Comparison of Posterior Pleural Pericardial Window and Pericardiocentesis in Patients with Cardiac Tamponade

Abstract

Objective: 

In our study, we aimed to compare the results of patients who underwent pericardiocentesis and posterior pleura-pericardial window in the treatment of cardiac tamponade.

Materials and Methods: 

The results of all patients presenting to our hospitals with cardiac tamponade and who underwent pericardiocentesis and/or posterior pleural pericardial window (PPPW) between January 2010 and May 2021 were compared and analyzed in a retrospective review. They were divided into Group A comprising 37 patients who underwent pericardiocentesis, and Group B comprising 37 patients who underwent PPPW.

Results: 

The mean age was 62.8 ± 7.6 years, with 54.1% males in Group A compared to 59.5 ± 12.3 years and 62.2% males in Group B. The most common etiology in Groups A and B was idiopathic in 24.3% and 16.2%, respectively. Atrial fibrillation occurred in 32.4% versus 10.8% in Groups A and B, respectively (P < 0.02), and recurrent cardiac tamponade in 24.3% versus 5.4% in Groups A and B, respectively (P < 0.02). The 30 days' mortality was 5.4% versus 10.8% in Groups A and B, respectively (P < 0.39).

Conclusions: 

Pericardiocentesis is a safe and effective treatment for cardiac tamponade in select cases; however, PPPW was associated with a lower incidence of postoperative atrial fibrillation and recurrent cardiac tamponade at 6 and 12 months' follow-up, respectively. PPPW appears a more effective treatment option, especially in recurrent pericardial effusion.

INTRODUCTION

Cardiac tamponade, which causes hemodynamic abnormalities and multiorgan failure due to increased pericardial pressure, is a serious disease with fatal outcomes.[¹] The causes of pericardial tamponade are malignant diseases (30%–60%), uremia (10%–15%), idiopathic pericarditis (5%–10%), infectious diseases (5%–10%), anticoagulant therapy (5%–10%), connective tissue diseases (2%–6%), and Dressler's syndrome (1%–2%). There are various procedures used in the treatment of acute and recurrent tamponade. Both drainage methods, percutaneous or open surgery, are effective in rapidly reducing intrapericardial pressure.[²] In cases requiring emergency treatment, echocardiographically guided pericardiocentesis has been shown to be a safe and effective procedure that can be performed at the bedside.[³] The treatments goals include the relief of tamponade, the reduction of recurrent effusion, prevention and diagnosis of the underlying disease.[⁴] Surgical drainage may be the preferred treatment for traumatic hemopericardium, purulent pericarditis, recurrent effusions and when pericardial tissue is required for diagnosis.[⁵] The optimal treatment method for life-threatening pericardial effusion and tamponade is controversial. The aim of this retrospective study is to compare the results of posterior pleural pericardial window (PPPW) and pericardiocentesis treatment in patients presenting with cardiac tamponade.

MATERIALS AND METHODS

Our study, which is in accordance with the Declaration of Helsinki, is E-92198657-772.02 no and was approved by the regional ethics committee. Patients who presented to Yozgat State City Hospital, Van and Bozok University Medical Faculty Hospitals with the diagnosis of cardiac tamponade and underwent pericardiocentesis and/or PPPW for treatment were evaluated for screening. The diagnosis was made with clinical and echocardiographic criteria.[⁵] In echocardiography, early diastolic collapse in the right ventricle, late diastolic collapse in the right or left atrium, and fluid accumulating in the inferior vena cava were evaluated as findings in favor of tamponade.[⁶] The procedure was considered successful after the pericardial fluid was drained and the tamponade resolved. Patients who underwent pericardiocentesis were classified as Group A and PPPW as Group B, with 37 patients in each cohort. The groups were evaluated in terms of demographics, etiology, additional comorbidities, and admission symptoms. During the procedure, the size, characteristics of the effusion, and any complications were noted. The groups were compared in terms of recurrence, arrhythmia, mortality, and general conditions. The mean drainage throughout the treatment, mortality up to 40 days, rhythm changes up to the 6^th month, and the number of symptoms and recurrences up to the 1^st year were compared. Major complications were ventricular arrhythmia disrupting hemodynamics, pneumothorax, cardiogenic shock, urgent need for surgery due to procedure, and iatrogenic cardiac perforation. Minor complications were low cardiac output, transient arrhythmia, and hypotension that improved with medical treatment. Group A patients presented with tamponade were diagnosed radiologically, cardiac effusion drainage was urgent and did not require cardiac surgery primarily.

