From the Guidelines
Management of pericardial effusion is primarily focused on treating the underlying cause and relieving symptoms, with pericardiocentesis being a class I indication for cardiac tamponade.
Key Management Strategies
- Pericardiocentesis: indicated for cardiac tamponade, large pericardial effusions (≥ 2cm), or for diagnostic purposes 1
- Systemic antineoplastic treatment: recommended as baseline therapy for large suspected neoplastic pericardial effusion without tamponade 1
- Intrapericardial instillation of cytostatic/sclerosing agents: may be used to prevent recurrences of malignant pericardial effusion 1
- Pericardial drainage: recommended in all patients with large effusions due to high recurrence rate 1
Treatment Options
- Pericardiocentesis with prolonged pericardial drainage: may be considered to promote adherence of pericardial layers and prevent further accumulation of fluid 1
- Pericardiectomy or pericardial window: may be considered for recurrent effusions or when biopsy material is required 1
- Intrapericardial injection of chemotherapeutic agents: may be used in some cases, such as intrapericardial cisplatin for malignant pericardial effusion 1
Important Considerations
- Echocardiography: is the imaging modality of choice for diagnosing pericardial effusion and cardiac tamponade 1
- Prognosis: is essentially related to the aetiology of the pericardial effusion, with large effusions having a worse prognosis 1
- Follow-up: is mainly based on evaluation of symptoms and echocardiographic size of the effusion, as well as additional features such as inflammatory markers 1
From the Research
Management of Pericardial Effusion
The management of pericardial effusion is guided by the hemodynamic effect, the presence of concomitant pericarditis or underlying disease, and its size and duration 2. The following are key considerations in the management of pericardial effusion:
- Assessment of size and hemodynamic importance: The first step is to assess the size of the pericardial effusion and its hemodynamic importance, as well as possible associated diseases 3.
- Treatment of underlying cause: Treatment should be targeted at the etiology as much as possible 3.
- Conservative management: 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.
- Pericardiocentesis: Large effusions can be treated with closed pericardiocentesis after routine evaluation for possible etiologies 4. Pericardiocentesis is also indicated for patients presenting with actual or impending tamponade 4.
- Placement of pericardial catheter: Placement of a pericardial catheter for 2-5 days is advised after pericardial fluid removal 5.
- Sclerosing therapies and pericardial window: Other treatment options include sclerosing therapies and pericardial window, which may be considered for recurrent or loculated effusions 6, 3.
- Empiric anti-inflammatory therapy: Empiric anti-inflammatory therapy may be worthwhile when diagnosis is still unclear, or idiopathic and inflammatory markers are elevated 3.
- Monitoring: The best frequency and timing of monitoring by echocardiography are yet to be established, especially for stable patients with large pericardial effusions 5.
Special Considerations
- Oncological patients: Cancer-related pericardial effusion is commonly the result of localization of lung and breast cancer, melanoma, or lymphoma to the pericardium, and drainage is needed when it leads to hemodynamic impairment 5.
- Immune checkpoint inhibitors: Pericardial effusion secondary to immune checkpoint inhibitors typically responds to corticosteroid therapy 5.
- Tuberculosis: Tuberculosis is a common cause of pericardial effusion in developing countries, and its diagnosis and treatment should be considered in the appropriate clinical context 2, 3.