitive procedure to be performed at presentation. This can be achieved with low complication rates, similar to treatment by simple drainage.

Surgical Management of Symptomatic Pericardial Effusion in Patients with Solid Malignancies

BACKGROUND

Symptomatic pericardial effusion in patients with cancer may lead to a life-threatening event that requires diligent treatment, but the best surgical treatment is still controversial. The purpose of this study was to identify predictors of survival for patients with solid malignancies and symptomatic pericardial effusion, which might help to select the best surgical treatment for each patient.

METHODS

We retrospectively analyzed 47 patients with solid malignancies concomitant with symptomatic pericardial effusion who underwent surgery between 1994 and 2004. Overall survival was calculated from date of surgery, and prognostic importance of clinical and pathological variables was assessed.

RESULTS

The most common primary sites of disease were breast (46.8%) and lung (25.6%). Initial pericardiocentesis were performed in 29 patients; median volume of fluid drained was 480 mL. Median interval from the diagnosis of primary cancer to the development of pericardial effusion (pericardial effusion-free interval) was 34.8 months. Definitive surgical treatment was performed in 43 patients, as follows: subxiphoid pericardial window (n = 21); thoracotomy and pleuropericardial window (n = 10); pericardiodesis (n = 8); and videothoracoscopic pleuropericardial window (n = 4). Pericardiocentesis was the only procedure in four patients. Median follow-up was 2.9 months. Median overall survival was 3.7 months. Pericardial effusion-free interval longer than 35 months and more than 480 mL of fluid drained at initial pericardiocentesis were determinants of better survival.

CONCLUSIONS

Pericardial window and pericardiodesis seem to be safe and efficacious in treating effusion of the pericardium. Pericardial effusion-free interval and volume drained at initial pericardiocentesis are determinants of outcome.

Echocardiography in the diagnosis and management of pericardial disease

This review covers the role of echocardiography in the diagnosis and management of the main pericardial disorders. The sensitivity of echocardiography in detecting pericardial fluid is very high and this technique allows the detection of effusion as well as the definition of the size of effusion (small, moderate and severe). The evaluation of the pericardial sac should be carefully performed through all the echocardiographic windows, differentiating diffuse from loculated (regional) effusions. Several echocardiographic and Doppler signs allow an accurate diagnosis of cardiac tamponade. The role of echocardiography is extremely important in atypical clinical presentation such as in patients in the postoperative period after cardiac surgery. Moreover, drainage of the effusion is mandatory in the presence of cardiac tamponade and in this regard echo-guided pericardiocentesis is the gold-standard method. Finally this review covers the echocardiographic diagnosis of pericardial cysts and masses and constrictive pericarditis.

Pericarditis

Pericarditis (inflammation of the pericardium) may be caused by infectious agents, autoimmune disorders, metabolic conditions, or malignancy, or it may be a complication of drug therapy, trauma, cardiac surgery, or smallpox vaccination. Diagnosis, based on clinical findings, electrocardiographic changes, chest radiograph, and ultrasound, may be confirmed as appropriate by pericardiocentesis. Although contemporary imaging technologies, such as computed tomography and magnetic resonance imaging, are useful, echocardiography remains the simplest and most expeditious noninvasive tool to assess inflammatory and infectious diseases of the pericardium. Although contemporary management of pericardial disease remains relatively unchanged, reports of innovative approaches to the management of pericardial effusion include the installation of intrapericardial thrombolytic agents to facilitate drainage of purulent effusions or balloon pericardiotomy for recurrent effusions. Both offer potential alternatives to the surgical pericardial window.

Cardiac tamponade

Cardiac tamponade is a common cardiac emergency requiring prompt diagnosis and intervention. A thorough understanding of the spectrum of clinical and hemodynamic changes in patients with pericardial effusion is vital for interventional cardiologists. This review discusses pathophysiology of cardiac tamponade with emphasis on hemodynamic aberrations. Specific clinical situations that lead to atypical hemodynamic presentations of cardiac tamponade are emphasized with a review of various diagnostic and therapeutic procedures.

Percutaneous treatment in patients presenting with malignant cardiac tamponade

The percutaneous treatment of pericardial effusion resulting in cardiac tamponade has undergone an evolution in recent years with the use of less invasive drainage techniques in selected cases. To determine optimal therapy modalities for oncology patients with malignant pericardial tamponade (MPT), the authors review their institutional experience with percutaneous needle puncture routes, means of imaging-guided drainage and percutaneous management of the pericardial fluid effusion (pericardial sclerosis and balloon pericardiotomy). Advantages and limits of the percutaneous techniques will be compared to the surgical treatment.

Cardiac tamponade, constrictive pericarditis, and restrictive cardiomyopathy

The pericardium envelopes the cardiac chambers and under physiological conditions exerts subtle functions, including mechanical effects that enhance normal ventricular interactions that contribute to balancing left and right cardiac outputs. Because the pericardium is non-compliant, conditions that cause intrapericardial crowding elevate intrapericardial pressure, which may be the mediator of adverse cardiac compressive effects. Elevated intrapericardial pressure may result from primary disease of the pericardium itself (tamponade or constriction) or from abrupt chamber dilatation (eg, right ventricular infarction). Regardless of the mechanism leading to increased intrapericardial pressure, the resultant pericardial constraint exerts adverse effects on cardiac filling and output. Constriction and restrictive cardiomyopathy share common pathophysiological and clinical features; their differentiation can be quite challenging. This review will consider the physiology of the normal pericardium and its dynamic interactions with the heart and review in detail the pathophysiology and clinical manifestations of cardiac tamponade, constrictive pericarditis, and restrictive cardiomyopathy.

Linfoma cardíaco primario: diagnóstico mediante biopsia transyugular

Primary cardiac lymphoma, defined as a non-Hodgkin's lymphoma involving only the heart and pericardium, is an extremely rare malignancy. It should be suspected in patients with a heart mass and heart failure, unexplained refractory pericardial effusion or rhythm disturbances. Transvenous intracardiac tumor biopsy under fluoroscopic or transesophageal echocardiographic guidance, is a minimally invasive technique which makes definite diagnosis possible. We describe a patient in whom primary cardiac lymphoma was diagnosed by this technique. He also underwent percutaneous balloon pericardiotomy because of severe refractory pericardial effusion. Seven months after diagnosis and treatment with standard chemotherapy, the patient remained free of disease.