Group B patients were cases requiring cardiac surgery due to tamponade and cases of recurrent tamponade after pericardiocentesis.

Study inclusion criteria: Patients diagnosed with tamponade who underwent either pericardiocentesis or PPPW for treatment.

Study exclusion criteria: Patients missing data on the compared parameters from the files or records.

Once cardiac tamponade was diagnosed treatment approach is to be determined by etiological reason. Pericardiocentesis or PPPW with left ministernotomy was preferred in the treatment of patients who developed tamponade for the first time, such as systemic diseases, malignancy, uremia, pericarditis, and connective tissue diseases.

In cases of cardiac tamponade as a result of aortic dissection or aneurysm rupture, penetrating heart injury, median sternotomy, and PPPW treatment were performed for drainage after emergency surgery. Left ministernotomy and PPPW were performed in patients who had previously been treated with pericardiocentesis for pericardial effusion who developed a recurrent cardiac tamponade. PPPW was applied to five patients who underwent pericardiocentesis and developed recurrent tamponade. Three of them were idiopathic; the others had malignancy and Behçet's disease [Figure 1].

Figure 1: Surgical preference algoritm.

Procedures

Subxiphoid surgery

A 10 ml syringe is connected to the 18G puncture needle. The needle is inserted into the skin at a 30° angle, 1 cm below the left xiphocostal angle, with the tip pointing toward the left shoulder. Meanwhile, the path of the needle from the apical four-chamber view to the right ventricle and atrium is followed by echocardiography. If bloodless fluid or noncoagulating blood enters the syringe during aspiration, it has entered the pericardial space. The soft J-tipped guidewire is advanced through the needle into the pericardial space, and the needle is removed, and the wire is left in place.

After the skin is cut with a scalpel, a 6F dilator is advanced over the wire to expand the subcutaneous and pericardium. The dilator is then removed and a multi-hole soft pigtail catheter over the wire is inserted into the pericardial space and sutured to the skin. In order to relieve the clinical situation, a triple tap is attached to the tip of the catheter with a 50 ml syringe, and then removing enough fluid to relieve the tamponade. About 100–300 ml of fluid is actively withdrawn and after free flow was established and the clinical condition improved, the catheter is connected to a collection bag, and free drainage is allowed for up to 2–5 days [Figure 2a and b].

Figure 2: (a) Cardiac tamponade Echo, (b) subxiphoid pericardiocenthesis and drenaige catheter.

Apical pericardiocenthesis

On the left, the intersection of the mid-clavicular line and the 5^th or 6^th intercostal space; the apex is designated as the entry site. In order not to damage the left internal mammary artery, puncture should not be performed at a distance of 4–5 cm to the left of the sternum. The patient is placed supine at an angle of 30°–45°. To view the right shoulder, an 18 G puncture needle is inserted over the 6^th rib and aspirated and advanced. When nonhemorrhagic pericardial fluid or noncoagulating blood comes in, a J-tipped guidewire is inserted through the needle and the puncture needle is removed. A 28 F caliber chest tube was inserted. Pericardial effusion is aspirated, and a fluid sample is sent for histological examination.

Posterior pleural pericardial window

This is performed using the left anterior thoracotomy technique. Under general anesthesia, with patient in the left lateral decubitus position, the chest is opened through the 5^th intercostal space and the left lung is deflated.

An inverted t-shaped incision 2.5 cm in length and width is made approximately 2 cm above the phrenic nerve. A 28 F silicone tube is inserted through the left midaxillary seventh intercostal space into the left pleural space. The tube is fixed with 4-0 silk sutures. A drainage tube in the pleural space is left for free drainage for up to 2–5 days [Figure 3].

Figure 3: (a-c) İncision for pericardial window and pericardial catheter tube.

Statistical analysis

Statistical analysis was performed with SPSS 25.0 program (IBM SPSS, Chicago, IL, USA). Descriptive data are reported as percentages and numbers. Pearson's Chi-square test and Fisher's exact test were used for comparisons between groups in terms of categorical variables. With the Kolmogorov–Smirnov test, it was verified whether the continuous variables were suitable for the normal distribution. Differences between groups were made with the Student's t-test. The results were evaluated with a 95% confidence interval and P values lower than 0.05 were accepted as statistically significant. So, [Table 2] Aneurysm and dissection results were significant. [Table 3] Purulant characteristic was statistically significant. Table 4 Atrial Fibrilation, Total arrhythmia, No effusion with symptom under 1 cm, Tamponade recurrence were statistically significant.

