What is the best acute treatment for metastatic pericardial effusion?

From the Guidelines

The best acute treatment for metastatic pericardial effusion is pericardiocentesis, which involves draining the fluid from the pericardial space using a needle or catheter, typically under echocardiographic or fluoroscopic guidance. This procedure provides immediate relief of cardiac tamponade if present and can be both diagnostic and therapeutic.

Key Considerations

• Following drainage, placement of a pericardial catheter for continued drainage for 2-3 days is often beneficial to prevent reaccumulation.
• For recurrent effusions, more definitive options include pericardial window creation (surgical or percutaneous), pericardectomy, or intrapericardial sclerotherapy using agents like bleomycin (60 units), talc, or tetracycline.
• Systemic therapy targeting the underlying malignancy should be initiated concurrently, as recommended by the European Society of Cardiology 1.
• Corticosteroids (prednisone 40-60mg daily with taper) may help reduce inflammation, and NSAIDs like indomethacin (25-50mg three times daily) or colchicine (0.6mg once or twice daily) can also reduce inflammation and prevent reaccumulation.

Evidence-Based Recommendations

• The 2015 ESC guidelines for the diagnosis and management of pericardial diseases recommend pericardiocentesis as a class I indication for cardiac tamponade 1.
• The guidelines also recommend systemic antineoplastic treatment as baseline therapy, pericardiocentesis to relieve symptoms and establish diagnosis, and intrapericardial instillation of cytostatic/sclerosing agents to prevent recurrences 1.
• A study published in the European Heart Journal in 2015 found that pericardiocentesis was effective in relieving symptoms and preventing recurrences in patients with malignant pericardial effusion 1.

Clinical Decision-Making

• The urgency of intervention depends on hemodynamic compromise, with immediate drainage necessary for cardiac tamponade.
• The approach should address the immediate life-threatening aspects of pericardial effusion while allowing for longer-term management of the underlying malignancy.
• It is essential to consider the patient's overall quality of life and prognosis when making treatment decisions, as recommended by the European Society of Cardiology 1.

From the Research

Treatment Options for Metastatic Pericardial Effusion

The best acute treatment for metastatic pericardial effusion can be approached through different methods, including pericardiocentesis and surgical pericardial window.

• Pericardiocentesis: This procedure involves the removal of fluid from the pericardial space using a needle, often guided by imaging techniques such as echocardiography. Studies have shown that pericardiocentesis can be effective in managing symptomatic malignant pericardial effusion, with success rates ranging from 94% to 97% 2, 3. However, the recurrence rate of effusion after pericardiocentesis can be significant, ranging from 31% to 34% 4, 3.
• Surgical Pericardial Window: This involves the creation of a window in the pericardium to allow for the drainage of fluid. A study found that surgical pericardial window had a low failure rate (<5%) and provided an opportunity for continued therapy, potentially improving quality of life and survival in selected patients 5. Another study compared pericardiocentesis and surgical pericardial window, finding that while both procedures had similar success rates, the surgical pericardial window had a lower re-accumulation rate but a higher risk of major bleeding 3.

Factors Influencing Treatment Outcome

The outcome of treatment for metastatic pericardial effusion can be influenced by several factors, including:

• Type of Primary Cancer: The type of primary cancer can affect the recurrence rate and survival after treatment for malignant pericardial effusion. For example, patients with adenocarcinoma of the lung may have a higher recurrence rate and poorer survival compared to those with breast cancer or other types of cancer 4.
• Response to Chemotherapy: The response to chemotherapy can also impact the outcome of treatment for malignant pericardial effusion. Patients with progressive disease despite chemotherapy may have a higher risk of recurrence and poorer survival 4.

Intrapericardial Sclerotherapy and Chemotherapy

In addition to pericardiocentesis and surgical pericardial window, intrapericardial sclerotherapy and chemotherapy have been explored as treatment options for malignant pericardial effusion. A study found that intrapericardial administration of cisplatin was effective in preventing the re-accumulation of fluid in patients with malignant pericardial effusion 6. Another study found that intrapericardial sclerotherapy with tetracycline or 5-fluorouracil was not as effective as cisplatin in preventing recurrence 6.