What is the management of pericardial effusion?

From the Guidelines

Pericardiocentesis is the primary intervention for symptomatic or large pericardial effusions, and it is recommended to relieve symptoms and establish the diagnosis of malignant pericardial effusion. The management of pericardial effusion depends on its severity, cause, and hemodynamic impact. Small, asymptomatic effusions often require only monitoring and treatment of the underlying cause. For symptomatic or large effusions, pericardiocentesis is performed under echocardiographic or fluoroscopic guidance with a subxiphoid approach, as recommended by the 2015 ESC guidelines 1. An indwelling catheter may be left for 24-72 hours for continued drainage.

Key Considerations

• In recurrent or loculated effusions, a pericardial window procedure may be necessary, as pericardiocentesis alone may not be sufficient to prevent recurrences 1.
• Medical management includes treating the underlying cause, such as antibiotics for bacterial infections, anti-inflammatory agents for autoimmune conditions, and using anti-inflammatory medications like colchicine, NSAIDs, or corticosteroids for inflammatory causes.
• Cardiac tamponade requires immediate drainage, and patients should be monitored with serial echocardiograms to assess effusion resolution.
• The prognosis varies widely based on the underlying etiology, with malignant effusions carrying a poorer prognosis than those caused by infection or inflammation.

Treatment Options

• Systemic antineoplastic treatment is recommended in confirmed cases of neoplastic aetiology 1.
• Extended pericardial drainage is recommended in patients with suspected or definite neoplastic pericardial effusion to prevent effusion recurrence and provide intrapericardial therapy 1.
• Intrapericardial instillation of cytostatic/sclerosing agents, such as cisplatin or thiotepa, may be considered to prevent recurrences in patients with malignant pericardial effusion 1.
• Radiation therapy may be considered to control malignant pericardial effusion in patients with radiosensitive tumours, such as lymphomas and leukaemias 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.

• Assessment of Pericardial Effusion: The first step is to assess the size, hemodynamic importance, and possible associated diseases of the pericardial effusion 3.
• Treatment: Treatment should be targeted at the etiology as much as possible 3.
• Asymptomatic Effusions: A small, asymptomatic pleural effusion of known etiology can be treated conservatively, mostly by treating the underlying cause and with careful observation for signs or symptoms of deterioration 4. A true isolated effusion may not require a specific treatment if the patient is asymptomatic 2, 3.
• Large Effusions: Large effusions can be treated with closed pericardiocentesis after routine evaluation for possible etiologies 4. Pericardiocentesis alone may be curative for large effusions, but recurrences are also common and pericardiectomy or less invasive options (i.e. pericardial window) should be considered with recurrent cardiac tamponade or symptomatic pericardial effusion 2, 3.
• Cardiac Tamponade: For patients presenting actual or impending tamponade, the definitive treatment is either closed or open pericardiocentesis, depending on fluid accumulation characteristics, and it should not be delayed for the administration of medical treatment (inotropes, intravenous fluids) 4. Pericardiocentesis is mandatory for cardiac tamponade and when a bacterial or neoplastic aetiology is suspected 2.
• Pericardial Biopsy: 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.
• Neoplastic Pericardial Effusion: Cancer-related pericardial effusion is commonly the result of localization of lung and breast cancer, melanoma, or lymphoma to the pericardium via direct invasion, lymphatic dissemination, or hematogenous spread 5. Drainage, which is mainly attained by pericardiocentesis, is needed when cancer or cancer treatment-related pericardial effusion leads to hemodynamic impairment 5.
• Monitoring: The best frequency and timing of monitoring by echocardiography in stable patients with large pericardial effusions are yet to be established 5.