From the Guidelines
Pericardiocentesis is the recommended treatment for cardiac tamponade and large pericardial effusions, as it can relieve symptoms and establish a diagnosis of malignant pericardial effusion. The management of pericardial effusion depends on the severity, cause, and hemodynamic impact of the condition. For small, asymptomatic effusions, observation may be sufficient while addressing the underlying cause. However, for symptomatic or large effusions, especially those causing cardiac tamponade, immediate pericardiocentesis is necessary to prevent further complications 1.
Diagnosis and Treatment
The diagnosis of pericardial effusion is typically made using echocardiography, which can confirm the presence of an effusion and assess its hemodynamic significance 2. Pericardiocentesis, guided by echocardiography or fluoroscopy, is the recommended treatment for cardiac tamponade and large pericardial effusions. The procedure involves inserting a needle through the chest wall into the pericardial space to remove fluid.
Recurrent Cases
In recurrent cases, a pericardial window procedure may be necessary to create a permanent drainage pathway. Anti-inflammatory medications like NSAIDs or colchicine may be prescribed for inflammatory causes, while corticosteroids like prednisone may be used for refractory cases 3. Patients should be monitored with serial echocardiograms to assess fluid reaccumulation.
Malignant Pericardial Effusion
For malignant pericardial effusions, systemic antineoplastic treatment is recommended, and extended pericardial drainage may be necessary to prevent effusion recurrence and provide intrapericardial therapy 4. Intrapericardial instillation of cytostatic/sclerosing agents, such as cisplatin or thiotepa, may also be considered to prevent recurrences. Radiation therapy may be considered for patients with radiosensitive tumors, such as lymphomas and leukemias.
Key Points
- Pericardiocentesis is the recommended treatment for cardiac tamponade and large pericardial effusions.
- Echocardiography is the imaging modality of choice for diagnosing pericardial effusion.
- Systemic antineoplastic treatment is recommended for malignant pericardial effusions.
- Extended pericardial drainage and intrapericardial instillation of cytostatic/sclerosing agents may be necessary to prevent effusion recurrence.
- Patients should be monitored with serial echocardiograms to assess fluid reaccumulation.
From the Research
Definition and Causes of Pericardial Effusion
- Pericardial effusion is a relatively common clinical condition with a variety of clinical manifestations ranging from incidentally discovered asymptomatic cases to life-threatening cardiac tamponade 5.
- The etiology encompasses idiopathic cases and forms secondary to different conditions, including autoimmune diseases, malignancies, metabolic disorders, etc. 5.
- Infections (viral, bacterial, especially tuberculosis), cancer, connective tissue diseases, pericardial injury syndromes, metabolic causes (i.e. hypothyroidism), myopericardial and aortic diseases are common causes of pericardial effusions 6.
Diagnosis and Assessment of Pericardial Effusion
- Echocardiography is essential to define the location and size of an effusion 7.
- The first step is to assess its size, hemodynamic importance, and possible associated diseases 6.
- Specific testing should be performed according to clinical suspicion, and the presence of elevated inflammatory markers and other criteria (chest pain, pericardial rubs, ECG changes) suggest pericarditis and management should be directed accordingly 6.
Management and Treatment of Pericardial Effusion
- Treatment should be targeted at the etiology as much as possible 6.
- 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 8.
- Large effusions can be treated with closed pericardiocentesis after routine evaluation for possible etiologies 8.
- 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 whenever fluid re-accumulates (especially with tamponade), becomes loculated, or biopsy material is required 6.
- In asymptomatic or minimally symptomatic chronic large idiopathic pericardial effusions, a conservative approach with watchful waiting seems the most reasonable option 5.