Asian Cardiovasc Thorac Ann 1999;7:297-300
© 1999 Asia Publishing EXchange Pte Ltd
Subxiphoid Approach for Treatment of Pericardial Effusion
Ali Sarigül, MD,
Bora Farsak, MD,
M 
anser Ate
, MD,
Metin Demircin, MD,
lhan Paao
lu, MD
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Department of Thoracic and Cardiovascular Surgery Faculty of Medicine, Hacettepe University Ankara, Turkey
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For reprint information contact: Ali Sarigül, MD Tel: 90 312 490 6076 Fax: 90 312 490 5612 email: whotur{at}dominet.in.com.tr Yesilyurt Sokak, No. 7/3, Cankaya, Ankara 06680, Turkey.
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Abstract
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Subxiphoid pericardiotomy was the primary treatment in 305 patients with pericardial effusion from January 1984 to June 1996. There were 198 males and 107 females, ages ranged from 15 days to 75 years. The procedure was carried out with local anesthesia and sedation in 263 (86.2%) patients and under general anesthesia in 42 (13.8%). Median drainage was 975.25 ± 48.46 mL in 264 patients with benign effusion and 1131.25 ± 97.48 mL in 41 (13.4%) with malignant disease; cytology was positive in 14 of 38 (36.8%) and pericardial biopsy showed cancer in 12 of 36 (33.3%). Intraoperative complications in 22 patients (7.2%) included cardiac arrest in 12 (3.9%) of whom, 7 (2.3%) died. Overall 30-day mortality was 16.3%; it was 46.3% (19/41) in malignant cases versus 11.7% (31/264) in cases of benign effusion. Follow-up of 234 (91.8%) hospital survivors for 18 ± 3.62 months (range, 2 to 54 months) showed recurrent pericardial effusion needing further intervention in 31 (13.2%) of whom, 8 had cancer and 23 had benign disease. Median survival in benign cases was more than 107 days versus 56 days in malignant cases. Because of its acceptable mortality and morbidity, subxiphoid pericardiotomy is recommend as an initial procedure.
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Introduction
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Cardiac tamponade is defined as hemodynamically significant cardiac compression by accumulating peri-cardial contents, which evokes and defeats compensating mechanisms.1 A wide variety of pathologic conditions can cause pericardial effusion leading to pericardial tamponade and drainage is required to prevent cardiac decompensation and death. The effusion can be drained by a variety of approaches, the most popular being the subxiphoid and transthoracic approaches, pericardiocen-tesis, pericardial sclerosis, and video-assisted thoracos-copy. The most effective method of drainage is still controversial.
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Patients and Methods
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From January 1984 to June 1996, 305 patients underwent surgical treatment for pericardial effusion. Their records were reviewed retrospectively with regard to age, sex, etiology, methods of diagnosis, volume of fluid drained, mortality, morbidity, subsequent pericardiectomy, complications (myocardial infarction, pulmonary embolism, renal failure, pneumonia, pneumothorax), and death.
Two-dimensional echocardiography was chosen for diagnosis in almost all patients. Preoperative studies also included chest radiography, central venous pressure measurements, and catheterization. Right heart catheterization was performed in 15 patients (4.9%). All patients were treated via the subxiphoid approach. Xylocaine (0.5%) was used for local anaesthesia and sedation in 263 (86.2%) of the adult patients who could cooperate, whereas general anaesthesia was preferred in 42 (13.8%) patients who were mostly children. A midline incision was made from the xiphisternal junction, approximately 10-cm long, the linea alba was divided and the xiphoid lifted anteriorly. Fatty tissue was dissected away until the pericardium appeared as a fibrous membrane, it was then grasped with fine-toothed forceps and incised, allowing the fluid to escape. A 2 x 2-cm segment was removed and a drainage tube was placed through a separate stab wound to drain the pericardium for a few days. No antibiotics, steroids, cytotoxic drugs, or other agents were instilled into the pericardium. Pericardial samples were sent for culture and histological studies; additional culture, biochemistry, and cytological studies were carried out on samples of the fluid.
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Results
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There were 198 males and 107 females treated for pericardial effusion (male to female ratio, 1.85). The patients ranged in age from 15 days to 75 years with a mean (± standard deviation) age of 26.98 ± 11.12 years. The difference in age distribution among the two types of disease was not statistically significant in analysis of variance. However, all patients younger than 18 years had benign disease. The primary causes of pericardial effusion in these 305 patients are listed in Table 1
. Uremia was the most common cause, followed by infectious diseases, effusion of cardiac origin, and malignancy. Eighty-two (88.2%) of the patients with uremia, 41 (75.9%) with infection, 37 (90.2%) with malignancy, 50 (94.3%) with effusion of cardiac origin, and 39 (60.9%) of those with other causes had shortness of breath as the primary symptom. Evidence of cardiac tamponade (hypo-tension with systolic pressure less than 100 mm Hg and pulsus paradoxus greater than 10 mm Hg) was documented in 80 patients (30.3%) with benign disease and in 24 (58.5%) with malignancy.
In the 41 patients with malignancy and pericardial effusion, cytology was positive for malignancy in 14 (36.8%) of the 38 patients in whom it was carried out and negative in 24 (63.2%). Pericardial biopsy was positive in 12 (33.3%) of the 36 patients in whom it was performed and negative in 24 (66.7%). Eight (57.1%) of the 14 patients with malignancy and positive cytology also had positive pericardial biopsy results, whereas 5 (35.7%) had a negative biopsy. Four (16.7%) of 24 patients with malignancy and negative cytology had a positive pericardial biopsy and 19 (79.2%) had a negative biopsy. Types of malignancy in these 41 patients are listed in Table 2.