RESULTS

Our cases consisted of 74 patients, 37 in each of Group A (Pericardiocentesis) and Group B (PPPW). The mean age of the patients was 62.84 ± 7.62 years in Group A and 59.54 ± 12.39 years in Group B. In Group A, 45.9% were females, 54.1% were males, 37.8% had hypertension, 51.4% had diabetes mellitus, 37.8% had COPD and overall comorbidity rate was 78.4%. While the most common symptoms of Group A patients were dyspnea with 86.55%, tachycardia was the second most common symptom with 83.8%. In group A, subxiphoid approach was performed in all 37 cases, and subxiphoid + apical pericardiocentesis was performed in 4 patients (10.8%). While 37.8% of group B were females and 62.2% were males, 43.2% had hypertension, 40.5% had diabetes mellitus, 24.3% had COPD, while the group overall comorbidities was 73%. In these patients, tachycardia and dyspnea were seen with equal frequency with a rate of 94.6%. As shown in Table 1, there was no statistically significant difference between Groups A and B in terms of demographics and comorbidities.

Table 1: Demographic data and co-morbidity results

The etiologies of effusion causing cardiac tamponade were not uniform but were caused by different diseases. The most common cause of tamponade was idiopathic in both groups. The rate was 24.32% (9 patients) in Group A and 16.21% (6 patients) in Group B. While there were no cardiac injuries in Group A, there were 7 (18.91%) cases in Group B. Of 37 patients who underwent PPPW, 14 (37.83%) were cases of aneurysm, dissection, penetrating heart injury, and postoperative revisions, and they underwent median sternotomy while the remaining 23 (62.16%) underwent a left minithoracotomy. Similarly, while there were no aneurysm and dissection patients in Group A, there were 4 cases (10.81%) in Group B. As a result, there was a statistically significant difference between the groups in favor of group B in patients with penetrating heart injury, aneurysm, and dissection.

Table 2: Etiology of cardiac tamponade

The etiologies of cardiac tamponade are shown in Table 2. Dressler syndrome and warfarin overdose were the least common etiologies in both groups. Transthoracic echocardiogram (TTE) was performed in all patients and pericardial effusions of 2 cm or more in diameter were defined as majör (large), and those below 2 cm were determined as minör (small). Large pericardial effusion was found in 21 Group A patients and 28 in Group B. The effusion fluid samples taken were sent for biochemistry, microbiology, and pathological examinations. The most common characteristic fluid appearance was serous in 70.3% (26 patients) in those undergoing pericardiocentesis, and 51.4% (19 patients) in PPPW. While the incidence of hemorrhagic fluid was 37.8% (14 patients) in the PPPW group, compared to 10.8% (4 patients) in the pericardiocentesis group which was statistically significant. We classified the fluid samples with erythrocyte count between 100 and 150,000 cells/μl as sero-hemorrhagic and those with 150,000 cells/μl or greater as hemorrhagic effusion. While there was no significant difference between the groups in terms of sero-hemorrhagic characteristics, there was a significant difference with hemorragic effusion between the two groups [Table 3].

Table 3: Characteristics of effusions causing tamponade

Total mean drainage, mortality up to 40 days, rhythm changes up to 6 months and the number of symptoms and recurrences up to the 1^st year was compared. There was a statistically significant difference in the rate of atrial fibrillation which occured in 32.4% (12) versus 10.8% (4) of the Pericardiocentesis and PPPW groups, respectively. Although there was a difference in the rates of atrial flutter, ventricular tachycardia, and supraventricular tachycardia, it was not statistically significant. The PPPW operative time was 37.19 ± 8.92 min. The intraoperative drainage volüme and the postoperative drainage volüme were 1210.46 ± 338 mL in total. Pericardiocentesis catheter insertion and procedure time mean was recorded as 10.37 ± 6.12 min.

There was no procedure-related mortality in either group. The 30-day mortality, including in-hospital mortality in the PPPW group was 10.8% (4 patients), resulting from ventricular fibrillation in two cases, sepsis and low cardiac output in the other two patients. Thirty-day mortality in the pericardiocentesis group was 5.4% (2 patients) resulting from stroke and cancer lysis syndrome.

The incidence of total arrhythmias was 54.1% (20) in pericardiocentesis group compared to 29.7% (11) in the PPPW group. At 1-year follow-up, 18.9% (7) and 73.0% (27) in the pericardiocentesis and PPPW groups, respectively had no symptoms and effusion. Patients undergoing pericardiocentesis had a significantly higher incidence of recurrent tamponade and effusions <1 cm compared to PPPW group. Although there were differences in mortality and drainage, they were not statistically significant [Table 4].

