From the Guidelines
Pericardiocentesis is the primary intervention for symptomatic or large pericardial effusions, and should be performed under echocardiographic or fluoroscopic guidance with a subxiphoid approach. Management of pericardial effusion depends on its severity, cause, and hemodynamic impact. Small, asymptomatic effusions often require only monitoring and treating the underlying cause 1. For symptomatic or large effusions, pericardiocentesis is the primary intervention, performed under echocardiographic or fluoroscopic guidance with a subxiphoid approach. In emergent cardiac tamponade, immediate drainage is necessary. Anti-inflammatory medications are used for inflammatory causes, including colchicine, NSAIDs like ibuprofen, or corticosteroids like prednisone 1. Recurrent effusions may require pericardial window creation or pericardiectomy. Neoplastic effusions might need sclerosing agents or intrapericardial chemotherapy 1. Patients should be monitored with serial echocardiography, with frequency determined by effusion size and clinical stability. The treatment approach balances addressing the underlying etiology while preventing complications like tamponade and recurrence, with the goal of relieving symptoms and preventing long-term sequelae.
Key Considerations
- The therapy of pericardial effusion should be targeted at the aetiology 1
- Aspirin/NSAIDs/colchicine and treatment of pericarditis is recommended when pericardial effusion is associated with systemic inflammation 1
- Pericardiocentesis or cardiac 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 aetiology 1
Treatment Options
- Pericardiocentesis: performed under echocardiographic or fluoroscopic guidance with a subxiphoid approach 1
- Anti-inflammatory medications: colchicine, NSAIDs like ibuprofen, or corticosteroids like prednisone 1
- Pericardial window creation or pericardiectomy: for recurrent effusions 1
- Sclerosing agents or intrapericardial chemotherapy: for neoplastic effusions 1
From the Research
Management of Pericardial Effusion
The management of pericardial effusion is guided by the haemodynamic impact, size, presence of inflammation, associated medical conditions, and the aetiology whenever possible 2.
Diagnosis and Treatment
- Pericardiocentesis is mandatory for cardiac tamponade and when a bacterial or neoplastic aetiology is suspected 2.
- Echocardiography plays a key role in the management of cardiac tamponade and must be consulted with regards to final treatment decisions 3.
- Pericardial biopsy is generally reserved for cases with recurrent cardiac tamponade or persistence without a defined aetiology, especially when a bacterial or neoplastic aetiology is suspected and cannot be assessed by other conventional and less invasive means 2.
- Colchicine may be effective in the treatment of large pericardial effusion when therapy with nonsteroidal anti-inflammatory drugs and/or corticosteroids fails 4.
- Intravenous immunoglobulin can be used in the treatment of cardiac tamponade in patients with systemic lupus erythematosus 5.
Approach to Pericardiocentesis
- Echocardiographically guided pericardiocentesis should be reserved for patients with hemodynamic compromise, an intrathoracic mass effect, or an uncertain cause 6.
- Not all patients with pericardial effusions require pericardiocentesis, and an algorithmic approach to the decision to perform pericardiocentesis is recommended 6.
- Pericardial puncture under echocardiographic and/or X-ray guidance can be used for significantly sized pericardial effusions, while inferior pericardiotomy can be used for limited sized but hemodynamically significant effusions 3.