Drainage volumes ranged from 40 to 4000 mL with a mean drainage of 975.25 ± 48.46 mL in 264 patients with benign effusion. Among those with malignant disease, mean drainage was 1131.25 ± 97.48 mL, for those with uremia it was 1197.37 ± 96.17 mL, in patients with tuberculosis it was 1125 ± 49.67 mL, and the volumes were lower in those with other diagnoses. The median duration of drainage was 6 days in malignant cases, ranging from 1 to 23 days, and 4 days in benign cases, ranging from 1 to 12 days.
Twenty-two patients (7.2%) had intraoperative com-plications. Cardiac arrest occurred in 12 patients (3.9%) of whom, 7 (2.3%) died. Six (2%) had pneumothorax that was treated with a chest tube. The overall 30-day mortality was 16.4% while it was 46.3% (19/41) for patients with malignancy versus 11.7% (31/264) for those with benign effusion. Complications are listed in Table 3. Twenty-one of the 255 hospital survivors were lost to follow-up. The other 234 patients (91.8%) were followed up for 2 to 54 months, with a mean follow-up of 18 ± 3.62 months. Median survival after subxiphoid pericardiotomy in patients with benign disease was more than 107 days versus 56 days in patients with malignancy. Recurrent pericardial effusion requiring further surgical intervention was observed in 31 (13.2%) of the 234 patients followed up of whom, 8 had cancer and 23 had benign disease. Twenty-one patients underwent a subsequent pericardiectomy (9%). The time between the first operation and recurrence was 48 ± 3.5 days and recurrence was mostly seen in the cases of uremia.
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Discussion
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Patients with pericardial tamponade are critically ill and require expeditious drainage of the pericardial space. However, the optimal management of pericardial effusion remains controversial. Approaches advocated include the subxiphoid approach with a pericardial window and a left anterior thoracotomy or median sternotomy with creation of a pericardial window and varying degrees of peri-cardiectomy.2,3 Excellent results are achievable with all of these methods and the surgical option is often dictated by the etiology of the effusion and the condition of the patient.4,5 Recently, with the resurgence of interest in thoracoscopy and the advent of video-assisted thoraco-scopic surgery (VATS), drainage of pericardial effusion by thoracoscopic techniques has been described.6,7
Pericardiocentesis may provide temporary relief of tamponade but it is not adequate for definitive therapy. Markiewicz and colleagues8 and Wong and colleagues9 reported 83% and 32% incidences of recurrent tamponade, respectively, after successful needle pericardiocentesis and a 15% rate of serious complications. These com-plications included 1 death, 1 cardiac arrest, 1 aspiration of a subdiaphragmatic abscess, and 5 ventricular punctures.9 Although Piehler and colleagues3 suggested a strong correlation between recurrence and the amount of pericardium removed, no significant correlation was found in most reported series.2,3,10,11 Indeed, in the series of Daugirdas and colleagues,12 the pericardium was only incised.
Thoracotomy with either pericardiectomy or creation of a window was the mainstay of treatment for pericardial effusion until Fontanelle and colleagues2 reported excellent results using the subxiphoid approach for drainage. Proponents of this approach cite the safety, efficacy, and low morbidity of the procedure.11,13 In comparing the transthoracic and subxiphoid approaches, attention must be paid to operative mortality and morbidity, efficacy, and long-term survival. Long-term survival was not found to differ in several studies.11,13 This suggests that survival depends more on the underlying disease than on the type or route of the surgical procedure employed. There were some significant differences noted for morbidity. It has been well documented that thoracic incisions result in large decrements in pulmonary function, which are slow to resolve. Similar decrements can be seen after the subxiphoid approach but these return to normal much more quickly than those after thoracotomy. Thoracotomy has been shown to result in a higher incidence of respiratory and pleural complications.13 The long-term efficacy can be assessed on the basis of long-term survival, recurrent effusion, and constrictive changes following subxiphoid drainage; most series report recurrent disease in 3% to 20% of patients.3,11,13 In our study, the incidence of recurrent pericardial effusion needing further surgical intervention was 10.2% and this was mostly seen in uremic patients.
Reports of high recurrence rates after pericardial drainage have led to an interest in VATS pericardiectomy.1,3,6,7,14 Advocates of VATS pericardiectomy point out that it allows for extensive pericardial resection. However, our data, similar to those of most others, suggest that extensive pericardiectomy is not necessary. VATS pericardiectomy requires single-lung general anaesthesia in all cases and patients with pericardial tamponade also require needle pericardiocentesis before VATS pericardiectomy. These are significant considerations in such gravely ill patients.
Although subxiphoid drainage appears to be an excellent therapeutic choice for the majority of cases of troublesome pericardial effusion, certain patients may be better served by a more aggressive initial approach because of the high risk of constriction, especially pediatric patients with purulent pericarditis due to influenza and those with tubercular pericarditis or radiation pericarditis.35–18 Sugimoto and colleagues4 and Moores and colleagues11 suggested that the success of pericardial drainage is dependent on obliteration of the pericardial space with adhesions and they supported this theory with autopsy findings. As a result of our experience, we believe that the subxiphoid approach should be the standard initial procedure in most patients requiring drainage for effusive pericardial disease. In experienced hands, it has less morbidity and a shorter hospital stay than other techniques. It can be performed easily under local anesthesia and provides expeditious, effective, and durable treatment with an acceptable morbidity and mortality. It also avoids contamination of the pleural cavities and facilitates pericardial biopsy.
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References
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Abstract
Introduction
