treatment efusi

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Treatment

Approach Considerations

Pharmacotherapy for pericardial effusion includes use of the following agents, depending onetiology:

Aspirin/NSAIDs Colchicine Steroids Antibiotics

Antineoplastic therapy (eg, systemic chemotherapy, radiation) in conjunction with

pericardiocentesis has been shown to be effective in reducing recurrences of malignant effusions.Corticosteroids and NSAIDs are helpful in patients with autoimmune conditions.

Pericardial sclerosis

Several pericardial sclerosing agents have been used with varying success rates (eg, tetracycline,

doxycycline, cisplatin, 5-fluorouracil). The pericardial catheter may be left in place for repeatinstillation if necessary until the effusion resolves.

Complications include intense pain, atrial dysrhythmias, fever, and infection. Success rates arereported to be as high as 91% at 30 days.

Surgery

Surgical treatments for pericardial effusion include the following:

Pericardiostomy Pericardotomy Thoracotomy Sternotomy Pericardiocentesis

Inpatient care

Patients with pericardial effusion who present with significant symptoms or cardiac tamponaderequire emergent treatment and admission to the intensive care unit (ICU). The pericardial

catheter (if placed) should be removed within 24-48 hours to avoid infection. Symptomaticpatients should remain hospitalized until definitive treatment is accomplished and/or symptoms

have resolved

Outpatient care


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Patients should be educated with regard to symptoms of increasing pericardial effusion and

should be evaluated whenever these symptoms begin to occur. Indications for echocardiography

after diagnosis include the following:

A follow-up imaging study to evaluate for recurrence/constriction - Repeat studies maybe performed to answer specific clinical questions.

The presence of large or rapidly accumulating effusions - To detect early signs oftamponade

Transfer

Symptomatic patients requiring treatment (who are surgical candidates) should receive care at an

institution with cardiothoracic surgery capabilities.

Consultations

A cardiologist should be involved in the care of patients with pericardial effusion. Cardiothoracicsurgery may be required for recurrent or complicated cases.

Aspirin/NSAIDs

Most acute idiopathic or viral pericarditis occurrences are self-limited and respond to treatment

with aspirin (650 mg q6h) or another NSAID. For idiopathic or viral pericarditis, ibuprofen ispreferred, given its low adverse effect profile, favorable impact on the coronary blood flow, and

large dose range. Based on severity and response, the dose can range from 300-800 mg every 6-8

hours.[27]

Aspirin may be the preferred nonsteroidal agent to treat pericarditis after myocardial infarction

because other NSAIDs may interfere with myocardial healing. Indomethacin should be avoidedin patients who may have coronary artery disease.

In a study of 196 patients at high risk for tamponade because of pericardial effusion more than 7days after cardiac surgery, Meurin et al found that diclofenac was not effective in reducing the

size of the effusion or in preventing late cardiac tamponade. In the multicenter, randomized,

double-blind trial, patients received either diclofenac (50 mg) or placebo twice daily for 14days.

[28]

ColchicineThe routine use of colchicine in combination with conventional therapy is supported by results

from the COlchicine for acute PEricarditis (COPE) trial. In this study, 120 patients with a first

episode of acute pericarditis (idiopathic, acute, postpericardiotomy syndrome, or connectivetissue disease) entered a randomized, open-label trial comparing aspirin treatment alone with

aspirin plus colchicine (1-2 mg for the first day followed by 0.5-1 mg daily for 3 mo).[29]


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In the study, colchicine reduced symptoms at 72 hours (11.7% vs 36.7) and reduced recurrence at

18 months (10.7% vs 36.7%). Colchicine was discontinued in 5 patients because of diarrhea, but

no other adverse events were noted. Importantly, none of the 120 patients developed cardiactamponade or progressed to pericardial constriction. The ICAP Trial (Investigation on Colchicine

for Acute Pericarditis) will provide further information regarding the use of colchicine as first-

line therapy.

