72. Pericardial Effusion- Indications and Guidelines

Gregory P. Boyajian MD, Ravi K. Ghanta MD
Baylor College of Medicine
July 2024

Abbreviations & Definitions

ACE – American College of Echocardiography
AHA – American Heart Association
CMR – Cardiac magnetic resonance imaging
ESC – European Society for Cardiology
VATS – Video-assisted thoracoscopic surgery

Indications & Guidelines for Management by Grade/Stage of Disease

Overview

The pericardium typically holds up to 50 mL of serous fluid. Any collection greater than this is evidence of a pathologic process.1 Pericardial effusion can be classified by onset (acute, subacute, chronic), size (mild, moderate, large), distribution (circumferential or loculated), and composition (transudate, exudate).2 Effusions can also be classified by etiology (benign vs malignant, traumatic, viral, idiopathic, etc.) or physiologic effect (asymptomatic, tamponade).1 Few US society guidelines directly address the topic of pericardial effusion. Therefore, this chapter relies heavily on the European Society for Cardiology (ESC) guidelines, American College of Echocardiography (ACE) guidelines, and expert consensus.

Diagnosis and Definitions

Echocardiography is widely recognized as the primary tool to diagnose pericardial effusions.2–4 When cardiac tamponade is suspected, 2D echocardiography with Doppler should be obtained emergently.4 However, in a patient who has recently undergone cardiac surgery, effusions may contain small but hemodynamically significant clots that are diagnostically challenging by TTE. In this scenario, the ACE recommends using TEE, CT, or CMR if the patient’s condition allows. However, an unstable patient condition may warrant emergent reopening of sternotomy.

The ACE recommends measuring effusions in diastole at the widest distance between the visceral and parietal pericardium. Small effusions are defined as <10 mm (100-250 mL of fluid), moderate effusions are 10-20 mm (about 250-500 mL of fluid), large effusions are >20 mm (more than 500 mL of fluid), and very large effusions are >25 mm. However, it should be noted that effusion size definitions are arbitrary and correlate poorly with the hemodynamic effect on the heart.

Effusion chronicity may help determine etiology and prognosis. According to ASE guidelines, acute effusions develop in less than 1 week, subacute effusions develop over more than 1 week but less than 3 months, and chronic effusions persist for more than 3 months.4 Large idiopathic effusions are considered chronic if present for over 3 months and have a 30-35% risk of progressing to tamponade.5 Large subacute effusions (4-6 weeks) may also have an increased risk of progressing to tamponade if refractory to medical therapy.6

Surgical Intervention

Treatment of a pericardial effusion should be targeted at the underlying etiology of the effusion. There are generally two reasons to drain a pericardial effusion: for diagnosis or to relieve symptoms/tamponade. Some authors state that it is unnecessary to drain even moderate to large asymptomatic pericardial effusions unless a diagnosis is required, while others advocate for drainage of subacute and chronic large effusions to attenuate the risk of developing tamponade2,3 Interventions for pericardial effusion include pericardiocentesis and pericardial window. Treatment of non-traumatic effusion with pericardiocentesis is associated with a higher rate of recurrence and need for repeat procedures than treatment with a pericardial window.7,8 In patients with malignant pericardial effusions, a chemotherapy plus pericardial window treatment strategy may result in greater survival than chemotherapy plus pericardial drainage or chemotherapy alone.9 Two common techniques for pericardial windows include the subxiphoid and transthoracic approach. It is unclear which technique results in less effusion recurrence, as some data suggests that the techniques are equivocal while other studies show that a transthoracic approach results in less recurrence.10–12

Pathologic Evaluation

Malignancy is a common cause of pericardial effusion in tertiary care centers. Therefore, pericardial fluid should be collected for fluid cytology evaluation.13 Pathologic evaluation of pericardial tissue is a common practice during the surgical creation of a pericardial window but may not add significant diagnostic value. Patients with suspected purulent pericarditis should undergo pericardial drainage for diagnosis, and fluid should be sent for bacterial, fungal, and tuberculous studies.2 Chylopericardium results in a milky opalescent pericardial effusion, with a triglyceride level >500 mg/dl, a cholesterol:triglyceride ratio of 1, negative cultures, and lymphocyte predominance.2

Summary Table

Recommendation Evidence
Echocardiography is the primary tool for diagnosis of pericardial effusion 2–4
Hospital admission is recommended for high-risk patients with pericardial effusion 2
Pericardiocentesis or surgery is indicated for cardiac tamponade or for symptomatic moderate to large pericardial effusions not responsive to medical therapy, and for suspicion of unknown bacterial or neoplastic etiology (class I) 2
Urgent pericardiocentesis or surgery is recommended to treat cardiac tamponade (class I) 2
Effective pericardial drainage is recommended for purulent pericarditis 2

Supporting Evidence for Current Indications & Guidelines

Research into the topic of pericardial effusion is mostly limited to retrospective, single-center data. A notable exception to this was a prospective study of over 1000 patients with pericarditis. This study demonstrated that large, idiopathic, chronic pericardial effusion is well tolerated for long periods in most patients, but severe tamponade can develop unexpectedly at any time.5 Ultimately, the few formal society guidelines on pericardial effusion rely heavily on expert consensus.

