What is the management of pericardial effusion?

Management of Pericardial Effusion

Pericardiocentesis is mandatory for cardiac tamponade regardless of etiology, and this represents the absolute priority intervention that supersedes all other management considerations. 1, 2

Immediate Assessment and Triage

Hemodynamic Evaluation

• Perform emergency pericardiocentesis immediately if cardiac tamponade is present, identified by dyspnea, tachycardia, pulsus paradoxus, hypotension, jugular venous distension, and echocardiographic findings of right ventricular diastolic compression, right atrial late diastolic collapse, inferior vena cava plethora, and abnormal ventricular septal motion. 1
• Use echocardiographic or fluoroscopic guidance during pericardiocentesis to minimize complications including myocardial laceration, pneumothorax, and mortality. 1, 2
• Temporarily administer intravenous fluids in dehydrated or hypovolemic patients while preparing for drainage. 2

Determine Size and Inflammatory Status

• Obtain transthoracic echocardiography as the first-line diagnostic tool to assess effusion size and hemodynamic impact. 1, 3, 4
• Measure inflammatory markers (CRP, ESR) to determine if the effusion is associated with systemic inflammation or pericarditis. 3, 4
• Consider CT or cardiac MRI when loculated effusion, pericardial thickening, masses, or associated chest abnormalities are suspected. 3, 4

Medical Management Algorithm

For Effusions WITH Inflammation/Pericarditis

First-line therapy consists of NSAIDs plus colchicine for at least 3 months with gradual tapering. 1, 3, 2, 4

• Administer aspirin 750-1000 mg three times daily OR ibuprofen 600 mg three times daily. 2
• Add colchicine 0.5 mg once or twice daily. 2
• Use aspirin (not other NSAIDs) for post-myocardial infarction pericarditis. 2, 4
• Taper treatment gradually over 3 months to prevent recurrence. 2

Second-line therapy with corticosteroids is reserved for patients with contraindications to or failure of first-line therapy. 3, 2, 4

• Corticosteroids carry higher recurrence rates and should not be first-line. 2
• Taper corticosteroids over a three-month period. 2
• Ensure patients are steroid-free for several weeks before any surgical intervention. 2

Third-line therapy for refractory cases includes azathioprine or cyclophosphamide. 3

For Isolated Effusions WITHOUT Inflammation

NSAIDs, colchicine, and corticosteroids are generally not effective for isolated effusions without inflammation. 1

• Target therapy at the underlying etiology when identified (60% of cases have an identifiable cause). 1
• Pericardiocentesis alone may be necessary for resolution of large effusions, but recurrences are common. 1

Indications for Drainage Beyond Tamponade

Perform pericardiocentesis for large pericardial effusions (≥20 mm or ≥2 cm), symptomatic moderate-to-large effusions not responsive to medical therapy, or suspected bacterial or neoplastic etiology. 1, 2

Drainage Technique and Duration

• Leave the drain in place for 3-5 days after pericardiocentesis. 1
• Consider prolonged pericardial drainage (up to 30 ml/24 hours) to promote adherence of pericardial layers and prevent reaccumulation. 1, 3
• Consider surgical pericardial window if drainage output remains high 6-7 days after pericardiocentesis. 1

Fluid Analysis

• Send pericardial fluid for chemistry, microbiology, and cytology. 1
• Cytological analysis is essential for confirmation of malignant pericardial disease. 2
• Consider pericardial or epicardial biopsy when malignancy is suspected and cannot be confirmed by less invasive means. 2

Etiology-Specific Management

Malignant Effusions

Systemic antineoplastic treatment is the baseline therapy for confirmed malignant effusions, with pericardial drainage recommended in all patients with large effusions due to high recurrence rates. 2, 4

• Consider intrapericardial instillation of cytostatic/sclerosing agents to prevent recurrences. 2, 4
• Use cisplatin for lung cancer pericardial involvement (93% and 83% free of recurrent effusions at 3 and 6 months, respectively). 1, 2
• Use thiotepa for breast cancer pericardial metastases. 2
• Tetracyclines as sclerosing agents control malignant effusion in 85% of cases, though side effects are frequent. 2
• Radiation therapy is very effective (93%) for radiosensitive tumors such as lymphomas and leukemias. 2

Tuberculous Pericarditis

Administer standard anti-TB drugs for 6 months to prevent constrictive pericarditis. 3, 2

• Consider empiric anti-TB chemotherapy for exudative pericardial effusion after excluding other causes in endemic areas. 2

Post-Cardiac Injury and Radiation-Induced Effusions

• Acute pericarditis following radiation therapy (occurring within days to months) is often self-limiting. 1
• Chronic pericarditis is often characterized as effusive-constrictive. 1
• Avoid anticoagulation in iatrogenic pericardial effusion as it increases risk of tamponade. 2

Surgical Options for Recurrent or Refractory Effusions

Effusions are more likely to recur with percutaneous pericardiocentesis compared with pericardiotomy, though there is no difference in length of stay or ICU admission. 1

Percutaneous Balloon Pericardiotomy

• Effective (90-97%) and safe for large malignant effusions with recurrent tamponade. 2, 4
• Creates pleuropericardial communication for fluid drainage. 2, 4

Surgical Pericardial Window

• Pericardial window via left minithoracotomy is safe and effective for malignant cardiac tamponade. 2, 4
• Consider when fluid reaccumulates, becomes loculated, or biopsy material is required. 1

Pericardiectomy

Pericardiectomy is indicated only for frequent and highly symptomatic recurrences resistant to medical treatment, pericardial constriction, or complications of previous procedures. 2

• Post-pericardiectomy recurrences can occur, possibly due to incomplete resection. 2

Monitoring and Follow-Up Strategy

Small Effusions (<10 mm)

• Mild idiopathic effusions are usually asymptomatic, have good prognosis, and do not require specific monitoring. 1, 3, 4

Moderate Effusions (10-20 mm)

Perform echocardiographic follow-up every 6 months for moderate idiopathic effusions. 1, 3, 2, 4

Large Effusions (>20 mm)

Large chronic effusions (>3 months) have a 30-35% risk of progression to cardiac tamponade and require more vigilant monitoring every 3-6 months. 1, 3, 2, 4

• Subacute (4-6 weeks) large effusions not responsive to conventional therapy with echocardiographic signs of right chamber collapse may have increased risk of progression and warrant preventive drainage. 1

Critical Pitfalls to Avoid

• Do not use anticoagulation in the setting of iatrogenic pericardial effusion. 2
• Do not use corticosteroids as first-line therapy due to higher recurrence rates. 2
• Do not assume slow heart rate (60-80 bpm) excludes tamponade in uremic patients, as autonomic impairment may prevent tachycardia despite fever and hypotension. 1
• Do not delay emergency pericardiocentesis when cardiac tamponade is suspected, as this is a life-threatening condition requiring immediate intervention. 1