[30]

Steroids

Steroid administration early in the course of acute pericarditis appears to be associated with anincreased incidence of relapse after the steroids are tapered. In the COPE trial, steroid use was an

independent risk factor for recurrence. Also, an observational study strongly suggested that the

use of steroids increases the probability of relapse in patients treated with colchicine.[29]

Systemic steroids should be considered only in patients with recurrent pericarditis that is

unresponsive to NSAIDs and colchicine or as needed for treatment of an underlying

inflammatory disease. If steroids are to be used, an effective dose (1-1.5 mg/kg of prednisone)should be given, and it should be continued for at least 1 month before slow tapering. The

European Society of Cardiology recommends that systemic corticosteroid therapy be restricted to

connective-tissue diseases, autoreactive pericarditis, or uremic pericarditis.[27]

The intrapericardial administration of steroids has been reported to be effective in acute

pericarditis without producing the frequent reoccurrence of pericarditis that complicates the useof systemic steroids,

[31]but the invasive nature of this procedure limits its use.

Antibiotics

Purulent pericarditis

In patients with purulent pericarditis, urgent pericardial drainage combined with intravenous (IV)antibacterial therapy (eg, vancomycin 1 g bid, ceftriaxone 1-2 g bid, and ciprofloxacin 400 mg

daily) is mandatory. Irrigation with urokinase or streptokinase, using large catheters, may liquify

the purulent exudate, but open surgical drainage is preferable.

Tuberculous pericarditis

The initial treatment of tuberculous pericarditis should include isoniazid 300 mg daily, rifampin

600 mg daily, pyrazinamide 15-30 mg/kg daily, and ethambutol 15-25 mg/kg daily. Prednisone1-2 mg/kg daily is given for 5-7 days and progressively reduced to discontinuation in 6-8 weeks.

Drug sensitivity testing is essential. Uncertainty remains whether adjunctive corticosteroids are

effective in reducing mortality or progression to constriction.

Surgical resection of the pericardium remains the appropriate treatment for constrictivepericarditis. The timing of surgical intervention is controversial, but many experts recommend a


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trial of medical therapy for noncalcific pericardial constriction and pericardiectomy in

nonresponders after 4-8 weeks of antituberculosis chemotherapy.

Hemodynamic Support

Patients who have an effusion with actual or threatened tamponade should be considered to havea true or potential emergency. Most patients require pericardiocentesis to treat or prevent

tamponade. However, treatment should be carefully individualized.

Hemodynamic monitoring with a balloon flotation pulmonary artery catheter is useful, especially

in patients with tamponade or threatened tamponade in whom a decision is made to defer

pericardiocentesis. Hemodynamic monitoring is also helpful after pericardiocentesis to assess

reaccumulation and the presence of underlying constrictive disease. However, insertion of apulmonary artery catheter should not be allowed to delay definitive therapy in critically ill

patients.

IV fluid resuscitation may be helpful in cases of hemodynamic compromise. In patients withtamponade who are critically ill, IV positive inotropes (dobutamine, dopamine) can be used but

are of limited use and should not be allowed to substitute for or delay pericardiocentesis.

Pericardiocentesis

As previously mentioned, pericardiocentesis is used for diagnostic as well as therapeutic

purposes. Pericardial fluid drainage can be performed by percutaneous catheter drainage or open

surgical approach. Individual patient characteristics (eg, loculated vs circumferential, recurrent

pericardial effusion, need for pericardial biopsy and location of pericardial effusion) and local

practice patterns aid in deciding the optimal method of drainage.

Percutaneous pericardial fluid drainage (pericardiocentesis) is the most common method used forpericardial fluid removal. It can be performed under fluoroscopic, echocardiographic, or CT

guidance.

Echocardiographic pericardial fluid drainage has established itself as the criterion standard

technique. In study of 1127 procedures performed on 977 patients, echocardiographic-guided

pericardiocentesis was successful in 97%, with 1.2% major and 3.5% minor complications.[32]

Italso established the extended drainage as a means to reduce the recurrence rate.

Use of a needle that is at least 5cm long and 16-gauge in diameter and that has a short bevel canminimize the risk of complications and should allow for adequate pericardial drainage. A system

allowing placement of a catheter over the needle is preferred.

Contrast echocardiography using agitated saline is useful in cases in which bloody fluid is

aspirated, to determine if the needle is in the ventricular cavity.


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Attaching an ECG electrode to the pericardiocentesis needle is also useful for avoiding

myocardial puncture. Electrical activity will be seen on the monitor when the needle comes into

contact with atrial or ventricular myocardium. These changes may be delayed, however, andinstill a false sense of security in needle placement. Sense of touch and the findings on aspiration

should guide the procedure, with the clinician ultimately relying on good clinical sense.