Ongoing Trials/Recent Publications

There are currently no ongoing trials.

Expert Commentary

Pericardial effusions are frequently encountered by the cardiothoracic surgeon. Post-cardiac surgery pericardial effusions associated with tamponade physiology require emergent intervention usually via re-opening of sternotomy. Most ICUs have a “get in the chest quick” kit to facilitate rapid relief of post-operative tamponade, and understanding when and how to do this is an essential skill to be acquired during training. Delayed post-operative pericardial effusions require a nuanced approach depending on the timing and surgical approach of the primary operation. Patients who have not undergone cardiac surgery but present with large effusions or tamponade physiology should first undergo ultrasound-guided percutaneous drainage at the bedside. Patients with an asymptomatic pericardial effusion may be managed expectantly, but those with a symptomatic effusion should undergo drainage. There are multiple reasonable surgical approaches – including open subxiphoid pericardial window, left anterior thoracotomy, VATS pericardial window, and robot-assisted VATS pericardial window depending on surgeon preference and patient factors. Importantly, vigilance is required at the time of induction as the loss of afterload secondary to anesthetics can lead to hemodynamic collapse in patients with an undrained effusion. In higher-risk patients, pre-induction prepping and draping may be prudent. In patients with suspected malignancy, we send pericardial fluid for cytology and routinely send the excised pericardial tissue for permanent pathology in all patients. It is important to make at least an adequate size window (usually 3-5 cm) and to place a pericardial drain. We find it helpful to utilize TEE or TTE to confirm complete drainage of the effusion.

Sources

  1. Azarbal A, Lewinter MM. Pericardial Effusion. 2017;35:8651.
  2. Adler Y, Charron P, Imazio M, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases. Eur Heart J. 2015;36(42):2921-2964. doi:10.1093/eurheartj/ehv318
  3. Gulati M, Levy PD, Mukherjee D, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2021;78(22):2218-2261. doi:10.1016/j.jacc.2021.07.052
  4. Klein AL, Abbara S, Agler DA, et al. American society of echocardiography clinical recommendations for multimodality cardiovascular imaging of patients with pericardial disease: Endorsed by the society for cardiovascular magnetic resonance and society of cardiovascular computed tomography. J Am Soc Echocardiogr. 2013;26(9):965-1012.e15. doi:10.1016/j.echo.2013.06.023
  5. Sagristà-Sauleda J, Angel J, Permanyer-Miralda G, Soler-Soler J. Long-Term Follow-up of Idiopathic Chronic Pericardial Effusion. N Engl J Med. 1999;341(27):2054-2059. doi:10.1056/nejm199912303412704
  6. Little WC, Freeman GL. Pericardial disease. Circulation. 2006;113(12):1622-1632. doi:10.1161/CIRCULATIONAHA.105.561514
  7. Laham RJ, Cohen DJ, Kuntz RE, Baim DS, Lorell BH, Simons M. Pericardial effusion in patients with cancer: Outcome with contemporary management strategies. Heart. 1996;75(1):67-71. doi:10.1136/hrt.75.1.67
  8. Adam J. Saltzman, MD, Yehuda E. Paz, MD, A. Garvey Rene, MD, Philip Green, MD, Ahmed Hassanin, MD, Michael G. Argenziano, MD, Leroy Rabbani, MD, and George Dangas, MD P. Comparison of Surgical Pericardial Drainage With Percutaneous Catheter Drainage for Pericardial Effusion. J INVASIVE CARDIOL. 2012;24(11):590-593.
  9. Çelik S, Lestuzzi C, Cervesato E, et al. Systemic chemotherapy in combination with pericardial window has better outcomes in malignant pericardial effusions. J Thorac Cardiovasc Surg. 2014;148(5):2288-2293. doi:10.1016/j.jtcvs.2014.04.031
  10. Brien PKHO, Kucharczuk JC, Marshall MB, et al. Comparative Study of Subxiphoid Versus Video-Thoracoscopic Pericardial “Window.” Published online 2005. doi:10.1016/j.atthoracsur.2005.05.059
  11. Langdon SE, Seery K, Kulik A. Contemporary outcomes after pericardial window surgery: Impact of operative technique. J Cardiothorac Surg. 2016;11(1):1-6. doi:10.1186/s13019-016-0466-3
  12. Liberman M, Labos C, Sampalis JS, Sheiner NM, Mulder DS. Ten-year surgical experience with nontraumatic pericardial effusions: A comparison between the subxyphoid and transthoracic approaches to pericardial window. Arch Surg. 2005;140(2):191-195. doi:10.1001/archsurg.140.2.191
  13. Gornik HL, Gerhard-Herman M, Beckman JA. Abnormal cytology predicts poor prognosis in cancer patients with pericardial effusion. J Clin Oncol. 2005;23(22):5211-5216. doi:10.1200/JCO.2005.00.745
Previous Topic
Back to Lesson
Next Topic
error: Content is protected!