Table 4: Postoperative complications and drainage

DISCUSSION

Pericardial tamponade is a serious condition that requires immediate intervention. In the treatment of tamponade, rapid and effective evacuation of the pericardial effusion is required. Echo-guided pericardiocentesis is an effective surgical drainage treatment method that is widely used in stable and unstable cardiac tamponade cases.[⁷] Pericardiocentesis is frequently preferred by cardiologists and cardiac surgeons in the treatment of tamponade despite its known limitations and risks.[⁸] The success rate of the procedure has been reported as 97% and complication rate 4.7%.[³] In our study, the pericardiocentesis complication rate was 5.2% compared to 2.7% in PPPW.

Pericardiocentesis has a relative contraindication in cases of aortic dissection and penetrating cardiac injury.[⁹] In cases of cardiac tamponade resulting from aortic dissection and penetrating cardiac injury, pericardial drainage without repair can rapidly drain circulating blood and result in cardiac arrest. To avoid this complication in our case series, patients with tamponade as a result of aneurysm, dissection, and penetrating cardiac injury underwent a median sternotomy for drainage and open heart surgery. It is possible to perform tamponade evacuation, cardiac repair with open heart surgery, and then perform PPPW for drainage. While median sternotomy was used for patients with dissection/aneurysm and cardiac injuries, PPPW via a left mini-thoracotomy was utilized in other patients. As in our series, it has been reported in the literature that PPPW is used for drainage of pericardial blood or fluid collection after open heart surgery requiring invasive intervention and in cases where noninvasive intervention is unsuccessful.[¹⁰¹¹¹²] Studies have shown that performing a PPPW after open heart surgery significantly reduces postoperative pericardial tamponade.[⁹] In our series, cardiac tamponade was not observed in patients undergoing open heart surgery and PPPW.

Although pericardiocentesis is easily available and quicker to perform compared to PPPW, it does have some limitations. In complicated effusions with adhesions and thrombosis that develop as a result of recurrent inflammatory processes, pericardiocentesis drainage is noneffective and carries an increased risk of iatrogenic cardiac injury.[¹³] Insufficiently drained fluid may affect cardiac filling after a while, leading to varying degrees of hemodynamic insufficiency. A surgical pericardial window should be considered for drainage of pericardial effusions that cannot be reached with percutaneous pericardiocentesis.[⁹¹³]

Recurrent pericardial effusions can develop in different systemic autoimmune diseases (such as systemic lupus erythematosus, rheumatoid arthritis, progressive systemic sclerosis, mixed connective tissue disease, Sjögren's syndrome, polyarthritis, giant cell arteritis, other systemic vasculitis). These effusions presentation can range from asymptomatic to cardiac tamponade.[¹⁴] In several studies comparing pericardiocentesis and surgical pericardial window techniques in the treatment of pericardial effusion; recurrence rates were lower in patients undergoing a surgical window.[^15161718]

In our multicenter review, it was observed that the rate of tamponade recurrence in patients who underwent pericardiocentesis was significantly higher than the group undergoing PPPW. We think that PPPW has an advantage over pericardiocentesis in effusion drainage over time.

Unlike pericardiocentesis, the resected pleural pericardial window continues to drain fluid after removal of the drainage tubes. However, a pericardial window in active infections and invasive cancer may potentially have the risk of spreading the existing pathology. We think that choosing pericardiocentesis technique as the first step will reduce the risk of spread in effusions causing tamponade. We used the pericardiocentesis technique in this group of patients (5.4%). However, there are studies showing that a subsequent pericardial window after the risk of spread is eliminated, can provide significant benefits in the treatment by allowing the effusion to be evacuated.[¹⁸¹⁹]

Atrial fibrillation was found to be significantly higher in the pericardiocentesis group than in the PPPW group. Studies comparing drainage techniques have shown that pericardial window techniques are superior in preventing atrial fibrillation.[¹³²⁰] We think that residual or reaccumulation of fluid or hematoma in the pericardium even in small amounts may play a role in triggering cardiac arrhythmias and atrial fibrillation probably through mechanical stimulation of the atrium from external compression. Our study results is limited by the relatively small number of cases in our series.

CONCLUSIONS

Pericardiocentesis performed under local anesthesia can be performed quickly and effectively relief cardiac tamponade. However, in cases with cardiac injury, aortic dissection, dense adhesions and recurrent effusions, the risk of complications increases and the effectiveness decreases. PPPW performed under general anesthesia though taking longer reduces the recurrence of cardiac tamponade and the rate of atrial fibrillation. There was no significant difference in morbidity and mortality between the two techniques.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.