Complications of pericardiocentesis include ventricular rupture, dysrhythmias, pneumothorax,

myocardial and/or coronary artery laceration, and infection. Recurrence rates for pericardial

effusion within 90 days may be as high as 90% in patients with cancer.

Pericardiotomy and Pericardiostomy

Balloon pericardotomy

In this procedure, a catheter is placed in the pericardial space under fluoroscopy. Inflation of the

balloon creates a channel for passage of fluid into the pleural space, where reabsorption occurs

more readily. Balloon pericardiotomy may be useful for recurrent effusions.

CT-guided pericardiostomy

Patients with effusions after cardiothoracic surgery often have limited echocardiographic

windows, as well as loculated effusions, and may be on continued ventilatory support, all of

which increase the difficulty of echo-guided pericardiocentesis.

CT pericardial fluid drainage has evolved as an emerging technique suited to overcome this

dilemma. It has been shown as an alternative technique in patients in whom fluoroscopically or

echocardiographically guided pericardiocentesis is difficult. Echocardiography can be limiteddue to various patient characteristics (eg, postoperative state, obesity, or chronic obstructive

pulmonary disease) or due to a limitation of echocardiography in differentiating pericardial fluid

from other possible surrounding structures.

In one large series, CT-directed diagnostic and therapeutic pericardiocentesis was attempted in

261 patients, with 98.4% success, 0.3% major complications and 6.9% minor complications.[33]

In 2010, Eichler et al reported their data on CT-guided pericardiocentesis in 20 patients whowere poor candidates for echocardiographic drainage or pericardial fluid was not well visualized

by echocardiography. All patients had successful drainage, with 0% mortality and no major

complications.[34]

A report by Palmer et al suggested that, in postsurgical cases, CT-guided pericardial drainage is

both safe and cost effective. The authors reported on 36 patients33 of whom underwent major

cardiothoracic surgery and 3 of whom were treated with minimally invasive procedureswhosesymptomatic pericardial effusions were drained using CT-guided percutaneous placement of an

indwelling pericardial catheter.[35]


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There were no clinically significant complications associated with any of the placement

procedures. Thirty-three patients experienced no symptom recurrence following catheter

removal, although pericardial effusion did recur in the remaining 3 patients, requiring a repeattreatment.

Comparing procedure costs, the authors determined that the CT-guided tube pericardiostomiescost 89% less than intraoperative pericardial window procedures would have. No significant

procedure-cost differences were found between CT-guided and ultrasonographically guided tube

pericardiostomies.

Subxiphoid Pericardial Window With Pericardiostomy

This procedure is associated with low morbidity, mortality, and recurrence rates, and can beconsidered as a reasonable alternative diagnostic or treatment modality to pericardiocentesis in

selected patients.[36]

The surgery can be performed under local anesthesia. This is advantageous because generalanesthesia often leads to decreased sympathetic tone, resulting in hemodynamic collapse in

patients with pericardial tamponade and shock. This procedure may be less effective wheneffusion is loculated.

One study indicated that the procedure may be safer and more effective at reducing recurrencerates than pericardiocentesis. However, only patients who were hemodynamically unstable

underwent pericardiocentesis, and no change in overall survival rate was observed.

Thoracotomy and Median Sternotomy

Thoracotomy

This procedure should be reserved for patients in whom conservative approaches have failed.Thoracotomy allows for creation of a pleuropericardial window, which provides greater

visualization of the pericardium. Thoracotomy requires general anesthesia and thus has higher

morbidity and mortality rates than does the subxiphoid approach.

Median sternotomy

This procedure is reserved for patients with constrictive pericarditis. The operative mortality rate

is high (5-15%).

Video-Assisted Thoracic Surgery

Video-assisted thoracic surgery (VATS) allows resection of a wider area of the pericardium than

the subxiphoid approach does, without the morbidity of thoracotomy.[37]

The surgeon is able tocreate a pleuropericardial window and address concomitant pleural pathology, which is

especially common in patients with malignant effusions.


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One disadvantage of VATS is that it requires general anesthesia with single lung ventilation,

which may be difficult in otherwise seriously ill patients.

treatment efusi

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