Incidence and Management of Hemopericardium: Impact of Changing Trends in Invasive Cardiology.

OBJECTIVE: As invasive cardiovascular care has become increasingly complex, cardiac perforation leading to hemopericardium is a progressively prevalent complication. We sought to assess the frequency, etiology, and outcomes of hemorrhagic pericardial effusions managed through a nonsurgical echo-guided percutaneous strategy. PATIENTS AND METHODS: Over a 10-year period (January 1, 2007, to December 31, 2016), 1097 unique patients required pericardiocentesis for clinically important pericardial effusions. Of these 411 had drainage of hemorrhagic effusions (defined as a pericardial hemoglobin level >50% of serum hemoglobin or frank blood in the setting of cardiac perforation). Clinical characteristics, echocardiographic data, details of the procedure, and outcomes were determined. RESULTS: Median patient age was 67 years (interquartile range, 56-76 years), and 60% were men. The procedure was emergent in 83% and elective in 17%. The site of pericardiocentesis was determined by echo-guidance in all: 68% from the left para-apical region, 18% from the left or right parasternal areas, and 14% were subxyphoid. Half (n=215 [52%]) occurred after cardiac perforation with percutaneous interventional procedure (ablation, n=94; device lead implantation, n=65; percutaneous coronary intervention, n=22; other, n=34), whereas 30% followed cardiac or thoracic surgery. Pericardial fluid volume drained was 546±440 mL. In 94% of cases, echo-guided pericardiocentesis was the only treatment of the effusion needed, whereas definitive surgery was required in 25 (6%) cases for persistent bleeding or acute management of the underlying etiology. There was no procedural mortality. Late mortality was better for hemorrhagic effusions compared with a contemporary cohort with nonhemorrhagic effusions. CONCLUSION: Echocardiographic guidance allows rapid successful pericardiocentesis in the setting of hemopericardium related to microperforation with interventional procedures, malignancy, or pericarditis, with most not requiring surgical intervention. Surgery should remain the first-line approach for aortic dissection or myocardial rupture.

Safety and Outcome of Percutaneous Drainage of Pericardial Effusions in Patients with Cancer.

Malignancy is a common cause of pericardial effusions. The findings, immediate safety and longer-term outcomes of pericardiocentesis are less well defined. We reviewed the cases of all patients with malignancy that underwent pericardiocentesis at our institution over a 10-year period. From January 1, 2007 to December 31, 2016, 171 patients with cancer underwent echo-guided pericardiocentesis. A total of 53% were male with a mean age of 60 ± 15 years. The average volume drained was 485 (IQR 350 to 719) ml. The procedure was technically successful in 170/171 (99.4%) of patients without significant complications; there were no procedure-related deaths. A total of 20% had hemorrhagic, 48% had serosanguinous, and 31% serous pericardial effusions. The type of effusion was not associated with outcome. Cytology (measured in 164) was positive in 58% and only weakly related to outcome (median survival nine versus 18 weeks, p = 0.04). Per our institutional practice, a pericardial catheter was left in place until there were less than 50 ml of net drainage in 24 hours (average 3 ± 2 days). A total of 135 patients had metastatic carcinoma, 23 patients had lymphoma or chronic leukemia and 4 metastatic sarcoma. Patients with either lymphoma or chronic leukemia had better survival than those with carcinoma or sarcoma (median survival 102 vs 12 weeks, p < 0.0001) with a 46% vs 3% 5-year survival, p < 0.0001). Echoguided pericardiocentesis with extended pericardial catheter placement is safe and effective in cancer patients with pericardial effusions. However, overall outcomes are poor in cancer patients with pericardial effusions that required drainage, particularly in those with carcinoma or sarcoma.

Effusive-Constrictive Pericarditis After Pericardiocentesis: Incidence, Associated Findings, and Natural History.

OBJECTIVES: This study sought to investigate the incidence, associated findings, and natural history of effusive-constrictive pericarditis (ECP) after pericardiocentesis. BACKGROUND: ECP is characterized by the coexistence of tense pericardial effusion and constriction of the heart by the visceral pericardium. Echocardiography is currently the main diagnostic tool in the assessment of pericardial disease, but limited data have been published on the incidence and prognosis of ECP diagnosed by echo-Doppler. METHODS: A total of 205 consecutive patients undergoing pericardiocentesis at Mayo Clinic, Rochester, Minnesota, were divided into 2 groups (ECP and non-ECP) based on the presence or absence of post-centesis echocardiographic findings of constrictive pericarditis. Clinical, laboratory, and imaging characteristics were compared. RESULTS: ECP was subsequently diagnosed in 33 patients (16%) after pericardiocentesis. Overt clinical cardiac tamponade was present in 52% of ECP patients and 36% of non-ECP patients (p = 0.08). Post-procedure hemopericardium was more frequent in the ECP group (33% vs. 13%; p = 0.003), and a higher percentage of neutrophils and lower percentage of monocytes were noted on pericardial fluid analysis in those patients. Clinical and laboratory findings were otherwise similar. Baseline early diastolic mitral septal annular velocity was significantly higher in the ECP group. Before pericardiocentesis, respiratory variation of mitral inflow velocity, expiratory diastolic flow reversal of hepatic vein, and respirophasic septal shift were significantly more frequent in the ECP group. Fibrinous or loculated effusions were also more frequently observed in the ECP group. Four deaths occurred in the ECP group; all 4 patients had known malignancies. During median follow-up of 3.8 years (interquartile range: 0.5 to 8.3 years), only 2 patients required pericardiectomy for persistent constrictive features and symptoms. CONCLUSIONS: In a large cohort of unselected patients undergoing pericardiocentesis, 16% were found to have ECP. Pre-centesis echocardiographic findings might identify such patients. Long-term prognosis in those patients remains good, and pericardiectomy was rarely required.